The evolution of medical ethics in a historical and philosophical context


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Abstract

Abstract.

Introduction. The modern model of medical ethics determines the attitude in society towards the medical profession as a whole, and, as a consequence, the social status of the medical profession in the hierarchy of the professional picture. The purpose of the article is to analyze the evolution of philosophical and religious concepts that define the body of models of medical ethics from a historical perspective. Materials and methods. A search of literature sources was performed. The key method of this research is the analysis of philosophical, sociological literature on the research problem, and the logic is built on the principle of deduction: from the general (philosophical aspect) to the particular (sociological aspect). Results. Historically, the primary model of medical ethics is the Hippocratic Oath with the central principle of “Do no harm.” The next model of medical ethics was formalized during the Renaissance. The key tenets of the Hippocratic Oath were rethought, including taking into account the Christian picture of the world, and embodied in the anthropocentricity characteristic of the Renaissance. A new model of medical ethics was formed based on the research of Paracelsus. The paternalistic model was based on the principle of “Do good.” The displacement of the paternalism model from medical ethics was carried out under the influence of the development of capitalist society. The deontological model of medical ethics is based on the concept of respect for duty. In the 1970-1980s, this model had a serious competitor - bioethics, which is based on the principle of patient autonomy. Conclusions. Currently, there is a simultaneous coexistence of deontological and bioethical models of medical ethics, which indicates the incompleteness of the crisis state of the ethical field of medicine.

Full Text

Introduction. The ethical component is one of the key regulators of the development of professional spheres, since it determines the social status of a particular profession. In particular, medical ethics, or rather its modern model in the historical and cultural context, determine the attitude in society towards the medical profession as a whole, as a result, the social status of the medical profession in the hierarchy of the professional worldview of the younger generation affects the popularity of the choice of the medical profession. The competitiveness of the medical profession, the level of requirements for the professional training of the future physician, and, as a result, the quality of applicants who choose the medical profession as a professional guideline in life depend on this factor. In addition, socially approved and socially disapproved methods of work and directions of scientific research depend on the dominant ethical model in the professional environment. These facts determine the relevance of studying the problem of the genesis of medical ethics in a historical and philosophical context.
The purpose of the work is to analyze the evolution of philosophical and religious concepts that define the body of models of medical ethics from a historical perspective.
Materials and methods of research. As T. A. Kornaukhova notes, medical ethics in modern science is understood in terms of two aspects: broad and narrow. The broad aspect of medical ethics covers the sphere of behavior of medical workers, primarily as representatives of the profession. In fact, a broad aspect of medical ethics covers interaction with the patient, attitude towards the results of one’s own activities, interaction with colleagues, and attitude towards one’s own professional development. The broad aspect of medical ethics is primarily a sociological cross-section of professional activity. The narrow aspect relates to the philosophical and ethical guidelines that form the public and private regulations of the behavior and professional activities of a medical worker [1]. In a narrow aspect, the conductors of medical ethics are the scientific community, the community of professional education, and the community of medical practitioners.
In our study, the following logic is appropriate. The primary analysis is the genesis of philosophical and religious concepts that define the body of models of medical ethics from a historical perspective. Secondary is the correlation of the social models of behavior of medical workers described in the scientific literature with the modern concept of medical ethics, which allows us to determine professional stereotypes and professional deviations at this historical stage.
In fact, the key method of this research is the analysis of philosophical, sociological literature on the research problem, and the logic is built on the principle of deduction: from the general (philosophical aspect) to the particular (sociological aspect).
Research results. Historically, the primary model of medical ethics is the Oath of Hippocrates (460-377 BC). This model was focused on regulating the interaction between physician and patient. The basic principles of the Hippocratic Oath [2] were 3 maxims.
Firstly, the doctor’s commitment to high moral principles is affirmed, and these principles determine not only medical activity, but also the social behavior of a representative of the medical profession. Despite the fact that this maxim is not directly indicated in the text of the oath, it is indirectly contained in all its settings: the extension of the provisions of the oath to all spheres of a doctor’s life.
Secondly, the central principle of both medical activity and medical research is considered to be the principle “Do no harm!”, That is, we are observing an obvious humanistic message of the philosophy of the oath. As a result, there was a ban on studying the human body through penetration. Accordingly, this stimulated the development of the palpation method and contributed to the formation of medical ideas based on the anatomy of animals, which in turn led to erroneous ideas (V.V. Sergeev) [3].

Thirdly, the text of the oath emphasizes the social equality of recipients of medical care, that is, the doctor undertakes to provide maximum care to each patient, regardless of his social or financial condition.
It would seem that the basis of the Hippocratic model of medical ethics is the principle of the unity of moral requirements for a person, but an analysis of the key maxims of the oath indicates something else: the doctor stands out from the human community like a clergyman, a priest, but this does not endow him with a different, narrow ethics; on the contrary, he thinks , lives and acts within the existing moral paradigm, but as an absolute example of moral service. In this regard, the role of the doctor is positioned with the role of the saint.
In subsequent centuries, this approach was integrated by the religious concept of Christianity, in the context of which the understanding of man primarily as a spiritual being established a relationship between the physical and spiritual state of the patient, and illness was perceived as a punishment for sins.
The next model of medical ethics was formalized during the Renaissance, although the revision of the basic humanistic principle of the Hippocratic model began in the Middle Ages under the influence of the social stratification of society, the development of law as a science and social activity. A new model of medical ethics was formed based on the research of Paracelsus (1493-1541). The key tenets of the Hippocratic Oath were rethought, including taking into account the Christian picture of the world, and embodied in the anthropocentricity characteristic of the Renaissance. The slogan of the new model of medical ethics was the principle “Do good”, which is not a paraphrase of the principle “Do no harm”, since an ontological transformation has occurred.
The first installation of Paracelsus’ model of medical ethics was associated with the awareness of the relationship between man and the Universe: both the Universe influences man, and man influences the Universe, therefore, a clear relationship is established between the physical condition of a person and his spirituality. As a result, the central attitude, which extends to the regulation of the life activity of both the doctor and the patient, is an unconditional requirement to do good [4].
The second attitude is the idea of paternalism, according to which a relationship is established between the doctor and the patient as between father and son (in earthly perception) and as between God and his creation man (in divine perception). Consequently, since the father and God always acts for the benefit of his son, that is, he does good, he not only will not harm him, but in addition to healing the physical body, he will correct his soul. This is how the idea of psychological closeness and support is introduced into the structure of interaction between doctor and patient [4].
The displacement of the model of paternalism from medical ethics was carried out under the influence of the development of capitalist society, when the quality of medical services began to be determined by the cost of drugs and the ability to receive appropriate care, which, of course, was determined by the financial condition of the patient. Obviously, the model of paternalism could not exist in such conditions, since specific contradictions arose between the moral and practical components of the doctor’s activity, however, the development of such relations was also regarded as a dead end. The resolution of these contradictions goes back to the deontological model of medical ethics, the basic principles of which were defined in the work of I. Bentham (1748-1832) “Deontology, or the science of morality” [5].
The deontological model is based on the concept of observance of duty. This concept is embodied in the form of detailed rules of conduct for a medical worker, differentiated depending on each medical area. At the same time, a certain freedom opens up for the doctor, depending on the specific situation. In the deontological model, the dominant role is assigned to the medical worker, the role of the patient is essentially passive. A subject-object relationship is established between the doctor and the patient, while the paternalistic model promoted subject-subject relationships.
This model still exists today. On its basis, professional profiles of medical workers have been developed; it is reflected in the list of competencies prescribed by the Federal State Educational Standard for secondary vocational and higher education for the organization and results of educational activities. At the same time, in the 1970-1980s, a serious competitor appeared for this model. This became possible in the context of a growing crisis of this model, which was expressed, firstly, in the patient’s lack of information (as a result, social discontent increased in the context of the democratization of values and relations in society). Secondly, the deontological model did not allow resolving social contradictions caused by the existence or possibility of carrying out such morally borderline medical procedures as abortion, euthanasia, medical experiments carried out on people, etc.

Bioethics is becoming a new model of medical ethics. B. G. Yudin, characterizing the bioethical model, notes that within the framework of this concept, the doctor and the patient are endowed with the same rights and responsibilities: the patient must own the entire picture of the course of the disease, he is an active participant in the treatment process, and he has the same responsibility for the effectiveness of treatment, as with a doctor [6].
The key principles of the bioethical model are the following: scientific validity of medical practice, timeliness of medical care and the preventive nature of the health care system, preservation of medical confidentiality, respect for the rights and freedoms of the patient.
Within the framework of the modern bioethical concept of medical ethics, requirements for the professional activities of medical workers are formulated, based on the principles of humanism, professionalism, the scientific nature of medical interventions, and self-criticism of behavior at the moral, ethical, professional, medical and legal levels. The specification of these requirements can be represented by a system of fundamental requirements: timeliness and relevance of the medical interventions provided; scientific validity and correctness of the technology for providing medical care; maintaining medical confidentiality; respect for the patient's rights and freedoms; compliance with the principles of medical ethics.
As a result, there has been a rapid development of medical research and technology, including in border areas (transplantology, prosthetics, genetics, etc.), new categories of health have emerged, for example, the congruence of individual and public health.
While previous models of medical ethics were assimilated into religious beliefs or perceived as entirely consistent with the logic of Christianity, the bioethical concept has generated a real ongoing discourse in the Christian world.
First of all, we note that the bioethical concept has received significant support from the Catholic Church. In fact, the philosophical foundations of bioethics are rooted in the practice of Catholicism: biosocial autonomy of the individual as the image and likeness of God, rationalization and regulation of all spheres of life, including the field of medicine. Despite the fact that one of the tenets of Protestant culture is the biosocial autonomy of man, the Protestant church opposed the rationalization of the spiritual and moral nature of medical activity. In this regard, Protestantism turned out to be close to the official position of the Orthodox Church, which negatively evaluates controversial procedures such as abortion, euthanasia, artificial insemination, etc. [7]
At the same time, we note that at the moment deontological and bioethical models of medical ethics coexist, which indicates the incompleteness of the crisis state of medical ethics. As a result, different models of group and individual behavior of medical workers are observed in the public space. As an example, we present the results of an empirical study by N.V. Alikperova, A.V. Yarasheva, S.F. Klyueva, K.V. Vinogradova. The authors identified 4 models of compliance with the principles of medical ethics based on a sample of 551 medical workers. Thus, there is a dominance of a behavior model that combines a friendly attitude towards patients and colleagues (more than a third of the sample). About a quarter of respondents practice a model in which ambition and career growth are key values. Also, a quarter of respondents have a situational model of applying medical ethics in practice. About 13% of respondents follow the deontological model [8].
Conclusion. Thus, in the historical and philosophical context, four models of medical ethics were formalized: the Hippocratic oath, paternalistic, deontological and bioethical models. Currently, there is a simultaneous coexistence of deontological and bioethical models of medical ethics, which indicates the incompleteness of the crisis state of the ethical field of medicine. This imposes increased responsibility on institutions of higher education, since it is within their competence to train future medical personnel, who must not only be highly professional specialists, but also have a high moral character. It should also be noted the need to conduct scientific research on modern problems of medical ethics, since moral problems are often solved by changing a person’s way of thinking.

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About the authors

Olesya Vladimirovna Morgacheva

Voronezh State Medical University named after N. N. Burdenko

Author for correspondence.
Email: biokafe@yandex.ru
Russian Federation, 10 Studencheskava Street, 394036 Voronezh, Russian Federation

Sergey Evgenievich Ruzhentsev

Voronezh State Medical University named after N. N. Burdenko

Email: rse123vrn@yandex.ru
ORCID iD: 0000-0001-9213-311
Russian Federation, 10 Studencheskava Street, 394036 Voronezh, Russian Federation

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