What is ethics? In the more than 2 centuries since the 1803 publication of Medical Ethics by Thomas Percival,1 physicians, ethicists, and the public have grappled with bioethics’ positive and proscription boundaries. Percival appreciated the emerging dichotomy between the “study of professional ethics … [which] cannot fail to invigorate and enlarge your understanding … [and] the observance of the duties which they enjoin.”1(pviii-ix) During the past century, the trajectory of medical ethics has tilted away from what ought to be (aspirational ethics) and toward what ought not to be (proscription ethics). From Tuskegee to Nuremberg, the 20th century represented a watershed period in ethical thinking because fear of repeating the gross excesses of the past led to an increasingly proscription approach to possible action in the future. The scope of medical ethics thus contracted because the field satisfied itself with prohibiting the morally repugnant while failing to consistently inspire an aspiration to the ethically ideal. Of the 1045 manuscripts with the word ethics in the title published during the past 4 decades in 5 leading general medical journals (Annals of Internal Medicine, The New England Journal of Medicine, JAMA, Lancet, and the British Medical Journal), only 35 focused on aspirational topics. With only 3.3% of ethics articles addressing positive, aspirational ethics, medicine has de facto legitimized a vision of bioethics as a predominantly proscription endeavor. This is unfortunate. We argue for the renaissance of excellence as the apotheosis of biomedical ethics. Excellence, in the Aristotelian sense, is the act of living up to an individual’s full potential, of performing the very best actions one can, that is, reached not through natural gifts but through practice. Excellence requires a constant shift in the target of aspiration because the more that is accomplished, the loftier the goal becomes, leading to a cycle of growth, development, and flourishing. Imagine for a moment that the spectrum of all possible ethical or unethical actions exists as a normal distribution (Figure). Our goal is to shift biomedical ethics from a concern about the far-left tail (the ethical floor) to a reification of the right (the ethical ceiling). We, thus, argue that the line between obligatory ethical acts and supererogatory ethical acts is blurred. Figure. View LargeDownload The Medical Ethics Bell Curve Although ethical actions are not truly normally distributed, it is helpful to conceptualize them to appreciate the discordance between our area of historical focus (the left tail) and our proposed area of ideal focus (the right tail). Obligation-oriented theories, such as principlism, play an important role in stopping grossly unethical actions. There is, however, a real danger of normative creep: as we focus increasingly on proscription ethics, we may lose focus on the aspirational and supererogatory ethics that define excellence in ethics. This gradual regression to the ethical lowest common denominator is echoed by the decrease in students’ empathy levels that takes place during medical school2,3 and, indeed, the reluctance of some training programs to formally acknowledge the need for ethics teaching modules at all. We are aware that our positivist approach has its shortcomings. Like all areas of medical ethics, its moral epistemology is opaque, and like other utilitarian arguments, it may be challenged by the demandingness objection. Moreover, it would be difficult to argue that common morality, whose mores govern the public at large, requires an aspirational, positive ethics. Still, professional ethical norms are broader than bare-bones common morality. A member of the general public would be hailed as a hero for saving a choking child; a physician is simply doing the expected. Our approach is not entirely novel; rather, it is an extension of a nascent trend in bioethics. Indeed, the American College of Physicians Ethics Manual attempts to codify some of the fundamental ethical tenets of medicine for practicing clinicians.4 Although its focus is largely on normative ethics, rays of aspirational ethics, including the discussion of positive duties surrounding the physician-patient relationship, the positive duties of the physician vis-à-vis society at large, and positive social justice–oriented duties, shine through. The manual also acknowledges that physicians “must have such virtues as compassion, courage and patience.”4(p74) Thus, we are not advocating an ethical about-face; rather, to paraphrase a review of the American College of Physicians Ethics Manual, it is a humble request for a shift in emphasis rather than ethics.5 As bioethics evolves, perhaps its admittedly needed proscription tenets may be framed consistently as a necessary, but not central, outgrowth of central aspirational-positive ideals. Normative, obligation-based ethical frameworks, whether principlist, deontological, utilitarian, or otherwise, serve a critical role as guards against gross unethical misdeeds. Obligation-based ethics set an important groundwork for patient and research-subject protection, whereas aspirational ethics need to be stressed for individual and professional growth. Framing the needed proscription and normative ethical rules in the context of the potential to help both individuals and society may lead to a subconscious shift in our approach as dermatologists to our positive duties to both individual patients and society. Why the focus on ethics in dermatology? Practicing ethical medicine is not a luxury; engaging in ethical exegesis is. Few would argue that dermatologists are among the most privileged of physicians, and indeed physician satisfaction surveys consistently highlight our field’s high professional and life satisfaction.6 Thus, dermatologists are uniquely poised to be on the vanguard of ethical thought, and indeed the American Academy of Dermatology has recently led a push for a more prominent role of ethics in dermatology with a new ethics pledge for members.7 Charity, volunteerism, philanthropy, and the desire to relieve suffering wherever it occurs need not remain frozen as aspirational ethical ideals but could form the basis of a renaissance in biomedical ethics. Back to top Article Information Corresponding Author: Jonathan Kantor, MD, MSCE, MA, Florida Center for Dermatology, PA, PO Box 3044, St Augustine, FL 32085 (firstname.lastname@example.org). Published Online: June 29, 2016. doi:10.1001/jamadermatol.2016.2135. Conflict of Interest Disclosures: None reported. Funding/Support: None reported. Disclaimer: The content of this publication is the sole responsibility of the authors and does not necessarily reflect the views or policies of the Office of the Surgeon General, the Uniformed Services University of the Health Sciences (USUHS), the Department of Defense (DoD), or the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. government. References 1. Percival T. Medical Ethics. Manchester, England: S. Russell; 1803. 2. Schwartzstein RM. Getting the right medical students—nature versus nurture. N Engl J Med. 2015;372(17):1586-1587.PubMedGoogle ScholarCrossref 3. Chen DC, Kirshenbaum DS, Yan J, Kirshenbaum E, Aseltine RH. Characterizing changes in student empathy throughout medical school. Med Teach. 2012;34(4):305-311.PubMedGoogle ScholarCrossref 4. Snyder L; American College of Physicians Ethics, Professionalism, and Human Rights Committee. American College of Physicians Ethics Manual: sixth edition. Ann Intern Med. 2012;156(1, pt 2):73-104.Google Scholar 5. Emanuel EJ. Review of the American College of Physicians Ethics Manual, sixth edition. Ann Intern Med. 2012;156(1, pt 1):56-57.Google Scholar 6. Leigh JP, Tancredi DJ, Kravitz RL. Physician career satisfaction within specialties. BMC Health Serv Res. 2009;9:166. doi:10.1186/1472-6963-9-166.PubMedGoogle ScholarCrossref 7. Stoff B, Scully K, Housholder A, Fabbro S, Kantor J. The American Academy of Dermatology (AAD) Ethics Pledge: I will put my patients’ welfare above all other interests, provide care that adheres to professional standards of practice, provide care for those in need, and foster collegiality through interaction with the medical community. J Am Acad Dermatol. In press.Google Scholar
JAMA Dermatology – American Medical Association
Published: Sep 1, 2016
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