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Should the Ethical Foundation of Medicine Be Subject to Popular Vote?

April 27, 2021

by Sharon Quick, MD

Medicine is an ethical vocation at its roots, established on principles of the Hippocratic oath, and all scientific research and medical procedures must conform to ethical guidelines and principles. A researcher motivated by a desire for promotion or fame could skew or falsify scientific data to get desired results, if not for ethical guidelines that prohibit this and sanctions for violation of them. Good science rests upon an ethical foundation. Or there could be human experimentation like that in the German concentration camps during World War II or the Tuskegee syphilis experiments on African Americans. Medical ethics guidelines were written to prevent such atrocities. The Belmont Report and the Nuremberg Code are established ethical guidelines from which National Institutes of Health (NIH) rulings were made to assesses medical research and to which most medical ethical boards adhere. The Belmont Report lists the following principles:


  1. Respect for persons (respecting a person’s autonomy, unless they do not have decision-making capacity, and then beneficence, nonmaleficence and justice are incorporated in deciding how to do what the person would have wanted or what is in their best interests)
  2. Beneficence (the goal must be to do good)
  3. Nonmaleficence (do no harm, which is a boundary for autonomy)
  4. Justice

Key elements of the Hippocratic Oath align with the Belmont report principles. Medical research, protocols, procedures, treatments, informed consent, etc. must conform to and not violate these principles. There may be cases where ethical principles seem to conflict, and nonmaleficence is the principle that often prevails as a boundary when there is a conflict. Patient autonomy, for example, cannot be allowed to the extreme that it harms others. Physicians may refuse patient requests that are not medically or ethically viable. For example, antibiotic requests are often denied when patients have viral illnesses. Patients may be overwhelmed by physical and psychological issues, and physicians may need to support such vulnerable patients, encouraging them to persist through treatment when there is a chance of a favorable outcome. A physician’s role is to value patients’ inherent dignity, regardless of their condition. Many medical decisions are not just science-based, but they are also about what is best for a patient, and they must integrate science and social, individual, ethical, spiritual and other factors. This ethical foundation is the essence of the medical profession and must be protected from forces that attempt to crack or destroy it.


There is a corollary to our rule of law. The U.S. Declaration of Independence states that all people are created equal, and that is the foundation of the right to life, liberty and pursuit of happiness. The U.S. Constitution is based on that ethical foundation, and laws cannot be democratically created that violate it.


The profession of medicine is a high ethical calling that incorporates science, but the public and government have been allowed to democratically vote to undermine the foundation of the ethics of medicine without any concern for how this affects the profession. It is like allowing the people to vote to oust the core principle of equality of persons upon which the Declaration of Independence is based. Legalization of assisted suicide violates the core principle that a physician never takes a life or assists in doing so. In areas where assisted suicide has been legalized, it has created distrust among physicians and distrust between physicians and their patients. For example, physicians cannot refer patients to other physicians without fear that their patient might be offered assisted suicide. Dr. Charles Bentz referred his depressed patient to an oncologist who prescribed lethal drugs to the patient, over Dr. Bentz’ objections, and his patient died in two weeks.1 Patients have to ask whether their physician would ever prescribe lethal drugs or else find another physician—because what if the patient’s core values preclude assisted suicide, but they are temporarily overwhelmed by conditions that make them see hastened death as a viable alternative, and they cannot trust that their physician might give them lethal drugs in their moments of weakness?


Assisted suicide legalization takes us back to the pre-Hippocratic days when doctors would kill or heal depending on who paid them more. We have already seen HMOs or medical insurance companies refusing to pay for treatment when survival rates are low but agreeing to pay for assisted suicide—seemingly a regression toward ancient pre-Hippocratic practice.


What assisted suicide has done to the practice of medicine is similar to what would happen to the practice of law if the public or the legislature passed a law over the objections of lawyers to allow lawyers to take bribes under certain limited circumstances, and in those circumstances the lawyers could not be sanctioned or barred from any legal professional organizations or business practices for doing so. There would be lawyers who take bribes, just as there are physicians who participate in assisted suicide. And it destroys the profession at its core.



1.         Dr. Charles Bentz related this story in a letter to the Washington State Senate on April 5, 2021.


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