Dennis Sullivan, MD, MA (Ethics)
Director, Center for Bioethics
Cedarville University
Center Website: www.cedarville.edu/bioethics
Email: sullivan@cedarville.edu
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Objectives:
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To review the major principles of modern
biomedical ethics
To provide a historical context for these rules
To consider how these principles may need
modification in a cross-cultural context
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2400 years of normative medical practice
Exemplified by the Hippocratic Oath (400 B.C.)
Four Rules:
 Beneficence
 Non-Maleficence
 Distributive Justice
 Autonomy
1Beauchamp,
Tom L., and James F. Childress. Principles of Biomedical
Ethics. 7th ed. New York: Oxford University Press, 2013.
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H: “I will apply treatment for the
benefit of the sick according to my
ability and judgment.”
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Always acting in the best interest of a
patient
H: “I will keep them from harm and
injustice.”
 “Primum non nocere:”
 First, do no harm
 (L. version first said by Galen)
 Two specific prohibitions:
 no assisted suicide
 no abortion
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Treat everyone the same, regardless of…
H: “Whatever houses I may visit, I will
come for the benefit of the sick,
remaining free of all intentional injustice,
of all mischief, and in particular of sexual
relations with both male and female
persons, be they free or slaves.”
Remarkable in a Greek society
where women and slaves had no
rights.
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The fourth dictum of medical principlism
Never even implied in the Oath, but very
important today
Gives rise to the idea of informed consent
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Professionalism
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Medicine is a high calling
The oath is akin to ordination
Confidentiality
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Keeping medical information private
H: “What I may see or hear in the course of
treatment or even outside of the treatment in regard
to the life of men, which on no account ought to be
spread abroad, I will keep to myself, holding such
things shameful to be spoken about.”
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Medical ethics seminar in New Delhi,
India
 Roopa: Pro-life (adopted an
abandoned baby girl)
 But had trouble when I said I would
refuse to refer a patient for abortion
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New Delhi conference: physicians not
willing to terminate life support
“Always wrong”
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It is euthanasia
According to these Christian physicians
In fact, withdrawal of futile treatments is
quite ethical (with strict qualifications)
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Western idea
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From Immanuel Kant and the Enlightenment
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Patients are willing and able to make their own
decisions
Implies a strong degree of individualism
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Not always true of developing cultures!
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“Don’t tell my wife she has cancer”
 Common request by a loving African husband
 In fact, she is illiterate and probably cannot comprehend
the facts
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More sinister:
 22 year old man with gangrene of left foot
 Needed amputation, consent by parents and him
 Blocked by village chief
Confidentiality
 Story of pastor with AIDS
 With tears: “I only cheated on my wife one time!”
 I spent over an hour, promising not to discuss his
infidelity with anyone
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Women have few rights (in the Western
sense)
AIDS, FGM, and poverty add to the gender
disparity
Few women recognize the disparity
We cannot correct these disparities at the
bedside
A clinician must accept these things and live
within the system
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Long-standing cultural practice
Koran: up to four wives (though may be
over-interpreted by Christians)
May be more related to folk Islam than high
Islam
In Africa, 4th wife is often very young
(12-14)
 Belief that this will give an older man vigor
 Pregnancy: “children having children”
 CPD  ischemic damage to anterior
vaginal wall
 VVF  constant leaking
 Women then abandoned, stigmatized
 Repair of VVF is a ministry opportunity
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How much do we practice Western medicine?
 Example of AAA in patient with Marfan’s
Syndrome
 Decided not to operate (for the greater good)
 Paternalism
 Not our habit
 But given the lack of education, may be the best
policy
 Resource limitations
 Frustrating
 Can be a big cause of overwork and burnout
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Four Rules:
 Beneficence
 Non-Maleficence
 Distributive Justice
 Autonomy
Other aspects
 Professionalism
 Confidentiality
Remember: “The rules are the same, but the context is
different.”
Dennis Sullivan, MD, MA (Ethics)
Director, Center for Bioethics
Cedarville University
Center Website: www.cedarville.edu/bioethics
Email: sullivan@cedarville.edu