Ethics is the systematic study of what is right and good with respect to conduct and character. As a branch of both philosophy and theology, ethics seeks to answer two fundamental questions: (1) should we do?, and (2) should we do it? As an intellectual discipline, ethics is concerned not only with making appropriate decisions about what we ought to do, but withjustifying those decisions. Thus, unlike other forums for the discussion of moral issues (e.g., television talk shows, barroom debates), ethics seeks to provide good reasons for our moral choices. In fact, it is the attempt to justify our actions that gives ethics its distinctive character.

Medical ethics is an application of ethical rules and principles to the practice of medicine. To ask what a physician should do in a particular case is to ask an ethical question, and to justify our answer we appeal to the same rules and principles that apply to persons in society generally.¹ For example, the physician’s obligation to protect patient confidentiality is merely an application of the rule that all of us have to guard carefully information that is entrusted to us. However, sometimes health care professionals are ethically required to assume risks not shared by laypersons, such as caring for persons with acquired immunodeficiency syndrome (AIDS).² To be a professional thus involves having certain obligations not shared by nonprofessionals. To understand why this is, it is helpful to examine what it means to be a physician, and how medicine differs from other sorts of occupations.

Medicine is a moral practice, because physicians are concerned primarily with advancing the interests of patients and doing for patients what they wish to have done for themselves. Unlike members of other kinds of practices (business, for example), the physician places the interests of others above her or his own interests. Indeed, this feature of medicine is one of the defining characteristics of the health care professions in general. Every encounter between a physician and a patient implicitly raises ethical issues, because a physician may–and indeed must–ask questions about how the welfare of the patient should be promoted.

Although every encounter between physician and patient raises ethical issues, these issues are not necessarily ethical or. A situation in which two or more choices are morally justifiable, but only one is capable of being acted on at a particular time, represents a moral dilemma.³ An ophthalmologist who has to decide between protecting the confidentiality of a patient with macular degeneration and protecting society from potential harm is caught in an ethical dilemma, since there are moral reasons for justifying each of two mutually exclusive options. No moral dilemma exists when a patient provides an informed consent to have cataract surgery, but the situation raises a moral issue, namely, whether the physician ought to act in the best interests of the patient and perform the surgery. Moral issues are unavoidable in ophthalmology because of the nature of professions in general and ophthalmology in particular.

To ask what one should do as a physician is often to ask a legal question as well, but it is incorrect to reduce the question to a matter for the legislature or the courts to resolve. For any legislative or judicial resolution to a problem concerning appropriate conduct, we may-and should-ask, “Is the law a good one?,” or “Was the court right?” Ethics, and not the law, establishes the ultimate standard for evaluating conduct.⁴ Still, there is a moral obligation to obey the law, and thus ethical analyses need to take into account the relevant statutes and court decisions.

A difficult problem in ethics concerns the source of ethical standards. People have appealed to many sources of authority in ethics: religious texts (e.g., the Bible, the Koran), natural law, philosophical argument (reason), intuition, personal experience, governmental decree, and the free negotiations of persons within a community. Traditionally in medicine, it has been the members of the profession who have selected its ethical norms and established codes of ethics. Because laypersons have a significant stake in the way that professionals conduct themselves, however, it is appropriate to include them in the selection of these norms.^s Our discussion is thus based not only on what the profession of ophthalmology has held to be right and good, but more broadly on what a reasonable person with knowledge of the relevant facts might hold to be appropriate. Since many ophthalmologists refer to codes of ethics, such as that of the American Academy of Ophthalmology, for solutions to ethical problems, we consider next the role of such codes in clinical ophthalmology.

One of the ways in which professionals have traditionally governed their behavior is through a code of ethics. A code of ethics is a statement of general principles of duty to which the members of the profession commit themselves, and through which the profession is given its moral character. The most familiar code of ethics in medicine is the Oath of Hippocrates, a document which may not have been written by Hippocrates⁶ at all and which contains several prohibitions that physicians no longer observe, such as the prohibition against performing surgery. Still, the Hippocratic Oath contains a statement which has profoundly shaped the distinctive nature of the practice of medicine for thousands of years: “I will apply dietetic measures for the benefit of the sick according to my ability and judgment.”⁶ As medical ethicist Robert Veatch has noted, “many modern physicians expand [this statement] beyond its original literal applications to dietetics to apply to all medical treatment, in fact, to all behavior affecting the patient.”⁷ What might be referred to as the Hippocratic principle summarizes the physician’s commitment to benefiting patients, and suggests that it is the physician who determines what counts as beneficial.

Modern codes of medical ethics have a direct debt of gratitude to the Hippocratic principle. For example, one of the principles of the American Academy of Ophthalmology (AAO) Code of Ethics states that “it is the responsibility of an ophthalmologist to act in the best interest of the patient,” a commitment that the Academy has elsewhere described as the code’s “exclusive goal.”⁸ Some have criticized the paternalistic nature of the Hippocratic principle, since the patient’s values and preferences are not taken into consideration.⁵ However, the AAO Code of Ethics, like the code of the American Medical Association (AMA), recognizes a commitment to respecting patient autonomy by requiring ophthalmologists to obtain informed consent before performing medical or surgical procedures and to provide services with “respect for human dignity” and “honesty.”

A code of medical ethics tells physicians not only what they should do, but what kinds of physicians they should be. For example, the AMA’s Principles of Medical Ethics makes reference to “physicians deficient in character,” and the AAO Code mentions the character traits of compassion and integrity. In other words, codes of ethics describe moral virtues as well as moral duties. A virtue is any quality of character that is valued; a moral virtue is a quality that has moral value.⁹ Other moral qualities that are valued by ophthalmologists are kindness, charity, and a commitment to ending unfair discrimination. A study of virtues complements that of duties by stressing the importance of good character in the moral life, and this is why many codes of professional ethics include reference to virtues.

There are limits to the usefulness of any code of ethics. A code should be of reasonable length (i. e., it should be concise). In order for it to apply to a range of situations, it must be general and avoid specificity. Both the brevity and generality of codes of ethics may make the principles contained in them difficult to apply in many situations. For example, the prohibition against deceptive or misleading advertisements in the AAO Code may not help ophthalmologists decide whether particular advertisements they want to place violate the Code; they need to know specifically what kinds of statements are deceptive or misleading. To counter this problem, some professional organizations, like the AAO, issue advisory opinions through an ethics committee or related body. These opinions clarify the codes and answer questions that practitioners have about how the code should be applied to specific circumstances.

A more deeply rooted problem concerns how the best interests of the patient are to be determined, and this problem cannot be easily resolved by requesting an advisory opinion from the ethics committee. The concept of the patient’s best interest is a value laden one, and thus the best interests of the patient cannot be determined independently from a particular set of values. For example, is it in the best interests of a patient to forego surgery so that the patient may attend a grandson’s wedding? If the problem may worsen irreversibly without surgery in the near future, the ophthalmologist is likely to say that the procedure is in the patient’s best interests. The patient might reply, however, that it is in his interest to attend the wedding. The dispute here concerns not the likelihood of delaying the surgery–both might agree that vision can be improved only by having the surgery sooner rather than later-but rather on the relative importance of two values: seeing, and attending an important event. A code of ethics does not and cannot decide how these values are to be rank-ordered, and thus it is often the case that appealing to a code of ethics will not resolve an ophthalmologist’s ethical concerns.

How, then, should an ophthalmologist approach ethical problems in the clinical setting? We present a systematic answer to this question.

Suppose that your best friend calls you one evening and tells you that he/she is faced with a difficult ethical dilemma involving an intimate other. “I don’t know if I should leave this relationship or try to work it out,” your friend says. “Please give me some advice!” What will your response be–to make a recommendation right away, or to ask for some more information? Most people choose the latter. This is because we recognize that good moral decision making begins with getting the facts straight (Table 1). Thus, the first step for making ethical decisions, in the clinical setting or anywhere else, is gathering the relevant facts.¹⁰

In the case presented at the beginning of the chapter, the relevant facts are that this patient’s macular degeneration is age related and irreversible. The patient does not accept this clinical reality, and his denial makes appropriate treatment difficult for both himself and his physician. There is an increased likelihood of an accident in any patient with poor visual acuity, since such a person may miss seeing signs, road hazards, pedestrians, or other motor vehicles. A legal fact which plays a role in this case is that some states ophthalmologists to report patients with inadequate vision to the Department of Motor Vehicles, so that the patients’ licenses can be revoked.

To resolve an ethical dilemma such as the one in this case, facts are necessary but not sufficient. Addressing moral problems differs from addressing mere technical ones in that the former involves a consideration of values as well as facts.¹¹ In addition to the relevant facts, an appropriate response to the question, “What should you do?” requires an account of the values that play a role in the case, and what moral guidelines or rules those values suggest. Identifying values is thus the second step of ethical analysis. Certainly one important value suggested by the case is the welfare of the public, which gives rise to the moral rule, “Protect others from harm.” It is this rule which is the moral basis of the law requiring ophthalmologists to report such cases to the Department of Motor Vehicles, since allowing patients with poor visual acuity to drive places others as well as the patients themselves at serious risk of injury and even death.