Before I try to give some outlines on the ethical problems medicine is faced I want to make some general and basic remarks.
What is the task of ethics and how ethics has to be discerned from morals and morality? In our tradition we are used to call morals all the norms, principals and rules a society has established to regulate our life in the perspective of morality. This is important for there are lots of other regulations, like rules of traffic, rules in behaviour and so on.
The German philosopher of the 19th century Arthur Schopenhauer has characterised morals in comparison to the animals, especially the porcupines. These animals are used to a so called hibernation and they learned in the long history of evolution the following: if they get during this period too near together, they can hurt themselves with their spikes and if they sleep too far from each other, they can freeze to death. Exactly the space – not to hurt each other and not to keep too far away – Schopenhauer called morals. Morals is depending on the cultural and religious traditions and form these roots originates the relativity of morals. Morals has changed in the different situations and periods of history. Moral standards in the 18th or 19th century differ from the standards of our time. If in our acting we obey the rules and norms of morality our actions are judged as something good. If we act against the standards of morality our acting is judged as bad or evil.
Ethics on the other hand is a theory, a reflection on moral. Why shall we do this and refrain from doing that? Moral says: „This should be“ and ethics asks „Shall this really be so?“ If we go back in the history of ethics if we turn to the roots of our western culture, Greek philosophers like Plato and Aristotle have been the first ones of a systematic reflection on ethics.
 
Ethics in the Greek language has two meanings: firstly „ethos“ in the sense of tradition, habits and common use and secondly as an attitude, a virtue. The Greeks regarded ethics as a part of practical philosophy which covers finally the whole of our actions. It had to answer the question what will be necessary to come to and to fulfil a good life, that means finally a life in happiness. Of course ethics also wants to give us a set of norms and principals. Normative ethics does not ask what are the valid norms and regulations, does not ask what is, but what shall be done.
Philosophical ethics, to put it in a nutshell, is a reflection on morals and different from common or religious explications, philosophical ethics is obliged to a reasonable argumentation. Philosophical ethics has to show why certain principals or norms should be established. I will not give you more than a glance on the rich history of ethics in western tradition from the Greeks to medieval age, the period of modernity (empirism and rationalism) to the age of illumination, where autonomy, freedom and independence of the individual human being have been the basis of all ethical reflections and argumentations.
If you look at the present situation, you can state that the mainstream in ethics is still rooted on the one hand in prescriptions, elaborated by Immanuel Kant and his categorical imperatives, based on autonomy and reason, on the other hand on the concepts of utilitarism.
The conception of Immanuel Kant which we call deontological and his imperatives: „Act only according to that maxim whereby you can at the same time will that it should become a universal law without contradiction. “ „Act in such a way that you treat humanity, whether in your own person or in the person of any other, always at the same time as an end and never merely as a means to an end. “ are primarily looking for the intention of our acting. For Kant, the good will of a human being is important, the consequences of our acting ranks second. For utilitarism like it was formulated by Jeremy Bentham or John Stuart Mill has the aim to maximize the greatest happiness and benefit for the biggest number of people. For utilitarism it is not the intention but the consequence of our acting that counts. The theory of values says, that good consequences are those that produce or promote happiness or pleasure. Utilitarism holds the results of actions are the only relevant feature in assessing actions. Considerations of an agent’s intentions, feelings or convictions are seen as irrelevant. To summarize utilitarism goes away from principals and is nearer to the context and the situation of ethical decision-
 
making than Kantianism. Roughly said, the mentioned two positions in ethics are still in conflict concerning the problems we are challenged in medical ethics.
Due to the developments in the last years concerning cultural, scientific and technological processes, many fields of our world and our living have rapidly changed. This is one of the reasons why „applied ethics“ has been born. At first glance is seems rather strange, for ethics in itself is a practical science. As Aristotle ages ago stated, the aim of ethics is not knowledge of what has to be done and what has to be not done, but acting. We do not start philosophical reflections in ethics concerning the good and the evil but to become good or better human beings.
Otherwise the problems emerging from the mentioned developments cannot be solved by general ethical norms and principals. Nobody would deny that the categorical imperatives of Kant, the utilitarian demand to maximize happiness for the biggest quantity of people or the so called „Golden Rule“ cannot meet to universal approach but for decision making confronted with the question: „Shall we really do what we can?“ (technically) we will not find a big help.
Applied ethics generally does not start from basic principles but cares for the particular situation. In decision making general principles are very often overriding the particular needs. Of course, this is not a confession to ethical relativism and a farewell to all principles but a contribution to the variety of values, ethical positions and methods. It is also a contribution to a pluralistic society and a plurality of values which has been established in western societies.
Applied ethics has many fields: you can find it in technology, ecology, economy, in the media, in science and also in politics.
One of the most interesting and at the same time most urgent field of applied ethics is medicine. The enormous success in medicine and medical treatments has created many challenges for ethics. Before we start to discuss this kind of developments I would like to give a short glance at the history of medicine and ethics. Medicine and ethics, and medical ethics has a long and varied history. It did not only begin in the days of Hippocrates, but even tribal societies without a written language already had more or less articulated values that directed the provision of health care by shamans, exorcists, witches and priests. One of the earliest
 
written Provisions comes from the code of Hammurabi 3000 years ago. A monument in the sanctuary of Asclepius for example tells doctors to be like God, saviour equally of slaves, of paupers, of rich men, of princes and to all a brother, such help he would give.
The ancient ethical codes were often expressed in the form of oaths. The best known in the western tradition is the oath of Hippocrates. His significance is a twofold one: the oath establishes the principles of beneficence and non-maleficience. Furthermore it includes the prohibition of on giving potion to produce an abortion or giving any poison to end the life of a patient.
Medicine and ethics have in this time been very closely linked. Both are finally oriented not to knowledge but to action. As the aim of ethics is doing the good the aim of medicine is also doing the good, to cure and to care, to prevent and to heal diseases. Medicine was from the begin considered as a mixture of arts (healing art) and science, giving to the doctor a competence concerning the knowledge about the biological and physiological processes of our body. A human being was regarded to be composed by body and soul and the healing of diseases was at the same time not only a healing of certain anatomical functions but the healing of a human person. If we look at the tradition of medicine in our western culture we can remark a change of issue starting a modern age with the success of hard science like chemistry, physics or biology. Especially in the 19th century medicine was not any more regarded as an art but more as a science. Of course the success in medical treatments and in knowledge about the human body has not only been the reason for advances. But it has also been creating lots of problems especially in the fields of ethics. I want to repeat my question: Shall we really do what we can? We are confronted with a situation where diagnosis and therapy have been increased and the possibilities of acting for a doctor are multiple ones. Many medical interventions which are common nowadays have not been possible 30 or 40 years ago. Think of the first heart transplantation performed by Christian Barnard 1967. Heart transplantation at this time was in a certain way a slap into the face of moral values. Heart as centre of our soul and personality and the transplantation of a heart was not only a medical but also an ethical question. Think of respirators and cardiopulmonal resuscitation, of artificial nutrition and hydration, of the technical possibilities to keep a human being alive even if there is a loss of brain functions or the status of coma. In the meantime heart or other transplantations have become some kind of routine.

Let me enumerate other technological possibilities: prematurely diagnosis is routinely offered, in vitro fertilisation and artificial insemination developed to help infertile married couples are in the meantime also used to single women or to postmenopausal women in their late forties or fifties. Also embryo splitting, therapeutic and even reproductive cloning are also methods the technology makes possible. This new technologies and the enlarged possibilities for Diagnosis and therapies are challenges for medical Ethics.
Medicine in the mean time is not only curing diseases but also optimizing our condition and the quality of life. Cosmetic operations, on breasts, a big nose or reducing fat by operations are as common as psychopharmacology. Once more, shall we really promote this way?
If we look at the long list of new medical technologies and possibilities we can get the impression of a gap between our technical power and moral and ethics.
How can we face all this and draw limits which we can morally legitimate?
The common model elaborated in the USA is the model of principalism, referring to mid-level principals and not starting from big descriptions or norms.
These principals are autonomy and beneficence, non-maleficience and justice. These principals and midlevel norms can correspond with most of the ethical theories and methods which are ad the moment discussed. Deontological and utilitarian models can be included into these principles.
Of courses this does not dissolve the problems, for even if their are tendencies to weighing and balancing, the various principles can get into conflict.
The respect for the patient’s autonomy, his tasks and wishes can run against the principle of Beneficence.
What to do in the case where cancered people refuse chemotherapy or other treatments where the doctors are convinced that this treatment could prolong their life, but minimize their quality of life.

We are faced here with differed goods. On the one hand the saving of a live, on the other hand a reduced quality of life. Not to reminded to the costs of such a treatment. Can we really evaluate the quality of life? What is the quality of life for the individual person?
Especially the quality of life argument is used by utilitarian’s and the argument or prolonging and saving live is an essential part of deontological ethics.
Let us have a nearer look on the conception of autonomy. Autonomy is a central notion of modernity and was fairly elaborated in the period of enlightenment. As the medical ethicist Pellegrino stated: The autonomy model of clinical decisions making is groomed in the dignity of human persons and the claim they have their own privacy, self direction, the establishment of their own values and life plans – and the freedom to act on results of their cognitions.
If we follow the value autonomy within the relationship between doctors and patients we have to consider that autonomy and freedom have been since several decades one of the most important conceptions and demands of the modern age. The enormous place in the debate of medical ethics that autonomy and freedom have been received is historically good understandable. Autonomy does not only mean freedom but in first line the capacity of giving moral norms and principals by self-determination. Immanuel Kant, who was one of the big players in the discussion concerning autonomy, reminds us that autonomy is not only self-determination and capacity of a person to decide on their own desires. Autonomy, independence and rationality are building a set of tools not to be ruled by others, by society and authorities, by religious norms ore national desires, but to decide on their own life.
Autonomy in the sense of Kant is the capacity to give us by free decision the norms, principles and laws we should obey. As we all know, Kant had in his Philosophy distinguished between causality by nature and the causality by freedom, Human beings – as Kant said – are on the one hand empirical creatures belonging biologically to nature and insofar we underlie natural causality and empirical laws.
On the other hand we are free and not obliged to empirical laws. Autonomy and freedom are for Kant the condition for responsible and ethical behaviour. The difference between freedom in the negative and positive sense is important. Negative freedom is the capacity not to be

determined by reasons belonging to our sensuality, even if Kant admits that our emotions and passions can have a big influence to our decisions.
Autonomy and freedom in the positive sense are the capacity to give for ourselves a law and norms concerning morality. Freedom means that we can submit ourselves by own decision to the rules of morality.
Autonomy is for Kant the reason of human dignity, and human dignity is something which has to be a guideline for respect and treatment concerning other persons. Autonomy and dignity can be regarded to be the highest principles not only for ethics in general, but of course also in medical ethics.
Liberty and autonomy are also the guidelines for utilitarian ethics. As J. Stuart Mill already stated in his essay “On Liberty” or as Jeremy Bentham proposed, we have to consider that not only in the political framework liberty and free will are the most important bases for ethical decisions. Autonomy within the field of medical ethics is also one of the aims of utilitarian conceptions.
To go back to our present time, Isaiah Berlin has been elaborating in his essay “Two concepts of liberty” the difference between a negative concept of freedom and a positive one. Negative freedom is for him linked to the question what a certain subject or a group of subjects should do without the intervention of society or other people. Liberty in this sense has a positive meaning: it shows how autonomy can be executed, that means the choice of options and the execution of the options. For libertarians like Dworkin and others liberty means to be able to make your decisions free from any external obstacles. Of course we could put this difference in the traditional conviction that we have on one hand freedom for something to do and on the other hand freedom from something.
In this context I want to remind that one of the greatest defenders of human freedom, Jean Paul Sartre, has been concentrating in his philosophy on an interpretation of freedom that was identical with human existence. Sartre pointed out that a difference between freedom of the will or freedom to act is secondary. Ontologically seen freedom is identical with our existence. This conception of course, which is a very strong one, reminds us that freedom is

linked to responsibility. For Sartre we are completely free in our decisions and we have to create ourselves in all our activity.
As already stated the emphasize on freedom and liberty is linked with the conception of human dignity. Human dignity is not only – as we have already seen in the philosophy of Immanuel Kant – one of the most important claims, it is also a request in the different declarations of human rights. In these declarations it is stated that all human beings are free and are born equally with dignity and rights. The link between rights and dignity is very important for medical ethics: to respect autonomy and dignity has become in the meantime a guideline for not only the relationship between doctors and patients but also for all medical and clinical interventions. But what is dignity? Referring to Kant we can say that human dignity is rooted in autonomy and reason.
Going back to the history we can see that in the early times of the Greeks and Romans dignity was regarded as an honour to a position in public life. During medieval times and the focus on religion dignity was contributed to the human being by creation. In the Christian tradition man was created to be an image of God and for this, human beings have a dominant position within the whole creation.
Briefly we can state that dignity can be regarded to be an intrinsic value, rooted in the fact of belonging to the species of human beings. From this perspective dignity has a metaphysical quality and as it is formulated in the Constitution, for instance, of the German Republic: “The dignity of man is inviolable. To respect and protect it shall be the duty of all public authority.” Even if we refrain from theological foundations this perspective can easily be combined with a secularized position like it was formulated by Immanuel Kant.
Another approach to the concept of dignity is rooted in mutual communication. If you follow one of the formulations of the categorical imperative elaborated by Immanuel Kant: “Act in such a way that you treat humanity, whether in your own person or in the person of any other, always at the same time as an end and never merely as a means to an end.”, we can say that appreciation and mutual esteem are the highest principles concerning dignity. Dignity can be regarded from this perspective as something which is created by mutual respect and is contributed within the community of our social and individual acting. In this way all the efforts to avoid violation, discrimination and humiliation are depending on communication

and of course on personal habits. If we follow the above mentioned first conception of human dignity, if dignity is an intrinsic attribute to human nature, it must not be protected, for nobody can annihilate dignity, not even by torture or other forces and pressures. If we follow the second conception (the social one) than we have on the one hand an ethical guideline but on the other hand we have a gap between self esteem and estimation by others. Humiliation is always a kind of violation of dignity.
This was the reason why in many constitutions and declarations of human rights the inviolability of human dignity was anchored. Human dignity is related closely to self estimation and can be lost if a person loses this self estimation. By laws there can be a protection of dignity, but not a right for the estimation of dignity.
From here arises the problem – whether we take dignity as an essence of human being or if we take it as a social construct – how to contribute dignity to human beings which do not have yet or not any more the capacity of autonomy and self estimation, e.g. embryos or new born children, people at the end of there life being in a vegetative status or people who are mentally disabled. Certain utilitarian positions argue – like Peter Singer – that persons without the capacity of autonomy, of interests and the ability to plan their future are not any more participating on dignity.
I have to say that I do not at all share this position, but the problem is a severe problem for Medical Ethics. In this context we are confronted with two very important and very difficult questions: what is the moral status of an embryo and what is the moral status of a person in coma? If you look at the question, which is in the moment heavily discussed, if a certain moment in the development of an embryo can be regarded to be the beginning of human life you can find many different arguments. Fertilisation, nidation, division of cells, development of totipotent or pluripotent cells can be regarded as an indicator of the beginning of human life.
From a Christian point of view human life begins at fertilisation, from a liberal standpoint nidation or the 14th day after fertilisation is considered to be the origin of human life. Does an embryo really have a demand and a right to be regarded as a human being with all rights and the demands we have outlined concerning the protection of dignity? The standard argument in favour is the following: every human being has a right to live. A human embryo is a human

being, therefore the embryo has a right to live. The standard response is to accept the first premises, that all human beings have a right to live, but to deny the second premise, that a human embryo is a human being. Attempts to say that it only becomes a human being at viability or at birth are not entirely convincing. Viability is so closely tight to the state of development of neonatal intensive care that it is hardly the kind of thing, which can determine when a being gets a right to live.
The question of dignity therefore is linked to the question of autonomy. It is a very delicate situation if you have to decide if abortion or even scientific research on embryos can be morally justified. These problems have been especially arising in artificial insemination (IVF). What is crucial is, that the embryo not to be kept beyond the point at which it has formed a brain and a nervous system and might be capital of suffering. Once more the ethical approach to these questions is a very different one. Traditionally the so called animation was in philosophical and religious perspective of Aristotle and Thomas was estimated 60 days after fertilisation, if it was a male embryo and 90 days if it was a female one. The problem is that an artificial insemination with the aim to come to pregnancy if it is impossible in the natural way has to produce several embryos, one of them is finally implanted and the ethical question is now: Should the other ones be destroyed or could they be fruitful to aims in research? Many Microbiologists and Biologists think that it could be ethically justified to involve them in research and to do experimentation with the aim of producing means and treatments against Alzheimer’s Disease or Parkinson. Other ones are warning that this is a severe violation of human dignity. The discussion is still going on and finally undecided.
If human dignity is something which needs social recognition we cannot decide if only the participation on the human species is sufficient to guarantee the right of protection. If we go back to the position of Kant, human dignity is an intrinsic value which has to be respected for each human being. Following the second formulation of the categorical imperative dignity must follow from the respect of every human being as an end and not as means. Formally seen every human being is bearer of dignity and in so far it is not important if we talk of an embryo or somebody being in the state of coma. From this derives the moral duty not to instrumentalize any human being. Of course the problem with this Kantian conception is the problem that Kant has linked dignity to autonomy and reason. A human life which does not possess these capacities cannot be regarded in the sense of Kant to be really a human life. If you refer to the argument that there is the potentiality which the embryo possesses, we can

argue at the other hand, that potentiality does not include any right. This is the famous “Prince Charles argument”: Prince Charles in Great Britain has the potentiality to become King of this Empire, but this does not include that he has the rights of a King of England. From this, the question is very difficult to decide if the destruction of an embryo is ethically wrong, because it means that a person, who might have existed, will now not exist. It depends on the decision if the embryo already contains the genetic basis for the particular person or if this is uncertain. The minimal characteristic which is needed to give the embryo a claim to consideration is sentience, the capacity to feel pain or pleasure. Consciousness or self-consciousness cannot be the criterion for this. As already stated the moral status of the embryo is very difficult to form a guideline for ethical decisions. This leads us also to the problem of personal identity and the status of a person. Is this an intrinsic value created by nature or is personality something which has to be understood as dynamic and as a result of social interaction. Do we possess our self by nature or must it be constituted in social cooperation? So we come to a lot of conditions showing us that human dignity is not a fact but result of an evaluation. Human dignity is not an attribute of our being, but it is a demand to be respected in our daily life.
If we consider the other side of human life – death or dying – we are confronted with similar problems. How is the moral status of a person in coma who has lost not only consciousness, but can only survive by technical aid. Shall we, if a human being falls in a persistent negative status undertake all means to prolong his life or shall we, when death approaches, let this person die? What should be decided on the ethical level? Should we, even in the case that only artificial nutrition or hydration can prolong a life, this really apply, like some metaphysical or religious philosophers claim for? Or should in the case, that there is not a minimal chance for recovering, mercy and palliative care override all other tasks?
The struggle between representatives of the principle of the sanctity of life and the others referring to the quality of life argument is still ongoing.
While so called passive euthanasia in the meantime is accepted by many countries, that means, that it can be ethically and legally justified to interrupt and to stop medical interventions, active euthanasia is in most of the western countries forbidden (exceptions are The Netherlands, Belgium and Luxembourg). Switzerland has admitted the so called assisted suicide. The theoretical difference between active and passive euthanasia is a very slippery one. The distinction between letting die and killing is not so easy to be drawn. It leads us back

to the ethical discussion if not-acting is also an acting. If we do not interfere when somebody is in the danger of death, for instance, when he has been fallen into a river and he cannot swim and is crying for help, and I do not help him, have I by this non-acting however not finally acted?
Many doctors believe that it is permissible for them to stop treatment when death is desirable in the case that a terminally ill patient in great pain wants to die. But they think, it would be wrong, actively kill a patient in the same situation. Utalitarians are likely to regard killing and letting die does morally equivalent since the outcome, a desirable death is achieved in both cases.
Here we have a convincing example that the principles of respect of the autonomy of the patient and the principles of beneficence and non-maleficience are in contradiction.
Can the right of living be turned into a duty of living – even against the autonomous decision of a patient? Within the western world and also in my home country there exists since several years the instrument of the so called “patients-will or patients-testament”. This has to be respected by doctors. If a patient in the stage of a certain disease refuses treatment and therapy, the doctor has to respect this even if he finds himself in an ethical dilemma. I am sure that the current distinctions of direct, indirect, active and passive euthanasia are theoretically important, but in the situation of decision-making not of a big help. Indirect euthanasia means that a shortage of life is accepted to give to the patient palliative care for instance by a bigger dose of morphine, which is shortening his life. Active euthanasia means to give to a patient a medicament or a poison, ending his life. Passive euthanasia is a refrain of treatment and to stop all technical measures. It is important that the autonomy of a person is in this situation respected. But is a person with great pain, suffering, or even in loss of his consciousness to be regarded as autonomous? Does self-determination stop in this situation? This is a very crucial problem and not very easy to be decided with the help of principles. If we take autonomy as self-determination and the right to make your own choices, this means that it is voluntary and authentical. Authenticity means that an action is consistent with the person’s attitudes, values and life-plans.
Autonomy as a deliberation means that a person knows the alternatives of a decision. This is also a question of informed consent. Finally autonomy is also a moral reflection, due to the

acceptance of moral values. This can open a bridge between doctor and patient, paternalism and autonomy.
What we need in this situation, I think is neither a rigid principalism overriding the special and unique situation nor a liberal position where you can act as you want.
The vulnerability and the needs of a human being is more important than the orientation on theories and commandments. Therefore I think medical ethics is not something static and gives us once for ever orientations but a dynamic process. A position respecting autonomy has at the same time to look for solidarity and dignity. Tolerance, help and care, the avoidance of humiliation can help us in this ethical dilemmas, where not only doctors but all human beings are involved. I think, that an ethical attitude based on this guidelines is an important contribution to human dignity and finally more important than all theoretical discussions.

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