TRADITIONAL PRINCIPLES OF MEDICAL ETHICS



INTRODUCTION
Traditional Medical Ethics involves the application of religious principles to patient care. The recent attack on life in the womb and other challenges to the natural law have necessitated the involvement of the biological sciences, especially Embryology. In addition, we live in a multicultural and secular environment, where any sense of objective morality has almost disappeared. This has only led to confusion among physicians, patients, and public alike. Universal agreement on moral issues between physicians and patients is no longer possible in our pluralistic society. We now speak of Biomedical Ethics, or the common term Bioethics, as the application of our ethical and moral principles to human life issues. This page introduces the traditional viewpoint on human life issues. Western medicine was founded on our Judeo-Christian and Greco-Roman heritage, where the sanctity of life and the dignity of the human person are paramount for decision-making in patient care. At the end of this presentation are links to individual topics.


TRADITIONAL PRINCIPLES OF MEDICAL ETHICS
There are seven principles of Medical Ethics: a Moral Code and moral justification; the Doctor-Patient Relationship; Patient Autonomy; Beneficence (the Good Samaritan); Do No Harm (or Nonmalificence); Justice; and the Physician's moral integrity and virtuous character. All seven principles must be in harmony for ethical medical care.

First, there must be a moral code and moral justification to guide the physician in his actions. We learn as early as the Old Testament from Hebrew Scripture the value of life. In the Book of Genesis, God said Let us make man in our image and likeness (Genesis 1:26). We learn that God instilled the "breath of life" in man (Genesis 2:7). Because all human beings are created according to God's image and given the breath of life, we are called to respect the dignity of each human being.

Moses, the originator of the first five books of the Old Testament, lived before 1250 BC. God gave Moses the Ten Commandments as noted in the Book of Exodus, the one concerning life stated in a clear and direct manner:
"Thou shalt not kill." Exodus 20:13
The Book of Leviticus is the third book of the Pentateuch and God tells his people "to love your neighbor as yourself" (Leviticus 19:18). The Ten Commandments are repeated in the Book of Deuteronomy 5:6-21.


The ancient writers of Greece were concerned with the principle of life. Plato considered the soul to be trapped within the body, happily released upon death. Aristotle saw the body and soul as one unit, the soul being the "life principle" of the body. Every physician who graduates from a medical school in the United States takes the Oath of Hippocrates, the Father of Medicine who lived in Greece from about 450-375 BC. The middle portion of the traditional Hippocratic Oath expressly forbids abortion and euthanasia:
I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone. To please no one will I prescribe a deadly drug nor give advice which may cause his death. Nor will I give a woman a pessary to procure abortion. But I will preserve the purity of my life and my art.

Jesus Christ gave us the Beatitudes as recorded in the New Testament. The Beatitudes are presented in a positive sense, virtues in life which will ultimately lead to reward in Heaven. He taught us the Golden Rule in the Sermon on the Mount, to do unto others as you would have them do unto you (Matthew 7:12). He taught us the two greatest commandments are to love God, and to love your neighbor as yourself (Matthew 22:36-40, Mark 12:28-31, Luke 10:25-28). St. Paul taught us to respect the human body, for our bodies are temples of the Holy Spirit (I Corinthians 6:19).

Thus the tradition of Western Christian civilization and American medicine is founded upon the Biblical ethic and the traditions of our Greco-Roman heritage. Our Declaration of Independence speaks of God our Creator and the Natural Law, that every man has certain unalienable rights, namely, Life, Liberty and the Pursuit of happiness. Thomas Jefferson recognized that we have freedom and dignity as human beings because we are creatures of God. The U. S. Bill of Rights guarantees the rights of every American citizen.


The second principle of medical ethics is the doctor-patient relationship. Essential to this relationship is the element of trust. This relationship has been described by Paul Ramsey as a covenant similar to the pact between Yahweh and his people as recorded in Hebrew Scripture. The patient trusts the physician to counsel him to make the right decision regarding his care, to ensure his privacy, and to be a patient advocate. The physician should be compassionate, truthful, and respect the personal dignity of the patient by giving him informed consent. He is to fulfill his traditional role as healer and protector of the patient's life.

Free and informed consent is required for medical treatments and procedures, except in an emergency situation when informed consent cannot be obtained and there is no indication that a reasonable patient would refuse consent to the treatment, as, for example, an unconscious trauma patient from a motor vehicle accident that presents to the emergency department.

Free and informed consent requires that the person or person's surrogate (or proxy) receive all reasonable information about the essential nature of the proposed treatment and its benefits; its risks, side-effects, consequences, and cost; and any reasonable and morally legitimate alternatives, including no treatment at all.

If a patient is incapable of making medical decisions, a proxy or surrogate, as an eldest son or a daughter who may be living with the parent and is in a position to best know the patient's wishes, is called upon to make treatment decisions. Should the proxy utilize the concept of substitute judgement or of best interest? Substitute judgement is a preference the patient has expressed in the past, whereas best interest decisions consider what treatment or lack of treatment would benefit the patient at that particular time. A balance of the two concepts often occurs in the clinical setting. For example, the family may remember the patient was adamant about not having gastric tube placement. The physician honors this request and the family and physician may decide it is in the best interest to give the patient intravenous fluids during the patient's final hours. Hopefully dialogue among the physician and family members can resolve the appropriate course of action.


The third principle is patient autonomy. Individual self-determination is highly valued in our American tradition, and rightly so. Patients should have the right to accept or refuse treatment, or allow the natural course of events to take place. It is important to remember that one must respect autonomy as long as we live in harmony with the first principle of our moral law and the sanctity of life.


The fourth principle of medical ethics is beneficence, or the act of helping others. Beneficence refers to the traditional role of the physician as the Good Samaritan. The compassionate physician performs acts of charity, kindness, and mercy; comes to the aid of the injured, the sick, and the dying; and relieves suffering. Natural or comfort care, the offering of food and water and the maintenance of body temperature and cleanliness for the dying elderly patient is a form of beneficence, as well as comforting the patient through a loving presence, palliation, and prayer. Jesus gave us the Parable of the Good Samaritan, as recorded in the Gospel of Luke:
Jesus replied, "A man was going down from Jerusalem to Jericho, and he fell among robbers, who stripped him and beat him, and departed, leaving him half dead. Now by chance a priest was going down that road; and when he saw him he passed by on the other side. So likewise a Levite, when he came to the place and saw him, passed by on the other side.
But a Samaritan, as he journeyed, came to where he was; and when he saw him, he had compassion, and went to him and bound up his wounds, pouring on oil and wine; then he set him on his own beast and brought him to an inn, and took care of him. And the next day he took out two denarii and gave them to the innkeeper, saying, `Take care of him; and whatever more you spend, I will repay you when I come back.'
Which of these three, do you think, proved neighbor to the man who fell among the robbers?" He said, "The one who showed mercy on him." And Jesus said to him,"Go and do likewise."
Gospel of Luke 10:29-37


The fifth principle of medical ethics is nonmalificence. Nonmaleficence is the warning, "Never do harm to anyone." This speaks for itself! The physician must evaluate whether any particular treatment or procedure is clinically indicated, and whether the procedure will provide benefit or undue burden to the patient. When considering a medical treatment for a patient, one speaks of ordinary and proportionate care versus extraordinary and disproportionate care. For example, mechanical ventilation may be ordinary and proportionate for an otherwise healthy 25 year old who suffered a near-drowning accident, whereas a respirator for an 88 year-old near-terminal patient with cancer of the lung would be extraordinary and disproportionate. The reference point is the patient!


The sixth principle of medical ethics is justice. Justice means respecting the rights and dignity of each human being. The real purpose of civil law is to guarantee an ordered social coexistence in true justice, so that all may "lead a quiet and peacable life, godly and respectful in every way" (1 Timothy 2:2).

The physician must be fair to his patient, respect his rights as a person, and give the patient proper access to health care.

Today the principles of social justice often impact upon health care, as the corporate world has engulfed the profession of medicine. Scripture firmly supports the concepts of social justice, such as the New Testament Letters of St. Paul: in his First Letter to the Corinthians 3:8, he states that "every man shall receive his own reward according to his own labour."

The publication of Rerum Novarum on May 15, 1891 by Pope Leo XIII contributed greatly to improved treatment of workers during the Industrial Revolution. Pope John Paul II had a major impact in his call for social justice in the mistreatment of workers in Communist Poland, an event that ultimately led to the fall of the Iron Curtain. In his followup encyclical Centesimus Annus, published May 1, 1991, the Pope warned corporations against treating workers as "units of production" in their quest for profit.


Finally, the seventh principle of medical ethics is the physician, as a leader in the community, must be diligent to develop a virtuous character and exhibit moral integrity. The virtues are discussed below. We have the best role model - the great Physician, Jesus Christ!



These seven principles of medical ethics play an important part in our daily practice of medicine, in life-and-death decisions, and on modern human life issues. A review of the natural law and Christian morality will provide background for a discussion of the primary principle of the sanctity of life.


THE NATURAL LAW
The very fact that we exist and have a human nature places us in this world, and by our very existence we have relationships! We have a relationship to God, to others, to ourselves and to the world. We are judged by our actions and relationships!

God is the one objective source of morality. God created the world, and He knows how it works! St. Augustine defined God's eternal law as "the reason or the will of God, who commands us to respect the natural order and forbids us to disturb it." The natural law is the expression of God's eternal law. The Natural Law teaches us to do good and shun evil.

St. Thomas Aquinas calls the natural law "the human participation in God's eternal law." Aquinas wrote about faith and reason, which are like two wings on which the human spirit rises to the contemplation of truth. Through faith we assent to Divine Revelation, and through reason people naturally understand some basic practical principles, which he calls the "primary principles of natural law." Since everyone knows them, no one can make a mistake about them.

Both the Old Testament and the New Testament refer to a natural law that God has written in the hearts of men. The prophet Jeremiah speaks of this law when he discusses the New Covenant:
I will put my law within them,
and I will write it upon their hearts;
and I will be their God, and they shall be my people.
Jeremiah 31:33

St. Paul speaks of a law God has written in the hearts of men, that our conscience is a witness, and we will be judged on our life:
They show that what the law requires is written on their hearts,
while their conscience also bears witness
and their conflicting thoughts accuse or perhaps excuse them
on that day when, according to my gospel,
God judges the secrets of men by Christ Jesus.
St. Paul to the Romans 2:15-16

Cicero was a famous Roman orator who lived in the first century BC. While his concept of God was markedly different than our own, he recognized the existence of an eternal unchanging law:
"True law is right reason in agreement with nature, universal, consistent, everlasting, whose nature is to advocate duty by prescription and to deter wrongdoing by prohibition. Good men obey its prescriptions and prohibitions, but evil men disobey them. It is forbidden by God to alter this law, nor is it permissible to repeal any part of it, and it is impossible to abolish the whole of it. There will not be one law at Rome and another law at Athens. There is now and will be forever one law, valid for all peoples and all times. And there will be one master and ruler for all of us in common, God, who is the author of this law, its promulgator, and enforcing judge.
Cicero, On the Republic, 51 BC




CHRISTIAN MORALITY
God created us and we are made in his "image and likeness [Genesis 1:26-28]." Thus man has an innate dignity because we are creatures of God. The natural response to God's gift of love and life is gratitude and obedience to Our Father! Moral conduct therefore shows itself to be consent to God our Creator - it is the human response to the creative love of God.

But our first parents, Adam and Eve, led by the Temptor, were disobedient, and moral disarray entered the world. The creatures put themselves before God, "worshiping and serving the creature rather than the Creator (Romans 1:25)."

Following the fall of Adam and Eve, God sent his only Son, "that whoever believes in Him may have eternal life (John 3:16)." And Jesus was obedient to His Father, and served as our model of moral behavior.
Moral behavior is living in harmony with the will of God!

It is for us to "live in Christ." Because of our weak nature, it is easy for us to fall (Romans 6-8; Galatians 5). But God sent us grace through the Holy Spirit, to help us be obedient to the Father, to "free us from the law of sin and death" (Romans 8:2). Grace perfects nature, to help us live the Way (Acts 9:2, 19:23, 22:4) of Christ!

Pope John Paul II published his encyclical on Christian morality in 1993, entitled Veritatis Splendor, or "The Splendor of Truth." It is the first encyclical ever in the 2000-year history of the Catholic Church on Christian morality. The Pope points out the natural law is unchanging and universal. The Pope states that "the negative precepts of the natural law are universally valid." For example, the "negative" precept, "Thou shalt not kill" is just as true today as it was 2000 years ago. Everyone is bound to observe at a minimum the precepts of the Ten Commandments. The Pope continues that while there is a minimum requirement, there is no limit to the greatest commandment, that you should love God and your neighbor as yourself. There is no limit to the amount of love and generosity one can bestow on your family or neighbor.

The Pope continues in Veritatis Splendor to address the problems of modern morality, or ethical relativism. Western society has been founded on objective sources of moral norms, on a covenant morality, on Divine Revelation and the Ten Commandments of God, and the Natural Law. The Pope quotes the Gospel of Matthew (19:16) when the rich young man approaches Jesus, and asks him, "Teacher, what good must I do?" The Pope instructs us to "turn to Christ once again in order to receive from him the answer to their questions about what is good and what is evil." He reminds us of the warning in Genesis 2:16-17 that man is "not to eat of the tree of knowledge of good and evil." The Pope shows us that "with this imagery, Revelation teaches that the power to decide what is good and what is evil does not belong to man, but to God alone."

The Pope confirms that we are to seek the truth with our conscience, and live accordingly. For we truly have freedom from the tyranny of sin and death when we are living God's will. As the Gospel of John puts it,
You will know the truth, and the truth will set you free.
John 8:32

Modern trends, however, detach morality from any objective norm. As the Pope points out, "currents of modern thought exalt freedom to such an extent that it becomes an absolute, and serves as a source of values." For man today, freedom becomes doing your own thing. Anything goes. When conscience is separated from truth, the person decides what is right and wrong. We now have the great American creative conscience.

The Reverend Billy Graham has written Storm Warnings, an exceptional - and frightening - book that looks at the consequences of ethical relativism in our society today. The problem with ethical relativism is that a society loses its moral compass, if everyone can decide for themselves what is right and wrong. This is why the family and society as a whole are breaking down, because we have people engaging in all sorts of outrageous behavior, thinking they can do as they please.

Pope John Paul II clearly points out that it is the object, or what is done, that primarily decides the morality of a particular act. One must also look at the intention, purpose, or motive and the circumstance or consequences.
A good moral act requires that all three must be good.

Our freedom is truly safe when we accept God and his truth!

We have only to look at Marxism and Hitler and Nazi Germany to see what happens when governments separate freedom from truth and "do their own thing."

Proponents for euthanasia place patient autonomy as the highest guiding principle, even over respect for the sanctity of life. They argue that the patient should have a right to choose death rather than face a horrible and painful terminal illness. The problem with this is that if self-determination is the sole guiding principle, then why withhold the right to choose death for anyone! And, as in Nazi Germany, the state then had the autonomy to choose death for anyone!

Proponents for abortion believe that the mother should have a choice if she wants to keep her baby, that it is for us to respect her rights and autonomy. There are two problems with this - first, this completely disregards the primary principle of the sanctity of life, and second, what about the respect for the autonomy of the baby!

It was in Nazi Germany that the physician first became a minister of death. There is a crisis today in American military medicine as seen in Guantanamo. Should these trends continue, this will forever destroy the very essence of our role as protector and physician advocate, and will destroy whatever trust patients have left for us. How will you know if your doctor has your best interest at heart when he recommends a treatment?

The Pope cautions us in his concluding remarks "of the risk of an alliance between democracy and ethical relativism, which would remove any sure moral reference point from political and social life, and on a deeper level make the acknowledgement of truth impossible. Indeed, if there is no ultimate truth to guide and direct political activity, then ideas and convictions can easily be manipulated for reasons of power. As history demonstrates, a democracy without values easily turns into open or thinly disguised totalitarianism."

We are happy when we live in harmony with God our Creator!

The practice of the virtues is essential to Christian morality, and key to the profession of Medicine. There are seven virtues, the Theological virtues of faith, hope, and charity, and the Cardinal or moral virtues of prudence, justice, fortitude, and temperance. The virtues of Faith, Hope and Charity unite us to God, and are also essential in patient care, for it is important that our care be based on God's healing power, that we instill hope in our patients and are compassionate with them. The moral virtues guide us in our conduct and relationships during life, especially in the art of medicine. Faith is a personal commitment to God who reveals His saving truths and to those truths which he reveals. Hope is the desire for God and the trust we will receive the graces to be with Him in heaven. Charity leads us to love God above all things and our neighbor as ourselves. Prudence is a moral virtue which helps us make the right choice in every instance to allow us to properly treat our patients and accomplish our ultimate goal of union with God. Justice leads us to respect the rights of others and to give them their due. Fortitude gives us the courage to carry out what is right, and be a true patient advocate, even in the face of difficulty! Temperance gives us self-control over our desires and appetites.


LIFE
Western medicine as described above has long upheld the primary concepts of the sanctity of life and respect for the dignity of the human person. It is important to recognize that the vast majority of physicians exhibit respect for life in their practice of medicine. The dramatic advances of modern medicine have in fact given us an unexpected glimpse of the transcendent through the phenomenon of Near-Death Experiences, as first described by Raymond Moody MD. Patients were able to describe events in their resuscitation that could only be explained by their being outside of their bodies. The neurosurgeon Walter Penfield in his studies exhibited the difference between the mind and the brain. The pediatrician Melvin Morse, in his studies of children who described near-death experiences, presented the concept that the soul is the source of energy to the body.

Technologic advances in medical care have allowed physicians to sustain life by extraordinary means, such as mechanical ventilation, electrical cardioversion and defibrillation, and cardiopulmonary resuscitation. The decision to withhold or discontinue extraordinary measures has created new ethical problems. These issues first received public attention with Karen Ann Quinlan in 1976, an unconscious patient on a ventilator with little hope of regaining consciousness. The right to refuse life-sustaining treatment by the parents of the unconscious Nancy Cruzan reached the Supreme Court in 1990.

Furthermore, the medical profession has been inundated with challenges to the natural law and to traditional concepts of life and death over the past 40 years. Nearly everyone has forgotten that the first successful heart and liver transplant in 1967 occurred after the patient was in full cardiac arrest!

The modern utilitarian concept of brain death, partly developped in the interest of harvesting organs for transplantation, holds that the brain is the seat of the "integrative function" of the body, that the body cannot live more than a few days following brain death.

However, this has been challenged in the medical literature. The pediatric neurologist Shewmon cites 175 cases where patients have lived longer than 1 week after being declared "brain dead," one child still alive 15 years later!

Traditionalists in the medical profession have been supported by Pope John Paul II, who published his landmark encyclical The Gospel of Life, Evangelium Vitae, on March 25, 1995. The encyclical defined The Culture of Life, where every human being as a child of God has an innate dignity and thus is worthy of life, love, and respect. He contrasted this from the Culture of Death, where humans are to be used by the powerful few in the name of efficiency and choice.

The encyclical, which contains over 300 Biblical references, addresses the assault on life and dignity of the human person in our modern world. "Civil law must ensure that all members of society enjoy respect for certain fundamental rights which innately belong to the person, rights which every positive law must recognize and guarantee." The Gospel of Life could not have been more timely, and Newsweek magazine featured the March 25, 1995 publication as its cover story. Evangelium Vitae provided the direction America needed to combat a Michigan doctor's unchecked practice of physician-assisted suicide. The Pope called the practice of Natural Family Planning, Organ Donation, Modern Pain Management, and Natural Death consistent with a culture of life, but condemned practices such as Abortion, Exploitation of the Embryo, and Euthanasia as symptomatic of a culture of death.

The Pope assailed modern trends that attack the dignity of life. "Choices once unanimously considered criminal and rejected by the common moral sense are now becoming socially acceptable. The end result of this is tragic: not only is the destruction of so many human lives extremely grave and disturbing, but no less grave and disturbing is the fact that conscience itself, darkened as it were by such widespread conditioning, is finding it increasingly difficult to distinguish between good and evil in what concerns the basic value of human life."

The Pope called on people everywhere to become "children of the Light" (Ephesians 5:8) and build a culture of life in a civilization of love. "Life is a gift from our Creator and it is a treasure to be given the utmost respect and dignity. Society must respect, defend, and promote the dignity of every human person at every moment and in every condition of that person's life."

The Pope recalls that Jesus is the Word of Life (1 John 1:1-4). "Truly great must be the value of human life if the Son of God has taken it up and made it the instrument of the salvation of all humanity."

The Pope reached out to women who have had an abortion, urging them "not to lose hope, to face the situation honestly, and give themselves over with humility and trust to repentance." He pointed out that the "Father of Mercies is ready to give you his forgiveness and his peace in the Sacrament of Reconciliation." He made the perceptive observation that they "can be among the most eloquent defenders of everyone's right to life," and through their commitment to life, they can "become promoters of a new way of looking at human life."

In a dramatic and foreboding ending, the Pope likened the culture of death's attack on human life to the dragon in Revelation 12:1-6. The Pope points out that "life is always at the center of a great struggle between good and evil, between light and darkness. The dragon wishes to devour 'the child brought forth,' a figure of Christ, whom Mary brought forth 'in the fullness of time (Galatians 4:4).' But in a way that child is also a figure of every person, every child, especially every helpless baby whose life is threatened."

The Culture of Life was beautifully displayed in the suffering and death of our beloved Pope John Paul II, in contrast to the 13-day starvation of Terry Schiavo before her horrible death on March 31, 2005. The Pope joined his two-month suffering to that of Christ (Colossians 1:24), and was offered sustenance until his peaceful death on April 2, 2005.

The following Biblical sources support a Culture of Life.

Genesis 1:26-27	"Be Fruitful and Multiply"
Exodus 20:1-17	The Ten Commandments
Deuteronomy 30:15-20	God the Author of Life
Psalms 128:3	Blessings of Family
Matthew 5:1-10	The Beatitudes
Matthew 25:31-46	Final Judgement
Mark 12:28-34	Love God and neighbor
Luke 10:29-37	The Good Samaritan
John 3:16	"God so loved the world"
Romans 2:15	Conscience
Ephesians 5:8	"Walk as Children of Light"
1 John 1:1-5	The Word of Life

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References and Suggested Reading
1 RSV Navarre Bible Series. Four Courts Press, Dublin, Ireland, 1999-2007.
2 Thomas Jefferson and all. The Declaration of Independence, Philadelphia, Pennsylvania, July 4, 1776.
3 Pope John Paul II. Evangelium Vitae - The Gospel of Life, Times Books, Random House, New York, 1995
4 St. Thomas Aquinas. Parts I and II of the Summa Theologica, translated by the Fathers of the English Dominican Province, St. Thomas More Press, 1912; Christian Classics, Allen, Texas.
5 Reich WT. Encyclopedia of Bioethics , Revised Edition. Simon & Schuster MacMillan, New York, 1995.
6 May WE. Catholic Bioethics and the Gift of Human Life. Our Sunday Visitor, Huntington, Indiana, 2000.
7 Ashley B, DeBlois J, O'Rourke KD. Health Care Ethics, A Catholic Theological Perspective, Fifth Edition. Georgetown University Press, Washington, D. C., 2006.
8 Pellegrino ED. Toward A Reconstruction of Medical Morality. Amer J Bioethics 6:65-71, 2006.
9 Ramsey P. The Patient as Person, Explorations in Medical Ethics. Yale University Press, New Haven, Connecticut, 1970, 2002.
10 Pope John Paul II. Theology of the Body - Human Love in the Divine Plan, Pauline Books & Media, Boston, 1997.
11 Pope John Paul II. Veritatis Splendor - The Splendor of Truth. Pauline Books & Media, Boston, 1993.
12 Billy Graham. Storm Warnings. Word Publishing, Dallas, Texas, 1995.
13 Gotcher RF. Theology of the Body - Reflections. Linacre Quarterly 73:115-131, 2006.
14 Beauchamp TL and Childress JF. Principles of Biomedical Ethics. Oxford University Press, Oxford, England, 1994.
15 Newsweek Cover Story. The Pope's Plea: Life, Death, and the Pope. April 10, 1995.
16 Moody RA, MD. Life After Life: The Investigation of a Phenomenon - Survival of Bodily Death. Mockingbird Books, Marietta, Georgia, 1975.
17 Penfield W, MD. The Mystery of the Mind: A Critical Study of Consciousness and the Human Brain. Princeton University Press, Princeton, NJ, 1975.
18 Morse, M, MD. A Near-Death Experience in a 7-year-old child. American J Diseases Children 137:959-961, 1983.
19 Shewmon DA, MD. Brainstem Death, Brain Death, and Death: A Critical Re-evaluation of the Purported Equivalence. Issues in Law and Medicine, 14:125-145, 1998.
20 Xenakis SN. Doctors Must Be Healers. Seton Hall Law Review 37:703-710, 2007.
21 Alexander L. Medical Science under Dictatorship. New England J Med 241:2, 39-47, 1947.
22 Curlin FA, Lawrence RE, Lantos JD. Religion, conscience, and controversial clinical practices. New Engl J Med 356:593-600, February 8, 2007.
23 O'Connell P, Mistrot J, Parsons KC. Letters in Response, Religion, conscience, and controversial clinical practices. New Engl J Med 356:1889-1892, May 3, 2007.
24 Dudzinski DM. Practicing Moral Medicine: Patient Care to Public Health. Amer J Bioethics 6:75-76, 2006.
25 Haddad LM, MD. Principles of Bioethics. Franciscan University, Steubenville, Ohio, 2003.