A new ethics series

Ethics lies at the very heart of medical practice. It defines what we do, why we do it and why we are there in the first place. It guides every moment of the relationship with patients and research subjects. Medicine is, in other words, a practice of ethics. In the tradition of medicine, both practitioners and the community have understood the role of ethics in different ways. For many centuries the philosophical aspect of medicine was specifically recognized, although formally separated from the concrete practices of surgery and pharmacy. The role of the doctor included that of spiritual and cultural guide, whereby both the meanings of illness and their impact on social life were organized and regulated. With the development of scientific medicine in the eighteenth century and afterwards − and the subsequent juridical unification of the profession − the reflective, non-instrumental dimension of health care was relegated to a secondary status, to the realm of ‘opinion’ rather than true ‘knowledge’. Ethics came to be regarded as a peripheral part of medicine, the underlying philosophical assumptions and rationale of which were tacitly accepted without question. It was only in the last half of the twentieth century, with the decline in the reputation and prestige of science and the rise in the consumer movement, that public acknowledgement of, and reflection about, the ethical aspect of medicine became firmly established. A new discipline, bioethics, was created, the task of which was to guide practice and the applications to society of scientific and technological innovation. Although in one sense this new role for ethics represented a revival of ancient themes, in another its conversion into a distinct academic discipline with its own techniques and standards was new. Furthermore, the agenda of the new discipline was defined rather narrowly, being limited to a few key issues examined in the light of a limited number of principles and philosophical perspectives. Ethics came to be seen as a technical activity in its own right, as the domain of yet another expert, and comparable to other areas of medical expertise. The limitations of this view of ethics as a technical, supplemental domain within medicine gradually became apparent. In response, a recognition has emerged of the inherent complexity and ambiguity of ethics, of its immanent connection with medicine, and of the sharp distinction between the structures of ethical reasoning and those of science proper. It is now widely − although not unanimously − accepted that ethics is not primarily concerned with the distinction between ‘right’ and ‘wrong’ and the construction of universal norms of action, but with plotting trajectories through complex, dynamic fields of values. It is recognized − again, not unanimously − that ethics follows its own peculiar logic, in which contradictory propositions can be simultaneously valid and absolute standards of truth of objectivity are lacking. Even more controversially, it is becoming accepted that ethics is not primarily concerned with outcomes or consequences, but about processes and communication, particularly the face-to-face communication between two people which establishes the common ground for action. This issue of the Internal Medicine Journal introduces a new series dealing with the ethical dimensions of medicine and research which seeks to take up the challenge of this complexity and diversity. Our focus will be on the many facets of ethics in medicine. We invite people involved in various capacities within the health-care system − as physicians, patients, policy makers or others − to offer reflections, particularly on their own specific case studies or experiences. We look forward to controversial viewpoints, and responses to them. Above all, we hope to stimulate and provoke, to precipitate debate, and thereby to continue to expand the depth and expanse of the ethical practice of medicine.