Ethics and Morality

Abstract

Introduction

Ethics and morality are a branch of philosophy dealing with moral principles. Morals conceptualise the tenets of human character or behaviour as good or bad, right or wrong. However, morals are an individual and subjective concept which vary across individuals, cultures and time. Intentions, decisions and actions which may be considered moral by one individual or society may be considered amoral by another. The need for an organised system of guidelines, which can be universally applicable to all members of a society and against which all moral or immoral actions can be judged is the driving factor behind foundation of ethics.

History of Ethics

A study of ancient Mesopotamian, Greek and Indian cultures over the millennia give a unique insight into ethics as a structural foundation of civilised society. The historical aspect of ethics and ethical systems helps guide present and future generations towards a harmonious and secure society across regional, organizational and global stages.

Study of Ethics

A study of moral philosophy endeavours to classify ethical systems based on various schools of thought which act as the guiding principle on which an ethical system is structured. The major branches of ethical philosophy include descriptive ethics which studies the prevalent ethical and moral standards, normative ethics which evaluates the prevalent moral norms and their interpretation and application, meta-ethics which reevaluates the prevalent ethical systems and applied ethics dealing with ethical considerations specific to a particular field.

Importance in Life and Clinical Orthopaedics

In this chapter, the authors have attempted to outline the importance of a structured ethical system in various walks of life, including personal, professional and social. A sound ethical system clearly outlines moral versus amoral behaviour, provides an objective means for judging the morality of decisions and actions, provides aids to teaching moral behaviour to new members of a society, defines behaviour of individuals professionally and personally, guides individuals in making decisions over issues of moral conflict or ambiguity and helps maintain structure and order in society so as to achieve the greatest good for the greatest number. The authors also discuss the essential role played by ethics in the life and practice of the modern-day Clinical Orthopaedician.

Introduction

The Oxford English dictionary defines morals as—Of or relating to human character or behaviour considered as good or bad; of or relating to the distinction between right and wrong, or good and bad [1].

Morals are a deeply individual and subjective concept and people often have strong and stubborn beliefs differentiating right from wrong, good from bad and just from unjust. An individual’s perception of morals is often influenced by life experiences, cultural norms, religious beliefs and upbringing. It evolves as one grows and encounters various experiences throughout their lives. As no two individuals grow through identical circumstances and formative experiences, there is often significant ambiguity between individuals regarding which intentions, decisions and actions may be considered moral or immoral.

Certain morals may be identified as universal, stemming from basic human nature and emotions. These values are considered virtuous by all individuals across cultures, beliefs, religions and time—wisdom; courage; justice; temperance to name a few.

In cases where moral intentions, decisions and actions of individuals do not concur, it is necessary to have a set of guidelines agreed upon by society to define moral or immoral behaviour by an individual. Thereby, arises the concept of ethics and morality.

Ethics and Morality

Ethics is defined in the Oxford English dictionary as—Of or relating to moral principles, esp. as forming a system, or the branch of knowledge or study dealing with these [2].

Ethics (Greek ethos: way of living) is a philosophical branch that studies human conduct specific to individual’s behaviour in society. They are moral principles that govern a person’s behaviour or the conduct of an activity.

Morality (Latin moralitas: manner, character, proper behaviour) is defined as the principles concerning the distinction between right and wrong or good and bad behaviour. It is the moral beliefs, views and attitudes of given individuals, societies and groups [3].

Ethics and morality are used interchangeably in the study of philosophy. Ethics deals with systematic reflections on moral views and standards (values and norms) and how one should assess actions, institutions and character traits [4]. Ethics will assess and evaluate the rational justification of an individual’s moral judgements of what is right or wrong and what is just or unjust [5]. These act as both, a code of conduct for the practice of moral behaviour by an individual or group and as a benchmark against which morally questionable decisions and actions may be judged. These provide a reference and aid in the teaching of moral behaviour for members of the society.

Ethics are formulated by a society based on reflections over moral views and standards. Being founded on the basis of systematic review of moral standards and values, they are grounded in logic and reasoning. They are instituted in a society as a formal system to guide an individual’s behaviour and tend to be objective and universally applicable in contrast to individual morals.

History of Ethics and Morality

Ancient Cultures

Ancient Greece and Mesopotamia are recognised by most historians as the cradle of human civilisation. It follows that the concepts of Ethics and Morality were first given shape from these cultures.

Moral thought during the ancient Greek era was originally based on mythology. These mythological stories, which were meant to instruct and teach, provided moral meaning, but no comprehensive framework. The earliest known literatures from ancient Greece and Mesopotamia, notably Iliad by Homer and the Epic of Gilgamesh set forth a set of values for influential members of society, which are considered desirable and worthy of honour [6]. Ethical claims are also found in ancient Egyptian and Sumerian scriptures, advocating practices of caring for the less fortunate as a means to please deities [7]. It was also in these scriptures that the primordial version of the Golden Rule of Morality first appears: do unto others, as you would have them do unto you [8].

The noted Greek philosopher, Socrates (circa 600 BC), is first credited with attempting to establish a framework of ethics using rational arguments and evaluation of current moral concepts. He advocated establishment of moral truths by rational questioning of the beliefs of others. He opposed the moral relativism of prevalent teachings during that era and insisted on formulation of moral principles from the beginning which would be equally applicable to all members of society. Similar works by Aristotle and Plato slowly gave structure to the concept of rthics in society and regulation of an individual’s moral behaviour according to a standard framework of guidelines [6]. Aristotle advocated “While many different goods were being pursued by different people and activities (as per their beliefs of what is good and bad), that good which is being pursued for its own sake is the supreme good.” Teachings by Aristotle extolled the importance of virtues and fixed habits of behaviour in moral life, such as courage, justice, prudence and temperance [9].

Ancient India

The foundation of ethics in Indian culture is visualised in the ancient Indian epics, the Ramayana and the Mahabharata, where the concept of Dharma is defined as duties of an individual towards upholding the natural order. These epics, along with the teachings of the Bhagwat Geeta, outline the concept of Sanatana Dharma or Eternal Law, which binds all beings. These scriptures provide structured guidelines towards the practices, behaviours and responsibilities of an individual in society. The concept of Karma (the accumulated balance of good and bad actions by an individual) holds prominence even in modern day ethical philosophy and teachings [10].

The tenets of Jainism as prescribed by the philosopher Mahavira Swami extoll the virtues of a perfectly ethical life through renunciation of violence in all its forms against all living beings [11]. The teachings of Gautam Buddha revolve around the Eight-fold Path, viz. right view, right resolve, right speech, right conduct, right livelihood, right effort, right mindfulness and right spiritual awareness [12].

All these ancient Indian scriptures provide an ethical framework which an individual must follow to lead a righteous, moral and virtuous life as a productive member of society.

Kantian Ethics

Eighteenth century philosopher Emmanuel Kant propounded the theory that right and wrong are founded on duty. He postulated that questions about happiness should not a focus on ethical thought, as ethics are universal, while different people derive happiness by different means. An action is only truly moral, if done from a sense of duty and the most valuable thing is a human will that has decided to act rightly. [13]

Utilitarianism

Betham and Mill in the nineteenth century proposed that right actions are those that are likely to result in the greatest happiness of the greatest number. This philosophy has popular support even in the twenty-first century [14].

Twentieth Century

The horrors of the two World Wars in the first half of the twentieth century led to a deepening focus on distress of fellow humans as central to development of ethics. This led to the establishment of the UNIVERSAL DECLARATION OF HUMAN RIGHTS, 1948, which asserted the fundamental moral rights of all human beings to life, education and other basic goods.

In the scenario of Indian ethics and morality during the twentieth century, mention must also be made of contemporary thinkers and philosophers, most notably, Mahatma Gandhi, who preached a code of morals and ethics, universally applicable to all mankind transcending age, gender, race, culture, beliefs and religion. Mahatma’s tenets of truth, non-violence, peace, dignity of labour, self-reliance, compassion and selfless service continue to inspire and impact moral codes and ethics of various societies all over the world [15].

Professional and Applied Ethics

Up until the mid- twentieth century, ethics were primarily theoretical and philosophical in nature, whereas medical ethics continued to deal with the issue of medical practice. The latter half of the twentieth century saw an upsurge in the fields of applied ethics like animal ethics, business ethics and environmental ethics.

As technological advancements continue to propel the human race ever further into the future, focus will also be required on new and emerging branches of ethics pertaining to computers, robots and artificial intelligence [16].

Medical Ethics

Hippocrates, the ancient Greek physician, known as the Father of Modern Medicine, born circa 460 BC, honoured by his contemporaries as a physician, is popularly believed to be the first Healer to introduce philosophic method in his practice and teachings [17]. He was known to be a man of impeccable moral standing and his teachings on both medical and ethical topics are relevant even in modern day medicine. The manuscript Corpus Hippocraticum not only contains information related to various medical matters, but also contains a code of principle for the teachers of medicine and their students. The Golden Rule of Medicine is also attributed to the Hippocratic manuscript: First, Do No Harm.

The Hippocratic Oath, an ethical code attributed to Hippocrates, has been adopted over the ages as a code of conduct for the medical profession and is still relevant today, often used in graduation ceremonies of medical institutions [18]. The Oath outlines the various obligations of the medical practitioner in his/her various roles as a teacher, a student and a caregiver. The physician vows to prescribe only beneficial treatments to the best of his/her ability and judgement; to refrain from causing harm or hurt; and to live a praiseworthy life as a contributing member of society, both professionally and personally. The Hippocratic Oath has undergone multiple revisions and reiterations over the years, to accommodate the progress and ever-increasing scope of medical practice.

Study of Ethics

Ethics, studied as a branch of philosophy, can be classified into four primary categories [14].

Descriptive Ethics

Descriptive ethics is a dimension that deals with the practical aspects of ethics and studies the prevalent ethical and moral standards of a society. It deals with the practical aspects of moral opinions, attitudes and actions. It describes the practice of moral behaviour by individuals in society [4]. As customs, laws, religious beliefs and circumstances vary from society to society and also within a society with the passage of time, it follows that the inter-society and intra-society ethical structure also varies. Descriptive ethics is hence a form of comparative ethics dealing with differences between societies and differences between the past and the present.

Normative Ethics

Normative ethics systematically evaluates prevalent moral norms and attempts to outline their understanding, interpretation and application on moral issues. The term normative ethics is derived from the root word ‘norms’ (defined as a situation or a pattern of behaviour that is usual or expected). This branch of ethics deals with the age-old questions like—How do you define whether a particular decision or action is morally right or wrong / good or bad? What are the ethical duties and obligations of members of a social institution, whether professional, political or economic?

The golden rule of normative ethics—“Do unto to others as we would have them do unto us” and its many variations like “People living in glass houses should not throw stones” are the foundation of normative ethics [8]. It is also called Prescriptive ethics as it outlines the principles which determine the rightness or wrongness of an action and also provides the justification for punishment in cases where these ethics are preached.

Over the centuries, theories postulated by various philosophers have attempted to frame moral foundations and guidelines for normative ethics. We briefly mention the historically important ones here.

Virtual Ethics

Advocated by renowned philosophers like Plato, Aristotle and Thomas Aquinas, virtual ethics focuses on values like prudence, justice, temperance and courage. Behaviour in society based on these virtues is considered ethical behaviour [9].

Deontological Ethics

Derived from the word duty, deontological ethics judges the rightness or wrongness of the actions of a person irrespective of the consequences. Deontological ethics includes schools of thought like Kantianism, which deals with the carrying out of one’s duty as the ultimate guide to ethical conduct [13]. It also propounded the twin principles of universality and reciprocity, i.e; ethical codes of conduct must be uniformly applicable to all members of society and that an individual’s treatment of fellow humans must reflect how they expect others to treat them (Golden Rule) [8]. Moral Absolutism is another theory of deontological ethics which proposes ‘Absolute Standards’ against which all moral ambiguities may be judged. Moral Absolutism defines rightness or wrongness of certain actions, regardless of the circumstances under which these actions are performed and does not provide for moral grey areas. Divine Command Theory judges the appropriateness of an action based on Divine Decree. The most notable example of the Divine Command Theory is the Ten Commandments of Moses as given in the Old Testament [19].

Consequentialism

Consequentialism or Teleology, as opposed to deontological ethics, judges the ethicality of an action based on the outcome of that action. This philosophy postulates that no action is right or wrong, in and of itself, but its rightness or wrongness is decided on the effect or outcome caused by the action. This theory is often quoted in modern terms by the simplistic adage “The ends justify the means.” Various philosophical theories of Consequentialism have been expounded through history, each theory defining a different desired outcome. Utilitarianism focuses on actions that contribute to the most happiness of the greatest number of people. Often referred to, in applied ethics as “For the Greater Good”, Hedonism and Egoism advocate actions that maximise pleasure and individual motives, respectively. Asceticism and Altruism are the philosophical opposites of Hedonism and Egoism, respectively, which focus on abstaining from personal pleasures and achieving spiritual progress with service to others [3].

Meta-ethics

Meta-ethics is a branch of ethical philosophy that deals with concepts, terminology and approaches to reasoning in ethics. It re-evaluates prevalent norms, statements and judgements in ethics. It deals with the basis of morality, whether it is subjective or objective and whether it is founded on rational or sentimental basis [14]. Meta-ethics is an analytical branch and may be described in simple terms as ethics about ethics. Although an obscure branch of philosophy, the key theories prevalent in meta-ethics include Naturalism, Non-naturalism, Emotivism and Prescriptivism.

Applied Ethics

Applied ethics are a sub-branch of normative ethics which are specific to a particular field. It deals with the philosophical examination and evaluation of morality in relation to the practises of that field. Primarily six categories of applied ethics are recognised: decision ethics, (guidelines for taking ethical decisions), professional ethics (governing behaviour of professionals), clinical ethics (good clinical practices), business ethics, organisational ethics (ethical frame work of organisations) and social ethics [16]. In recent years, applied ethics has gained more importance with new issues facing humanity on a daily basis—bioethics, environmental ethics, computer ethics, ethics related to social media, ethical considerations arising from issues related to robotics and artificial intelligence, to name a few.

Importance in Life

“The Preservation of human life is the ultimate value, a pillar of ethics and foundation of all morality.”

This all-encompassing albeit simplistic quote brings us to the most fundamental and practical aspect of the discussion on ethics and morality, i.e. Why do we need ethical constructs and moral principles in our personal, professional and social lives [20]?

Fundamental Rights

“All men are born equal and every human has the right to basic human needs like food, clothing, shelter and education.”

This dictum is the basis of all moral behaviour and ethical considerations, not only in a particular society, but for the whole of humanity. Fundamental ethical considerations like respect, compassion, prudence, temperance and protection against discrimination, exploitation and slavery form the bedrock of civilisation.

Law and Order

The organisation and advancement of a society has inextricable ties to its ethical framework. Often ethics and laws go hand in hand towards maintaining the security of a society, group or organisation. Ethics may even succeed law in safeguarding the society especially in cases where issues of morally questionable actions arise, which may not necessarily be overtly illegal.

The Common Good

A society in which individuals follow ethical norms in their personal, professional and social lives and participate as responsible and productive members contributes to establishing an environment conducive to the personal growth of each member and overall progress of the society as a whole [21].

Professional Security

A professional code of ethics relating to any profession helps create a secure environment, in which a set standard for each member of the profession can be expected. It is an assurance on behalf of the practitioners of the profession to act in a manner that protects the well-being of the public. It protects both professionals and their clients from avoidable legal complications. It provides a framework for professionals as well as their clients regarding their rights and responsibilities. It also ensures a uniform standard of care to every person seeking the services of a given profession.

Ethical Decision Making

The versatile nature of moral principles between individuals, groups, societies and time periods often raises many questions of moral ambiguity where different moral principles may dictate different courses of action. Often, in such circumstances, making a moral decision is complicated, not as a choice between right and wrong, but as a choice between better of two right decisions. Such conflicts in moral decision making may occur at individual, personal, professional and group/organisation levels. A framework of ethics will provide clear guidelines to enable the individual, group or organisation to take decisions, which would benefit all involved and help them avoid taking decisions or actions that might be considered unethical in retrospect, although based on good moral intentions.

Importance in Organisations

Any organisation, whether corporate or government, business or charitable, requires a strong ethical infrastructure which must be followed at all levels from legislative, executive to employee. This facilitates smooth running and overall progress of the organisation. It contributes towards raising the morale and overall satisfaction of the members of the organisation. It also engenders the sense of loyalty towards the organisation amongst its members. An organisation known to be driven by ethical and moral values garners respect and credibility among the general population. This is quintessential to the success of any organisation [22].

Ethics in Clinical Orthopaedics

An orthopaedic surgeon in clinical practice is expected to maintain stellar standards of ethical conduct, in personal and professional life: a healthy relationship with the medical industry at large, with professional mentors, colleagues and students, with paramedical staff and caregivers, without causing undue burden on personal and family life is a must. In a professional capacity, the code of ethics of a practicing orthopaedic surgeon involves proficiency in an extensive array of disciplines like patient care, healthy communication, educated informed consents, patient confidentiality, responsible behaviour, continued medical education and competence to name a few [10].

Arguably, the most important and all-encompassing facet of professional and ethical conduct in clinical orthopaedic practice revolves around developing a relationship between the surgeon and patient based on mutual trust, open communication and comfort. A positive patient–surgeon relationship is essential for ensuring optimal care and outcomes. The patientsurgeon relationship begins with the first contact between the surgeon and the patient, whether in an emergency setting or on an outpatient basis. The initial contact with the patient, a comforting greeting, an attentive hearing of the patient’s complaints, empathy towards their plight and pain, reassurance to allay anxiety and fears, frank discussion with the patient and caregivers regarding the condition; providing clear and concise details on the available avenues of management, involving the patient in the decision-making process, open and frank discussion on the risks and benefits involved in each available avenue of treatment, inviting questions from patient and caregivers, encouraging them to voice their concerns, providing a frank prognosis while still maintaining respect for the patient’s cultural and religious beliefs, being accessible to the patient in event of any emergency or to address any further concerns, respecting the patient’s autonomy in the decision-making process, procuring a valid informed consent from the patient and/or caregivers, maintaining accurate communication records, protecting the patient’s privacy and confidentiality—all these must form a standard protocol for every patient with whom a surgeon may interact in a professional or personal capacity. An orthopaedic surgeon’s practice must also be based on an innate sense of social justice—every patient has a right to equal and fair treatment, irrespective of age, gender, race, religion, cast, ethnicity or socio-economic status. Health-care resources must be allocated fairly and steps should be taken to avoid discrimination, even accidentally, in any form [23, 24].

An orthopaedic surgeon, apart from maintaining a healthy patient–surgeon relationship, is also expected to maintain a standard of ethics and decorum in their interactions with colleagues and other members of the medical community. Maintaining a level of medical and surgical competence by attending medical education seminars, skill-based workshops, medical conferences and participating in research opportunities; being aware of recent advances in medical technology and being familiar with their advantages, disadvantages, indications and contraindications before employing them in clinical practice; avoiding situations of conflict of interest as regards affiliation with pharmaceutical companies and research grants and declaring the same as appropriate; avoiding negative publicity, refraining from false and deceptive advertising or over-promising results; maintaining a clean image in extra-professional and personal life; avoiding unhealthy professional rivalries; refraining from bad-mouthing professional colleagues and maintaining a respectful attitude in all communications with other medical personnel—are all essential characteristics of an ethical medical professional [25].

Modern health-care practices require orthopaedic surgeons to work with a team of health-care professionals: physicians, anaesthetists, rheumatologists, oncologists, plastic surgeons, nurses and physiotherapists. It is essential to develop guidelines and protocols that facilitate streamlined team dynamics and ensure that each member of the team understands the patient diagnosis, treatment plan and other important information, along with their own role in the team [26].

Health-care professionals often answer a higher calling when they choose to enter the medical profession. Despite stellar dedication and professionalism while on duty, health-care professionals often find it difficult to balance work and life causing stress, fatigue and burnout affecting their own health and family life. This affects their efficiency at work and may compromise the quality of care provided to their patients. A healthy work-life balance includes setting boundaries around work hours, setting realistic expectations regarding workload and taking breaks/vacations at regular intervals. It is equally essential for an orthopaedic surgeon to prioritise their own health: exercise, eating healthy and getting enough sleep. A healthy work–life balance is not a fixed schedule,e but an ongoing process where the surgeon must keep trying various strategies and adjustments till they find a balance that suits them [27].

The recent COVID-19 pandemic has forced orthopaedic practitioners to re-evaluate and modify age-old established practices to accommodate the needs and demands of the patient. This has given rise to virtual modalities of examination, consultation and even education. As newer modalities of patient care and health-care evolve, so must the ethical guidelines which govern the medical and orthopaedic profession. The basic tenets of empathy, integrity and beneficence, although universal, must be modified and adapted to suit the changing times.

Declarations

Conflict of Interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Ethical Approval

This article does not contain any studies with human or animal subjects performed by the any of the authors.

Informed Consent

For this type of study informed consent is not required.