Thank you for having the courage to address the limitations of the commonly accepted approach to modern medical ethics.1,2 Drs Tunzi and Ventres’ recommendation to evaluate a given situation using several analytic methods is compelling. Both articles address the overlap between the ethical, moral, and legal perspectives to a problem, but stop short of defining what distinguishes them. Such a distinction is important because although in an idealized homogenous society the three would be identical,3 in a society rich in diversity they are often in conflict. Absent a clear distinction, a practitioner runs the risk of providing a moral solution to an ethical problem, or relying on a legal solution that may not be ethical.
Moral obligations may be shared by groups within a community,4 but are at their core personal and subjective—an internal belief system.3 Moral violations may have social ramifications, but absent direct overlap with legal and ethical obligations, will not inherently have personal or professional consequences.
Legal obligations come from an external political authority.3,4 Various stakeholders may or may not agree on a given law or its interpretation, and laws may be in direct conflict with moral obligations. Violations of the legal system may have direct personal and professional consequences regardless of the “rightness” of an action taken.
Ethical obligations also come from an external source, but they are obligations that we voluntarily take, often as a predicate to membership in a particular society.3 Applied ethics in particular set standards of conduct for individuals and groups.4 Violations of an ethical system may have direct personal and professional consequences. Unless there is direct overlap with legal obligations, penalties are typically limited to exclusion from a group (which, when that group is “those able to practice medicine” can be a potent consequence).
With these distinctions, we might consider that the duties to which Dr Saultz refers—to balance the interests of patients with societal interests, duties that flow from core concepts—are ethical duties, not moral duties. This is important because while an individual physician may take moral objection to a particular tenet of commonly accepted family medicine practice, they must still adhere to the ethical code of family medicine or face exclusion from that group. This perspective further allows us to maintain Drs Tunzi and Ventres’ ethical humility, and recognize that an appropriate ethical code for us may not apply to other cultures.
Thank you again for confronting and developing this important topic.