The article discusses the evolution of medical ethics, highlighting a shift from focusing on the internal

morality of medicine to considering external societal and cultural values. This transformation has led to
the emergence of disciplines like bioethics and health care ethics, involving professionals from various
fields, not just medical doctors. The article also introduces the concept of "applied ethics" or "principlism,"
which uses moral principles to address biomedical issues.
The article presents a case involving a patient with diabetes and dialysis, where ethical decision-making
is explored within the context of respecting autonomy versus medical paternalism. It critiques the
limitations of applied ethics in fully capturing the complexity of the decision-making process.
The article acknowledges criticisms of applied ethics, particularly from medical professionals who find it
too dogmatic and theoretical. It points out the need for a more comprehensive approach that bridges the
internal and external moralities of medicine.
To address these issues, the article suggests an empirical research approach in medical ethics, studying
ethics in action within healthcare contexts. It advocates for a deeper understanding of the internal morality
of healthcare practices and the external morality prevalent in society. It also calls for the development of
new theoretical perspectives on health care practices and the creation of a bioethics framework that
integrates both internal and external moralities.
In conclusion, the article proposes a hermeneutical ethics approach that emphasizes understanding and
critiquing the meanings and interpretations of moral knowledge in healthcare practices, striving for a
richer understanding of ethical complexities. This approach combines empirical research with
philosophical analysis to provide a more holistic and normative perspective on medical ethics.

1. "In a bustling hospital, a team of healthcare professionals gathers for a clinical consultation regarding a
challenging case. A terminally ill patient has expressed a desire for physician-assisted suicide, raising
profound ethical questions. The healthcare team, consisting of doctors, nurses, and ethicists, embraces
the contemporary approach of medical ethics. In this clinical setting, they apply the principles of 'applied
ethics' or 'principlism' to navigate the complex ethical dilemmas at hand. They carefully analyze the
situation using well-defined moral principles such as autonomy, beneficence, non-maleficence, and
justice. Through this process, they weigh the patient's autonomy against the potential harm and ethical
implications of assisting in their death. The discussion delves into the societal and cultural values that
shape their decisions. Meanwhile, in the academic world of ethics research, scholars take a different
approach. They are focused on in-depth examination and exploration of the ethical dimensions
surrounding physician-assisted suicide. They seek to understand the various moral quandaries
associated with this practice, considering historical perspectives, cultural variations, and philosophical
underpinnings. Their goal is not to provide a definitive answer but to contribute to the ongoing dialogue
about the complex ethical issues involved in end-of-life care."

2. Mr. S., born in 1950, has been suffering from diabetes mellitus type 1 for many years. He has been
receiving dialysis treatment since 1991. Due to complications, parts of his arms and legs had to be
amputated. At a certain point, the attending nephrologist discussed the possibility of discontinuing dialysis
with Mr. S. The patient strongly believed that the decision about life and death should be in God's hands,
and he wanted to continue with dialysis.
However, his condition deteriorated further. One of the amputation wounds became infected and very
painful, and Mr. S. became unable to communicate his wishes clearly. The medical team faced a dilemma
between respecting the patient's earlier autonomous decision to continue dialysis and the belief that his
suffering might outweigh the benefits of the treatment. Ultimately, they decided to give Mr. S. morphine to
relieve his breathing difficulties, which led to his death.
Ethical Dimensions: The case raises several ethical questions and dilemmas:
1. Respect for Autonomy vs. Medical Paternalism: The central ethical dilemma revolves around
respecting Mr. S.'s earlier autonomous decision to continue dialysis versus the medical team's
paternalistic judgment that he might be suffering more harm than good.
2. Ambiguity in Patient's Wishes: Mr. S.'s earlier explicit wish to continue dialysis was clear when
he was in a better condition, but as his condition deteriorated and he couldn't communicate, the
medical team faced uncertainty about his true wishes. They also suspected that his earlier wishes
might have been influenced by his religious beliefs.
 3. Professional Judgment: The doctors had to rely on their professional judgment, based on their
experiences and norms of good medical practice, to make decisions when the patient couldn't
express his wishes clearly.
Critique of Applied Ethics: The article critiques applied ethics for its limited ability to fully address the
complexities and uncertainties of this case. It argues that applied ethics, which often relies on principles
like respect for autonomy and beneficence, may oversimplify the moral dimensions of real-life medical
dilemmas. In this case, focusing solely on the conflict between respect for autonomy and beneficence
doesn't capture the full scope of the ethical issues.
The article suggests that a more comprehensive approach, such as the proposed hermeneutical ethics, is
needed to understand and interpret the meanings embedded in such complex healthcare practices. It
emphasizes that ethical decision-making should go beyond applying principles and instead involve a
deeper exploration of the internal and external moralities at play.
In summary, the case of Mr. S. serves as an example of the limitations of applied ethics in addressing
complex real-world medical dilemmas and supports the article's argument for a more nuanced and
comprehensive approach to medical ethics.

3. The article discusses potential solutions to the challenges faced by contemporary medical ethics. It
notes that various suggestions have emerged in the literature to address these challenges, such as
casuistry, virtue ethics, hermeneutical ethics, and narrative ethics. These approaches share a common
goal of reconnecting the internal and external moral dimensions of medicine without reducing one set of
norms and values to the other.
The dominant conception of medical ethics is criticized for creating a strong distinction between the
values, norms, and rules intrinsic to medical practice (internal morality) and those prevailing in society,
culture, and religious traditions (external morality). The article argues that a better understanding of the
interaction between these moral dimensions requires a theoretical framework relevant to medical practice
and an acknowledgment of the norms and values inherent in medicine. However, it also requires a critical
and detached perspective to assess medical practice objectively.
The central question posed is how to develop a theoretical perspective on medical ethics that bridges
philosophical reflection with the practical realities of medical practice. This perspective aims to clarify
specific bioethical problems, examine various conceptions of bioethics, and explain the emergence and
resolution of ethical issues in healthcare settings. It emphasizes the importance of understanding why
certain problems arise in healthcare practices and how they can be discussed and resolved through
interactions among healthcare professionals, patients, administrators, and others involved in the
healthcare system.

4. Recent medical ethics research is shifting away from simply applying established ethical principles and
theories. Instead, it focuses on studying ethics in real healthcare practices. Researchers use methods like
observing healthcare settings, surveys, interviews, and data analysis to understand the moral rules and
values within those practices, like surgery, genetic counseling, intensive care, and neonatal care.
This shift is fascinating but comes with challenges. Researchers must navigate practical issues like study
design and obtaining support from healthcare practitioners. The big question is whether empirical data
can determine what is morally acceptable. While it can help explain moral issues, it doesn't automatically
justify decisions or policies. Descriptive ethics, which observes how people act morally, doesn't prescribe
what they should do.
So, while empirical studies are useful, they can't decide what's morally right. The need for empirical
research shouldn't be overstated. It's just the first step. Ethics research should go beyond description and
develop a normative theory to connect empirical findings with normative judgments about what's good
and right in healthcare practices.

5. In a broader approach to medical ethics research, four steps are outlined:

1. Understanding Healthcare Practices: The first step involves studying different healthcare
settings in detail to grasp the moral norms and standards that guide these practices. This requires
both empirical research and philosophical inquiry. It recognizes that ethics is already present in
clinical settings, even if it's not explicitly labeled as such.
2. Analyzing External Morality: The second step involves examining the external moral values,
norms, and attitudes that influence healthcare practices. This means studying the societal values
 related to health, disease, dying, and healthcare. For instance, exploring how public policies
reflect values like solidarity and justice.
3. Developing New Theoretical Perspectives: The third step aims to create fresh theoretical
viewpoints on healthcare practices by considering empirical realities. This involves looking at
healthcare as a complex set of activities guided by shared rules, cognition, action, and norms.
Different disciplines like philosophy of medicine, medical ethics, and history of medicine can
collaborate on this.
4. Reimagining Bioethics: The final step is about developing a new conception of bioethics that
sheds light on the intricate interplay between the internal and external morality in healthcare
practices. It involves integrating empirical findings and insights to better understand and clarify
how these moralities interact in various healthcare scenarios.
In essence, this approach seeks to bridge the gap between the theoretical and practical aspects of
medical ethics by deeply analyzing healthcare practices and the moral values surrounding them.
The question here is how a hermeneutical (interpretive) approach can have normative (guiding) power. In
simpler terms, how can this approach go beyond describing facts and individual experiences, and provide
guidance in ethics?
Hermeneutical ethics doesn't rely on fixed ethical rules and comparing real situations with ideal ones.
Instead, it's like education. It doesn't dictate what should be done based on specific principles; rather, it
shows various possible perspectives and actions. By uncovering different ways of looking at a situation, it
enriches our understanding. This richer understanding can influence and modify our behavior, although
it's not predictable exactly how. For hermeneutical ethics to be normative and critical (able to provide
guidance and evaluate), it needs to analyze and explain the experiences discovered in empirical studies.
It's not enough to repeat what's commonly accepted in ethics. Hermeneutical ethics must try to
understand and question the meanings behind this common knowledge. This means both doing empirical
research to understand meanings in practices and interpreting these meanings critically, while being open
to input from others.
Main Argument
The main argument of the article is that in the field of medical ethics research, there is a need to bridge
the gap between ethical theory and actual medical practices. The authors emphasize the importance of
understanding both the internal morality of medical practices (how ethics is already at work in healthcare)
and the external morality (values and norms in society) to develop a more comprehensive and relevant
approach to medical ethics. They suggest that this can be achieved through empirical research, analyzing
values in healthcare, creating new theoretical perspectives, and redefining how ethics can be normative
and critical. In essence, they argue for a more holistic and practical approach to medical ethics research.
Here are the key points and arguments made in the article:
1. Shift from Internal to External Morality: The author suggests that medical ethics has moved
away from focusing on the internal values, norms, and rules specific to the practice of healthcare.
Instead, it now places greater emphasis on external moral values prevalent in society and culture.
2. Changing Terminology and Practitioners: The article notes that the terminology used in
medical ethics has evolved, with many people preferring terms like "bioethics" or "health care
ethics." Additionally, the practitioners in the field have diversified, with more philosophers,
theologians, sociologists, and historians claiming to be "ethicists."
3. Autonomy of Medical Ethics: The article highlights that modern medical ethics has become an
autonomous discipline, no longer embedded in the practice of medicine. It's no longer exclusively
the domain of medical doctors.
4. Role of Ethics in Medical Practice: The author argues that the role of ethics in healthcare has
shifted from philosophical reflection within medicine itself to monitoring, regulating, and controlling
medical practice based on social and cultural values.
5. Critique of Applied Ethics: The article critiques the dominant approach of applied ethics,
particularly for being overly dogmatic and theoretical. It suggests that applied ethics can be
limited in its understanding of complex clinical situations and may not adequately consider the
uncertainties and ambiguities faced by healthcare practitioners.
6. Empirical Research in Ethics: The article discusses a growing trend in medical ethics research
that focuses on empirical studies and understanding ethics in action within healthcare practices. It
 suggests that empirical data alone cannot establish what is morally acceptable and calls for a
new approach to connect empirical research with normative judgments.
7. Toward Normative Ethnography: The author proposes a more comprehensive approach to
medical ethics, involving four steps: examining health care contexts, analyzing external
moralities, creating new theoretical perspectives, and developing a new conception of bioethics
that accounts for the complex interaction between internal and external morality.
8. Hermeneutical Ethics: The article concludes by suggesting that a hermeneutical approach to
ethics, which focuses on understanding and challenging meanings found in practices, can be
normative and critical. It emphasizes the importance of interpreting meanings presented in
empirical studies and enriching our understanding of ethics in healthcare.
In summary, the article argues for a reevaluation of contemporary medical ethics, emphasizing the need
to bridge the gap between internal and external morality while incorporating empirical research and a
hermeneutical approach to ethics.
Strengths and Weaknesses
The strengths of this article can be summarized as follows:

1. Historical Contextualization: The article provides a historical context for the evolution of
medical ethics. It explains how medical ethics has shifted from focusing on the internal morality of
medicine to considering external societal and cultural values. This historical perspective helps
readers understand the broader changes in the field over time.
2. Identification of a Shift: The article identifies a significant shift in the role and methodology of
medical ethics, moving from being embedded in medical practice to becoming an autonomous
discipline. This shift is crucial for understanding the changing dynamics of medical ethics.
3. Critique of Applied Ethics: The article critically evaluates the concept of applied ethics or
principlism, highlighting its strengths and weaknesses. It acknowledges the value of applied
ethics in clarifying moral dilemmas but also points out its limitations, especially in addressing the
complexities of real-world medical practices.
4. Ethical Case Study: The inclusion of a detailed ethical case study (Mr. S.) adds practical
relevance to the article's theoretical discussions. This case study illustrates how applied ethics
can sometimes fall short in capturing the nuances of complex decision-making in clinical practice.
5. Focus on Empirical Research: The article emphasizes the importance of empirical research in
ethics, specifically in understanding the moral dimensions of healthcare practices. It recognizes
that empirical data can provide insights into the values and norms inherent in clinical settings.
6. Proposal for Normative Ethnography: The article introduces the concept of normative
ethnography, suggesting a new approach to understanding the interaction between internal and
external moralities in healthcare practices. This proposal opens up avenues for further research
and theoretical development.
7. Integration of Philosophy and Empirical Research: The article encourages the integration of
philosophical reflection with empirical research, bridging the gap between descriptive and
normative ethics. This interdisciplinary approach is seen as a way to create a more
comprehensive understanding of bioethical issues.
8. Reevaluation of Normativity: The article challenges traditional notions of normativity in ethics,
proposing that normativity involves not only prescribing correct principles but also enriching
understanding by presenting alternative perspectives. This reevaluation encourages critical
thinking and open dialogue.
The weaknesses of this article can be summarized as follows:

1. Lack of Clarity: The article is quite dense and uses complex language and concepts, which can
make it difficult for readers to follow and understand the author's arguments. It would benefit from
simplifying the language and providing clearer explanations of key ideas.
2. Limited Engagement with Counterarguments: The article seems to present a one-sided
perspective on the topic without adequately engaging with potential counterarguments or differing
viewpoints. A more balanced approach that considers opposing ideas would strengthen the
article's credibility.
 3. Overemphasis on Theory: The article focuses heavily on theoretical aspects of medical ethics
and philosophy, which may not resonate with all readers, particularly those looking for practical
insights or real-world applications of ethics in healthcare.
4. Complex Methodological Discussion: The article delves into methodological discussions about
empirical research and normative ethnography, which might be too technical and detailed for
some readers. A simpler explanation of these methods and their relevance would be beneficial.
5. Lack of Practical Guidance: While the article discusses the need for a new conception of
bioethics, it doesn't offer practical guidance on how to achieve this or how healthcare practitioners
can apply these ideas in their daily work.

Conclusion
Overall, the article discusses the evolution of medical ethics, challenges with the current approach, and
the need for a more holistic and empirically informed perspective on ethical issues in healthcare.

The moral compass of the medical industry is medical ethics. It offers instructions on how
healthcare workers should handle challenging circumstances, put patients' needs first, and
uphold the greatest standards of professionalism and compassion. In the end, it makes sure that
the interests of patients and the larger community continue to be at the heart of medical practice.