Slides (PDF) · Student tasks · Български
Set aside about 15 minutes to read and reflect. The text follows the presentation “Introduction to medical ethics”, the first of seven practical classes. Every class follows the same logic: the ethical problem → the arguments → the Bulgarian legal rule → a case you decide and justify. Afterwards you should be able to tell morality, ethics, law and deontology apart, apply four ethical theories to one clinical problem, explain the four principles and their critics, trace the main documents from Hippocrates to Oviedo, name the Bulgarian sources that bind a physician, and analyse a case with a structured method.
Morality, ethics, law and deontology
Morality is the set of beliefs, rules and values by which a group judges conduct as right or wrong; it is learned through family, culture and religion. Ethics is the systematic, critical reflection on morality: it asks which norms are justified and why. Normative ethics asks what ought to be done; applied ethics asks what follows for a concrete field such as medicine; metaethics asks what “good” and “duty” mean; descriptive ethics records what physicians and patients actually believe and do. Medical ethics is normative and applied: it must end in a justified decision, not only in a description of opinions.
Law comes from state authority, is written and hierarchical, binds one jurisdiction and is enforced by state coercion — fines, imprisonment, damages, loss of licence. Ethics rests on reasoned argument, conscience and the professional community, and can support, exceed or criticise the law. The two overlap but are not identical. An act can be lawful but ethically questionable — a physician accepts a generously paid “advisory board” place with almost no real work, declares it as the rules require, and then prescribes the company’s product. And law itself can be ethically wrong: the eugenic sterilisation laws of the 20th century (Buck v. Bell, USA, 1927) show that legality does not guarantee moral acceptability.
Deontology has two meanings. Medical deontology — in the Central and Eastern European tradition — is the doctrine of the physician’s professional duties towards patients, colleagues and society. Deontological ethics is a family of moral theories (Kant, Ross) in which rightness depends on duties and rights, not only on consequences. Bioethics is wider than medical ethics: the word was used by Fritz Jahr in 1927 and coined independently by Van Rensselaer Potter in 1970–1971, and research scandals, dialysis allocation, transplantation and intensive care gave it its biomedical focus. Medical ethics asks “what should this doctor do for this patient?”; bioethics also asks “what should society allow medicine and science to do?”
A clinical decision can involve five kinds of “ought”: an ethical argument (force of reasons), a legal rule such as Health Act Art. 87(1) (state sanction), a professional rule such as the Code of Professional Ethics (sanction by the Bulgarian Medical Association), an institutional policy (employment discipline; it must comply with the law) and a personal conviction (a personal moral reason that does not override professional and legal duties and does not bind the patient). Good reasoning says which kind of “ought” it uses. An ethical problem asks what is right; a dilemma exists when two moral requirements cannot both be fulfilled; both differ from factual uncertainty.
Ethical theories
Consequentialism judges acts by their outcomes. In utilitarianism (Bentham, 1789; Mill, 1861) the right act produces the greatest overall well-being, counting everyone equally. Act utilitarianism evaluates each act; rule utilitarianism follows the rules whose general observance gives the best results — confidentiality is kept even when one breach looks useful. It is impartial and attentive to real effects, and is influential in priority setting and public health, but it may justify sacrificing an individual for the many, and the sum of benefit says nothing about who bears the burden.
Deontology puts duties, rights and dignity first. Kant’s categorical imperative (1785) asks us to act only on a maxim we could will as a universal law and to treat every person always as an end, never merely as a means — so no deception “for the patient’s good” and no use of a patient for teaching or research without consent. W. D. Ross (1930) described several prima facie duties — fidelity, reparation, gratitude, justice, beneficence, self-improvement, non-maleficence — each binding unless outweighed by a stronger duty in the concrete situation. Deontology protects the individual and grounds informed consent, but duties conflict and strict rules can ignore context.
Virtue ethics (Aristotle) asks “what kind of physician should I be?” — the right act is what a person of good character with practical wisdom (phronesis) would do; medical virtues include trustworthiness, compassion, honesty, courage, justice, prudence and integrity. Its limit: “a good doctor would know” is not an argument. The ethics of care (Gilligan, 1982; Noddings) roots morality in relationships of dependence and sees persons in their families and communities (relational autonomy); its risk is partiality and excusing paternalism inside the family. Casuistry, narrative ethics and communitarianism are other approaches you will meet.
The class runs one case through all four lenses: a man with a newly confirmed, untreated HIV infection asks his physician not to tell his wife, who is also the physician’s patient, and refuses condoms “for now”. Consequentialism asks about the harms to the wife and to public trust; deontology about the promised confidentiality and the wife’s right not to be exposed to serious harm; virtue ethics about what an honest, courageous, compassionate physician would do and how he would first try to persuade the patient; care ethics about how the relationships can be protected. The Bulgarian rules on confidentiality and its limits are the topic of Class 3.
Principlism and its critics
Beauchamp and Childress (Principles of Biomedical Ethics, 1979; 8th edition 2019) proposed four mid-level principles. Respect for autonomy means respecting the informed, voluntary decisions of persons capable of making them and supporting those whose capacity is limited — it does not mean the patient can demand any treatment, and a diagnosis alone does not remove capacity. Beneficence requires positive action — treat, prevent, rescue, relieve — weighing benefit against burden in the light of the patient’s own goals, but not deciding for a capable patient what is good for him. Non-maleficence requires due care and proportionate risk, not avoidance of every risk. Justice requires fair distribution of benefits, risks and costs and no discrimination — not identical treatment regardless of need.
The principles are prima facie and not ranked in advance. Two operations make them usable. Specification narrows a principle for a context (“respect for autonomy includes the right of an adult with capacity to refuse life-sustaining treatment”); balancing decides which obligation weighs more here, and the infringement must be necessary, minimal and openly justified. Soft paternalism protects a person whose particular choice is shown not to be autonomous (for example in delirium); hard paternalism overrides an autonomous choice and needs exceptional justification.
Justice has several theories: egalitarian (Rawls — fair equality of opportunity; inequalities only if they benefit the worst off), utilitarian (maximise health gained per resource, for example QALYs), libertarian (Nozick — no general redistributive right to health care) and communitarian (shared community values). The course textbook adds its own classification: status-based proportionality, social justice, utilitarian maximisation, a guaranteed minimum followed by allocation by contribution, and perfect justice as an ideal. The Bulgarian Constitution gives citizens the right to health insurance guaranteeing affordable medical care (Art. 52(1)).
Principlism has critics. Clouser and Gert (1990) called the principles “chapter headings” that give no method when they collide. Gillon (1994; 2003) defended them, adding attention to scope and treating respect for autonomy as “first among equals”. Rendtorff and the Barcelona Declaration (1998) proposed a European alternative — autonomy, dignity, integrity and vulnerability — closer to European law. Care and virtue ethics object that principles neglect relationships and character; in family-centred cultures decisions are often shared — but sharing a decision is not the same as taking it away from the patient.
From Hippocrates to Oviedo
The Hippocratic Oath (c. 4th century BCE) obliges the physician to help “according to my ability and judgment”, never to injure, to give no deadly drug, to avoid injustice and sexual relations with patients, and to keep silent about what is seen in treatment. Beneficence, non-maleficence, confidentiality and integrity survive; what is missing is the patient’s consent, any concept of justice in access, and a public, accountable standard. Primum non nocere is a later Latin formula, not a line of the Oath. Before 1945 come the Code of Hammurabi, Christian, Byzantine and Islamic hospitals, Thomas Percival’s Medical Ethics (1803), the basis of the first AMA Code (1847), the Red Cross and First Geneva Convention, and in 1901 the first congress of Bulgarian physicians, which founded the Bulgarian Medical Association.
Nuremberg was the turning point. The Doctors’ Trial (1946–1947) judged 23 defendants, 20 of them physicians, for lethal experiments on prisoners and the killing of disabled people; its judgment formulated the Nuremberg Code (1947), whose first principle is that “the voluntary consent of the human subject is absolutely essential”. Abuse did not end there: the Tuskegee study (1932–1972) withheld treatment for syphilis from Black men, and the scandal led to the Belmont Report (1979) — respect for persons, beneficence, justice.
After 1945 the World Medical Association produced the Declaration of Geneva (the physician’s pledge; the 2017 revision added respect for autonomy and dignity and care for the physician’s own health), the International Code of Medical Ethics, the Declaration of Helsinki on research (2024 revision) and the Declaration of Lisbon on patients’ rights, which the Bulgarian Code refers to expressly (Art. 10). The Oviedo Convention (Council of Europe, 1997) is the first binding international treaty on biomedicine: “the interests and welfare of the human being shall prevail over the sole interest of society or science” (Art. 2). Bulgaria deposited its ratification in April 2003 and the Convention has been in force for Bulgaria since 1 August 2003. Under the Constitution (Art. 5(4)), a ratified, promulgated treaty in force is part of domestic law and supersedes conflicting domestic legislation.
The Bulgarian framework
The hierarchy runs from the Constitution (1991) through ratified treaties (ECHR, Oviedo) and Acts of Parliament (the Health Act, the Medical Establishments Act, the Health Insurance Act, the Act on the Professional Organisations of Physicians and Dentists, the Criminal Code, the Obligations and Contracts Act), alongside EU law (GDPR, the Clinical Trials Regulation), to ordinances and medical standards, professional rules and, last, hospital rules. Three constitutional provisions matter most: no medical experiments without voluntary written consent (Art. 29(2)); the inviolability of private life (Art. 32(1)); and no forced medical treatment except as provided by law (Art. 52(4)).
The Health Act makes the patient a holder of rights: a patient is any person who has sought or is receiving medical care (Art. 84(1)); care is provided without discrimination (Art. 85); the patient has rights to accessible, quality care, more than one opinion, protection of health data, clear information, prevention of pain and access to the record (Art. 86(1)); complaints go to the Regional Health Inspectorate, which checks them within 7 days (Art. 93); and the patient must also care for his own health and not harm others (Art. 94).
Under the Act on the Professional Organisations of Physicians and Dentists (1998), every practising physician is a member of the Bulgarian Medical Association (BMA) and entered in the register of a regional college. The BMA drafts the Code of Professional Ethics and controls its observance. Complaints are examined by the ethics commission of the regional college (Art. 39), and the penal decree is issued by the chair of the college’s board (Art. 40(3)). The sanctions are a reprimand, a fine of one to five minimum monthly wages, or removal from the register for 3 months to 1 year (Art. 38) — without excluding criminal, civil or labour-disciplinary liability (Art. 42(1)). The Code itself (State Gazette 79/2000, amended 85/2013) obliges every physician to give emergency care when health and life are in immediate danger (Art. 11), forbids procedures without consent except under immediate threat to life (Art. 26 — read with Health Act Arts 87–90), requires the physician to explain the prognosis without treatment when a patient refuses (Art. 29), forbids ending a patient’s life (Art. 30) and allows refusal on conscience to terminate a normal pregnancy (Art. 32).
One act can therefore bring four kinds of liability — disciplinary (towards the employer, under the Labour Code), administrative (including BMA sanctions and inspection by the Regional Health Inspectorate), criminal (for example negligent bodily harm or death in the exercise of a profession) and civil (contractual or tort damages). In Bulgaria the core of medical ethics is codified and its breach has legal consequences — but meeting the legal minimum is not the same as being a good doctor.
How to analyse a case
The eight-step method runs: facts (medical, the patient’s values, context, conflicts of interest, applicable law); the ethical question, formulated from the decision-maker’s position; stakeholders; principles and duties in tension; options — more than two, including a compromise, a time-limited trial, a second opinion or ethics consultation; weighing; decision and justification; and communication and review. Avoid three errors: treating ethics as arithmetic, letting one principle win automatically (the “autonomy trap” or the “paternalist trap”), and confusing “legal” with “ethical”. The four-box method of Jonsen, Siegler and Winslade organises the same facts into medical indications, patient preferences, quality of life and contextual features.
The worked example is an adult Jehovah’s Witness with capacity who is bleeding after surgery and refuses blood. A capable adult may refuse at any time (Health Act, Art. 90(1)); the refusal is documented with signatures (Art. 90(2)); the team uses the options the patient accepts and does not abandon him. A clear, specific and current refusal must be protected — urgency alone does not cancel autonomy (Pindo Mulla v. Spain, ECtHR Grand Chamber, 2024). Where refusal and a threat to life coincide, the head of the establishment may decide on life-saving treatment (Art. 90(4)) — a different situation from a patient who cannot consent (Art. 89(2)), analysed in Class 2. The class ends with three cases: a son who asks the GP not to tell his mother about her diagnosis, the last intensive-care bed for an 82-year-old and a 45-year-old, and a double antibiotic dose that caused no established harm.
Before opening the student tasks, try to answer in three sentences: why a signature on a consent form after an explanation the patient did not understand is neither legal nor ethical; what “prima facie” means; and who examines a complaint that a physician breached the Code of Professional Ethics.