Evidence-based bioethics: delineating the connections between science, practice, and values in medicine

The origins of bioethics, self-defined as “science of survival”, are diverse (1). They can be traced back to the Code of Hammurabi (1754 B.C.), which introduced specific rules and drastic penalties for physicians in the cases of therapeutic failure. Using a connection between responsibility for a medical intervention (rules 215-225) and measurable outcome, the Code represents an early attempt to establish strict behavioral guidelines: “If a physician make a large incision with the operating knife, and kill him, or open a tumor with the operating knife, and cut out the eye, his hands shall be cut off” (2). There is a significant difference between the evidence collected to make a value judgment for a particular case and the evidence that serves in the process of testing a certain hypothesis about the nature of things (3). The Judgment of Solomon represents the model and the case for a peculiar bioethical method and approach in a “life-or-death situation” decision-making. When King Solomon of Israel was called to make a judgment regarding two women who both claimed to be the mother of a child, he employed a wise and intuitive method. He was tricking the “mothers” into revealing their true feelings. From a bioethical point of view, his task was to distinguish the right outcome from the wrong outcome without any empirical evidence. The episode has become an example of a middle ground argument (argumentum ad temperantiam), where an impartial judge displays wisdom in making a decision. Solomon was collecting evidence with a non-standard, non-epidemiological method for informed decision making. The Case of Re A (Separation of Conjoined Twins and a decision of the Court of Appeal of England and Wales) likewise demonstrates the complexity of bioethical decision-making (4). The Hippocratic Oath (500 B.C.E.) marks the beginning of Western ethical reasoning and decision-making in medicine. However, the well-known phrase “primum non nocere” (first, do no harm), which became the binding ethical rule of the utmost importance is not in the Hippocratic Oath. It comes from The History of Epidemics, which is part of the Hippocratic corpus (5). The same applies to the well-known principles of non-maleficence and beneficence “salus aegroti suprema lex” (well-being of the patient is the most important law).