An Introduction to Medical Ethics

Dr. Philip S.L. BehEmail: philipbeh@pathology.hku.hk

What is ethics?

Why is there a need to talk about ethics?

Overview of this lecture

An overview of ethical theoriesAn overview of rightsFour principles of medical ethicsRecognition of conflictsAnalysis of dilemmas and conflicts using the four principles.

Ethical theories

There are many ethical theories and even more ethical philosophers.Two major strands can be simplified as:-

Concern for the right act (Deontological)Concern for the consequence (Teleological)

Human Cloning

“Is wrong and should be absolutely prohibited, as this is playing God.”

(Deontological)

“Can save many lives and should therefore be supported.”

(Teleological)

Deontological ethics (Rights)Based on natural law and divine command e.g.

like the laws of gravity – such natural rights are “built into the universe”.

Based on common humanity e.g. all human beings have rights simply by virtue of being “human”.

Based on rationality e.g. people who are capable of rational, autonomous thought are entitled to claim moral rights.

Based on interests e.g. To claim rights meaningfully, one must have interests.

Different “Rights”

Inalienable rights – cannot be transferred e.g. “the right to life”Absolute right – cannot be overridden by any circumstancesPrima facie rights – rights which may be overriden by stronger moral claims

Inalienable right

Example – A right to lifeIn such a situation suicide or martyrdom would be condemned as morally wrong.A mother who sacrificed her life for her child would be similarly condemned.

Absolute right

Example – A right to lifeIf this is so, the taking of life is always wrong, be it war, in self-defense, capital punishment or abortion

Prima facie right

Example – A right to privacy would be overridden by a right to life in an emergency.

Rights and duties

Having a right requires a corresponding duty to respect that right.Generally such claims imposes a “duty to act”

Problems with rights

Rights and interests can compete and conflict with one anotherDifficult to establish the extent a right entails a corresponding dutyDisagreements on who/what have rightsDifficult to satisfy the rights claims of all

Moral Duty

A moral duty is an act that a person ought to do. Contrast with legal duty, civil duty, professional duty, etc.

Moral principles

Specify that some type of action or conduct is either prohibited, required or permitted in certain circumstancesMoral principles commonly used in medical practice are:-

AutonomyNon maleficenceBeneficenceJustice

Four basic moral principles

AutonomyNon maleficence (Do no harm)Benficence (Do good)Justice

Autonomy

A person’s ability to make or exercise self-determining choicesA person should be free to choose and entitled to act on their preferences provided their decisions and actions do not violate or impinge on the significant moral interests of others.

Example

In your opinion, a patient needs surgery.The patient however can refuse and their refusal has to be respected.This right to autonomy (self-determination) underpins the medicolegal understanding of INFORMED CONSENT.

Against the principle of autonomy

Treating patients without their consentTreating patients without giving them all the relevant information necessary for making an informed and intelligent choice (informed consent)Telling patient “white lies”.Witholding information from patients when they have expressed a reflective choice to receive it.Forcing information on a patient when they have expressed a reflective choice not to receive it.Forcing anyone to act against their reasoned moral judgment or conscience.

Non Maleficence (Do No Harm)

Above all, do no harm.Stringent duty not to injure others

Example

You have a terminal patient and you feel you can no longer offer him anything that could cure him.He heard that the taking of arsenic may cure him and asked you to give him arsenicArsenic is a poison.

Against the principle of non-maleficence

Sawing off someone’s good leg.Operating on someone who did not have appendicitisPuncturing the heart whilst doing a bone marrow aspiration

Beneficence (Do good)

Provision of benefitsPreventing and removing harm

If an act does not bestow benefit or fails to address an imbalance of harms over benefits, the act could rightly be condemned.

Example

A patient cut his fingers on a machine. He had loss a lot of blood.You gave him a matched blood-transfusionYou stopped the bleeding and repaired the wounds on his hand.

Against beneficence

Refusing to provide treatmentRefusing to help an accident victimRefusing to help a prisoner or a suspect of crime

What is Justice?

No common agreementRetributive justice – “an eye for an eye”Justice as mercyJustice as harmony in the soulJustice as equalityJustice as what is deservedJustice as love

Justice

PracticallyJustice as fairness• What is deserved

Justice as equality (distributive justice)• All are required to bear an equal share of

society’s burdens and benefits • All patients have a right to your best

diagnosis and treatment.

Against justice

Favouring one patient over anotherSenior and experienced doctors treats private patients only.

Conflicts

It is not uncommon that in every day clinical practice you will encounter situations where even the four basic principles are in conflict.There is no simple answer and each case must be considered and weighed.Seek help and discuss the issues with colleagues.

Conflicts

During the delivery of a baby, problems develop and you are faced with a choice.

The mother or the child?Whose autonomy prevails?Non-maleficience (but to whom?)Beneficence (to whom?)Justice (to whom?)

Conflicts

If the mother said – “save the baby”Does this resolve your conflicts?Is the mother’s autonomy absolute?Is non-maleficience physical, psychological or holistic?

Conflicts

A baby is born anencephalic (no brain matter). Is there autonomy?What about beneficence?What about non-maleficience?What about justice?

Conflicts

The anencephalic baby develops a chest infection.Do you treat with antibiotics?AutonomyNon-maleficienceBeneficenceJustice

A young teenage mother who was a victim of rape came to the hospital for an abortion.

What will you do?What moral principles?

Ethical Dilemma (1)

The abortion was performed but the abortus was “alive”.

What will you do?What moral principles?

Ethical Dilemma (2)

A patient is admitted into hospital in coma and requires resuscitation and respirator and ICU care.

What will you do?What moral principles?

The patient is moved into the ICU, but it soon becomes clear his liver is completely damaged. The cause of his liver failure was chronic alcoholism.

What do you do?What ethical principles?

His family begs you to keep him alive by whatever means. A victim of a car accident has just arrived at the hospital and needs an ICU bed. There are no more ICU beds available.

What do you do?What moral principles?

The son of a colleague has come forward to offer part of his liver for a “live donor transplant”.

What would you do?What moral principles?

The victim of traffic accident dies, the family has agreed to donate his liver. There are however others on the waiting list. The cause of their liver failure were due to allergies to medication given by doctors.

What would you do?What moral principles?

Modern Medicine has brought new dilemmas and new conflicts.

ReferencesDoctors’ Decisions – Ethical Conflicts in Medical Practice – G.R. Dunstan & E.A. ShinebourneMoral Dilemmas in Modern Medicine – Michael LockwoodClassic Cases in Medical Ethics – Gregory E. PenceMedical Harm – Historical, Conceptual and Ethical Dimensions of Iatrogenic Illness – Virginia Sharpe & Alan I. FadenDemanding Medical Excellence – Doctors and Accountability in the Information Age

References

Ethics and Law for the Health Professionals – Kerridge L, Lowe M, McPhee J. - Social Science Press, 1998. (Australia)Principles of biomedical ethics – Beauchamp TL, Childress JF – Oxford University Press 1994The New Dictionary of Medical Ethics – Boyd KM, Higgs R, Pinching AJ – BML Publishing Group 1997