Medical ethics

Lesson Plan Aims and Objectives: To define medical ethics To list and describe the main theories and principles of medical ethics To provide examples of ethical clinical practice

Medical Ethics is the study of moral values and judgments as they apply to medicine. Ethical principles heavily govern the practice of medicine^[1][2]and ethical theories form the basis of ethical argument. With high profile cases regarding malpractice of doctors and the recent medical advances in technology, more and more clinical practices are coming under the scrutiny of both the media and the general public. For example, hand-washing was once a common courtesy, but now it could be deemed unethical to not do so. This is a result of the discovery of "superbugs" (e.g. MRSA), which are potentially fatal due to their resistance to available antibiotics,^[3]and the public demand for health services to improve their standards.

However, medical ethics is not an exact science. In certain situations it may be difficult to know what is ethically "correct". Ethical debates commonly arise on medical wards; therefore, a comprehensive knowledge of medical ethics is paramount to deciding the best course of action.

Ethical theories can be seen as schools of thought when judging the rightness or wrongness of a proposed action or when choosing from a number of proposed actions. There are two main ethical theories that apply to medical practice:

• Consequentialism refers to those moral theories which hold that the consequences of a particular action form the basis for any valid moral judgement about that action.^[4]
• Deontology is an approach to ethics that focuses on the rightness or wrongness of actions themselves, as opposed to the rightness or wrongness of the consequences of those actions.^[5]

Clinical Example A doctor comes out of a room after witnessing a patient suffer a distressing death. The family approach the doctor and ask if he suffered. The doctor lies and says "He went peacefully". Consequentialist view - this eases the burden of the family at a distressing time. Deontologist view - lying is fundamentally wrong and the family are entitled to the truth.

The ethical principles that govern medical practice should act as a framework when making medical decisions. When ethical dilemmas arise the best approach is to think through these ethical principles logically and methodically.

Beneficence is the act of "doing good" while non-maleficence is the act of "not doing bad". In practical terms, medical practitioners have an ethical responsibility to strive to do what is in the best interests of their patients. However, it is important to remember that some medical interventions may seem beneficial but may also carry with them the possibility of causing harm. In fact, nearly all medical treatments and procedures, it could be argued, harm the patient in some way, but it is more to do with the magnitude of the benefit versus the magnitude of potential risks.^[6]

Clinical Example A doctor has diagnosed an elderly lady with rheumatoid arthritis and wants to prescribe an NSAID to relieve the pain and reduce the inflammation. - Beneficence However, he does not want the patient to develop gastrointestinal bleeding, a common side-effect of NSAIDs, especially in the elderly - Non-maleficence

Autonomy is the right of a patient to make an informed, uncoerced decision about their own health management. If this principle is disregarded by a medical professional because he/she believes another decision would be better for the patient, then it is termed paternalism. An autonomous decision should never be overruled by a medical professional, but not all decisions are autonomous. For patients to have autonomy, they must have the capacity to receive, retain and repeat the information that is given to them, provided the information is complete and given to them in a manner that they can understand.

Clinical Example A patient with breast cancer is told by her oncologist that there are two treatment options, a total mastectomy or a partial mastectomy with radiotherapy. The patient decides to have a total mastectomy - Autonomy An oncologist decides that a patient with breast cancer should receive a total mastectomy - Paternalism

Consent is an extension of autonomy and has many types. Implied consent is when a doctor assumes that certain actions or body language from a patient imply that the patient has consented to the planned action of the doctor. Expressed oral consent is when a patient has verbally given the doctor permission to proceed with the intended action. Expressed written consent is documented evidence that the patient has, usually with a signature, given consent to a procedure. Written consent should only be obtained after oral consent. Fully informed consent is consent given after being given all the information about the procedure. When possible, fully informed consent, both written and oral, should be obtained before any procedure, examination or treatment.^[7]

Clinical Example A patient with tonsillitis is in the ENT ward and a doctor approaches with a syringe. The patient stretches out her left arm in the direction of the doctor. The doctor takes a sample of her blood. - Implied Consent The doctor then asks if she can take the patient's blood pressure. The patient says yes. - Expressed oral consent Then the doctor asks the patient to consent for surgery by reading and signing a form consenting to a tonsillectomy after explaining to the patient the risks and benefits of the procedure. The patient reads and signs the document and expresses her wish to have the procedure. - Fully informed written and oral consent

The ethical principle of Truth-telling is the process in which a doctor gives the patient all known information about their health. It allows the patient to be fully-informed and, therefore, allows for the ethical principles of autonomy and consent. A point of note that always needs to be considered is the fact that some patients do not want the information. Therefore it is important to ask the patient if they want to know or not. The only other (extremely rare) occasion when it is acceptable not to tell the patient the truth is when the patient may come to harm when being told, e.g. "If you tell me I have cancer I will kill myself!".^[8]

The ethical principle of confidentiality ensures that the medical information held about a patient is accessible only to those to whom the patient has given access via autonomous and full-informed consent. In order to achieve trust between medical professionals and their patients, confidentiality must be maintained. Confidentiality may be broken if information shared by the patient refers to a potential danger to public safety or if it is ordered by a court.^[9]

Clinical Example A doctor informs a patient that he cannot drive because of his recent diagnosis of epilepsy. The patient agrees but, when driving to work one morning, the doctor sees the man driving. The doctor must inform the local driving authority due to concerns regarding public safety.

The ethical principle of preservation of life is a will to treat a patient's illness with the aim of prolonging life. After all, most patients want to live longer; most doctors may have joined the profession to save lives. This principle may be overruled if the patient has made a living will stating their desire not to be resuscitated.^[10]

Justice refers to the distribution of things and positions of people within society. In a medical setting, justice involves the allocation of health-care resources in a fair way. This may be an equal distribution (egalitarianism) or a maximization of the total or average welfare across the whole society (utilitarianism).^[11]

The Four Topic Method is a way to provide a framework in which the clinician faced with an ethical issue to analyze the case in an objective form. The Four topic Method developed by Jonsen, Siegler and Winslade in 1982 includes the following and are aligned with the ethical principles of Autonomy, Beneficence, Non-maleficence, Justice:

• Medical Indications ( Beneficence and Non-Maleficence)
• Patient Preferences ( Autonomy)
• Quality of Life (Beneficence, Non-Maleficence and Autonomy)
• Contextual Features ( Justice : Loyalty and Fairness)

Jonsen,A. R., Sieglar, M., Winslade, W.J,( 2012) Clinical Ethics: a practical approach to ethical decisions in medicine. McGraw-Hill: New York

Lesson Summary The ethical theories that apply to medicine are: Consequentialism Deontology The ethical principles that apply to medicine are: Beneficence Non-maleficence Autonomy Consent Truth-telling Confidentiality Preservation of life Justice

• Medical ethics/History
• Ethical medical research
• Bioethics
• Should suicide be legal?

1. ↑ http://gmc-uk.org
2. ↑ http://ama-assn.org
3. ↑ Soulsby EJ (2005). "Resistance to antimicrobials in humans and animals". BMJ 331 (7527): 1219–20. doi:10.1136/bmj.331.7527.1219. PMID 16308360. http://www.bmj.com/cgi/content/full/331/7527/1219. 
4. ↑ Mackie, J. L. (1977). Ethics: Inventing Right and Wrong. London: Penguin. 0-14-013558-8. 
5. ↑ Olson, Robert G. 1967. 'Deontological Ethics'. In Paul Edwards (ed.) The Encyclopedia of Philosophy. London: Collier Macmillan: 343.
6. ↑ R Gillon. Medical ethics: four principles plus attention to scope. BMJ 1994;309:184
7. ↑ M A Graber, J F Tansey. Autonomy, consent, and limiting healthcare costs. J Med Ethics 2005;31:424-426
8. ↑ D Kirklin. Truth telling, autonomy and the role of metaphor. Journal of Medical Ethics 2007;33:11-14; doi:10.1136/jme.2005.014993
9. ↑ Debashis Singh. Confidentiality, consent, and the media. student BMJ 2000;08:45-88 March ISSN 0966-6494
10. ↑ M C Samaan, M Cuttini, V Casotto, C A Ryan. Doctors’ and nurses’ attitudes towards neonatal ethical decision making in Ireland. Archives of Disease in Childhood - Fetal and Neonatal Edition 2008;93:F217-F221
11. ↑ P Nortvedt, R Pedersen, K H Grothe, M Nordhaug, M Kirkevold, A Slettebo, B S Brinchmann, and B Andersen Clinical prioritizations of healthcare for the aged--professional roles J. Med. Ethics, September 1, 2008; 34(5): 332 - 335.