Introduction to Medical Ethics

What are medical ethics? Ethics and morals interchangeable but ethics implies a professional context It is about making decisions, deciding priorities in healthcare A complex field, not black and white People will have different views and values, so important to use ethical reasoning responsibly, with integrity

Different models/concepts Beauchamp’s 4 principles Deontology Consequentialism or utilitarianism Virtue ethics A hypothetical scenario to illustrate how decisions might be difficult You are standing next to some railway points; a runaway train if not stopped will crash into a group of 4 people. If you pull the lever and redirect the train, the train will still crash but kill just one person.

Beauchamp’s 4 ethical principles Beneficence The obligation to do good, to provide benefits, balanced against risks Non-maleficence The obligation to avoid doing harm Respect for autonomy Respect the decision-making capacity of autonomous persons Justice Obligations of fairness in distribution of benefits and risks

Comments of the 4 principles Each principle is binding but they may conflict with eachother Each principle is open to interpretation What is justice? Is it about punishment/retribution? Is it about being fair? Should fair distribution be according to rights? Or what someone deserves? Or what someone needs? Needs seems most appropriate, equally, without discrimination. QALYs: quality-adjusted life years: tries to quantify the quality of life, compare treatments, allocate resources; makes judgements explicit

Deontology This is the study of duty; famous proponent was Immanuel Kant We should act according to duty, regardless of outcome. Duties may conflict e.g. preserving confidentiality and reporting crime Purist ideology whereby you act in a way that you would wish everyone to act; but not in your own interests unless everyone is treated the same way. Can be inflexible and weakness is the disregard of consequences.

Utilitarianism Assesses actions according to whether benefits outweigh disadvantages Famous proponent was Jeremy Bentham who talked of “ the greatest good, or greatest happiness, of the greatest number.” Results or outcomes are what matters most: the end justifies the means. Distinction from deontology. One should sacrifice self-interest if that will bring about an increase in the general good. At one extreme, you might shoot old people if that brought about more resources for a greater number of younger people. Overall benefit often has an unequal distribution and sacrifices some for the benefit of others.

Virtue Ethics This is about doing the right thing. It is what a virtuous person would do in the same circumstances. It is person-based rather than action-based About the virtue or moral character of the person more than the action or the outcome It doesn’t give clear guidance on what to do when faced with a difficult dilemma and virtues can vary according to time, place, culture, such as prudence, bravery, temperance. Less helpful to us, perhaps?

The Ethical Grid: Seedhouse A comprehensive tool to help us when faced with an ethical dilemma in healthcare 4 different layers: A blue central layer that considers core principles of health care A red layer that considers duties or moral obligations (deontology) A green layer that considers consequences (utilitarianism) An outer black layer that considers external considerations. Use each layer so that a decision takes account of a full range of factors.

The Blue layer: core principles in healthcare Create autonomy: autonomy can be thought of as a human quality of being able to act, to flourish, to live life without impediments. Mending a broken leg or treating depression allows someone to go and live and fulfil their potential. Respect autonomy: autonomy is also about the principle that someone has the right to make decisions about themselves; it also requires him to be informed adequately so that consent is informed. Denying a sticky bun to a child may not respect their autonomy in one sense but the parent may actually create autonomy by allowing them to be fitter and healthier These principles may conflict with each other; respecting autonomy usually over-rides creating autonomy unless it harms others.

Blue layer: core principles in health care Respecting people equally Not to do so implies discrimination Serve needs first This follows from basic needs of food and shelter but also means people should have a treatment even though some might consider that they don’t deserve it, such as the patient who smokes or does something else to harm their health; prisoners should receive treatment by the same principle At least one blue box should be used when deliberating about health decisions.

Red Layer: Duties or moral obligations Beneficence: do the most positive good Non-maleficence: minimise harm Keep promises: this equates to confidentiality as to breach confidentiality is to break an implied promise by doctors to their patients. It is, however, also a professional code of practice and also appears in the outer black layer of external considerations Tell the truth There are other important duties but these seem most relevant to health care. The first two might have been considered core principles in health care in the blue layer?

Green layer: consequences This layer makes us consider consequences of decisions and who is the patient. A doctor might view the individual patient as the main focus whereas a health visitor or social worker might focus on the family as a whole. This is very relevant with regard to allocation of resources as an expensive treatment for one individual may reduce funding options for a wider group. The 4 boxes in the green layer are: most beneficial outcome for the individual; most beneficial outcome for a particular group, most beneficial outcome for society and most beneficial outcome for oneself.

Black layer: external considerations. Obvious considerations include the law and professional codes of practice, such as GMC guidance. Other considerations are the effectiveness and efficiency of the proposed intervention, the risks of the intervention, the resources available. Others are issue of disputed facts/evidence or degree of certainty of the evidence, and the wishes of others.

How to use the ethical grid? The ethical grid is a tool, like a screwdriver is a tool. The user has the responsibility to use it wisely and with integrity. First consider the issue and state the proposed intervention or hypothesis. Try and come to an initial position intuitively, listing pros and cons. Then use the grid to challenge your position, not to support it. Try to involve others as this may enhance the quality of the decision- making Use every layer of the grid but not every box within each layer will be relevant. The grid enable a careful and comprehensive analysis and challenge to your original position