HEALTHCARE & MEDICAL ETHICS CMG Healthcare Conference, 30/11/2017 Dr Noreen O’Carroll RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn HEALTHCARE & MEDICAL ETHICS

OUTLINE Ethical reasoning in healthcare The Four Principles’ method for ethical decision-making The BMA’s approach to ethical problems The Principle of Double Effect and end-of-life care decisions Ethical practice in healthcare

TYPOLOGY OF ETHICAL ISSUES With-holding & with-drawing treatment Consent / Refusal Confiden-tiality Disclosing errors With-holding & with-drawing treatment PAS & Euthanasia DNARs Allocating resources Capacity

ETHICAL REASONING IN HEALTHCARE "The ethical aspects of clinical care and decision-making need to be explicit and reasons have to be given for the decisions taken. This is as true of the ethical as of the scientific aspects of clinical care.”

THE VALUE OF ETHICAL REASONING INTELLECTUAL & ETHICAL AUTHORITY Ethical reasoning gives clinical judgements the intellectual & ethical authority they lack when they emanate from mere opinion or feeling. NEW PERSPECTIVES Ethical reasoning opens up new perspectives on dilemmas, enabling one to follow arguments wherever they take one.

THE FOUR PRINCIPLES METHOD SPECIFICATION: narrowing the scope of abstract principles by the addition of content from a specific case. BALANCING: the process of finding reasons about which moral norms should prevail. Respect for Autonomy DECISION Beneficence Nonmaleficence Justice

Respect for Autonomy Beneficence

THE BMA METHOD 1. Recognise the situation as one that raises an ethical issue 2. Break the dilemma down to its component parts 3. Seek additional information, including the patient’s viewpoint 4. Identify any relevant legal or professional guidance YES Is the issue resolved? NO 5. Subject the dilemma to critical analysis YES Is the issue resolved? NO 6. Be able to justify your decision with sound arguments If there is an unresolvable conflict or the law is unclear, it may be necessary to seek a court declaration

Is ethical decision-making simply ‘reason-giving’, i. e Is ethical decision-making simply ‘reason-giving’, i.e., giving reasons to justify one’s decision to act in a particular situation one is facing, having considered and calculated the reasons for and against? Or are there some actions that are always wrong in themselves and so admit of no exceptions?

THE PRINCIPLE OF DOUBLE EFFECT ATTEMPTS TO DISTINGUISH between ethical and unethical acts. ACKNOWLEDGES that in complex cases an action can have two effects: one good & one bad. ACCEPTS that some acts are always wrong in themselves, e.g. perjury, paedophilia, the direct killing of the innocent

BASIC TENET OF PRINCIPLE OF DOUBLE EFFECT ACTION GOOD EFFECT Intended BAD EFFECT Foreseen There is a real moral distinction between intention & foresight.

PRINCIPLE OF DOUBLE EFFECT Four conditions re moral permissibility NATURE OF THE ACT: It must be good in itself. INTENTION OF THE AGENT: To produce the good effect, though the bad effect may be foreseen. DISTINCTION BETWEEN MEANS & EFFECTS: The bad effect cannot not the means to the good effect. PROPORTIONALITY: The good effect must outweigh the bad effect & there must be a sufficiently grave reason to permit the bad effect.

THE CASE OF DR COX* Lillian Boyes was a 70-year-old woman with very severe rheumatoid arthritis, the pain of which seemed to be beyond the reach of analgesics. She was expected to die within a matter of days or weeks. She asked her doctor, Dr. Cox, to kill her. Out of compassion for his patient, and because this is what she wanted him to do, Dr. Cox injected a lethal dose of potassium chloride. *R. v Cox 1992, summarised in Hope T, Savulescu J, Hendrick J, Medical Ethics and Law (2008) 2nd ed. Churchill Livingstone/Elsevier, p. 181.

October 2017 Noel Conway, 67, who suffers from motor neurone disease, lost his High Court challenge against the law on assisted dying in the UK.

Brittany Maynard 2014 Brittany died in Oregon, USA on 1/11/2014 by taking lethal medication prescribed legally by a doctor. She had been diagnosed with a glioblastoma and told that she had six months to live.

2013: Marie Fleming challenged the constitutionality of the ban on assisted suicide in Ireland. The High Court & Supreme Court ruled against her. Marie died on 20/12/2013.

Marc and Eddy Verbessem 2013 The twin brothers who had congenital deafness and were beginning to go blind, died by legal voluntary euthanasia in Belgium.

27th October 2017 WORLD MEDICAL ASSOCIATION “The WMA and its national member medical associations, which include the Australian Medical Association, have strongly reiterated their long-standing opposition to physician assisted suicide and euthanasia on the basis that they constitute the unethical practice of medicine.” https://www.wma.net/

ETHICAL PRACTICE IN HEALTHCARE ETHICS Is ethical decision-making only about giving reasons for or against certain kinds of choices & actions? RIGHT & WRONG Are some actions wrong in themselves and can never be the means used to achieve a good effect? E.g., Prescribing medication to a patient to take his/her own life The direct intentional killing of a patient HEALTH CARE How does this impact on ethical practice in healthcare?

RECOMMENDED READING Beauchamp T L & Childress, J F, Principles of Biomedical Ethics. 7th edition. Oxford University Press, 2013. BMA, ‘Bridging the gap between theory and practice: the BMA’s approach to medical ethics’ in Medical Ethics Today: The BMA’s Handbook of Ethics and Law. Third edition. (Wiley-Blackwell, BMJ|Books, 2012): 13-19. BioEdge, https://www.bioedge.org/ Pellegrino, Edmund D., ‘The Lived Experience of Human Dignity’ in Human Dignity and Bioethics. Edited by Edmund D Pellegrino, Adam Schulman, and Thomas W. Merrill. (University of Notre Dame Press, 2009): 513-539.   Woodward P A, editor. The Doctrine of Double Effect: Philosophers Debate Controversial Moral Principle. University of Notre Dame Press, 2001. World Medical Association, https://www.wma.net/ Declaration on End-of-Life Medical Care, 2011. Statement on Physician-Assisted Suicide, 1992 and reaffirmed 2015 & 2017. Resolution on Euthanasia, 2002 and reafirmed 2015 & 2017. World Medical Association reiterates strong opposition to physician assisted suicide and to Australian Bill, 27th October 2017