Applied medical ethics Dr. Deepthi Edussuriya

A man without ethics is a wild beast loose upon this world Albert Camus

At the end of this lesson you should be able to… ….solve ethical dilemmas, using a framework for making good ethical decisions, in order to obtain the best possible outcome

How do we make decisions? Gut reaction/feelings - personal/emotional - tends to be one of 2 things - not bad as it informs us of how our community might react - feelings may tell us not to do the right thing if it is hard Religion - advocate high ethical standards - may not address all types of problems we face

Culturally accepted norms cultures can become corrupt -or blind to certain ethical concerns (USA to slavery) Science just because something is scientifically or technologically possible, it may not be ethical

Rule obedience - tell us how to react to things - one rule fits all approach might be unethical as it fails to consider the specific interests of those involved - can become ethically corrupt, designed to serve the interests of narrow groups - difficulty in designing/enforcing - slow to address new problems

Guidelines - tells us how we are expected to react - decision based on reflection/reasoning - more than one perspective - made to ensure good practice - guidelines issued by medical professional bodies should always be considered - since guidelines may change in the light of experience/new evidence it is necessary to be aware of any changes

A framework for making good ethical decisions is necessary because… ethical decision making is a skill a skill needs to be practiced when practiced regularly, the method becomes so familiar that we work through it automatically without consulting the specific steps

The framework Recognition of an Ethical Issue Get the Facts Evaluate alternative actions Make a Decision and Test It Act and Reflect on the Outcome

Making good ethical Decisions requires… Recognition of an Ethical Issue A clue that an action or situation needs an ethical rather than simply a business judgment is that the action/situation could - be damaging to someone - violate what is generally consider right/good - be more than what is legal/most efficient

Get the Facts - What are the relevant facts of the case? What facts are not known? Can I learn more about the situation? Do I know enough to make a decision? - What individuals and groups have an important stake in the outcome? Are some concerns more important? Why? - What are the options for acting? Have all the relevant persons and groups been consulted? Have I identified creative options?

Evaluate alternative actions by asking the following questions: - Which option will produce the most good and do the least harm? (Utilitarian Approach) - Which option best respects the rights of all who have a stake? (Rights Approach) - Which option treats people equally or proportionately? (Justice Approach) - Which option best serves the community as a whole, not just some members? (Common Good Approach) - Which option leads me to act as the sort of person I want to be? (Virtue Approach)

Make a Decision and Test It - Considering all approaches, which option best addresses the situation? - If I told someone I respect of the option I have chosen, what would they say? Act and Reflect on the Outcome - How can my decision be implemented with the greatest care/attention to concerns of all stakeholders? - How did my decision turn out and what have I learned from this specific event

Approaches to making ethical decisions Utilitarian Approach Common Good Approach Deontological approach Rights Approach Casuist approach Fairness/Justice Approach Virtue Approach Putting the Approaches Together

Utilitarian theory the choice that yields the greatest benefit to the most people is the choice that is ethically correct founded on the ability to predict the consequences of an action provides a logical and rationale argument for each decision and allows a person to use it on a case-by-case context

Example A baby born prematurely at 24 weeks gestation is put in intensive care. However she is not thriving and scans suggest she has profound brain damage. She cannot breathe unassisted and the care team believe she is suffering and it is not in her interest to keep her alive. The parents do not agree. What should the clinician do?

Utilitarian Greater benefit to more people if life terminated as the medical staff and facilities will be freed even at the expense of the parents happiness

Flaws Based on predicting the future. No human being can be certain that his predictions will be true and this uncertainty can lead to unexpected results Necessity to compare the various types of consequences against each other on a similar scale. Eg., money vs happiness Not always concerned with justice/ beneficence/autonomy for an individual, if oppressing the individual leads to the solution that benefits a majority of people.

Possibility of conflicting benefits/risks What is ethically right for a surgeon who is running late for his list? - to drive breaking traffic rules to arrive at his surgical list on time because the fasting patients benefit from this decision - follow the traffic law because this benefits an entire society A group for whom there is a risk of harm may not be the group likely to receive any benefit - clinical research trials.

Common good approach

Ideal derived from utilitarianism Community members are bound by the pursuit of common values and goals (Affordable healthcare, Unpolluted environment)

Flaws Individualism (Individual freedom goals & interests “Free-rider problem” Available to everyone even those who don’t do their part. Therefore if more free riders common good will be destroyed Pluralistic society Different people have different ideas. Impossible to agree on one social system.

Deontological theory States that people should adhere to their obligations and duties when analyzing an ethical dilemma A person who follows this theory will produce very consistent decisions since they will be based on the individual's set duties

Flaws… No rationale for deciding an individual's duties. Eg., an MOH may decide that it is his duty to always be on time to meetings. What is the rationale for this? Not to keep others waiting or to the fact that he has to always sit in the same chair Does not provide guidance when there are conflicting obligations Eg., a person who must be on time to meetings is running late, how is he supposed to drive? Is he supposed to speed, breaking his duty to society to uphold the law, or is he supposed to arrive at his meeting late, breaking his duty to be on time?

Is lying right or wrong? Utilitarian/Consequentialist may argue that lying is wrong because of the negative consequences produced by lying. However a consequentialist may allow that certain foreseeable consequences might make lying acceptable A deontologist might argue that lying is always wrong, regardless of any potential "good" that might come from lying

Casuist theory Compares a current ethical dilemma with similar ethical dilemmas and their outcomes Allows to determine the severity of the situation and to create the best possible solution according to others' experiences

Flaws There may not be a set of similar examples for a given ethical dilemma. eg., is new and unexpected Assumes that the results of the current ethical dilemma will be similar to results of the previous experience

Rights theory

Human rights of the individuals set forth by society are protected and given the highest priority Rights are considered to be ethically correct and valid since a large or ruling population endorses them Examples of Rights to be adhered to : - right to the truth/privacy/not to be injured/what is agreed 

Example A couple with primary subfertility were tested for STD before assisted reproduction. The man was diagnosed with STD. He requested their doctor not to disclose his diagnosis to a third party including his wife. He even threatened with suicidal intention and denial of treatment. How should the doctor deal with this situation?

Flaws Conflicting rights Right to privacy vs right to truth Duty vs right

Fairness & Justice Approach

Everybody needs to be treated equally Everybody needs to be treated equally. If individuals, can’t be treated equally then they need to be treated properly based on some criteria/standard. This means that the communities or people affected by your decisions can’t be favoured or benefit from an unfair advantage.

Virtue theory

Act after judging a person by his character rather than by an action that may deviate from his normal behavior It takes the person's morals, reputation and motivation into account when rating an unusual and irregular behavior that is considered unethical.

Example A person plagiarized a passage that was detected by a peer The judgment will be based on whether the plagiarizer normally follows the rules and has good standing amongst his colleagues, if so the peer may judge his friend more leniently. (Perhaps the researcher had a late night and simply forgot to credit his or her source appropriately). Conversely, a person who has a reputation for scientific misconduct is more likely to be judged harshly

Flaws Does not take into consideration a person's change in moral character. Eg.,, a scientist who may have made mistakes in the past may honestly have the same late night story as the scientist in good standing. Neither of these scientists intentionally plagiarized, but the act was still committed. On the other hand, a researcher may have a sudden change from moral to immoral character may go unnoticed until a significant amount of evidence mounts up against him or her

Decision-making process Although all of the ethical theories attempt to follow the ethical principles in order to be applicable and valid by themselves, each theory falls short with complex flaws and failings. However, these ethical theories can be used in combination in order to obtain the most ethically correct answer possible for each scenario.

a utilitarian may use the casuistic theory and compare similar a utilitarian may use the casuistic theory and compare similar situations to his real life situation in order to determine the choice that will benefit the most people. - the deontologist and the utilitarian who are running late for their list may use the rights ethical theory when deciding whether or not to speed to make it to hospital in time. Instead of speeding, they would slow down because the law in the rights theory is given the highest priority, even if it means that the most people may not benefit from the decision to drive the speed limit.

Ethics is knowing the difference between what you have a right to do and what is right to do