Medical ethics has a long history from the days of Hippocrates to the present. Ethics are dynamic and the same ethical principles are not necessarily followed the world over. Medical ethics will quickly become part of your life upon gaining a place at medical school but an appreciation of modern medical ethics is also a necessary tool at your medical school interview.
We provide an introduction to medical ethics and its basic principles to help start you on your journey.
The reason that we need medical ethics is not always obvious to the un-initiated. The author of this article considered himself to be a man of reasonable morality and believed initially that if you looked at a situation and then examined your conscience then you would know the right thing to do. A lot of world religions teach us ethical codes that are accepted as moral norms such as don’t steal, don’t kill, don’t be an adulterer, honour your parents etc. These ethical codes are accepted by most without question but unfortunately they are not encompassing enough when it comes to the world of medicine. Simply being of moral character does not provide enough frame-work for the doctor to know how to act and make appropriate decisions. Having a system of medical ethics that is widely accepted gives you a starting point for tackling the difficult dilemmas put forward by medicine. It is worth remembering that medical ethics is not just the domain for clinical trials but forms part of the daily life of every doctor.
Let us consider an example:
A 70 year old man is at the doctor’s clinic. He has an abdominal aortic aneurysm (AAA) (a widening of a blood vessel in the abdomen) which he has been told had a 10% chance of bursting per year and killing him almost instantly. He has been told that the surgeons can fix it but he has a 5% chance of dying during the procedure.
It can be seen here that there is no moral conflict. The patient wants to live and assuming moral norms the doctor will want the patient to live also. This still however leaves the ethical dilemma of whether or not the operation should be done. This is because the procedure carries an inherent risk associated with it, which cannot be fully mitigated against. Of course guidelines based on evidence are present to help advise when and where certain procedures should and shouldn’t be done. These guidelines however cannot cover every situation, will be generalized in nature and be considering the population as a whole rather than the individual. It becomes apparent that doctors need a framework for making ethical decisions in order that they can advise and treat their individual patients correctly.
Many great physicians and philosophers, such as Hippocrates, Aristotle and Immanuel Kant have tried to define a framework. Most western medicine follows the "four principles" approach put forward by Tom Beauchamp and James Childress in their book “Principles of biomedical ethics”. This is popularly becoming known as principlism. This system of ethics follows four main principles which can be applied to biomedical ethics:
1. Non-maleficence - “do no harm”
Non-Maleficence is the aim of not inflicting harm on others. Harm in medicine usually refers to physical or psychological harm. There was a similar statement in the Hippocratic oath. This is often a tricky concept for medical doctors because certainly some of our procedures have harm as a foreseen side effect, yet we still do the procedures.
If we look at the man in our example above, the surgeons have stated death as a possible outcome. Also we have not mentioned the fact that he could feel quite sick and ill from the anaesthetic and may suffer pain from the surgery, so how is this acceptable? A way of trying to specify the principle is that an action may be seen to have two effects, one good and one harmful, which in the case of our gentleman may be weighed up as a good improvement in lifespan versus death. In this case the surgeons may do the operation with the intended effect of extending the patient life but with the foreseen but unintended risk of death during the operation. Under these circumstances it may be seen as morally appropriate to proceed with the operation. This is sometimes called the “Rule of Double Effect”. Essentially we are striking a balance between non-maleficence and beneficence here and this becomes part of the daily routine of a doctor. Even with things that may seem trivial such as an x-ray, the doctor should be thinking whether the harm being done by the radiation is justified.
Beneficence is a principle that says that our actions should contribute to or improve our patients’ welfare. It is closely linked with non-maleficence and there is not a sharp cut-off between the two principles since lots of medical interventions are both beneficial but carry some risk or side effect that may be detrimental. In certain ethical systems non-maleficence and beneficence are one ethical principle covering a spectrum between doing no harm and doing only good. The principle of beneficence sounds easy since most of us want to do the right thing for our patients and improve their health outcomes, so where is the difficulty? In the case of our man with the AAA, it seems obvious that the operation gives him a 95% chance of extending his life and this is obviously beneficial. We have discussed balancing this against non-maleficence but suppose I now add to the scenario an advance in medicine that offers an alternative procedure that fixes the AAA but with only a 1% death rate. The trouble is that the new procedure costs 10 times as much. This suggests that at some point we have to put a constraint on beneficence as we are limited by practical constraints such as cost, time and number of doctors. In the end our medical resources are finite and we have to bring about the results for the population as a whole meaning that not every treatment may be offered. There is often controversy in the news where very expensive drugs that would benefit people with rare conditions are not offered on the NHS in the UK or on private insurances in America because they do not provide the best population health outcomes. This leads well into the next ethical principle which is Justice.
The concept of Justice relates to fairness. The formal principle of justice is often attributed to Aristotle who is alleged to have said “Equals must be treated equally and unequals must be treated unequally”. This takes a bit of getting your head around to start with but essentially it means that not everybody in society needs to be treated the same but we must treat people of a similar demographic in the same way. An example of this could go back to our poor old gentleman with his triple AAA and the now two methods of treatment that are available to him. It would not be considered justice if he were offered the first procedure if he lived in one part of the country but the safer procedure if he lived in another area. This would not be seen as a justice seeing as the man is being discriminated against based on where he lives. There have been many cases in the news in the UK talking about access to cancer therapies being a “Postcode Lottery” with the general public perceiving this as unfair. It may also be possible that the NHS could offer both procedures and this still fits the criteria for justice. Imagine that instead of being 70, our man with the AAA is now 60, very fit, still working and runs half marathons, he could be looking at 40 years more life with the procedure and it may make sense to use funding for the more expensive procedure. Now we propose the converse that instead of being 60, our man is 92, still smoking and although fit enough for the operation is generally of low mobility, then it may make sense to treat him with the cheaper operation so that you have more money left to serve other people. This is not going against the principle of justice because you are saying that the situation of the two patients is different. The term justice also covers the point of distributive justice. It is the concept of medicine that refers to how we spend our finite money. As can be seen from our earlier discussions on beneficence, difficult decisions on what treatments are and aren’t provided in healthcare are required.
4. Respect for Autonomy
This ethical principle relates to the autonomous choices that an individual can make. It comes from the Greek and literally means self-rule or self-governance. It is a concept that is relatively modern and until recently there was often a paternalistic approach with “Dr knows best” and the patients put their lives in the doctors’ hands. Some of your patients still often ask for this approach and will ask you to take the decision, or your opinion and we must be careful to make sure that we respect their autonomy. With respect to our gentleman with his AAA, a doctor cannot tell him whether or not to have his operation or not, but merely point out the facts which would include details of the procedure, intended benefits of the procedure, foreseeable risks of the procedure and any other information that the patient may find relevant to his procedure such as recovery times, length of stay in hospital etc. It is the job of the doctor to provide the information such that the patient can make a balanced informed decision as to whether they consent to the procedure or not. It is also the responsibility of the doctor to present the information in a way and at a level that the patient understands. The patient has not made an autonomous decision if they did not understand what was happening. Problems with autonomy occur when we do not believe that the patient has the mental capacity to make an informed autonomous decision. Great care is taken in medicine in establishing whether or not someone has mental capacity and it must be remembered that certain disease processes can impact on capacity such as delirium, dementia and neurological disease. In returning to our example in this instance I think autonomy forms the crux of the ethical debate for this gentleman. The surgeons have offered to do the operation with the intended benefit of prolonging his life. They have also pointed out the possibility for unintended harm in the operation. We can assume that since the operation has been offered there is some form of distributive justice, which allows for this treatment to be paid for in some national health systems. This leaves it in the hands of the patient to make an autonomous decision as to whether he finds the 5% risk of dying as a suitable trade of for likely extending his life by several years. This is a decision that must be taken autonomously by him since the 5% risk will represent an acceptable risk to some and an unacceptable risk to others. Autonomy also allows the patient to follow there own cultural, religious and spiritual beliefs with regards to treatment.
When applying to medical school, you will be asked about an ethical situation or ethical dilemma at almost all your interviews, in most countries. If you can show an understanding of modern medical ethics and how the four principles may apply, then you will be in good shape.
Some scenarios to consider may be:
1) The withdrawal of ventilation in the dying patient.
2) The treatment of patients with self-inflicted disease
3) Termination of pregnancy.
4) The management and treatment of people with dementia.
5) The use of highly expensive treatments in rare disease.
6) The use of animals in clinical trials.
7) The use of humans in clinical trials.
9) Should we be carrying out bariatric surgery?
10) Should doctors ever go on strike?