An Introduction to Medical Ethics

1. An Introduction to Medical Ethics Dr. Philip S.L. Beh Email: philipbeh@pathology.hku.hk

2. What is ethics?

3. Why is there a need to talk about ethics?

4. Overview of this lecture • An overview of ethical theories • An overview of rights • Four principles of medical ethics • Recognition of conflicts • Analysis of dilemmas and conflicts using the four principles.

5. Ethical theories • There are many ethical theories and even more ethical philosophers. • Two major strands can be simplified as:- • Concern for the right act (Deontological) • Concern for the consequence (Teleological)

6. Human Cloning • “Is wrong and should be absolutely prohibited, as this is playing God.” • (Deontological) • “Can save many lives and should therefore be supported.” • (Teleological)

7. Deontological ethics (Rights) Based on natural law and divine command e.g. like the laws of gravity – such natural rights are “built into the universe”. Based on common humanity e.g. all human beings have rights simply by virtue of being “human”. Based on rationality e.g. people who are capable of rational, autonomous thought are entitled to claim moral rights. Based on interests e.g. To claim rights meaningfully, one must have interests.

8. Different “Rights” • Inalienable rights – cannot be transferred e.g. “the right to life” • Absolute right – cannot be overridden by any circumstances • Prima facie rights – rights which may be overriden by stronger moral claims

9. Inalienable right • Example – A right to life • In such a situation suicide or martyrdom would be condemned as morally wrong. • A mother who sacrificed her life for her child would be similarly condemned.

10. Absolute right • Example – A right to life • If this is so, the taking of life is always wrong, be it war, in self-defense, capital punishment or abortion

11. Prima facie right • Example – A right to privacy would be overridden by a right to life in an emergency.

12. Rights and duties • Having a right requires a corresponding duty to respect that right. • Generally such claims imposes a “duty to act”

13. Problems with rights • Rights and interests can compete and conflict with one another • Difficult to establish the extent a right entails a corresponding duty • Disagreements on who/what have rights • Difficult to satisfy the rights claims of all

14. Moral Duty • A moral duty is an act that a person ought to do. Contrast with legal duty, civil duty, professional duty, etc.

15. Moral principles • Specify that some type of action or conduct is either prohibited, required or permitted in certain circumstances • Moral principles commonly used in medical practice are:- • Autonomy • Non maleficence • Beneficence • Justice

16. Four basic moral principles • Autonomy • Non maleficence (Do no harm) • Benficence (Do good) • Justice

17. Autonomy • A person’s ability to make or exercise self-determining choices • A person should be free to choose and entitled to act on their preferences provided their decisions and actions do not violate or impinge on the significant moral interests of others.

18. Example • In your opinion, a patient needs surgery. • The patient however can refuse and their refusal has to be respected. • This right to autonomy (self-determination) underpins the medicolegal understanding of INFORMED CONSENT.

19. Against the principle of autonomy • Treating patients without their consent • Treating patients without giving them all the relevant information necessary for making an informed and intelligent choice (informed consent) • Telling patient “white lies”. • Witholding information from patients when they have expressed a reflective choice to receive it. • Forcing information on a patient when they have expressed a reflective choice not to receive it. • Forcing anyone to act against their reasoned moral judgment or conscience.

20. Non Maleficence (Do No Harm) • Above all, do no harm. • Stringent duty not to injure others

21. Example • You have a terminal patient and you feel you can no longer offer him anything that could cure him. • He heard that the taking of arsenic may cure him and asked you to give him arsenic • Arsenic is a poison.

22. Against the principle of non-maleficence • Sawing off someone’s good leg. • Operating on someone who did not have appendicitis • Puncturing the heart whilst doing a bone marrow aspiration

23. Beneficence (Do good) • Provision of benefits • Preventing and removing harm • If an act does not bestow benefit or fails to address an imbalance of harms over benefits, the act could rightly be condemned.

24. Example • A patient cut his fingers on a machine. He had loss a lot of blood. • You gave him a matched blood-transfusion • You stopped the bleeding and repaired the wounds on his hand.

25. Against beneficence • Refusing to provide treatment • Refusing to help an accident victim • Refusing to help a prisoner or a suspect of crime

26. What is Justice? • No common agreement • Retributive justice – “an eye for an eye” • Justice as mercy • Justice as harmony in the soul • Justice as equality • Justice as what is deserved • Justice as love

27. Justice • Practically • Justice as fairness • What is deserved • Justice as equality (distributive justice) • All are required to bear an equal share of society’s burdens and benefits • All patients have a right to your best diagnosis and treatment.

28. Against justice • Favouring one patient over another • Senior and experienced doctors treats private patients only.

29. Conflicts • It is not uncommon that in every day clinical practice you will encounter situations where even the four basic principles are in conflict. • There is no simple answer and each case must be considered and weighed. • Seek help and discuss the issues with colleagues.

30. Conflicts • During the delivery of a baby, problems develop and you are faced with a choice. • The mother or the child? • Whose autonomy prevails? • Non-maleficience (but to whom?) • Beneficence (to whom?) • Justice (to whom?)

31. Conflicts • If the mother said – “save the baby” • Does this resolve your conflicts? • Is the mother’s autonomy absolute? • Is non-maleficience physical, psychological or holistic?

32. Conflicts • A baby is born anencephalic (no brain matter). • Is there autonomy? • What about beneficence? • What about non-maleficience? • What about justice?

33. Conflicts • The anencephalic baby develops a chest infection. • Do you treat with antibiotics? • Autonomy • Non-maleficience • Beneficence • Justice

34. Ethical Dilemma (1) • A young teenage mother who was a victim of rape came to the hospital for an abortion. • What will you do? • What moral principles?

35. The abortion was performed but the abortus was “alive”. • What will you do? • What moral principles?

36. Ethical Dilemma (2) • A patient is admitted into hospital in coma and requires resuscitation and respirator and ICU care. • What will you do? • What moral principles?

37. The patient is moved into the ICU, but it soon becomes clear his liver is completely damaged. The cause of his liver failure was chronic alcoholism. • What do you do? • What ethical principles?

38. His family begs you to keep him alive by whatever means. A victim of a car accident has just arrived at the hospital and needs an ICU bed. There are no more ICU beds available. • What do you do? • What moral principles?

39. The son of a colleague has come forward to offer part of his liver for a “live donor transplant”. • What would you do? • What moral principles?

40. The victim of traffic accident dies, the family has agreed to donate his liver. There are however others on the waiting list. The cause of their liver failure were due to allergies to medication given by doctors. • What would you do? • What moral principles?

41. Modern Medicine has brought new dilemmas and new conflicts.

42. References • Doctors’ Decisions – Ethical Conflicts in Medical Practice – G.R. Dunstan & E.A. Shinebourne • Moral Dilemmas in Modern Medicine – Michael Lockwood • Classic Cases in Medical Ethics – Gregory E. Pence • Medical Harm – Historical, Conceptual and Ethical Dimensions of Iatrogenic Illness – Virginia Sharpe & Alan I. Faden • Demanding Medical Excellence – Doctors and Accountability in the Information Age

43. References • Ethics and Law for the Health Professionals – Kerridge L, Lowe M, McPhee J. - Social Science Press, 1998. (Australia) • Principles of biomedical ethics – Beauchamp TL, Childress JF – Oxford University Press 1994 • The New Dictionary of Medical Ethics – Boyd KM, Higgs R, Pinching AJ – BML Publishing Group 1997