Introduction to ethics in medical practice

Anna SmajdorLecturer in EthicsUniversity of East

Angliaa.smajdor@uea.ac.u

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http://www.bbc.co.uk/news/health/

What medical ethics teaching can’t do

• Tell you what’s right and wrong – but it might help you to understand ethical issues

and think more deeply about them

• Make you a good person – but it might help to make you a better person,

and a better doctor, through thinking about and understanding ethical issues

What your medical ethics teaching is for

• Recognise common areas of ethical dispute in medicine• Recognise ethical beliefs & assumptions (your own and

those of others)• Recognise the impact of your ethical beliefs on your

practice• Be able to articulate and evaluate your ethical beliefs• Recognise and understand the ethical viewpoints that

conflict with your own beliefs• Participate in the resolution of ethical conflicts that arise in

practice

And (pragmatic considerations)• To fulfil government requirements• To help you pass your exams

The evolution of ethicsCan animals behave (un)ethically?

Ants – Maurice Maeterlinck argues that ants behave ethically, because they are altruistic

Maeterlinck says ants are ethical because they are altruistic.

What assumption(s)does this imply?

fthat ‘altruistic’ equals ‘ethical’that ants can choose to do this

‘Ethics’ in animals

What about human beings?

Ethical norms probably part of evolutionary history as a social species. To this extent, humans perhaps not qualitatively different from other animals.

BUT – with the ability to debate ethical problems, and construct new ethical codes, it’s no longer a question of instinct. We can deliberate about our actions to ensure we make the ‘ethical’ choice. The question is: how?

Ethics is about right and wrong: what ought one to do? – Socrates

Some common fallacies:Ethical questions CAN’T be answered simply by referring to a) empirical facts, b) the law, c) religion, d) majority views.

EG: ‘is euthanasia wrong?’

A1: euthanasia will always happen whatever we think about itA2: Euthanasia is legal in the NetherlandsA3: The Catholic church forbids euthanasiaA4: Most British people think euthanasia is acceptable.

None of these is valid as the sole answer to an ethical question.

Theory and argument: approaches to ethical reasoning

In the Western philosophical tradition, ethical questions are explored through philosophical reasoning. Consideration of ethical theory may help in recognising and constructing arguments

• Relativism/Subjectivism• Virtue ethics• Consequentialism• Deontology• Four principlesApplying ethical approaches – sample question: is

euthanasia wrong?

Moral relativism & subjectivism

• Relativism: ethics dependent on social contextEuthanasia is OK if you live in Switzerland but not in the

UK– Were the Nazis right to send 6 million Jews to their

deaths? They lived in a place where it was ‘OK’ to do so– Was slavery a good system? It was widely accepted at

the time

• Subjectivism: ethics is a matter of personal opinionEuthanasia is OK if you think it’s OK– But - our values/choices affect others– Am I entitled to my personal view that slavery is OK?– Or that Jews should be killed?

Aristotle (384 BC – 322 BC)

Virtue ethics – balancing between extremes

Courage CowardiceCompassion Selfishness

Diligence LazinessTemperance Greed

WISDOM

Would a virtuous doctor perform euthanasia? Would a virtuous patient request it? What sort of person would he/she be?

Consequentialism/Utilitarianism Famously associated with John Stuart Mill (1806-1873)

• Only outcomes count

• The greatest good for the greatest number

• No absolute prohibitions

• Ends justify the means

‘…the only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others.’

Euthanasia is OK if overall benefit results - could mean killing those who are unprofitable to society?

Deontology• Morality is about following rules -

consequences are not important.

• Some acts are intrinsically wrong. So they are wrong in ALL circumstances. EG, killing.

• Means and ends – never treat another human being solely as a means, but always as an end in him/herself.

Famously associated with Immanuel Kant (1724-1804)

Euthanasia is wrong, as it is the killing of another human being

Core concepts – four principles

Autonomy: Greek origin, literally means “self-rule”. “The capacity to make reasoned decisions and act on them” (The New Dictionary of Medical Ethics) . Contrasts with paternalism - assumption that doctor knows best. Respect for autonomy means that the patient’s choices decisions and values are key.

Non-maleficence – not doing harmBeneficence – doing goodJustice – treating people fairly, without discrimination

Does euthanasia respect autonomy? Does it harm the patient? Or benefit them...?

What does respect for autonomy entail?

Respect for people’s mental & physical integrity:

No treatment without consent.

Patients assumed competent unless evidence otherwise

Consent must be freely given & fully informed

Provision of accurate & relevant information

Absolute right to refuse treatment, even if death will result (but no right to demand treatment)

Confidentiality: doctors must not divulge facts about their patients

A critique of autonomy-focussed medicine

Degrees of autonomy – gradually attained as children grow older; sometimes gradually lost as adults grow older

Critics of autonomy: individualistic, ignores society, disregards relationships, downgrades the doctor’s role?

Ethical conflicts in medicine Autonomy vs paternalism

refusal of treatment

Individual vs societyallocating scarce resources

Beneficence vs non-maleficencescreening programmes – greater harm than good?

Acts vs outcomeseuthanasia, abortion

Objective vs subjective valuesbest interests; quality of life; futility judgements

Q: Is euthanasia acceptable?

Ethics is about right and wrong: what ought one to do? – Socrates

Ethical questions can’t be answered simply by referring to a) external facts, b) the law, c) religion, d) public opinion.

Challenging an ethical argumentClaim: ‘euthanasia is wrong’

Arguments (an argument is a conclusion supported by one or more reasons):

1. It is wrong to harm people2. euthanasia harms peopleConclusion: euthanasia is wrong

DISAGREE? Show where the argument is flawed….

Potential challenges:

‘Harming people is not always wrong’ – rejects 1st claim‘Euthanasia does not harm people’ – rejects 2nd claim‘Euthanasia is not wrong because it harms people, but for other

unrelated reasons’ – accepts that the argument is flawed, but suggests the conclusion is justified on separate grounds: need to draw up new argument

Reflective equilibriumGMC:

“You are personally accountable for your professional practice and must always be prepared to answer for your decisions and actions” [GMC Good Medical Practice, p1]

Where there is an ethical issue, you need to show you’ve

a) recognised that there’s a potential problem

b) thought through the relevant optionsc) selected a course of action based on

careful, conscientious analysis of the problem

Conclusion

Van Rensselaer Potter: need to create professionals with the ‘knowledge of how to use knowledge’ [Potter 1971]

• Values are diverse + disputed – no factual answers• Moral theories can help but not always conclusive• Reflective equilibrium offers a way of addressing

ethical questions, identifying + evaluating ethical assumptions + engaging in ethical debate

• Ethical issues extremely broad + cover a wide spectrum of social, ethical + scientific questions

• Need to connect scientists & doctors with social & ethical values

References and further reading

General Medical Council. Good medical practice. 4th Edition. 2007. London: General Medical Council

Beauchamp T L, Childress J F. Principles of Biomedical Ethics. Oxford University Press. 2001.

Boyd, Higg, Pinching (eds). The new dictionary of medical ethics. BMJ. 1997.

Rawls J. A theory of justice. OUP. 1999O’Neill O. Autonomy and Trust in Bioethics. Cambridge:

Cambridge. University Press, 2002, 30, 83–5.Hope T, Savulescu J et al. Medical ethics and law: the core

curriculum. Churchill Livingstone. 2nd Edition. 2008.Potter, V.R. 1971. Bioethics, A bridge to the future. Englewood

Cliffs: Prentice-Hall.Daniels, Norman, "Reflective Equilibrium", The Stanford

Encyclopedia of Philosophy (Fall 2008 Edition), Edward N. Zalta (ed.), URL = <http://plato.stanford.edu/archives/fall2008/entries/reflective-equilibrium/>