1. Medical Ethics
By Shauna O’Sullivan

2. Outline Background Definition of Medical Ethics Ethical Guideline
Principles of Medical Ethics

3. Background
Medical professionals increasingly find themselves confronted with moral questions and ethical dilemmas
Need to reflect on the moral dimension  led to a number of international ethical codes and guidelines
Developments in science and technology in the 20th century have led to advances in medicine and health care that have been benefited millions
Most famous of these guidelines is the Declaration of Geneva , which was adopted in 1948 by the World Medical Association. Since its development, it has undergone a series of amendments in 1968, 1983 and 1994.
In October 1949, the WMA adopted an international code of Medical Ethics in London
Health and Medical research were adopted by some international agencies, including the United Nations

4. Background
Documents present a set of basic principles for medical ethics that are deemed universally valid by interested bodies
Many countries have established their own national medical ruling bodies to govern ethical issues that arise within their medical communities

5. Overview of Medical Ethics
Medical profession has maintained simple medical ethics standards for more than 4,000 years
Hippocratic Oath, Prayer of Moses Maimonides, Bible, Holy Koran, as well as cultures, traditions and social mortality have shaped ethical standards
Majority of these documents focus on “avoiding harm to patients”
- Moses ben-Maimon, called Maimonides and also known as Mūsā ibn Maymūn, was a preeminent medieval Jewish philosopher and one of the greatest Torah scholars and physicians of the Middle Ages. He was a rabbi, physician and philosopher in Morocco and Egypt. Although his writings on Jewish law and ethics were met with acclaim and gratitude from most Jews even as far off as Spain, Iraq and Yemen, and he rose to be the revered head of the Jewish community in Egypt, there were also vociferous critics of some of his rulings and other writings particularly in Spain. Nevertheless, he was posthumously acknowledged to be one of the foremost rabbinical arbiters and philosophers in Jewish history, his copious work a cornerstone of Jewish scholarship. His fourteen-volume Mishneh Torah still carries canonical authority as a codification of Talmudic law. In the Yeshiva world he is known as "haNesher haGadol" (the great eagle) in recognition of his outstanding status as a bona fide exponent of the Oral Torah.

6. Definition of Medical Ethics
A system of moral principles that apply values and judgments to the practice of medicine
“Ethics is the moral reasoning of actions”
Morality refers to social norms that distinguish between right and wrong in human conduct
Ethics refers to a professional moral conduct
Moral actions based on professional character and ethical principles in each profession
- Ethics is an intrinsic part of medical practice and shapes the contemporary medical profession

7. Medical Ethics
Medical professionals must confront ethical dilemmas on a consistent basis
Ethical dilemmas are not rare phenomena and thus merit special attention

8. Medical Ethics
Do the best for the patient and place the patient’s interests before the interests of the physician
Purpose is to protect and defend human dignity and patient’s rights
It is not about avoiding harm; rather, it is a set of norms, values and principles

9. Ethical Guidelines
International guidelines such as the Declaration of Geneva (1948) proclaim that medical care must not violate any universally applicable standards
Help medical and professional professionals around the world to:
Recognize ethical dilemmas in medical and health care
Provide general rules and principles to guide decision making processes during these dilemmas

10. Ethical Guidelines Ethics is culturally defined
Applied ethics involves cultures and traditions
Relies on academia to inform the profession of ethical theories and principles
International guidelines acknowledge the need to account for cultural values and traditions
-Professional medical ethics involves expertise from fields such as philosophy, social sciences, medicine, research science, law and theology
-International guidelines such as the Declaration of Geneva (1948) proclaim that medical care must not violate any universally applicable standards. These guidelines help medical and professional professionals around the world to recognize ethical dilemmas in medical and health care and provide general rules and principles to guide decision making processes during these dilemmas.
Culture and tradition often outline medical ethics in the context where it should be applied
-International guidelines are guidelines: they have no power on national conduct, which may be their primary weakness. It is not always advisable to rely on them when medical practioners are facing critical ethical situations that may specifically relate to local beliefs

11. Why is it important to adhere to ethical standards in medical care?
Promotes the aim of medical care: to alleviate suffering
Built on communication between medical providers and patient’s or patient’s families
Helps build support for medical care
Ethical standards promote the values that are essential to good communication, such as trust, accountability, mutual respect and fair medical care
Many ethical standards in medical care, including informed consent, protection of privacy and maintenance of confidentiality, provide grantee for respect for persons

12. Ethical Principles
In the realm of health care, it is difficult to hold rules or principles that are absolute
Even thought they are not absolute they serve as powerful action guides in clinical medicine
For medical practice to be considered “ethical”
It must respect all 4 of these principles: autonomy, non- maleficence, beneficence and justice

13. Autonomy
The right of patients to make decisions about their medical care without their health care provider trying to influence the decision
Patient autonomy does allow for health care providers to educate the patient but does not allow the health care provider to make the decision for the patient

14. Autonomy
Respect for autonomy is one of the fundamental guidelines of medical ethics
Autonomy in medicine is not simply allowing patients to make their own decisions
Physicians have an obligation to create the conditions necessary for autonomous choice in others

15. Autonomy
For a physician, respect for autonomy includes respecting an individual’s right to self-determination as well as creating the conditions necessary for autonomous choice
This principle is the basis of “informed consent”
- Individuals come to doctors for guidance in making choices because they do not have the necessary background or information for making informed choices
Physicians educate patients so that they understand the situation adequately. They calm emotions and address fears that interfere with a patient’s ability to make decisions. They counsel patients when their choices seem to be disruptive to health and well-being.
Respect for autonomy also includes confidentiality, seeking consent for medical treatment and procedures, disclosing information about their medical condition to patients, and maintaining privacy.

16. Informed Consent
Informed consent is more than simply getting a patient to sign a written consent form
Process of communication between a patient and physician that results in the patient’s agreement to undergo a specific medical intervention

17. Informed Consent Communication process must involve:
Patient's diagnosis, if known;
Nature and purpose of a proposed treatment
Risks and benefits of a proposed treatment
Alternatives to the treatment
Risks and benefits of the alternative treatment
Risks and benefits of not receiving treatment

18. Autonomy
Includes confidentiality, seeking consent for medical treatment and procedures, disclosing information about their medical condition to patients, and maintaining privacy
Illustrative case: Jehovah’s Witnesses have a belief that it is wrong to accept a blood transfusion
What happens if a blood transfusion is needed to save a person’s life?
Illustrative case: Jehovah’s Witnesses have a belief that it is wrong to accept a blood transfusion
- In a life threatening situation where a blood transfusion is required to save the life of a patient, the patient must be informed and consequences of refusing must be made clear
- When properly and compassionately informed, the patient is then free to choose. This changes when children/minors are involved based on the state (at least in the US)
- The concept of prima facie (“first face”). -The physician has a prima facie duty to respect the autonomous choice of the patient as well as avoid harm and to provide medical benefit

19. Non-maleficence “Do no harm ”
Physicians must refrain from providing ineffective treatments or acting with malice toward patients
This principle is difficult as many beneficial therapies also have serious risks
The pertinent ethical issue is whether the benefits outweigh the burdens
The principle of nonmaleficence requires of us that we not intentionally create a needless harm or injury to the patient, either through acts of commission or omission
Physicians should not provide ineffective treatments to patients as these offer risk with no possibility of benefit and thus have a chance of harming patients.  In addition, physicians must not do anything that would purposely harm patients without the action being balanced by proportional benefit.  Because many medications, procedures, and interventions cause harm in addition to benefit, the principle of non-maleficence provides little concrete guidance in the care of patients.  Where this principle is most helpful is when it is balanced against beneficence. In this context non-maleficence posits that the risks of treatment (harm) must be understood in light of the potential benefits.  Ultimately, the patient must decide whether the potential benefits outweigh the potential harms.

20. Non-maleficence
Considered negligence if one imposes a careless or unreasonable risk of harm to another
Providing a proper standard of care
Avoids or minimizes the risk of harm is supported by moral convictions but laws of society as well

21. Non-maleficence This principle affirms the need for medical competence
It is clear that medical mistakes occur
This principle articulates a fundamental commitment on the part of medical professionals to protect their patients from harm

22. Non-maleficence
Illustrative case: How to best treat a pregnant women with newly diagnosed uterine cancer
A single action may have 2 effects, one that is considered good and the other bad (Principle of double effect)
What do you think about this case? What is right and what is wrong?
Illustrative case: How to best treat a pregnant women with newly diagnosed uterine cancer
- A single action may have 2 effects, one that is considered good and the other a bad effect (Principle of double effect)
- The usual treatment for uterine cancer is removal of the uterus however this procedure would result in the death of the fetus. What action is morally allowable, or, what is our duty?
- It can be argued in this case that the women has the right to self-defense and the action of a hysterectomy is aimed at preserving her life. The unintended consequence (though undesired) is the death of the fetus
- 4 conditions that usually apply to the principle of double effect:
1. The action itself must not be intrinsically wrong, it must be a good or neutral act
2. Only the good effect must be intended, not the bad effect, even though it is foreseen
3. The bad effect must not be the means of the good effect
4. The good effect must outweigh the evil that is permitted
Illustrative case: What happens when the patient cannot decide for himself and others must determine what is in the best interest of the patient, or what constitutes the lesser harm . This brings in the concept of advanced directives.
Illustrative case: Patient dying of intestinal carcinoma
- The patient my forego CPR with cardiac or respiratory arrest or life sustaining technology such as dialysis or respirator. Determination is made by the patient who is alone the authority of the “greater” or “lesser” harm for him.

23. Beneficence
Duty of the health care provider to be of benefit to the patient
Take positive steps to prevent and to remove harm from the patient
These duties are viewed as self-evident and viewed as the proper goals of medicine
These goals are applied to both the patient, and to the good of society as a whole
Vaccinations for disease prevention example
Physicians are expected to refrain from causing harm, but they also have an obligation to help their patients. The goal of medicine is to promote the welfare of patients, and physicians possess skills and knowledge that enable them to assist others. Due to the nature of the relationship between physicians and patients, doctors do have an obligation to 1) prevent and remove harms, and 2) weigh and balance possible benefits against possible risks of an action. Beneficence can also include protecting and defending the rights of others, rescuing persons who are in danger, and helping individuals with disabilities.
These goals are applied both to individual patients, and to the good of society as a whole. For example, the good health of a particular patient is an appropriate goal of medicine, and the prevention of disease through research and the employment of vaccines is the same goal expanded to the population at large.
It is sometimes held that nonmaleficence is a constant duty, that is, one ought never to harm another individual. Whereas, beneficence is a limited duty.
A physician has a duty to seek the benefit of any or all patients, however, the physician may also choose whom to admit into his or her practice, and does not have a strict duty to benefit patients not acknowledged in the panel. This duty becomes complex if two patients appeal for treatment at the same moment. Some criteria of urgency of need might be used, or some principle of first come first served, to decide who should be helped at the moment.

24. Beneficence
Illustrative case: One clear example exists in health care where principle of beneficence is given priority over the principle of respect of autonomy
Example is in the Emergency Room: Patient is incapacitated by the grave nature of accident or illness
We presume that the reasonable person would want to be treated aggressively and we rush to provide beneficent intervention
Clinical educations: Resuscitating a drowning victim, providing vaccinations for the general population, encouraging a patient to quit smoking and start an exercise program, talking to the community about disease prevention.

25. Autonomy vs. Beneficence
Often the most common and difficult ethical issues to navigate arise when the patient’s autonomous decision conflicts with the physician’s beneficent duty
Should a patient who has had heart bypass surgery continue to smoke?
What would you do if a patient with pneumonia refuses antibiotics?

26. Justice
Justice in health care is usually defined as a form of fairness, or as Aristotle once said, "giving to each that which is his due“
Deals with issues of treating patients equally
Physicians should treat similarly situated patients similarly and allocate resources justly
This implies the fair distribution of goods in society and requires that we look at the role of entitlement/ The question of distributive justice also seems to hinge on the fact that some goods and services are in short supply, there is not enough to go around, thus some fair means of allocating scarce resources must be determined.
One of the most controversial issues in modern health care is the question pertaining to "who has the right to health care?" Or, stated another way, perhaps as a society we want to be beneficent and fair and provide some decent minimum level of health care for all citizens, regardless of ability to pay
Our society uses a variety of factors as a criteria for distributive justice, including the following:
To each person an equal share
To each person according to need
To each person according to effort
To each person according to contribution
To each person according to merit
To each person according to free-market exchanges

27. Justice
If you had ten patients and only enough medicine to save five, who would you give the medication to first?

28. Summary
Medical professionals increasingly find themselves confronted with moral questions and ethical dilemmas
Ethics refers to a professional moral conduct
For medical practice to be considered “ethical”
It must respect all 4 of these principles: autonomy, non- maleficence, beneficence and justice

29. Any Questions?

30. References www.ama-assn.org (AMA code of ethics)
(Ethics in Medicine)
Gillon R. Medical Ethics: four principles plus attention to scope. BMJ Jul 16; 309(6948):184-8.