1. Antony Vaughan General Practitioner
Medical Ethics
Antony Vaughan
General Practitioner
Why me?
Week long Medical Ethics Course Imperial College London 1996 Prof Raanan Gillon

2. Medical ethics principles
Beneficence
Non-maleficence
Autonomy
Justice
Dignity
Truthfulness
Medical ethics is the discipline of evaluating the merit, risks and social concerns in medicine. These principles act as guides to what to consider in particular situations.
The principles can contradict each other leading to ethical dilemmas.
Some ethical questions may include-:
What method do we use to determine moral standards?
Why be moral at all?
Are there moral standards which are common to all humanity?
Is free will a necessary condition for moral praise or blame?

3. Ethics: the study of the moral value of human behaviour
Medical
Business
Environmental
Legal
Political
Feminism
Animal rights
Bioethics
Gay rights
Business-honesty, equity,employers, employees, companies, society.
Environmental-pollution,waste,conservation,natural resources,urban planning.

4. Philosophy Logic Metaphysics Ethics
Ethics is a division of philosophy.
Logic-reasoning,inference,relation between new assertions and established ones.
Metaphysics-basic nature of reality, of being, of existence, of space, of time.
Ethics-study of decisions and principles that apply for a long time to a whole society or to mankind.

5. History of ethics Early Greeks Ancient India Socrates Plato Aristotle
Epicurus
Ancient India
Hindu
Early European
Thomas Aquinas
Mamonides
Modern philosophy 1700-
Thomas Hobbes
Immanuel Kant
Jeremy Bentham
John Stuart Mill
David Hume
Hindu people of ancient India described highest ethical standards called absolute ethics, millennia later the Quakers had similar ethical standards.
Mamonides was a Jewish Rabbi who strove to reconcile the teachings of the Bible with the philosophy of science , and he and Thomas Aquinas initiated the debate of ethics within a divine law as against natural law.(Natural Law-moral standards are derived from the nature of human beings). Thomas Aquinas was born into Italian nobility and joined the Dominican friars. He received a high level of university education and drew on the works of Aristotle in forming his religious philosophy.
Bentham & Mill were Utilitarians
Arthur Schopenhauer derived his ideas from the ethical ideas of ancient India
More modern philosophers include Jean Paul Sartre, Christine Karsgard and John Rawls

6. Approaches to ethics Result based ethics Standard based ethics
Ethical intuitionism
Ethical egoism
Virtue ethics
Emotivism
Results-states that the moral goodness or badness is determined by the results or consequences of an act or rule. One example of this theory is Utilitarianism-started by Jeremy Bentham the morally correct rule is the one that provides the greatest good to the greatest number of people.
Standards-determines that a rule or act is morally right if it meets a certain standard. One such theorist was Immanuel Kant
Intuitionism-states that an act or rule is determined to be right or wrong by appeal to the common intuition of a person-sometimes referred to as your conscience.Anyone with a normal conscience will know it is wrong to kill an innocent person.
Egoism-each person should do whatever promotes their own best interests-this becoming the basis for moral choices.
Virtue-ethical actions should develop +ve character traits in a person so that person will do what is morally right Aristotle was an exponent- more later.
Emotivism-study of language used in ethical discussions. As people get emotional about ethical subjects they can use language which attempts to evoke similar emotions in a listener.

7. Study of ethics Meta-ethics Normative ethics Applied ethics
Meta-investigation of ethical statements-are they capable of being true or false?-if so are they always true-if so are they true absolutely or relative to a situation, individual or society. Eg Do we always act from self interest?
Normative-theory of conduct, study of right and wrong, obligations and duties,what is evil.Theory of value-what sort of things are good, what sort of situations are good? Is it good for everyone to be equally well off? The theories of Bentham and Kant are normative theories.
Applied-applies normative ethics to specific controversial issues such as abortion and euthanasia.

8. Medical ethics Medical Health care ethics Clinical ethics Bioethics
Medical-doctor centred
Health care-includes nurses and other health care providers
Clinical-based on patient cases
Bioethics-issues of fair distribution of resources, and around reproduction and genetic problems

9. Ethical topics Patient confidentiality Doctor paternalism
Rights of patient to refuse treatment
Rights of patients who lack capacity
Organ removal
Involuntary detention
Foetal testing, selection and abortion
+ Rights of patients to request assistance in dying

10. Medical oaths and codes
Ideal doctors
Welfare of patients
Advancement of medical knowledge
Honour of profession
Awareness of limits of power
Strive to help but “above all do no harm’
Most oaths and codes portray the ideal Dr as devoted to the welfare of their pts and the advancement of medical knowledge whilst upholding the honour of the profession and aware of the limits of their powers and the potential harm they may cause. Hippocrates said “Strive to help but above all do no harm” currently known as beneficence and non-maleficence.

11. Doctors criticised for:
Paternalism
Acting without patient’s knowledge or consent
Assuming patients share idea of benefits and treatment risks
Drs are criticised as being paternalistic and acting in what they consider the pts’ best interest without the knowledge or consent of the pt.They assume the pt shares or should share their ideas of the risks,benefits and burdens of Rx.A pt’s free and informed consent reflects an implicit contract refined and reviewed as Rx progresses-this is the principle of Autonomy. This principle raise problems Does the pt need free and informed consent for minor procedures with little risk. Is informed consent needed if the pt may be medically harmed by information re diagnosis and prognosis.
Does autonomy cover voluntary euthanasia, can children or mentally ill people give consent for some procedures, are refusals to Rx to be honoured even if the pt risks death, can parents or surrogates give or refuse consent when the pt is too ill to consider the options or to speak. The consideration of a principle in this way is known as Scope.

12. Consequentialism (teology)
Actions should provide a good outcome
Greatest good for the greatest number
Strengths
Resolves conflicts between individuals & society
Also used in political & business ethics
Weaknesses
Difficult to predict outcome
Society’s needs may not be correct morally
Individual needs & conscience can suffer from utilitarian thinking
What society finds desirable may be evil eg eugenics, and removing individuals from society for the betterment of society eg resusitation of very premature babies

13. Dying widow
A 71-year-old widow is dying of end stage breast cancer with secondaries in brain and bone. She can still converse well. Her husband died 8 years ago. Her two sisters died before her-one from breast cancer. Her one source of comfort has been her only child, a computer specialist, who took leave from his work 6 months ago to be with his mother during the final episode of her life.
As the patient slips in and out of consciousness and her pain control medications increase she asks for her son Mark, “Why isn’t he here? Is Mark alright?” Yesterday her doctor and nursing staff were informed that Mark had died in the family house, an apparent suicide. He had become despondent over his mother’s approaching death. According to a note he wanted to “be there” with his aunts and father before his mother arrived.
Should the health care providers tell the patient about her son’s death?
A Utilitarian might respond that the harm to society by lying might outweigh any harm to the pt caused by the truth.(as it reinforces Drs lying).
Conversely another utilitarian might argue that the truth might cause harm to this pt and by extrapolation to all pts and therefore to society at large.
Another utilitarian may emphasise the importance of truth telling but recognise this is trumped by family and professional considerations.

14. Deontology Duties and obligations Assumes people naturally act morally
Nothing can be imposed on anyone without their will or consent
Kant argued that persons are naturally moral.A person would act morally for no other reason than he was required to act that way as a person.
Nothing can be imposed on anyone without their will or consent.

15. Deontology 2 Strengths Weaknesses
Avoids rationalisation and delusions to justify personal actions
Corrects inauthentic reasons for being moral
Above constraints overrule the common good
Weaknesses
Cannot resolve conflicts between moral persons who disagree
No room for compromise
Inauthentic reasons-: one may be found out, it might not be good for your CV, may result in public shame.
The Universal Law of Kant asks that a person enquires of a proposed action “would the resolution be good in every instance?”
Kant also argued that there are conditions that can never be overridden whatever the outcome eg killing or harming an innocent person.
For deontologists such constraints overule the common good or the desire to modify moral principles to suit one’s own self interest.
If 2 moral persons must act on differing principles then compromise from those principles will void the duty based ethic and become one of utility.

16. Dying widow
A 71-year-old widow is dying of end stage breast cancer with secondaries in brain and bone. She can still converse well. Her husband died 8 years ago. Her two sisters died before her-one from breast cancer. Her one source of comfort has been her only child, a computer specialist, who took leave from his work 6 months ago to be with his mother during the final episode of her life.
As the patient slips in and out of consciousness and her pain control medications increase she asks for her son Mark, “Why isn’t he here? Is Mark alright?” Yesterday her doctor and nursing staff were informed that Mark had died in the family house, an apparent suicide. He had become despondent over his mother’s approaching death. According to a note he wanted to “be there” with his aunts and father before his mother arrived.
Should the health care providers tell the patient about her son’s death?
The deontologist has an exceptionless duty to tell the truth even if it is delayed. One could never justify lying to a pt for whatever reason.

17. Virtue theory
Virtues (habits) formed by personality, parental and social training, professional training and standards
All human beings have an inborn routine that tends to the good in moral action (needs moulding)
Examples of virtue; courage, love, friendship, responsibility, faithfulness, truth telling
Doctors also need compassion, humility and integrity (respect for science)
Eg courage as a virtue may be taught to a timid child who will then stand up for their beliefs.
Some societies encourage moderation in eating and drinking whereas others encourage overindulgence Sat night and the Roman vomitorium.
Persons inborn routine to the good needs moulding and directing to refine that routine away from vices and unbalanced behaviours.
Certain communities can produce people they consider high in virtue but other communities may have quite opposite ideas (cf freedom fighters and terrorists)
Morally strong communities may stress different virtues.

18. Virtue theory 2 Strengths Weaknesses
Health professionals’ character is crucial as they interpret and apply the ethical theory
Encompasses duty of professional (deontological) and goodness of actions (teological)
Do good and avoid evil (Thomas Aquinas)
Weaknesses
Agreement of what is virtuous is often difficult
Society need to agree what is right and good
Virtue was the traditional and dominant theory in medical ethics until recently emphasising the moral worth of the professional.

19. Dying widow
A 71-year-old widow is dying of end stage breast cancer with secondaries in brain and bone. She can still converse well. Her husband died 8 years ago. Her two sisters died before her-one from breast cancer. Her one source of comfort has been her only child, a computer specialist, who took leave from his work 6 months ago to be with his mother during the final episode of her life.
As the patient slips in and out of consciousness and her pain control medications increase she asks for her son Mark, “Why isn’t he here? Is Mark alright?” Yesterday her doctor and nursing staff were informed that Mark had died in the family house, an apparent suicide. He had become despondent over his mother’s approaching death. According to a note he wanted to “be there” with his aunts and father before his mother arrived.
Should the health care providers tell the patient about her son’s death?
2 Drs may regard themselves as courageous kind and compassionate but they may disagree on how to act. One may think being kind and comforting to the Pt may mean not telling her the truth. The other may put truth telling above compassion.
Both, however, may conduct a greater self examination than is found in other theories asking what effect this decision has on their own lives and those of their families colleagues and students who may look to them as role models.

20. Branches of medical ethics
Public policy ethics
Applied medical ethics
Clinical medical ethics
Age based rationing
Medical research
Treatment availability
Professional codes
Abortion
Euthanasia
Fertility
Genetic manipulation
Case analysis
Patient & family involved
The above 3 categories are often intertwined eg people with AIDS may be concerned re public policy on the availability of Rx, they may participate in arguments as to whether Drs can refuse to treat them and they will want to be involved with decisions regarding their care and what is to happen if and when they are dying.

21. Four principle approach (Beauchamp & Childress)
Autonomy
Beneficence
Non-malificence
Justice
University of Georgia The Georgia Mantra
These principles should always be respected unless there is some strong reason to justify overruling them. The principles have compatibility with deontological and consequentialist theories and some aspects of the virtue theory.

22. Four principle approach 2
Strengths
Compatible with deontological and consequentialist theories & some aspects of virtue theory
Objective, specific, works well in clinical situations
Weaknesses
Conflict between autonomy and justice, & beneficience and non-maleficence
Need to weight one principle over another
2 of the principles are in the Hippocratic oath-beneficence and non maleficence.
Many Drs are not happy with autonomy as a major principle as it may override good medical judgement and encourage detachment on the part of the Dr.
Justice is a remote concept medically but it was prominent in the theories of Plato and Aristotle.
Care is rationed using, for eg ,waiting lists and drug budgets. Traditional Drs regard the management of these as a conflict of interests.
Using the principle theory in the truth telling case-if autonomy is weighted then she is told,if beneficence then not. What is needed is attention to the pt’s life story and values, and an awareness of the healing relationship to justify giving one principle greater moral weight over another in a particular case.

23. Alternative approaches
Normative ethics
Libertarianism
Beneficence in trust
Communitarian ethics
Narrative ethics
Feminist ethics
Normative-basing decisions on what is expected of health professionals such as fidelity, respect for autonomy, honesty, respect for life, justice, equality. In deciding what norms to embrace then an autonomy model would produce different primary principles and moral obligations than a beneficence model.
Libertarianism-places autonomy first whatever the situation.”All ethics is respect for autonomy and one cannot be ethical if you ignore a persons’ autonomy” This underscores the right of the individual over the community and has achieved an almost sanctified quality in Western secular society.The right to freedom.
Beneficence in trust-Health professional acting in the best interests of their pts while keeping in trust with their moral values.It gets away from undue emphasis on autonomy and recognises that a pt may have fundamental values that preceed his expressed wishes. The responsibility of the health care professional is to not only respect the pt’s decisions but also to create a care plan on the basis of the pt’s values. Such decisions take place over time and require the pt and professional to get to know each other well.
Communitarian-Individual rights come with community needs such as the need to offer oneself for research and to provide organs for transplant.
Narrative-The importance of the individual’s life story for a proper moral analysis, also emphasises negotiation in the Dr pt relationship.
Feminist-Based on the ethics of caring Women care differently from men. They are presumed to be more interested in relationships,nurture,attachment and reconciliation.More practical less theoretical ethics.

24. Autonomy Informed consent Confidentiality Keeping promises
Lack of deceit
Empowerment
To exercise respect for autonomy health care workers must be able to communicate well with their pts.(not just talking but also listening-and not just with the ears).To know when pts require information and when they do not want a lot of information. Some pts do not want to know a bad prognosis; some do not want a long list of alternative options for Rx and prefer to leave the decision to their Dr. Respecting such attitudes shows as much respect for autonomy as giving information when it is wanted. Most pts want information and to participate in their medical care.

25. Beneficence & non-maleficence
Any effort to help may result in harm
Education and training
Risk, probability of benefit and harm
We can consider these principles together but must keep them separate as in some instances we will have no obligation of beneficence towards a person but will still have an obligation not to harm them.
In order to adhere to these principles we must have rigorous education before and throughout our professional lives. We must also be clear about risk and probability when we make our assessment of benefit and harm. This knowledge comes from good medical research which then becomes a moral obligation.

26. Justice Fair adjudication between competing claims
Personal decision making
Organisational, professional and societal decisions
Treating equals equally and unequals unequally. Aristotle said this and we are still arguing as what constitutes equal and unequal.
We need to distinguish whether it is the individual,the organisation, the profession or society that is making the decision.For instance how do I respond to a request for an abortion is different from what is the hospital’s view,or the profession’s view, or society’s view as expressed in law.

27. Scope To whom or to what we owe moral obligations Patients
Children
Mentally ill or impaired
Right to life
Not to be unjustly killed
Right to be kept alive
Who or what counts as an autonomous agent? When we disagree about a 14 yr old girl taking the pill we are disagreeing about the scope of application of the principle of the respect of autonomy.
New born babies are clearly not autonomous as they do not have the capacity to deliberate but 7yr olds can deliberate to a degree. How much capacity for logical thought and deliberation does a person need to become an autonomous agent?
Context is important A child may not be autonomous enough to decide whether to have an operation but be quite able to decide what to wear or eat.
Right to life- the scope of not to be unjustly killed is obviously larger than that of the right to be kept alive.Does the scope of not to be unjustly killed include human embryos,fetuses,newborn babies, pts in a vegetative state?
These contentious issues are not about our agreed moral obligations but about to whom and what we owe them-that is they are questions about the scope of our agreed moral obligations.

28. Change of mind over advanced directive
Mr Z made a written advance directive 5 years ago. Mr Z suffers from chronic obstructive pulmonary disease and the advance statement provides that if he is admitted in respiratory failure he will not be ventilated. The advance directive is placed in his notes. Mr Z is brought into A&E in respiratory failure and is acutely confused because of low oxygen levels in his blood. He states that he wants 'everything done' in order to save him. The doctor in charge of his care decides to ventilate him.

29. Refusal of Treatment by an Incompetent patient
Mrs Y is 56 years old. She has a learning disability and lives in a care home. She is admitted to hospital with an ovarian cyst. The cyst is blocking her ureter and if left untreated will result in renal failure. Mrs Y would need an operation to remove the cyst. Mrs Y has indicated quite clearly that she does not want a needle inserted for the anaesthetic for the operation to remove the cyst - she is uncomfortable in a hospital setting and is frightened of needles.
The clinician is concerned that if the cyst is not removed Mrs Y will develop renal failure and require dialysis which would involve the regular use of needles and be very difficult to carry out given her fear of needles and discomfort with hospitals. The anaesthetist is concerned that if Mrs Y does not comply with the procedure then she would need to be physically restrained. Mrs Y's niece visits her in the care home every other month. The niece is adamant that her aunt should receive treatment.
Should the surgeon perform the operation despite Mrs Y’s objections?

30. Prevention or Treatment?
Decisions about setting priorities for treatments and services on a larger scale raise difficult ethical issues for PCTs. A PCT may seek advice on the ethical issues arising from these ‘macro-level’ decisions from a priorities forum, or a PCT may develop their own ethics committee to inform these decisions.
Metroville PCT has a sum of recurring money that has been ring-fenced for use in the area of ischaemic heart disease. The PCT has two proposals for developing services in this area and must decide which proposal to fund.
Proposal 1 is from the local acute trust and is for an increase in angiography and angioplasty services. The proposal cites evidence from research studies to show that reducing waiting times for angioplasty will save lives and is a cost effective use of resources.
Proposal 2 is from the local diabetes group and is for a project that will focus on the small Asian community within the population. This community has a high prevalence of diabetes and ischaemic heart disease and traditionally has tended to use health care services only when they are acutely ill rather than attending for regular care of their chronic diseases. The proposal is to provide a specialist diabetes nurse and health advocate for this population and an educational programme for the whole community focusing on prevention of diabetic complications and promotion of life-style changes to reduce the incidence of new cases of diabetes. There is no research evidence for this intervention but there is some anecdotal evidence from other areas that this approach has some success.
The PCT must choose one of these proposals.

31. Confidentiality and HIV
Bob has attended the genito-urinary clinic at his local Trust hospital. Bob is seen by Dr Gomez who informs him that he is HIV positive. Dr Gomez counsels Bob to contact his sexual partners to inform them of his status. Bob starts a course of treatment.
For the last 18 months Bob has been in a relationship with Sue. They are expecting a baby in 2 months time. Before this relationship Bob had a series of sexual partners.
On a subsequent visit to the clinic it becomes clear to Dr Gomez that Bob has not told Sue of his HIV status. Dr Gomez is aware of the impending arrival of their baby and tells Bob that steps should be taken to assess whether Sue is HIV positive and whether the baby is at risk so that if necessary treatment may be started.
Bob adamantly refuses to tell Sue and says that if she is told without his consent then he will stop his course of treatment.
What should Dr Gomez do? Should he inform Sue, or Bob’s GP?

32. Parents refuse to withhold Rx
Baby C born 8 weeks prematurely and contracted meningitis soon after birth. As a result she suffered severe brain damage and an inability to respond to stimuli. She was receiving artificial ventilation. The treating team thought that it was not in the baby's best interests to continue with artificial ventilation, without which she would die within an hour. With continuance of such treatment she would live for at most one year, probably experiencing pain and distress. For religious reasons her parents could not agree to withdrawal of treatment.
What issues should an ethics committee consider in reviewing such a case?

33. Competent patient refuses Rx
Mrs X is 35 and is in need of dialysis. She is refusing treatment because she is scared of treatment which she believes is invasive. She has been counselled about the nature of the treatment - there are no alternatives that would be of practical benefit. She is competent to make treatment decisions. She understands that if she refuses dialysis she will die. She has a daughter of 15 years who lives at home. The clinician feels very strongly that she should receive dialysis but despite numerous attempts to persuade her she refuses.
Can the clinician treat her?

34. Who should have the bed?
Barry is a 32 year old man with meningitis and is brought into the A&E department of hospital A. He is unconscious with an extremely low blood pressure and evidence of renal failure. His condition is grave and without intensive care support he is almost certain to die. With intensive care support he may make a full recovery. Until this illness he has been fit and well. The Intensive Care Unit (ICU) in hospital A is full, with some patients critically ill and some in a relatively stable condition but for who optimum care would still require the facilities of an ICU. There is evidence that moving a patient from an ICU early increases their chances of complications and may increase mortality. There is an available bed in an ICU in hospital B, which is fifty miles away. The intensive care consultant on call must decide if Barry should be moved to hospital B or if a patient already in ICU should be transferred to allow Barry to be admitted. The clinical ethics committee is asked to review the case retrospectively and advise on how such cases should be approached in the future