Medical ethics

chapter 20 Medical ethics



INTRODUCTION




Ethics: ‘Relating to morals, treating of moral questions. Set of principles of morals, science of morals, moral principles, rules of conduct.’


Oxford Dictionary


‘Ethics’ is a word derived from the Greek ethikos, which means ‘habit’ or ‘custom’. Put simply, in modern usage it is the study of how we ought to live or act in response to the situations confronting us in daily life. Medical ethics in particular is a branch of bioethics and is the study of how we ought to live or act as doctors. Ethics, being a branch of philosophy, relates to things such as ‘right’, ‘wrong’, ‘duty’ and ‘morality’. Making decisions of an ethical nature in medical practice is often difficult and demanding, and the clinician has to balance medical considerations with legal and moral ones.


Taking the time to reflect upon ethical issues, and having a structured approach to doing this, can help clinicians to navigate through many potentially challenging situations. Not taking time for this can compound ethical and moral concerns. This has effects upon our wellbeing and can also have medico-legal implications. As with many medico-legal dilemmas, ethical problems are often compounded by poor communication.


This chapter does not present a detailed analysis of particular and complex bioethical issues such as euthanasia, stem cell research or abortion. Nor does it make concrete pronouncements about the ‘correct’ view on given topics or course of action in given situations. It does, however, give an overview of generic ethical terms, concepts and methods that can be applied by the clinician to particular situations. We are interested here in ‘applied ethics’ and not simply ‘theoretical ethics’ or ‘meta-ethics’.



DEFINITIONS, TERMS AND MEANING


Many ethical conflicts lie in our understanding and interpretation of words. It is therefore useful before considering principles and concepts in more detail that some remarks are made about the language of ethics and the meaning of words commonly used in ethical discourse. It is easy to assume that different people mean the same thing by a word when they use it. This assumption gives rise to many misunderstandings. For example, one person might interpret ‘freedom’ as having all external restraints removed from their behaviour, whereas another might equate freedom with an internal state of self-awareness, balance and self-control. One person might equate happiness with pleasure or wealth, whereas another might equate it with spiritual enlightenment. One of the first points is that we should reflect on the meaning of the words we often take for granted.


As was mentioned, there is a distinction between meta-ethics and applied ethics. Meta-ethics is the ‘philosophical inquiry into the concepts, theories, language and intellectual foundations of ethics—as opposed to practical ethical questions’.1 So when a moral philosopher seeks to say what it means to say that something (a value or action) is ‘right’ or ‘wrong’, they are seeking to clarify the language or concepts of moral judgments rather than to say what one ought or ought not to do.2 It is like standing beside (meta) ethical actions and seeking to provide conceptual clarity to the usage of moral language.


Normative ethics is ‘concerned with establishing basic ethical principles or standards (“norms”—from the Greek for builder’s rule or square). Examples include normative theories (e.g. deontology or teleological), normative principles (e.g. the principles of bioethics), and declarations or statements whether on the core values of medicine or on specific duties of doctors and nurses in particular circumstances’.1 The following definitions of terms commonly used in ethical discourse are from the Oxford Dictionary.


• autonomy ‘right of self-government; personal freedom’. Sometimes seen as a principle opposed to paternalism, it relates to the patient’s right to make decisions about their healthcare on their own behalf

• beneficence ‘doing good; active kindness’. It is derived from the word ‘benefit’ and also carries the sense of providing advantage

• competence ‘ability to do a task’. In the medical context it usually relates to a person’s mental state, ability to understand information, and to make decisions.

• confidential ‘spoken or written in confidence; entrusted with secrets’

• consent ‘voluntary agreement, compliance’

• deontology ‘the science of duty’

• duty ‘moral or legal obligation; binding force of what is right’

• due ‘person’s right; what is owed him’

• inform ‘tell a person of or about a thing or subject’

• informed consent giving that consent having been previously informed in an appropriate way of all relevant background and facts

• justice ‘fairness; exercise of authority in maintenance of right. Due allocation of reward of virtue and punishment of vice’. In its most general sense it relates to the lawfulness (natural or human-made) of actions, but in the context of medical ethics justice is most often associated with fairness in relation to the distribution of resources

• non-maleficence to be maleficent is to be ‘hurtful, criminal’, so non-maleficence means to do nothing hurtful or unlawful

• paternalism ‘of or like a father; government limiting the subject by well meant regulations’. In the medical context it relates to the doctor being granted a position of authority on the basis of their knowledge, skills and care for the patient.

• right ‘just, required by morality or duty, proper, true, correct. What is just or fair treatment of a person’

• rights carries the meaning as above; also taken as a complementary principle to duties in that rights don’t exist in the absence of a corresponding duty and vice versa

• trust ‘firm belief in reliability, honesty, veracity, justice, strength’

• utilitarianism ‘doctrine that actions are right because they are useful’

• virtue ‘moral excellence, uprightness, goodness’.


ETHICAL APPROACHES



MICRO-ETHICS AND MACRO-ETHICS


In ethical discourse, community debate and media coverage, most attention is given to macro-ethical issues such as euthanasia, abortion, stem cell research and genetic engineering. These issues, as important as they are, are nevertheless far removed from the vast majority of clinical encounters between doctors and patients. All clinical encounters contain ethical issues but they are generally not obvious. These micro-ethical issues include everyday ethical concerns relating to such things as the doctor–patient relationship, communication, information giving, certificate writing, the management of common problems, and physical examination. As every clinical encounter contains ethical content and is ethically relevant, it is deserving of consideration, whether it be:


• the way the doctor does or does not inform the patient about what treatment is being offered,

• whether the doctor does or does not include the patient in the decision-making process,

• the level of care and compassion shown by the doctor towards the patient,

• the way in which a patient’s medical records are stored, or

• how much care the doctor takes to avoid drug interactions.

It is therefore important to be reflective about all aspects of clinical medicine and not just those aspects that are more prominent in the media. When considering the factors that affect patient satisfaction or have potential medico-legal implications, it is far more common for these to involve the micro-ethical rather than the macro-ethical.



MEDICAL ETHICS AND THE LAW


It is beyond the scope of this chapter to give a detailed discussion of the laws pertaining to medical practice. In any case, laws vary so widely between and within countries that any such overview would be of little relevance. The best source of information relating to medical law is likely to be one’s medical defence association. The broader issue relevant to ethicists regarding the relationship between law and ethics is: are they the same and do they lead to the same course of action?


The case could be made that they reflect each other in that laws reflect ethical principles and morality, and ethical and moral precepts are enshrined in law. Indeed, some would argue, as Plato did, that ethics is the bedrock of the law. If you offend one you offend them both, if the laws of the land are just.


Another case could be made that ethics and law are different. They may overlap but they are not the same, in that what is considered legal is generally, but not always, ethical. For example, a law could be made that some might consider unethical, such as apartheid being written into law. Equally, a thing that some people might consider ethical could be illegal, such as abortion.


In an endeavour to resolve the potential conflict, some might argue that if ethics and law appear to conflict then we may be confused about what is ethical, or an unjust law has been enacted. Either:


• what is considered ethical but illegal at one time or by one group of people is not truly ethical, or

• what has been written into law but is considered unethical is not a wise and just law, or

• law and ethics only fit in relation to natural law rather than human-made law, and they do not fit if human-made laws do not reflect natural law.

From a clinician’s perspective, when there is concern about a course of conduct that seems ethical but conflicts with the law, it is pertinent to seek advice from a legally qualified person or organisation. If there is no way of following what seems to be legal and ethical at the same time then it might be useful to reflect more deeply on our assumptions about what is truly ethical. Sometimes, in an attempt to preserve both, a difficult decision remains that depends upon a clinician weighing up how important the ethical principle is versus how severe the legal consequences are for not following the law.



PRINCIPLES-BASED ETHICS3


The meaning of the word ‘principle’, in the broadest sense, comes from the Latin principium meaning ‘beginning or source’. It also carries the meaning of a fundamental truth, law or motive force. It is also a starting assumption as the basis for further reasoning or the foundation upon which many other things are based. The principle ‘Do no harm’, for example, spawns a vast array of other societal morals, manners, customs, precepts, rules and laws. Whether we accept the validity of traditional principles or not, principles of one sort or other, consciously or unconsciously, form the basis of our actions. We may govern our actions with one overriding principle, a number of complementary ones, or even a number of conflicting principles. We could be consciously aware of those principles we live by or completely oblivious to them; nevertheless they govern our conduct.


Principles-based ethics has been the most widely adopted and taught paradigm in contemporary medical ethics. Some of these, such as autonomy and paternalism, and beneficence and non-maleficence, are complementary, like two sides of the same coin. In medical ethics discourse, the most commonly cited principles are:


• autonomy

• paternalism

• consent

• justice

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Jun 3, 2017 | Posted by in GENERAL SURGERY | Comments Off on Medical ethics

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