Transcript An Introduction to Medical Ethics

An Introduction to Medical
Ethics
Dr. Philip S.L. Beh
Email: [email protected]
What is ethics?
Why is there a need to talk
about ethics?
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.
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)
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)
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.
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
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.
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
Prima facie right
Example – A right to privacy would be
overridden by a right to life in an
emergency.
Rights and duties
Having a right requires a corresponding
duty to respect that right.
Generally such claims imposes a “duty
to act”
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
Moral Duty
A moral duty is an act that a person
ought to do. Contrast with legal duty,
civil duty, professional duty, etc.
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
Four basic moral principles
Autonomy
Non maleficence (Do no harm)
Benficence (Do good)
Justice
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.
Example
In your opinion, a patient needs
surgery.
The patient however can refuse and
their refusal has to be respected.
This right to autonomy (selfdetermination) underpins the
medicolegal understanding of
INFORMED CONSENT.
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
Non Maleficence (Do No Harm)
Above all, do no harm.
Stringent duty not to injure others
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.
Against the principle of nonmaleficence
Sawing off someone’s good leg.
Operating on someone who did not
have appendicitis
Puncturing the heart whilst doing a
bone marrow aspiration
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.
Example
A patient cut his fingers on a machine.
He had loss a lot of blood.
You gave him a matched bloodtransfusion
You stopped the bleeding and repaired
the wounds on his hand.
Against beneficence
Refusing to provide treatment
Refusing to help an accident victim
Refusing to help a prisoner or a suspect
of crime
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
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.
Against justice
Favouring one patient over another
Senior and experienced doctors treats
private patients only.
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.
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?)
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?
Conflicts
A baby is born anencephalic (no brain
matter).
Is there autonomy?
What about beneficence?
What about non-maleficience?
What about justice?
Conflicts
The anencephalic baby develops a chest
infection.
Do you treat with antibiotics?
Autonomy
Non-maleficience
Beneficence
Justice
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?
The abortion was performed but the
abortus was “alive”.
What will you do?
What moral principles?
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?
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?
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?
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?
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?
Modern Medicine has
brought new dilemmas and
new conflicts.
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
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