Transcript Introduction to Medical Ethics

Introduction to Medical
Ethics
What are medical ethics?
• Ethics and morals interchangeable but ethics implies a professional
context
• It is about making decisions, deciding priorities in healthcare
• A complex field, not black and white
• People will have different views and values, so important to use
ethical reasoning responsibly, with integrity
Different models/concepts
• Beauchamp’s 4 principles
• Deontology
• Consequentialism or utilitarianism
• Virtue ethics
• A hypothetical scenario to illustrate how decisions might be difficult
• You are standing next to some railway points; a runaway train if not
stopped will crash into a group of 4 people. If you pull the lever and
redirect the train, the train will still crash but kill just one person.
Beauchamp’s 4 ethical principles
• Beneficence
• The obligation to do good, to provide benefits, balanced against risks
• Non-maleficence
• The obligation to avoid doing harm
• Respect for autonomy
• Respect the decision-making capacity of autonomous persons
• Justice
• Obligations of fairness in distribution of benefits and risks
Comments of the 4 principles
• Each principle is binding but they may conflict with eachother
• Each principle is open to interpretation
• What is justice?
• Is it about punishment/retribution? Is it about being fair?
• Should fair distribution be according to rights? Or what someone
deserves? Or what someone needs?
• Needs seems most appropriate, equally, without discrimination.
• QALYs: quality-adjusted life years: tries to quantify the quality of life,
compare treatments, allocate resources; makes judgements explicit
Deontology
• This is the study of duty; famous proponent was Immanuel Kant
• We should act according to duty, regardless of outcome.
• Duties may conflict e.g. preserving confidentiality and reporting crime
• Purist ideology whereby you act in a way that you would wish
everyone to act; but not in your own interests unless everyone is
treated the same way.
• Can be inflexible and weakness is the disregard of consequences.
Utilitarianism
• Assesses actions according to whether benefits outweigh disadvantages
• Famous proponent was Jeremy Bentham who talked of “ the greatest good,
or greatest happiness, of the greatest number.”
• Results or outcomes are what matters most: the end justifies the means.
Distinction from deontology.
• One should sacrifice self-interest if that will bring about an increase in the
general good.
• At one extreme, you might shoot old people if that brought about more
resources for a greater number of younger people.
• Overall benefit often has an unequal distribution and sacrifices some for
the benefit of others.
Virtue Ethics
• This is about doing the right thing. It is what a virtuous person would
do in the same circumstances.
• It is person-based rather than action-based
• About the virtue or moral character of the person more than the
action or the outcome
• It doesn’t give clear guidance on what to do when faced with a
difficult dilemma and virtues can vary according to time, place,
culture, such as prudence, bravery, temperance.
• Less helpful to us, perhaps?
The Ethical Grid: Seedhouse
• A comprehensive tool to help us when faced with an ethical dilemma
in healthcare
• 4 different layers:
• A blue central layer that considers core principles of health care
• A red layer that considers duties or moral obligations (deontology)
• A green layer that considers consequences (utilitarianism)
• An outer black layer that considers external considerations.
• Use each layer so that a decision takes account of a full range of
factors.
The Blue layer: core principles in healthcare
• Create autonomy: autonomy can be thought of as a human quality of being
able to act, to flourish, to live life without impediments.
• Mending a broken leg or treating depression allows someone to go and live
and fulfil their potential.
• Respect autonomy: autonomy is also about the principle that someone has
the right to make decisions about themselves; it also requires him to be
informed adequately so that consent is informed.
• Denying a sticky bun to a child may not respect their autonomy in one
sense but the parent may actually create autonomy by allowing them to be
fitter and healthier
• These principles may conflict with each other; respecting autonomy usually
over-rides creating autonomy unless it harms others.
Blue layer: core principles in health care
• Respecting people equally
• Not to do so implies discrimination
• Serve needs first
• This follows from basic needs of food and shelter but also means
people should have a treatment even though some might consider
that they don’t deserve it, such as the patient who smokes or does
something else to harm their health; prisoners should receive
treatment by the same principle
• At least one blue box should be used when deliberating about health
decisions.
Red Layer: Duties or moral obligations
• Beneficence: do the most positive good
• Non-maleficence: minimise harm
• Keep promises: this equates to confidentiality as to breach
confidentiality is to break an implied promise by doctors to their
patients. It is, however, also a professional code of practice and also
appears in the outer black layer of external considerations
• Tell the truth
• There are other important duties but these seem most relevant to
health care. The first two might have been considered core principles
in health care in the blue layer?
Green layer: consequences
• This layer makes us consider consequences of decisions and who is
the patient. A doctor might view the individual patient as the main
focus whereas a health visitor or social worker might focus on the
family as a whole.
• This is very relevant with regard to allocation of resources as an
expensive treatment for one individual may reduce funding options
for a wider group.
• The 4 boxes in the green layer are: most beneficial outcome for the
individual; most beneficial outcome for a particular group, most
beneficial outcome for society and most beneficial outcome for
oneself.
Black layer: external considerations.
• Obvious considerations include the law and professional codes of
practice, such as GMC guidance.
• Other considerations are the effectiveness and efficiency of the
proposed intervention, the risks of the intervention, the resources
available.
• Others are issue of disputed facts/evidence or degree of certainty of
the evidence, and the wishes of others.
How to use the ethical grid?
• The ethical grid is a tool, like a screwdriver is a tool. The user has the
responsibility to use it wisely and with integrity.
• First consider the issue and state the proposed intervention or hypothesis.
• Try and come to an initial position intuitively, listing pros and cons.
• Then use the grid to challenge your position, not to support it.
• Try to involve others as this may enhance the quality of the decisionmaking
• Use every layer of the grid but not every box within each layer will be
relevant.
• The grid enable a careful and comprehensive analysis and challenge to your
original position