Medical Ethics

What is medical ethics, and why do we need them? 

• What is ethics? 

  • Covers the study of the nature of morals and specific moral choices to be made 

  • It can attempt to answer the question: which general moral norms for the guidance and evaluation of conducts should we accept and why? (Beauchamp TL, Childress JF. Principles of bioethics. 7th ed. Oxford University Press; 2013.)

  • Some moral norms for correct conduct are common to everyone despite differences in culture, religion, etc. = common morality 

  • Some are norms that only exist within a certain group = particular morality 

  • Bioethics and Clinical ethics are two examples of particular morality that should govern physician professional standards 

  So why do we need them? 

• The best example of why we need medical ethics is to look at history and when medical ethics was ignored 

• There have been multiple times in history when there have been medical abuse of human subjects in research and medical interventions without informed consent

• Examples: Tuskegee syphilis study, Henrietta Lacks and the use of HeLa cells, World War II etc. 

• To avoid repeating history, we should follow the following principles of medical ethics 

• And of course, there is always 1-2 questions on CREOGs and your written boards about medical ethics, so this is a good time to review them!

The Fundamental Principles of Medical Ethics 

• Beneficence 

• Obligation of the physician to act for the benefit of the patient and help protect and defend the rights of others, prevent harm, remove conditions that will cause harm, help persons with disabilities, and rescue persons in danger 

• This is distinct from the next principle of “nonmaleficence” in that beneficence has positive requirements (actually doing something to promote benefit to others) 

• Some examples: providing vaccines, speaking at an event to discuss STI prevention, encouraging a patient to stop smoking 

• Nonmaleficence 

• The obligation of a physician not to harm the patient 

• Obvious examples - do not kill, do not cause pain and suffering, do not incapacitate, etc.

• Practical application is more difficult – this is when the physician needs to weigh the benefits against risks/burdens of all interventions and treatments 

• This can especially come into play in things like end of life care decisions and pain/symptom control 

• Autonomy

• Patients have the power to make rational decisions and moral choices for themselves, and each person should be allowed to exercise their capacity for self-determination 

• Like other principles, autonomy does need to be weighed against other competing moral principles 

• Sometimes, autonomy needs to be overridden in the cases where patients are not deemed to have decision-making capacity 

• Capacity: person’s ability to use information they are given and make a choice that is congruent with their own choices and preferences 

• This is different from competency = legal judgment that is informed by assessment of capacity 

• See our previous episode on informed consent where we talk about how to assess capacity!

• Autonomy can also at times be in conflict with certain social norms depending on culture/religion etc 

• Example: in some cultures, full disclosure of medical status, end-of-life status, etc. is frowned upon and some cultures may prefer a family-centered approach where these statuses are hidden from the patient 

• As the definition currently stands, respecting the principle of autonomy obliges physician to disclose medical information and treatment options that are necessary for the patient to exercise self-determination

• Justice 

• The fair, equitable and appropriate treatment of persons 

• The thing that is important to take away, especially in the US for this principle is “distributive justice” 

• Fair, equitable, and appropriate distribution of health-care resources

• There are different principles of distributive justice, and can be based on equal share, according to need, according to effort, according to contribution, according to merit, and according to free-market exchanges 

• Each principle is not exclusive and these principles are often combined in application

• However, this does increase the difficulty in choosing, balancing, and refining these principles  

• Examples of justice: rules for allotment of scarce resources, allotment of time for outpatient visits

Three Other Principles Derived from the Original Four

• Informed Consent

•  In order to obtain informed consent, things that are required: 

• Patient who is able to give consent 

• Presentation of accurate information that includes: 

• Diagnosis (if it is known) 

• Nature and purpose of the recommended interventions 

• The risks, benefits, and alternatives of all options 

• Documentation of the conversion and the ultimate decision 

• We won’t go into this too much because we have a whole episode! 

• Truth-Telling 

• This is a vital component of the physician-patient relationship – full disclosure of disease process is the normal in the US 

• However, this may be variable in other countries 

• Confidentiality 

• Physicians are obligated not to disclose confidential information given by a patient to another party without the patient’s authorization 

• Primary exemption would be disclosure of necessary medical information for care of patient to other health-teams 

Some examples of conflicts between principles

• Paternalism 

• When beneficence and autonomy collide 

• The physician may be trying to do what he/she thinks is best for the patient, but patient autonomy suggests that patients have the right to refuse treatment 

• Paternalism happens when physician takes away patient autonomy by nondisclosure, manipulation, deception, or coercion 

• Consumerism 

• Extreme form of patient autonomy where the physician’s role becomes limited to providing all the medical information and available choices and letting the patient select; ie. a menu of choices  

• This does not permit the physician full use of his/her knowledge and skill for beneficence