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