Ethics tutorial

Aims

  • Defining ethics
  • Clarify the meaning and significance of key ethical concepts
  • Outline important types of ethical theory, and their relevance to medical ethics.
  • Offer a conceptual framework useful for ethical analysis of medico-moral problems in a variety of professional contexts.
  • Give opportunities to participants – under supportive conditions – to articulate their current medico-moral attitudes, and explore reasoned arguments that challenge their existing assumptions and ethical stances.

What is (medical) ethics?

  • A set of moral principles.
  • The study of morality.
  • The philosophical study of moral values and rules.
  • Of or relating to moral action and conduct; professionally right; conforming to professional standards.
  • The branch of philosophy concerned with evaluating human action. Some distinguish ethics, what is right or wrong based on reason, from morals, what is considered right or wrong behaviour based on social custom.
  • The study of right and wrong in conduct.
  • A system or code of morals of a particular religion, group, or profession.

Principles of medical ethics (American Medical Assoiation)

Duties of a Doctor (GMC)

Recent ethical issues

  • End of life care
  • Medical errors
  • Priority setting
  • Biotechnology

Medical errors

Medical ethics: four principles plus attention to scope

R Gillon BMJ 1994;309:184 (16 July)

The “four principles plus scope” approach provides a simple, accessible, and culturally neutral approach to thinking about ethical issues in health care. The approach, developed in the United States, is based on four common, basic prima facie moral commitments –

  1. respect for autonomy (deliberated self rule)
  2. beneficence
  3. non-maleficence
  4. justice

plus concern for their scope of application.

It offers a common, basic moral analytical framework and a common, basic moral language. Although they do not provide ordered rules, these principles can help doctors and other health care workers to make decisions when reflecting on moral issues that arise at work.

What are the implications of respect for autonomy in health care?

  • Treating others as ends in themselves
  • Informed consent
  • Confidentiality
  • Communication eg listening, how much does the patient want to know
  • Truthfulness
  • Respecting patient attitudes

Beneficence and non-maleficence

  • Do no harm
  • Providing the benefits we profess
  • Offering the patient net benefit eg chemotherapy
  • Discussing risk and probability

Justice

  • fair distribution of scarce resources (distributive justice)
  • respect for people’s rights (rights based justice)
  • respect for morally acceptable laws (legal justice).

…basic precept is equality – but people can be treated unjustly even if treated equally

  • Allocation of resources – postcode prescribing
  • Needs of “your” patients vs the needs of “my” patients
  • Cost to taxpayer, etc

Personal decision making

Whose decision is it?

  • Me – confounding factors are
    • my own interests
    • discriminatory actions
    • punishment of patients
    • wasting resources
    • respecting the patient’s rights
  • The organisation
    • This organisations decisions vs society’s
    • Turning moral choices into “scientific” choices
    • Competing and mutually incompatible choices
    • Can’t please everybody
  • The profession
  • Society

Scope

  • To whom or what do we owe the moral obligations? Eg who are we morally obliged to help, how?
  • Is everyone autonomous? A 14 year old girl requesting the OCP? Children? Mentally ill? Mentally impaired?
  • Who has rights? Plants? The environment? Animals? Right to life, to not be killed or to be kept alive?
  • How do we deliver scarce resources fairly according to the principles of justice? Who to?

Health care professionals and their organisations all profess a commitment to help their patients and clients, and to do so with minimal harm. This commitment is underwritten by the societies in which they practise, both informally and through legal rules and regulations that define the health care professionals’ duties of care.

Lords publish report on assisted dying bill

A House of Lords Committee today published its report on a Bill seeking to legalise assistance with suicide and voluntary euthanasia for terminally-ill people who are mentally competent and suffering unbearably.

There is insufficient time remaining for the Bill to be considered adequately in this session of Parliament, so the Committee has presented a thorough and balanced report on the subject of assisted suicide and voluntary euthanasia based on wide-ranging evidence. The Committee heard from more than 140 witnesses in four countries, considered over 60 formal written submissions and received over 14,000 letters and e-mails.

The Committee recommends that its report should be debated early in the next Parliamentary session and that, if a new bill is introduced along similar lines, a Committee of the whole House should examine it. The Committee identified a number of key issues which, it hopes, those who draft any future bill will address. These include:

  • The need for any future bill to distinguish clearly between assisted suicide and voluntary euthanasia in order to give the House the opportunity to consider them separately and to decide, if it should favour a change in the law, whether it would be appropriate to legalise only one or both of them.
  • The need for qualifying conditions for assisted suicide or voluntary euthanasia to be set which reflect the realities of clinical practice as regards the prognosis of terminal illness and which define a patient’s suffering in as objective a manner as possible – eg ‘unrelievable’ rather than ‘unbearable’ suffering.

The Chairman of the Committee, Lord Mackay of Clashfern said:

“Ending or helping to end someone’s life, albeit with their consent, is an awesome issue, and opinion within the Committee has been divided. We have explored the underlying ethical principles involved and the practical implications of any change in the law on intentional killing and assistance with suicide. And we have looked at the experience of other countries where legislation of this nature is in force.”

“Our Report is intended to inform future debate and to improve public understanding of this complex and emotive subject.”

Report on assisted dying bill

“Right to die”

BMJ 2005;330:799 (9 April), doi:10.1136/bmj.330.7495.799

The moral basis of the right to die is the right to good quality life

Ethics

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