|Basic Ethical Principles||Return to Ethics Theme|
1. Core Knowledge:
The practice of medicine has changed in ways that highlight the relevance of ethical issues. Medical science can intervene in ways (such as genetics, stem cells) that were not previously possible; patients are better informed; litigation is more common; physicians have to be aware of the cost implications of their treatment for society; they have to juggle obligations to the hospital, the health region and the government.
Ethics deals with right and wrong conduct, with what we ought to do and what we should refrain from doing.
Medical ethics concerns how to handle moral problems arising out of the care of patients; often clinical decisions must consider more than just the patient's medical condition.
"Ethical issues arise when not all values can be respected. The values in conflict must then be prioritized and the essence of 'doing ethics' is to justify breaching the values that are not respected." (Margaret Somerville, November 2008)
Ethics is not the only discipline that deals with these issues: the law and theology also prescribe certain behaviours. Law is concerned with rules enacted by a certain society and that have effect within geographical boundaries.
Evolving bases for ethical reasoning.
First, be aware of a distinction between ethical arguments that are based on set principles ("lying is always morally wrong", or "our religion forbids it"), which is called "principlism" and arguments of a more flexible nature in which the circumstances of a case influence the decision. This is called casuistry, or case-based argument. Here, theory plays a lesser role, and judgments are reached by referring to paradigms or 'pure cases' that illustrate accepted appropriate ways of acting. This is also how the law works, and you may see a parallel with the difference between deductive and inductive reasoning.
Religious tenets differ from ethical principles in the source of their authority: they are based on the word of God as interpreted by believers, rather than on a process of reasoning. Religions can permit reasoning about rules of behaviour, but this can only occur within the framework of the fundamental beliefs of the religion. Over time, our approach to ethics has evolved from a religious basis towards a secular code of ethics.
More detail on bases for ethical arguments. You should also be aware of other foundations for systems of clinical ethics, such as feminism and hermeneutics.
Discussion topic: should you prescribe an antibiotic for a viral illness when a patient demands it? Core question to ask yourself: What does this patient want (relevant to autonomy)? What can be done for them? (beneficence) Is the request fair? (justice) This discussion introduces . . .
2. Nice to Know:
The Four Traditional Pillars of Medical Ethics
Traditional approaches to medical ethics quote the four fundamental principles described below.
- Respect for autonomy of the patient. Autonomy refers to the capacity to think, decide and act on one's own free initiative. Physicians and family members therefore should help the patient come to their own decision by providing full information; they should also uphold a competent, adult patient's decision, even if it appears medically wrong.
- Beneficence: promoting what is best for the patient. The general moral principle of doing good to others is focused by the lens of being in a professional caring relationship. The definition of 'what is best' may derive from the health professional's judgment or the patient's wishes (see Autonomy); these are generally in agreement, but may diverge. Beneficence implies consideration of the patient's pain; their physical and mental suffering; the risk of disability and death; and their quality of life. At times, beneficence can imply not intervening, if the benefit of therapy would be minimal.
- Non-maleficence: do no harm. In most cases of treating sick patients this adds little to the beneficence principle. But most treatments involve some degree of risk or have side-effects, so this principle reminds us to ponder the possibility of doing harm, especially when you cannot cure. May there be harmful consequences of labelling this patient as having bipolar disorder? In dealing with healthy people (e.g., preventive care, immunizations), do the benefits outweigh the potential harms? Remember that medicine has a long history of doing harm. In the 18th and early 19th century, surgery was highly lethal and giving birth in hospital led to higher maternal mortality than home births. Such problems are not entirely a matter of the past: the recent outbreaks of C. difficile in Quebec hospitals had killed 100 patients by early 2004, and the problem continues. For historical material on the dangers of medicine, see a web site on Victorian British medicine
- Justice. Resources are limited; you cannot cure everybody and so priorities must be set (hence the notion of triage). In allocating care, the Justice principle holds that patients in similar situations should have access to the same care, and that in allocating resources to one group we should assess the impact of this choice on others. In effect, is what the patient is asking for fair? Will it lead to a burden to others (such as the family caregivers)? While your primary duty is to your patient, others will be affected by your decisions and there may be a tension between beneficence, autonomy and justice.
Confidentiality forms a cornerstone of the doctor-patient relationship, but it is increasingly hard to maintain with the growth of electronic data. In order to protect the trust between doctor and patient, the physician should not release personal medical information without the patient's consent. Like other ethical duties, however, confidentiality is not absolute. It can be necessary to override privacy in the interests of public health, as in contact tracing for partners of a patient with a sexually transmitted disease. Note that you are legally obligated to report a possibly HIV infected patient to the public health authorities. However, this should always be done in a way that minimizes harm to the patient.
Discussion topic: A patient's relative gives you information on the patient but asks you not to reveal where the information came from. Do you have to keep this secret?
Disclosure. For the patient to be well informed and to make informed choices (i.e., autonomy), the doctor must disclose information that is materially relevant to the patient's understanding of their condition, their treatment options and likely outcomes. This would include, for example, information on medical errors made in their care. As the American College of Physicians says: "Errors do not necessarily constitute improper, negligent, or unethical behavior, but failure to disclose them may."
Discussion topic: A teenage patient requests an abortion but asks you not to tell her parents. How do you balance protection of the patient's confidentiality against the rights of her parents?
There are some circumstances under which you may choose not to disclose information to a patient, including when the patient specifically asks not to be told (you should still offer them the chance to know the truth); when a patient is incapacitated (here you typically inform the family); during an emergency when the patient's condition is unstable and immediate care is required; and the controversial notion of 'therapeutic privilege', which means that the doctor deems that the risk of informing the patient is worse than not doing so (e.g., they might attempt suicide, or refuse necessary treatment).
Link to Disclosing adverse events
Informed Consent follows from the principle of patient autonomy, and consent is required before you may provide care. "No medical intervention done for any purpose - whether diagnostic, investigational, cosmetic, palliative, or therapeutic - should take place unless the patient has consented to it" (Hébert, p. 84). Informed consent also serves as a significant protection to you against possible litigation.
Consent may be expressed or implied; the former (e.g., via a signed consent form) typically occurs in hospitals and relates to specific procedures. Consent may be given verbally, but a consent form provides evidence of consent. It is not a contract, however, and the patient can withdraw consent at any time. For routine procedures such as a blood pressure check, consent may be implied if the patient comes voluntarily to the doctor’s office for a check-up.
For consent to be ‘informed’ the patient must receive a full description of the procedure, its risks and benefits, the prognosis with and without treatment, and alternative treatments. The patient must have the mental competence to comprehend the information, and must give specific authorization for the doctor to proceed with the plan. The onus is not exclusively on the doctor: the patient should ask questions when they are uncertain and should think carefully about their choices.
More detail: Note the distinction between consent and assent, which may mean merely following the doctor’s orders. Consent forms that the patient typically signs in a hospital are chiefly for information, and will not necessarily protect the doctor from litigation. Patients commonly do not remember the contents of the consent form.
Link to CMPA brochure "Consent: a Guide for Canadian Physicians
Putting it into practice
Several groups have proposed frameworks that help you to address the ethical aspects of a difficult situation in a systematic manner.
Hébert's book (page 20) suggests the following steps in reaching an ethical decision:
- Describe the case simply but with the pertinent facts
- Specify the ethical dilemma
- What alternatives do you have?
- List the key considerations: Autonomy; Beneficence (what are the medical alternatives?); Justice (rights of patient vs. family, etc); Context (situational factors such as your own feelings, your peers, the law)
- Propose a resolution
- Review this choice critically: formulate it as a general maxim and review its plausibility
- Do the right thing!
Hébert PC. Doing right: a practical guide to ethics for medical trainees and physicians. Oxford University Press, 1995
The Ottawa Hospital has developed guidelines suitable for an ethics consultation service (in English et en français) that you may find helpful.
Ethics (2): Putting these principles into practice
The World Medical Association's self-instructional course on "Fundamentals of Medical Ethics".
Tri-Council policy on research ethics developed by three Canadian research councils.
It comes with a tutorial on research ethics
Canadian Medical Association's code of ethics
UK Clinical Ethics Network training materials from Oxford University