By Emma Smith
It is an unfortunate fact that ethical dilemmas with no clear-cut answers are faced by each and every doctor, health and social care professional throughout their careers. Difficult decisions are made daily, and there can be major consequences for them.
Situational ethics, unlike many ethical theories, considers context as well as the individual’s personal ideals and judgement to determine what the “right decision” is in a given situation. Medical law, to an extent, relies on this; the law states clear rights and wrongs, but it is impossible for guidelines to cover every situation. A good understanding of different ethical theories, their roots, and how they apply to real life situations can be beneficial when these grey areas are encountered and the outcome becomes reliant upon an individual’s moral principles. Principlism, consequentialism, deontology and virtue ethics are important theories to consider; they can be exemplified using real cases and medical scenarios.
Therefore, it is these select theories that I will be introducing to you today.
Scenario: A patient has debilitating pain in her neck, shoulders and arms. The surgeon gains consent to perform spinal cord decompression, but does not explain the small risk of paraplegia (lower body and leg paralysis), which she develops post-surgery [Sidaway v. Board of Governors of the Bethlem Royal Hospital, 1985].
Principlism is a practical approach to dealing with real-life ethical dilemmas, by following universal and basic ethical guidelines. The four ethical pillars of medicine is a principlist concept very familiar to medical students. Autonomy, beneficence, nonmaleficence, and justice can be exemplified by considering the Sidaway case.
In this case, the surgeon believed that going through with the procedure was the best option, they did not harm the patient intentionally, and they could not have known the eventual outcome. This demonstrates beneficence, doing good, and nonmaleficence, avoiding harm. However, in order to respect the patient’s autonomy, the right to make informed and voluntary choices, consent must be gained after adequately explaining the risks of the procedure. This patient was of sound mind and could weigh up the risks and benefits herself, but she was arguably denied the opportunity. The last of the four principles, justice, concerns what is morally right from a wider, societal viewpoint. Had the patient decided that the procedure was too risky and not consented to it, the time and money used for it to have been undergone may have benefitted someone else. Although it’s not the main issue in this case, this demonstrates the complexity of ethical problems and how many factors must be considered.
Another (often overlooked) ethical theory to consider as a side note is dynamism: the idea that situations change, so a decision made at one time may not continue to be in the patient’s best interests. This makes some judgement calls, for example, when a patient has fluctuating capacity, incredibly difficult to handle “correctly”. Is it better to do nothing than to do what might be wrong?
Scenario: Should you allow a patient to die if their organs would save several other dying patients?
Consequentialism is another class of ethical theory where the morality of an action is based upon its consequences. Utilitarianism, a type of consequentialism, values the best interests of every individual equally when weighing up an overall outcome, whereas one’s self-interest is valued more in egoism, and less in altruism.
The beliefs of an act utilitarian would be consistent with sacrificing one life for several others, as it directly benefits the most people. An altruist may agree with this, as the consequences faced for killing an individual person would be less important than the fact that they had saved multiple lives.
In contrast to that, there would be no consequences for not actively influencing the situation at all by allowing the patients to die naturally, and so an egoist would disagree, alongside a rule utilitarian, that the moral principle of murder being wrong overrides all other principles.
In reality, this is complicated; the weighting of each consequence may change depending on certain circumstances. What if the patient with matching organs was in a coma with little chance of recovery, and a doctor could simply withdraw treatment? What if the patients waiting to be saved were criminals or homeless, or instead, doctors or firefighters?
Deontology and virtue ethics
Deontological, or duty-based ethics, centre around core rules which everyone must follow. For example, Kant’s moral theory argues that the “categorical imperative” should not be violated; this is an unconditional requirement to do what would be considered right by any rational being, independent of contextual details. Another example is the prima facie duties, which includes fidelity, gratitude, justice and beneficence. Prima facie is based on intuition, literally meaning “at first glance”, so the duty most applicable to the situation is the one to take precedence.
On the other hand, a virtue ethicist aims to become a virtuous person who, by possessing desired qualities such as trustworthiness, integrity and compassion, are said to hold a complex mindset capable of dealing with complex problems intuitively. Although fundamentally different, similar outcomes could arise from applying either deontology or virtue ethics to a given situation, as they are based on similar morals such as fairness, trust and doing good.
Good medical practice
The relevance of ethics in medical practice has been recognised since the Hippocratic Oath, which states that physicians must use treatment to help the sick, never intentionally harm any patient, and keep anything that they hear in the profession secret. This ancient text is reflected in the modern day European Convention on Human Rights, for example the right to life, the rights to protection from degrading treatment and discrimination, and the right to respect for private life. Furthermore, the Good Medical Practice guidelines provided by the General Medical Council reiterate all of these points in the context of medical practice in the UK.
Medical ethics is riddled with complexity; the theory behind it has been studied over many centuries, and law and guidelines have been developed in an attempt to make sense of it all. These complexities grow when human emotion and instinct are factored into the equation, and decisions on everything from the lives of unborn foetuses to end of life care become all the more challenging.
This is the first installment by Emma in an intended series about Medical Ethics.