medical ethics and ethical reasoning

how to tackle ethical reasoning questions

• define issues and terms

  • e.g. mandatory = mandatory for all of society? all healthcare professionals?

• consider for and against

• apply relevant medical ethics and laws

• never sit on the fence, always come to a justified conclusion

  • e.g. yes because the risks do not outweigh the greater benefits to society (explain)

4 pillars of medicine 

1. autonomy 

2. beneficence 

3. non-maleficence

4. justice 

autonomy

the right of a patient to make their own choices

• ensure patient can give informed consent

• respect patient wishes

• provide patient-centered care

beneficence

the aim of medicine is to do good and benefit the patient as well as society (societal beneficence)

• preventing greater harm to the patient

• consider long term

  • e.g. invasive surgery, risk of harm and complications, but if surgery would improve patient’s quality of life it is in their best interest

non-maleficence

first do no harm (not always possible)

• mediating current harm and prevent greater harm to the patient in the future

justice 

the aim of medicine is to be fair and treat all people with dignity 

• aim for equity over equality - allocating resources to who those with the highest need, not giving it equally

• abide by the law

UK legal age of consent

16

the 3 C’s

• consent

• capacity

• competency

consent

• voluntarily giving permission for medical treatment to be carried out

• can be withdrawn at any time

• patient must have capacity and must have enough information to give informed consent

  • implied consent, e.g. holding your arm out for a blood test

  • verbal consent

  • written consent

capacity 

• able to understand, retain and process information on your own

  • weigh the benefits, risks and alternatives

• can come to a reasoned conclusion which you can communicate

factors that may decrease decision-making capacity

• dementia

• stroke

compliance

how likely the patient is to listen to your advice

• 40% of patients are compliant

  • doctor-patient relationship is weakening, need better communication and public trust

competency

18+ assumed to be competent and therefore have capacity

able to make a rational/reasonable decision, able to refuse or accept treatment

Gillick competence

under 16s can consent to medical treatment if they demonstrate Gillick competence

• able to understand professional advice

• able to process the nature of the implications of proposed treatment

Fraser guidelines

a subset of Gillick competence specific to providing contraception to minors without parental consent

a doctor can give contraception to a minor if:

1. the person fully understands the advice

2. they cannot be persuaded to involve parents or allow a healthcare professional to do so

3. they are likely to begin or continue sexual intercourse regardless of whether contraceptive treatment is received or not

4. their physical or metnal health may suffer without contraceptive treatment

5. treatment is in their best interests

confidentiality

the right of the patient to

allows for patient trust

because you have a duty of care, confidentiality can be broken if: 

the patient is a risk to:

• themselves, e.g. 

• someone else, e.g. refusing to inform a sexual partner of a current STI

• society, e.g. driving with epilepsy or diabetes, DVLA unaware 

who can patient data be shared with?

nobody, apart from other doctors involved in the patient’s care

a patient has a genetically communicable disease such as Huntington’s disease

which relatives can you inform?

none: the patient should decide this 

however, perhaps you could ask the patient to inform their children, but the patient’s partner does not need to be informed 

13 year old patient asking for contraception and insists her parents must not be told

• sexual relationships at/under 13 are a safeguarding issue: contact safeguarding lead at hospital

• discover the age of the sexual partner to check for potential grooming

• ask open questions to try and detect information

• treat the safeguarding issue and the contraception request separately: apply Fraser guidelines to decide whether to give or not

you have only one liver

2 people need the liver

who should get it?

• young alcoholic patient

• elderly cancer patient

consider genetic matching of the liver

consider who it will benefit the most in terms of quality adjusted life years

it could be that there is a higher likelihood of longer-lasting benefit for the younger patient

must consider the clinical urgency of each person’s condition

a single doctor would not make this decision alone

you are the only doctor available and 2 patients enter simultaneously

who do you attend to first?

• a child with a severe injury

• an elderly person experiencing a heart attack

• justice - make sure the care is equitable

• beneficence - doing the best thing for both patients

• non-maleficence - do not harm anybody, mitigate harm already done

• do not solely use age to prioritise

• consider who has the highest chances of survival

• clinical urgency - although the other patient may also be in a lot of pain and is equally deserving of care, you should consider prioritising the most life-threatening condition, e.g. cardiac arrest, heart attack, etc.

• allocate nurses/members of MDT to look after the child while you stabilise the elderly person

should organ donation be compulsory?

• autonomy of patients will be undermined - not providing patient-centered care, removing people’s right to make decisions about their bodies

• societal beneficence - organ donations can save thousands of lives, more donated organs means less patients waiting on a transplant waiting list

• in the UK, everyone is considered an organ donor unless they opt out: maximises organ donations, protects patient autonomy

• educational campaigns to promote

should patients pay a fine for missed NHS appointments?

• beneficence - fines may reduce missed appointments so improves access for the rest of the public so leads to:

• justice - everyone has fair access to appointments

• non-maleficience - finanical harm to low-income people, may discourage them from booking, people may miss appointments due to transport costs or not being able to miss work otherwise they won’t get paid

• justice - not fair for people with the barriers stated above

• we shouldn’t punish patients

• educational campaigns

is it ethical for patients to use private healthcare to avoid NHS waiting times?

could be unethical as access to private depends on a person’s wealth/ability to pay

• social injustice: healthcare access shouldn’t depend on your wealth

quality difference

• NHS and private should be the same quality as both are regulated by the General Medical Council

• access depends on financial status

• if unemployed and care for children or vulnerable people, private may not be the wisest option as it is very difficult to afford

depends on urgency of condition

• NHS has very long waiting lists so privatisation will alleviate pressures on the NHS and reduce the waiting times

• NHS appointment may not be tailored to work life: since the NHS is high in demand, you may be given quite random appointment times which and some people may have to miss work to attend an appointment so they lose money for that day

should vaccines be mandatory?

• societal beneficence - achieves herd immunity, supports healthcare system resiliience

• non-maleficence - protects vulnerable groups in society

• autonomy - undermined, so may erode patient trust

• justice - may disproportionately affect certain groups, some cannot receive vaccines due to pregnancy, allergies, ilnesses

• non-maleficence - vaccines may have side effects

• vaccination should not be mandatory

• education campaigns to encourage herd immunity