Ethical Pillars

Question 1

What are the 4 ethical pillars?

Answer 1

1) Autonomy
2) Beneficence
3) Non-maleficence
4) Justice
(Also, 5) Confidentiality)

Question 2

What is autonomy?

Answer 2

Patients have the right to choose their treatment and to refuse it, as long as they are in a position to understand and process the information in order to come to a decision (patient competence).

Question 3

What is the term for a patient being in a position to understand and process information in order to come to a decision?

Answer 3

Patient competence

Question 4

What are the limitations of autonomy?

Answer 4

• A patient cannot simply demand any treatment they like. They can only choose from the options outlined to them.
• In cases where a parent makes a decision for a child, the beneficence may outweigh the parents’ decision. (e.g. A parent refusing treatment for a life-threatening condition that their child has can be overruled by the doctor acting in the child’s interest)

Question 5

What things must be considered with regards to autonomy?

Answer 5

1) Have we explained fully the patient’s medical condition, their options for treatment and the advantages and disadvantages of those treatments?
2) Is the patient able to retain this information, evaluate their options and arrive at a decision?
3) Has the patient provided informed consent for our actions?

Question 6

What is beneficence?

Answer 6

Always doing what is good for the patient. This may depend on the patient’s circumstances.

Question 7

What are the limitations of beneficence?

Answer 7

• It only applies if it outweighs maleficence

* What is good is highly dependent on the circumstances

Question 8

What things must be considered with regards to beneficence?

Answer 8

1) Will this choice resolve the medical problem?
2) Is this proportionate to the scale of the problem?
3) Is this compatible with the patient’s individual case?
4) Is this in line with the patient’s expectations?

Question 9

What is non-maleficence?

Answer 9

Acting in a way that does not harm the patient, whether actively or by omission.

Question 10

What things must be considered with regards to non-maleficence?

Answer 10

1) What are the risks associated with intervention/non-intervention?
2) Do I possess the required skills and knowledge to carry this out?
3) Is the patient being treated with dignity and respect?
4) Is the patient being put at risk by other factors (e.g. staffing, resources)?

Question 11

What is justice?

Answer 11

• Whether an action is fair across a population in terms of legality and societal expectations. Benefits, costs and risks must also be spread fairly, especially when in short supply.
• No-one should be disadvantaged against -> In the NHS, lower income patients receive free prescriptions

Question 12

What is another name for justice?

Answer 12

Equity

Question 13

What things must be considered with regards to justice?

Answer 13

1) Is this action legal?
2) Does this action unfairly contradict someone’s human rights?
3) Does this prioritise one group over another?
4) If it does prioritise one group over another, can that prioritisation be justified in terms of overall benefit to society or in terms of morality?

Question 14

What is confidentiality?

Answer 14

Respecting a patient’s right to control the information that concerns their own health.

Question 15

Example:
A 26 year old male has been involved in a high-speed collision in which he sustained blunt force trauma to his head as his head hit the front windscreen of his car. He did not lose consciousness, he is fully responsive and has no indications of neurological damage. He does, however, have a significant head wound which is bleeding continuously. This patient has refused treatment on the grounds that he feels “fine” and is refusing to have sutures to close his head wound. He would like to leave the Department.

Answer 15

Even though the best interests of this patient would be served by undergoing a CT scan and having sutures, as he is an adult with full mental capacity, we must respect his autonomy in choosing to leave the Department. We cannot prevent him from leaving, and if we did it would be unlawful detainment.

Question 16

Example:
A 52-year-old man collapses in the street complaining of severe acute pain in his right abdomen. A surgeon happens to be passing and examines the man, suspecting that he is on the brink of rupturing his appendix. The surgeon decides the best course of action is to remove the appendix in situ, using his trusty pen-knife.

Answer 16

From a beneficence perspective, a successful removal of the appendix in situ would certainly improve the patient’s life. But from a non-maleficence perspective, let’s examine the potential harms to the patient.
First of all, the environment is unlikely to be sterile (as is that manky pen-knife) and so the risk of infection is extremely high.
Second, the surgeon has no other clinical staff available or surgical equipment meaning that the chances of a successful operation are already lower than in normal circumstances.
Third, assuming that the surgeon has performed an appendectomy before, they have almost certainly never done it at the roadside – and so their experience is decontextualized and therefore not wholly appropriate.
Fourth, unless there isn’t a hospital around for miles this is an incredibly disproportionate intervention.

Question 17

Example:
Patients suspected of having cancer are prioritised within the NHS with the maximum waiting time for referral being two weeks (as opposed to eighteen weeks for non-urgent referrals). Patients diagnosed with cancer are entitled to a range of treatments including radio- and chemotherapy. These treatments are expensive and treat a small, but significant proportion of patients.

Answer 17

First, let’s analyse the counter-arguments to prioritisation of patients with suspected cancer. One could argue that the prioritisation of these patients over others perhaps infringes the universal right of all patients to receive timely access to healthcare services – in particular access to GP services.
One could also argue that the public expenditure on radio- and chemotherapy treatments could be spent on less expensive treatments that would treat a greater number of people, such as an increase in statins for those at risk of cardiovascular disease.
On the first point about waiting times, one could argue that as cancer patients are referred to specialist oncology centres, their urgent referral actually liberates other services (such as General Practice) and therefore increases access for non-cancer patients.
We could also point to the clinical evidence that shows that early diagnosis and treatment of cancers not only increases survival rates, but also reduces the cost of treatment. Therefore, urgent referrals actually optimises the distribution of resource across the health service.
The second point is a bit more muddied and relates to what is known as the “distribution problem”. In short, do you offer the treatment that maximises the number of years of life, regardless of how many people benefit, or do you offer the treatment that treats the maximum number of people, regardless of how many more years those people will live as a result? Arriving at a morally acceptable answer to this distribution problem is particularly tricky in a system which is publically funded (i.e. almost everyone has paid into the system).
But let’s assume for argument’s sake that British culture is such that we believe in attempting to save the lives of anyone, no matter the cost, because that is the morally right thing to do. We could bolster our counter-argument further by saying if we fail to treat a patient suffering from cancer, we will ultimately spend more money on treating that patient for the co-morbidities associated with the cancer itself. Therefore, unless we are prepared to remove all rights to treatment for that patient, it is ethically and objectively better to treat them early.

Question 18

Example:
An 8 year-old child has been admitted to hospital with a significant open fracture to their left leg. The limb is deformed with significant bleeding and the patient is extremely distressed. The parents are demanding immediate action be taken.

Answer 18

There are a number of options for treatment here, but let’s take an extreme one – amputation. If the bleeding is life threatening, the limb injured sufficiently and the risk of infection extremely high then amputation could be a treatment option. It would be “good” for the patient in as much as the injury would be resolved and the threat to life from bleeding or infection somewhat reduced.
But let’s consider the implications of amputation. The treatment would result in a life-changing injury and the risks of infection or massive bleeding aren’t proportionate. The limitations to their physical movement also carry other future risks that could inadvertently result in further physical and mental health issues.
Most important of all, there are other interventions available to us that have better outcomes attached. Using blood products to manage the bleeding, reducing the fracture if possible and orthopaedic surgery if necessary will have better outcomes for this patient. That course of action is “more good” than amputation.

Question 19

What is Gillick competence?

Answer 19

The term used to describe whether a child under 16 years of age can consent to their own treatment without parental permission.