Medical ethics Flashcards
What are the 4 pillars of medical ethics?
Patient autonomy
Beneficence
Non-maleficence
Justice
what is Patient autonomy? 3 things
Autonomy means that a patient has the ultimate decision-making responsibility for their own treatment
Autonomy also means that a medical practitioner cannot impose treatment on an individual for whatever reason
Why is Autonomy Important?
Autonomy is important because we need to make sure that the patient is actively involved in their diagnosis and treatment – and not just deferring to their Doctor.
give autonomy examples
End of life care - no more pain relief, do not resuscitate or no further medication
how would you answer this in terms of autonmy?
‘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 that 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.’
Even though the best interests of this patient would be served by undergoing a CT scan and having sutures, he is an adult with full mental capacity, and so 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.
what to remember when discussing autonomy at the interview
Have you explained fully the patient’s medical condition, their options for treatment and the
advantages and disadvantages of those treatments?
Is the patient able to retain this information, evaluate their options and arrive at a decision?
Has the patient provided informed consent for our actions?
what are the cases where an individual is deemed to be unable to make autonomous decisions?
Mental capacity act - ie demetira, brain injusry, stroke, mental health illnes, unconcious
what is Beneficence
All medical practitioners have a moral duty to promote the course of action that they believe is in the best interests of the patient
what should we take into consideration for beneficence?
Will this option resolve this patient’s medical problem?
Is it proportionate to the scale of the medical problem?
Is this option compatible with this patient’s individual circumstances?
Is this option and its outcomes in-line with the patient’s expectations of treatment?
What are the pros vs cons of a treatment?
Why Is Beneficence Important?
it ensures that healthcare professionals consider individual circumstances and remember that what is good for one patient may not necessarily be great for another.
how would you answer this in terms of beneficnce?
‘An eight-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’
Many options:
life-threatening - If the bleeding is life-threatening, the limb sufficiently injured 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). HOWEVER 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.
ALSO - Using blood products to manage the bleeding, reducing the fracture if possible and orthopaedic surgery if necessary will have better outcomes for this patient ( “more good” than amputation.)
what does beneficince help us do?
Beneficence asks us to promote a course of action, but in practice, we also need to de-promote certain courses of action if there are better options available.
what to remember when discussing beneficince at the interview
Have you thoroughly considered every option and weighed up what the best course of action is for the specific patient in the scenario?
Does the best course of action align with patient expectation?
What Is Non-Maleficence?
Sister to Beneficnce
ONE OF THE MOST IMPORTANT
Non-maleficence states that a medical practitioner has a duty to do no harm or allow harm to be caused to a patient through neglect. Any consideration of beneficence is likely, therefore, to involve an examination of non-maleficence.
How Is Non-Maleficence Different to Beneficence?
- it acts as a threshold for treatment. If a treatment causes more harm than good, then it should not be considered. This is in contrast to beneficence, where we consider all valid treatment options and then rank them in order of preference.
- we tend to use beneficence in response to a specific situation – such as determining the best treatment for a patient. In contrast, non-maleficence is a constant in clinical practice. For example, if you see a patient collapse in a corridor you have a duty to provide (or seek) medical attention to prevent injury.
how would you answer this in terms of Non-Maleficence vs Beneficince?
‘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.’
Beneficince perspective:
successful removal of the appendix in situ would certainly improve the patient’s life.
non-maleficence perspective:
The environment is unlikely to be sterile (as is that manky pen-knife) and so the risk of infection is extremely high
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
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
Unless there isn’t a hospital around for miles, this is an incredibly disproportionate intervention.
what to remember when discussing non-maleficnce at the interview
What are the associated risks with intervention or non-intervention?
Do I possess the required skills and knowledge to perform this action?
Is the patient being treated with dignity and respect?
Is the patient being put at risk through other factors (e.g. staffing, resources, etc.)?
Does Beneficince and non-maleficnce clash with the principle of autonomy?
At times, these principles may conflict with a patient’s autonomy. For example, a treatment that not might be desired because it is painful or unpleasant could still be argued to be applied as it would be in the patient’s ‘best interest’ in the long term.
The best interest principle is to be applied when a patient is found to be incompetent in making a decision. A medical practitioner is to act on the patient’s behalf.
This can be a source of conflict given that doctors have a strong desire to achieve the best outcome for their patients, while patients may not always want any such treatment.
What is justice?
the principle that when weighing up if something is ethical or not, we have to think about whether it’s compatible with the law, the patient’s rights, and if it’s fair and balanced.
we must ensure no one is unfairly disadvantaged when it comes to access to healthcare. Justice is one reason why the NHS has certain entitlements, such as free prescriptions for lower-income individuals.
what are the principles of justice?
Respect for morally acceptable laws (legal justice)
Fair distribution of scarce resources (distributive justice)
Respect for people’s rights (rights-based justice)
how would you answer this in terms of justice?
‘Patients suspected of having cancer are prioritised within the NHS, with the maximum waiting time for referral being two weeks (as opposed to 18 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.’
It could be argued that prioritising cancer patients means you’re limiting the ability of other patients to access healthcare
A counter-argument might be that by referring these patients to specialist oncology centres, you’re actually freeing up other services
It could also be argued that spending public money on radio- and chemotherapy on a smaller group of people is taking budget away from less expensive treatments that would benefit a greater number of people – for example, an increase in statins for those at risk of cardiovascular disease
A counter-argument would be that early treatment increases survival rates and actually reduces the cost of cancer treatment
what to remember when discussing non-maleficnce at the interview
Is this action legal?
Does this action unfairly contradict someone’s human rights?
Does this action prioritise one group over another?
If it does prioritise one group over another, can that prioritisation be justified in terms of overall net benefit to society or does it agree with moral conventions?
what is Consequentialism
Consequentialism is an ethical ideology that states the morality of an action is dependent purely on its consequences. A simpler way to phrase this would be that the “ends justify the means”. If your action has an overall benefit, then it does not matter about the action itself.
Example: Your patient has a terminal illness and is not likely to survive the operation she is about to undertake. Just as she is about to be anaesthetised, she asks you: “Doctor, will I be okay?”. A consequentialist ideology supports that lying in this circumstance is acceptable, even though lying itself is not a moral action.
what is utilitarianism?
Utilitarianism says the best action is that one that brings about the best increase in utility (benefit). Utility is generally considered on a broad scale, often taking into consideration wider society and not just the patient in question. It’s a form of consequentialism.
Example: You have a sum of money to either fund a very expensive treatment for one patient with a rare disease or five patients with a very common and easy-to-treat disease. Utilitarian ethics dictates that treating the five patients is morally superior as a greater overall benefit is achieved.
