Medical ethics

Question 1

What are the 4 pillars of medical ethics?

Answer 1

Patient autonomy
Beneficence
Non-maleficence
Justice

Question 2

what is Patient autonomy? 3 things

Answer 2

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

Question 3

Why is Autonomy Important?

Answer 3

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.

Question 4

give autonomy examples

Answer 4

End of life care - no more pain relief, do not resuscitate or no further medication

Question 5

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.’

Answer 5

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.

Question 6

what to remember when discussing autonomy at the interview

Answer 6

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?

Question 7

what are the cases where an individual is deemed to be unable to make autonomous decisions?

Answer 7

Mental capacity act - ie demetira, brain injusry, stroke, mental health illnes, unconcious

Question 8

what is Beneficence

Answer 8

All medical practitioners have a moral duty to promote the course of action that they believe is in the best interests of the patient

Question 9

what should we take into consideration for beneficence?

Answer 9

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?

Question 10

Why Is Beneficence Important?

Answer 10

it ensures that healthcare professionals consider individual circumstances and remember that what is good for one patient may not necessarily be great for another.

Question 11

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’

Answer 11

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.)

Question 12

what does beneficince help us do?

Answer 12

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.

Question 13

what to remember when discussing beneficince at the interview

Answer 13

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?

Question 14

What Is Non-Maleficence?

Answer 14

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.

Question 15

How Is Non-Maleficence Different to Beneficence?

Answer 15

1. 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.
2. 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.

Question 16

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.’

Answer 16

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.

Question 17

what to remember when discussing non-maleficnce at the interview

Answer 17

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.)?

Question 18

Does Beneficince and non-maleficnce clash with the principle of autonomy?

Answer 18

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.

Question 19

What is justice?

Answer 19

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.

Question 20

what are the principles of justice?

Answer 20

Respect for morally acceptable laws (legal justice)

Fair distribution of scarce resources (distributive justice)

Respect for people’s rights (rights-based justice)

Question 21

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.’

Answer 21

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

Question 22

what to remember when discussing non-maleficnce at the interview

Answer 22

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?

Question 23

what is Consequentialism

Answer 23

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.

Question 24

what is utilitarianism?

Answer 24

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.

Question 25

what is deontolgy?

Answer 25

Deontology is also known as “duty-based ethics”. This ideology states that the correct course of action is dependent on what your duties and obligations are. It means that the morality of an action is based on whether you followed the rules, rather than what the consequence of following them was.

This is in direct contrast with consequentialism.

Example: If your terminally ill patient asks if they’ll be ok after a surgery they’re unlikely to survive, a deontological approach would suggest you don’t lie to comfort them. That’s because according to this concept, lying isn’t morally acceptable because it’s our obligation not to lie – no matter the consequences.

Question 26

what are The challenges to upholding the principles of justice

Answer 26

While this might be the most obvious element to an ethical framework, it is worth noticing that despite many organisations making fairness core to their approach, in reality, healthcare systems can be subject to many different biases, which may or may not be intentional.

In recent years, there has been much debate over whether certain operations should be available on the NHS, for example, knee operations for those who are morbidly obese given that their lifestyle is likely to have played a significant role in their need for treatment.

However, these patients are taxpayers who have a genuine medical need, thus it is argued that it is unfair to deny them treatment. The same argument applies to alcoholics and smokers, both population groups who are not denied NHS treatment.

Question 27

what is Gillick competence

Answer 27

medical law to decide whether a child (under 16 years of age) is able to consent to their own medical treatment, without the need for parental permission or knowledge.