Medical ethics in psychiatry Flashcards
Features of Utilitarianism
Consequences linked to well-being and happiness
The greatest good for the greatest number
Increase happiness, diminish suffering
Focuses on the consequences of our actions
Ends justify the means
Actions have consequences. Utilitarianism reduces all morally relevant factors to consequences.
The claim is controversial because if the suffering of the few>gain of the majority, thus the net good does not increase.
Transplant problem, Imagine that each of five patients in a hospital will die without an organ transplant. The patient in Room 1 needs a heart, the patient in Room 2 needs a liver, the patient in Room 3 needs a kidney, and so on. The person in Room 6 is in the hospital for routine tests. Luckily (for them, not for him!), his tissue is compatible with the other five patients, and a specialist is available to transplant his organs into the other five. This operation would save all five of their lives, while killing the “donor”. There is no other way to save any of the other five patients. We need to add that the organ recipients will emerge healthy, the source of the organs will remain secret, the doctor won’t be caught or punished for cutting up the “donor”, and the doctor knows all of this to a high degree of probability (despite the fact that many others will help in the operation). Still, with the right details filled in (no matter how unrealistic), it looks as if cutting up the “donor” will maximize utility, since five lives have more utility than one life (assuming that the five lives do not contribute too much to overpopulation). If so, then classical utilitarianism implies that it would not be morally wrong for the doctor to perform the transplant and even that it would be morally wrong for the doctor not to perform the transplant. Most people find this result abominable. They take this example to show how bad it can be when utilitarians overlook individual rights, such as the unwilling donor’s right to life. Or enslaving 2% of the population making the economy stronger, increasing overall welfare
Weighing up the treatment of glue ear versus varicose veins. Short life with cancer or a long life with significant disability. The net happiness>misery of the christians, morality demands it as greatest good of the greatest number.
Child-abuse paradox, should we painlessly euthanise the child, as he will have a miserable life, sterilise or reform the parents.
Breaking a promise to a dying person or a vaginal exam under GA against consent. Why are these decisions wrong when they do not cause harm to the individual?
A society or individual should formulate rules to benefit, then sticking by the rules as if they were duties.
Features of deontological ethics
Rules to distinguish right from wrong
Ethical actions follow universal moral laws
Follow the rules and do your duty (fits in with human intuition)
Rigidity in following rules not applying though to actions
Avoids subjectivity and uncertainty
Avoids subjectivity and uncertainty, no weighing costs and benefits
Missile strike, could hack into the system to stop it but that is against your professional code of ethics. Form of lying and cheating.
Features of virtue ethics
Leading a moral life based on virtuous habits
Acquire virtue through practice
Making the right choices
Practical wisdom -phronesis
Can a virtuous person be morally good? Honesty, courage can be faults? Acting on suffering, wrongdoing, facing danger. Lacking practical wisdom -phronesis
The Dark Knight - batman has the opportunity to kill the joker, Utilitarians would endorse killing the joker, deontologists would state it was wrong to kill, virtue ethics would highlight the character of the person who kills the joker, does batman want to take his enemies lives.
Beauchamp and Childress’s ‘four principles’ of biomedical ethics
Respect patient’s autonomy
Maximise welfare – beneficence
Minimise harm – non-maleficence
Respect justice principles (including both attention to resource allocation and justice as fairness)
Helpful for thinking about ethical dilemmas in medicine
How do we interpret the principles of ethics?
Sometimes we disagree with what these principles mean!
Different people in the decision making process may interpret them in different ways
Factors such as culture, class, gender
Power differentials between patient and psychiatrist
Beneficence v non maleficence in psychiatry
Psychiatrists need to think about the risk of harm to the patient but also the risk of harm to others (even if this overrides the wishes of the patient)
Conflicting principles
Sometimes the principles conflict!
E.g. a patient detained under the Mental Health Act for treatment – a patient’s autonomy is overridden in the pursuit of beneficence
Patients who lack capacity – most would agree that if someone lacks capacity it is morally justifiable to try to do what is best for them
But sometimes it is not always clear that people lack capacity. They may be capacitous but just making an unwise decision
Interpreting facts
With any ethical dilemma, useful to start with an analysis of the facts.
However, professionals may interpret facts in different ways to patients, e.g. in terms of any course of action and likelihood.
Professionals can disagree about the facts – e.g. if they have had differing experiences.
Many ‘facts’ of a case are actually predictions, and reasonable people can differ in their predictions of the future.
What are the Difficulties in tackling ethical dilemmas
Sometimes despite ethical reasoning it may feel that there is no ‘good’ option available.
Ethical answer may be ‘justified’ but can lead to ‘bad’ feelings amongst staff – e.g. a patient who was acutely mentally unwell and treated under restraint may make a full recovery but this can still leave staff who were involved feeling uncomfortable.
Ethical dilemmas contain complex interpersonal dynamics – there is a relational context. Human tendency to act in tribes and create a moral distance between themselves and others.
At its most essential, ethical medicine requires each clinician to have the courage to recognise when wider institutional or team behaviour encourages bad practice – and to challenge it.
What is a practical approach to ethical dilemmas?
What are the facts?
What are the morally significant features of each option?
Patient preference, capacity, best interests, consequences
What are the moral arguments for and against each decision?
What does the law or guidance say about each option?
Ask for help – clinical ethics committees, senior colleagues
You are an FY2 doctor on placement in psychiatry and are on-call overnight. Sarah has been brought to A+E by paramedics after her housemate found her vomiting in her room, surrounded by empty paracetamol packets. She hadn’t called for help and was very reluctant to attend A+E, and now wishes to go home.
Her paracetamol level is 184mg/l after 4 hours, meaning that she needs treatment with an antidote to avoid permanent liver damage and possibly even death. She is refusing such treatment and wishes to go home, stating she wants to die, she understands she may die from this overdose and she may act further to end her life; her only regret is agreeing to come to A+E in the first place.
The A+E consultant believes she has mental capacity to make this decision but is concerned and asks you to assess her. She says the same, and after a short-time stops speaking to you, and you don’t know what has triggered this. Her housemate doesn’t know her very well, and has no idea what has triggered this.
She is not previously known to mental health services. You agree she has mental capacity, is not psychotic, seems low but does not have overt symptoms of depression. What do you think should happen?
A. She has capacity, and so she should be allowed to take her own discharge and act as she wishes.
B. She is suicidal and we have little information, so she should be detained to a general hospital ward under the Mental Health Act for assessment (section 2) and given treatment with the antidote against her will (it is legal to do so).
C. As she has capacity you agree to her wishes, so you advise her housemate to monitor the situation and if her consciousness becomes impaired then an ambulance can be called again and she can then be treated, as she would lack capacity..
