Fundamentals Of Medical Ethics

Journal of Medical Ethics

Journal of Medical Ethics (Photo credit: Wikipedia)

During our MBBS days, the topic of Medical Ethics was probably included in Forensic Medicine and was never stressed. In these days of Consumer Awareness and doctors having been brought under the purview of Consumer Forums, there is a need for every practicing doctor to be aware of the basics of medical ethics.

A common framework used in the analysis of medical ethics is the “four principles” approach postulated by Tom Beauchamp and James Childress in their textbook “Principles of Biomedical Ethics.”

  1. Autonomy: Patient has the right to refuse or choose the treatment
  2. Beneficience: Doctor should act in the best interests of the patient.
  3. Non-maleficence: “Primum non nocere” or First, do no harm.
  4. Justice and Protection of Human Rights:

Autonomy

The principle of autonomy recognizes the rights of individuals to self-determination. This is rooted in society’s respect for individuals’ ability to make informed decisions about personal matters. Autonomy has become more important as social values have shifted to define medical quality in terms of outcomes that are important to the patient rather than medical professionals. The increasing importance of autonomy can be seen as a social reaction to a “paternalistic” tradition within healthcare.

Sometimes patient can not take a decision for himself. In such cases, psychiatrists and clinical psychologists are often asked to evaluate a patient’s capacity for making life-and-death decisions at the end of life. Persons with a psychiatric condition such as delirium or clinical depression may not have the capacity to make end-of-life decisions. Therefore, for these persons, a request to refuse treatment may be taken in consideration of their condition and not followed. Unless there is a clear advance directive to the contrary, in general persons lacking mental capacity are treated according to their best interests. On the other hand, persons with the mental capacity to make end-of-life decisions have the right to refuse treatment and choose an early death if that is what they truly want. In such cases, psychiatrists and psychologists are typically part of protecting that right. In these situations, the treating doctor should be wary of legal action being taken against them because what is ethical need not be legal!!

Beneficence

The term beneficence refers to actions that promote the well being of others. In the medical context, this means taking actions that serve the best interests of patients. However, uncertainty surrounds the precise definition of which practices do in fact help patients.

Some scholars, such as Edmund Pellegrino, argue that beneficence is the only fundamental principle of medical ethics. They argue that healing should be the sole purpose of medicine, and that endeavors like cosmetic surgery and euthanasia fall beyond its purview.

Non-Maleficence

The concept of non-maleficence is embodied by the phrase, “first, do no harm,” or the Latin phrase: Primum Non Nocere. Many consider that should be the main or primary consideration : that it is more important not to harm your patient, than to do them good. This  is partly because enthusiastic practitioners are prone to using treatments that they believe will do good, without first having evaluated them adequately to ensure they do no (or only acceptable levels of) harm.

It is not only more important to do no harm than to do good; it is also important to know how likely it is that your treatment will harm a patient. So a physician should go further than not prescribing medications they know to be harmful – he or she should not prescribe medications (or otherwise treat the patient) unless s/he knows that the treatment is unlikely to be harmful; or at the very least, that patient understands the risks and benefits, and that the likely benefits outweigh the likely risks.

In practice, however, many treatments carry some risk of harm. In some circumstances, e.g. in desperate situations where the outcome without treatment will be grave, risky treatments that stand a high chance of harming the patient will be justified, as the risk of not treating is also very likely to do harm. So the principle of non-maleficence is not absolute, and balances against the principle of beneficence (doing good).

Conflicts between autonomy and beneficence/non-maleficence

Autonomy can come into conflict with beneficence when patients disagree with recommendations that healthcare professionals believe are in the patient’s best interest. When the patient’s interests conflict with the patient’s welfare, different societies settle the conflict in a wide range of manners. In general, Western medicine defers to the wishes of a mentally competent patient to make his own decisions, even in cases where the medical team believes that he is not acting in his own best interests. However, many other societies prioritize beneficence over autonomy.

Justice and Human Rights

The human rights era started with the formation of the United Nations in 1945, which was charged with the promotion of human rights. The Universal Declaration of Human Rights (1948) was the first major document to define human rights. Medical doctors have an ethical duty to protect the human rights and human dignity of the patient so the advent of a document that defines human rights has had its effect on medical ethics. Most codes of medical ethics now require respect for the human rights of the patient.

In applying and advancing scientific knowledge, medical practice and associated technologies, human vulnerability should be taken into account. Individuals and groups of special vulnerability should be protected and the personal integrity of such individuals respected.

1 Informed consent: in Medical ethics usually refers to the idea that a person must be fully informed about and understand the potential benefits and risks of their choice of treatment. An uninformed person is at risk of mistakenly making a choice not reflective of his or her values or wishes. It does not specifically mean the process of obtaining consent, or the specific legal requirements, which vary from place to place, for capacity to consent. Patients can elect to make their own medical decisions, or can delegate decision-making authority to another party. If the patient is incapacitated, laws around the world designate different processes for obtaining informed consent, typically by having a person appointed by the patient or their next of kin make decisions for them. The value of informed consent is closely related to the values of autonomy and truth telling.

A correlate to “informed consent” is the concept of “informed refusal.”

2 Confidentiality is commonly applied to conversations between doctors and patients. This concept is commonly known as patient-physician privilege.

Legal protections prevent physicians from revealing their discussions with patients, even under oath in court.

Confidentiality is an important issue in primary care ethics, where physicians care for many patients from the same family and community, and where third parties often request information from the considerable medical database typically gathered in primary health care.

3 Communication: Many so-called “ethical conflicts” in medical ethics are traceable back to a lack of communication. Communication breakdowns between patients and their healthcare team, between family members, or between members of the medical community, can all lead to disagreements and strong feelings. These breakdowns should be remedied, and many apparently insurmountable “ethics” problems can be solved with open lines of communication.

4 Referral: Doctors who receive income from referring patients for medical tests have been shown to refer more patients for medical tests. Fee splitting and the payments of commissions to attract referrals of patients is considered unethical and unacceptable in most parts of the world.

5 Vendor relationships: Studies show that doctors can be influenced by drug company inducements, including gifts and food. Industry-sponsored Continuing Medical Education (CME) programs influence prescribing patterns. Many patients surveyed in one study agreed that physician gifts from drug companies influence prescribing practices. A growing movement among physicians is attempting to diminish the influence of pharmaceutical industry marketing upon medical practice

6 Futility of Further treatment: The concept of medical futility has been an important topic in discussions of medical ethics. What should be done if there is no chance that a patient will survive but the family members insist on advanced care? Previously, some articles defined futility as the patient having less than a one percent chance of surviving. Some of these cases are examined in court.

Advanced directives include living wills and durable powers of attorney for health care. In many cases, the “expressed wishes” of the patient, if the patient decides to give a DNR (Do Not Resuscitate) statement are documented in these directives, and this provides a framework to guide family members and health care professionals in the decision making process when the patient is incapacitated.

“Substituted judgment” is the concept that a family member can give consent for treatment if the patient is unable (or unwilling) to give consent themselves. The key question for the decision making surrogate is not, “What would you like to do?”, but instead, “What do you think the patient would want in this situation?”.

In conclusion, Medical Ethics is different from Medical Jurisprudence. Ethics is based on humanistic approach while Jurisprudence is based on the Law of the Land. It is important for all doctors to avoid being on the wrong side of the law to avoid litigation but it is more important to be an ethical doctor, who will ultimately win laurels and also command better practice in due course.

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