Medical Ethics Lecture Notes PDF

Medical Ethics Ethical issues and general principles for APK Michael Trimble Clinical Reader | Honorary Consultant in Medicine [email protected]  Learning objectives Following this lecture and the accompanying tutorial students should be able to:...

Medical Ethics Ethical issues and general principles for APK Michael Trimble Clinical Reader | Honorary Consultant in Medicine [email protected]  Learning objectives Following this lecture and the accompanying tutorial students should be able to: Recognise the ethical elements core to medical practice. Know key ethical theories. Understand how individuals form ethical opinions, in order to reflect on their own ethical framework, and be able to engage in reasoned ethical debate. Describe and utilise an approach to ethical reasoning in the clinical setting. Ethical basis of medical practice The practice of medicine is an inherently ethical endeavour. The clinical encounter is the essence of Medicine – What is wrong? – What can be done? – What should be done for this patient? Edmund D. Pellegrino and David C. Thomasma, A Philosophical Basis of Medical Practice We expect newly qualified doctors to demonstrate appropriate generic personal and professional values and behaviours. They must keep to our ethical guidance and standards, Good medical practice and the explanatory guidance, which together describe what is expected of all doctors who are registered with us. Outcomes 1 - Professional values and behaviours - GMC (gmc-uk.org) Newly qualified doctors must behave according to ethical and professional principles. They must be able to: Summarise the current ethical dilemmas in medical science and healthcare practice; the ethical issues that can arise in everyday clinical decision-making; and apply ethical reasoning to situations which may be encountered in the first years after graduation. Outcomes 1 - Professional values and behaviours - GMC (gmc-uk.org) Ethics in C25 Ethics and law It would not be correct to say that every moral obligation involves a legal duty; but every legal duty is founded on a moral obligation. Lord Chief Justice Coleridge (1893) I would expect medical ethics to be formed by the law rather than the reverse. Hoffman LJ (1993) Ethics: a branch of Philosophy Metaphysics Ontology – study of how things are Epistemology – study of knowledge Logic – how we reason Value theory Aesthetics - beauty Ethics - good A history of Western moral philosophy Classical era The Christian era – Common morality / natural law – Moral absolutes Enlightenment and Modernism – Duty – Rights – Utility Postmodern thought The trolley problem Philippa Foot (1920 – 2010), Judith Jarvis Thomson (1929 –2020) A runaway train is racing toward five men who are tied to the track. Unless the train is stopped, it will inevitably kill all five men. There is a switch that will divert the trolley to a siding where one man is working. Should you flick the switch? The trolley problem Utilitarianism (aka Consequentialism, ethical hedonism) Jeremy Bentham (1748-1832), John Stuart Mill (1806-1873) Actions are right or wrong according to the balance of their good or bad consequences Good is defined as pleasure, and bad as pain The right act in any circumstances is the act that produces the best overall result The greatest good for the greatest number – ‘greatest happiness principle’ ‘The ends justify the means’ The trolley problem Deontology / Duty-based ethics Immanuel Kant (1724-1804) The act itself is more important than the outcome of that act. The rightness or wrongness of actions does not depend on their consequences but on whether we fulfil our duty. Categorical imperative Act only according to that maxim whereby you can, at the same time, will that it should become a universal law. Practical Imperative Act in such a way that you treat humanity, whether in your own person or in the person of any other, never merely as a means to an end, but always at the same time as an end. The trolley problem Doctrine of double effect Thomas Aquinas (1225-1274) The intended effect of care must be positive Any harmful effects of care should be predicted but not intended Harmful effects of care should not be used as a way to achieve beneficial results The beneficial effects of care should outweigh the harmful effects Interventions should be appropriate and proportionate The trolley problem Rights Theory “We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.” The Declaration of Independence July 4, 1776 The trolley problem Moral sense theory (aka moral sentimentalism) David Hume (1711 -1776), Scottish Enlightenment philosopher Anthony Ashley Cooper, 3rd Earl of Shaftesbury (1671 –1713), English politician and philosopher Moral sense: an emotional responsiveness manifesting itself in approval or disapproval The trolley problem Classical virtues: Prudence, justice, temperance, courage Theological virtues: Faith, hope, love (Thomas Aquinas, 1225-1274) Moral realism: Natural Law “The moment you say that one set of moral ideas can be better than another, you are, in fact, measuring them both by a standard, saying that one of them conforms to that standard more nearly than the other. But the standard that measures two things is something different from either. You are, in fact, comparing them both with some Real Morality, admitting that there is such a thing as a real Right, independent of what people think, and that some people's ideas get nearer to that real Right than others. Or put it this way. If your moral ideas can be truer, and those of the Nazis less true, there must be something—some Real Morality—for them to be true about” CS Lewis Right and wrong as a clue to the meaning of the universe Religious Religiousbeliefs beliefs as a source of ethics Character and identity “What should I do?” Or “How should I live?” The Four Principles Respect for Autonomy ~ Greek auto nomos = self-rule Beneficence ~ Latin bene facare = to do good Non-maleficence ~ Latin maleficentia evildoing, mischievousness, injury Justice ~ Latin iustitia "righteousness, equity, the rewarding to everyone of that which is his due" The Belmont Report, 1978 The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research, Report of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. Respect for persons: protecting the autonomy of all people and treating them with courtesy and respect and allowing for informed consent. Researchers must be truthful and conduct no deception (integrity); Beneficence: the philosophy of "Do no harm" while maximizing benefits for the research project and minimizing risks to the research subjects; and Justice: ensuring reasonable, non-exploitative, and well-considered procedures are administered fairly — the fair distribution of costs and benefits to potential research participants — and equally. 23 The Belmont Report, 1978 The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research, Report of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. Respect for persons: protecting the autonomy of all people and treating them with courtesy and respect and allowing for informed consent. Researchers must be truthful and conduct no deception (integrity); Beneficence: the philosophy of "Do no harm" while maximizing benefits for the research project and minimizing risks to the research subjects; and Justice: ensuring reasonable, non-exploitative, and well-considered procedures are administered fairly — the fair distribution of costs and benefits to potential research participants — and equally. 24 Newly qualified doctors must behave according to ethical and professional principles. They must be able to: Summarise the current ethical dilemmas in medical science and healthcare practice; the ethical issues that can arise in everyday clinical decision-making; and apply ethical reasoning to situations which may be encountered in the first years after graduation. Outcomes 1 - Professional values and behaviours - GMC (gmc-uk.org) Where do clinical ethical dilemmas most commonly arise? Neonatal End of Life Emergency care Terminal and/or chronic illness Consent issues / Capacity / Lack of capacity Breach of Confidentiality Cultures, values, faith not respected Duties of a doctor (non-compliance) Rationing Evolving technologies, e.g., genetics, allogenic transplants  Quandary ethics or Quotidian ethics quotidian a.& n. 1. a. Daily, of every day. 2. Commonplace Ethical basis of medical practice The practice of medicine is an inherently ethical endeavour. The clinical encounter is the essence of Medicine – What is wrong? – What can be done? – What should be done for this patient? Edmund D. Pellegrino and David C. Thomasma, A Philosophical Basis of Medical Practice What do you mean by good? The biomedical good – that which can be achieved by medical interventions into a particular disease state. The patient’s perception of their own good at the particular time and circumstances of the clinical decision. The good of the patient as a human person capable of reasoned choices. This reflects back on respect for the patient as a person. The ultimate good – that which accords with basic convictions and core beliefs Edmund D. Pellegrino and David C. Thomasma, For the Patient’s Good Self-evident ethical principles Respect for persons (including oneself) Fidelity & Honesty Justice Reparation Beneficence Non-maleficence Compassion After WD Ross The Right and the Good. OUP 1930 An approach to ethical problems 1. Identify the problem: what are the facts of the case in question? 2. What is your emotive response? 3. Are there any relevant rules that can be applied? 4. If the rules do not provide an adequate answer, what principles apply? 5. Is there a conflict with your basic convictions?  Clinical decision making Dual-process model of decision-making Ethical debate: Levels of moral discourse After Henry David Aiken Level Characteristics Example Expressive- a) No reasons are given for the moral Simple decisions / gut feeling evocative judgement. b) The moral judgement applies to one particular case Rules a) The rule applies not just to one The law immediate case but to all similar The GMC cases but also NICE, SIGN, etc. b) The rule tells us directly what to do or not to do Principles a) A principle supports rules – or Autonomy, beneficence, non- criticises them maleficence, justice b) A principle is more general than a Consequences / Duty rule; it does not tell us directly and Virtues concretely what to do. Post-ethical / a) A basic conviction is the basis for our Personal core beliefs / world view basic principles, rules and overall ethical convictions reasoning b) You can’t go deeper than basic convictions “Thick” and “thin” debate Thick debate: Deep and wide range of thought with consideration of ends as well as means. Thin debate: Focus on means of achieving ends rather than the rightness of the ends themselves. 37 Levels of moral discourse Level Characteristics Thin Expressive- a) No reasons are given for the moral evocative judgement. b) The moral judgement applies to one particular case Rules a) The rule applies not just to one immediate case but to all similar cases b) The rule tells us directly what to do or not to do Principles a) A principle supports rules – or criticises them b) A principle is more general than a rule; it does not tell us directly and concretely what to do. Post-ethical / basic a) A basic conviction is the basis for our convictions principles, rules and overall ethical reasoning Thick b) You can’t go deeper than basic convictions The Four Principles Respect for Autonomy ~ Greek auto nomos = self-rule Beneficence ~ Latin bene facare = to do good Non-maleficence ~ Latin maleficentia evildoing, mischievousness, injury Justice ~ Latin iustitia "righteousness, equity, the rewarding to everyone of that which is his due"  Character and identity “What should I do?” Or “How should I live?” “What kind of doctor will I be?”