ETHICS IN APPLIED MEDICINE

Approach to ethical dilemmas

Define the nature of the problem.
• Example:
A baby born prematurely at 24 weeks
gestation is put in intensive care. However she
is not thriving and scans suggest she has
profound brain damage. She cannot breathe
unassisted and the care team believe she is
suffering and it is not in her interest to keep
her alive. The parents do not agree. What
should the clinician do?
 Dissect problem by considering…

• Consequences
What are the consequences of any given course of action?
Consider both benefits and harms

• Duties and Obligations

What are the duties of the clinician? Does the dilemma arise
from a conflict of duties? To whom does the clinician owe
these duties? If so how best can this dilemma be resolved?

• Categorical imperatives
Is it a case of respect for confidentiality/informed consent?

• Application of principles
How might the four key principles of ethical clinical practice be
applied?
 Theories of applied ethics

• Utilitarianism (consequentialism)

• Deontological ethics
 Utilitarianism
• The practical consequences of various policies are
evaluated on the assumption that the right policy
will be the one which results in the greatest
happiness

• The problem then is to determine

- the necessary ratio of benefit to harm
- how these are measured and weighed
- who should make the choice
• Predicting consequences- consequences are
inherently unpredictable

• A group for whom there is a risk of harm is not

the group likely to receive any benefit - clinical
research trials.
 Deontological ethics

• Notions based on 'rules' i.e. that there is an

obligation to perform the 'right' action,
regardless of actual consequences

• Sometimes described as "duty“/"obligation"

or "rule" -based ethics, because rules "bind
you to your duty"
 Deontological ethics…
Duties and obligations are rarely determined by
empirical data – they are difficult to quantify or
measure and they are extremely difficult to partition

• Consider a person who has been asked to look after a

dog whilst also caring for children playing on
playground swings and roundabouts. How best should
this person discharge their duty if the dog should run
off?

• Consider a family practitioner who is treating a patient

for a sexually transmitted disease and this patient’s
partner is also one of the GP’s patients.
• When considering the choice between two
alternative actions, A and B, the
consequentialist approach considers which
of the two choices is likely to produce the
greatest net benefit.
• Consider, however, what should happen if B
is likely to produce the most benefit but A
has been promised.
 There are several ways to consider this problem…

• Consequentialist approach
Considers the result of breaking the promise in the net
evaluation of benefits and harms, adhering to the view that
the ends might still justify the means (including breaking the
promise) if the net benefit is sufficient to outweigh the cost of
breaking the promise (such costs may involve considerations
such as loss of trust and unhappiness at the decision).

• The deontological approach

Considers the promise as a duty, the breech of which requires
specific justification involving a conflict of duties (say the
duty to keep the promise against the duty to do what is in the
best interest of the patient, or community). This emphasis on
outcome on the one hand and duty on the other may lead to
different resolutions.
 The ‘Principles’ approach.
Four fundamental principles are often applied in
modern medical ethics
1. Respect for individual autonomy – individuals are
regarded as moral agents with duties and
obligations and the capacity to understand and
make ethical decisions.
2. Principle of beneficence – seek to do good
3. Principle of non-maleficence – avoid doing harm
4. Principle of Justice – people should be treated
fairly.
However, applying any one of these principles
may conflict with one or more of the others
• For example, applying principles beneficence and
non-maleficience in relation to a mentally ill
patient may conflict with autonomy

• Consider these principles in relation to the case of

the premature baby presented above. How should
the clinician resolve principles beneficence and
non-maleficience? Where do the parents stand in
relation to the principle of autonomy?
Paternalism (‘doctor knows best’) -the exception not the
rule
• Modern medicine seeks to avoid a paternalistic (doctor knows
best) approach to their patients. Instead it considers the
doctor and patient mutually engaging in the decision making
with the final decision on treatment options being that of the
patient. Respect for autonomy, informed consent and
confidentiality are now key markers for ethical practice and
there must be exceptional circumstances or reasons for
breeching them.

• Nevertheless, there may be circumstances where the

paternalistic approach is still a major factor.
In the case of the sick premature baby in intensive care
presented above. A key approach here for ethical practice is to
consider how best the clinician should act in the interest of
this baby whilst still respecting the involvement of the parents
in the decision.
 Which of the following do you consider to be the
best description ?

• 1) Ethics decides what is right or wrong

• 2) Ethics decides what is moral
• 3) Ethics considers the nature of, and how
best to deal with conflicts in moral
imperatives
 Deontology
• Deontology is the consideration or study of
duties and obligations.
• The discharge of duties may have
consequences but the duties exist regardless
of these outcomes – they are ‘ends in
themselves’.
• A deontology approach considers how best to
deal with conflicts of duties, to whom they are
owed and how extensive they are.
 Which of the following is true (more than one may
be true)?

1. A Utilitarian approach in ethics considers the

consequences of actions or choices
2. A Utilitarian approach in ethics considers that
ends may justify means
3. A Utilitarian approach in ethics considers
whether clinicians have discharged their
duties in the best interests of their patients.
• Generally both 1 and 2 are correct.
• 3 might be considered in utilitarian ethics where
‘best’ interest is judged by an assessment of the
greatest benefit in relation to harm; although
‘duty’ in a utilitarian perspective is usually
determined by a consideration of the best
outcome – i.e. ends justifying means.
• In contrast deontology considers duties to exist
independently of outcome.
 Informed Consent
There are essentially two views of consent:
• 1. ‘clinician-centred’ view,
a legalistic approach to consent and considers what the
clinician should tell a patient about the nature of a
procedure and the risks. It is the minimum required to
protect the clinician
• 2. The second is a ‘patient-centred’ view, which
considers what is necessary to enable the patient to
make an informed choice. This is what is referred to in
ethics as ‘informed consent’.
 Informed consent requires that everything is done
to ensure that the patient understands
1. The nature of the procedure – what is to be done
and in simple terms how it is to be done.
2. The risks involved (but as above, this is not simply
a list of all possible risks).
3. The consequences – what are the likely outcomes
of the procedure and alternatives
4. The alternatives – this includes information about
what the likely outcome would be if the patient
chooses not to have the procedure and any other
alternative the patient themselves may ask about
where relevant.
• A pregnant woman with a previous section
has been advised to go for a normal delivery
for her 2nd delivery. While in labour, she wants
to have a section because she is worried
about a rupture of the uterine scar. The
clinicians are confident that the labour would
progress without a complication. Should the
obstetrician do a section to abide by the
patients wish?
• A couple who have been married for ten years visit a
gynaecologist for infertility treatment. The woman has
a history of irregular menstrual cycles. The
Gynaecologist treats the patient to stimulate the
ovaries without success. After a few cycles of
treatment the patient decides to see the gynaecologist
on her own. She reveals that she had never had cycles
(primary amenorrhea). The patient does not wish her
clinical condition to be discussed with her husband
because she is concerned about the consequences in
relation to her marriage. Considering that the doctor
was consulted by the couple for fertility treatment,
what should the doctor do?
 Human Rights and medical practice

• “All humans should be treated equally”

• “All humans should be treated fairly”

• “All humans should be given an equal

consideration of their interests”
• Treating people equally in all circumstances
would lead to unfairness because it would fail
to take account of differing physical and
mental abilities or of the social and economic
circumstances of the individual.
• Treating people equally without regard for
their interests, their abilities or their
circumstances is likely to be unfair.
• I cannot run a hundred metres in 10 seconds, nor
am I an accomplished concert pianist. From a
moral perspective, however, I do expect to be
given an equal consideration of my interests and
needs when I consult a medical practitioner. I
certainly would not wish that they consider my
life to be of less value because I do not have
these abilities.

• Central to the concept of human rights is that

they apply simply because someone is human
and for no other reason.
• Human Rights provide a universal framework
for ethical medical practice. It is debatable
whether this framework provides clear
solutions to ethical dilemmas.
• It can be said to present a frame of moral
imperatives in the form of rights.
• The major impact of human rights is in
relation to discrimination and justice, access
to health care and empowerment.