Medical Ethics
Medical ethics are there to help the doctors to decide what is morally right.
Every profession in the society has their own ethical code, which were formed by taking into consideration the special interaction they have with the public or their clients e.g. lawyers and clients, Engineers and customers etc.
We need these separate codes of professional ethics because the general moral principles we follow during our day to day interaction with our fellow human beings are not enough.
Doctors sometimes have to take decisions which cannot be decided using every day moral values e.g. is it possible for anyone to decide whether the husband of a woman who is HIV positive should be told that fact in spite of her objections using day to day moral values?
Therefore, you can see that there is a difference between general ‘morality’ and ‘ethics’.
Morality
The definition given by the Oxford Dictionary is “principles concerning the distinction between right and wrong or good and bad behaviour.
Morality consists of a society’s most general standards. These standards apply to all people in society regardless of their professional or institutional roles.
Moral standards include those rules that most people learn in childhood, e.g. “don’t lie, cheat, steal, harm other people, etc.”
Ethics
You can see that moral standards distinguish between right and wrong, good and bad, virtue and vice, justice and injustice.
Ethics are not general standards of conduct but the standards of a particular profession, occupation, institution, or group within society. The word “ethics”, when used in this way, usually means ethics of a particular profession e.g. business ethics, medical ethics, sports ethics, military ethics, etc. Ethics do not have any meaning unless is qualified by some ‘adjective’. They should always be ethics of some profession and it is called ‘professional ethics’.
Ethics and Law
One other aspect of ethics, which puzzles the mind of the medical student, is its relationship with the law. Some of the differences between ethics and law are as follows
• Some actions that are illegal may not be unethical e.g. riding a motorbike without a helmet
• Some actions that are unethical may not be illegal e.g. adultery
• Laws can be unethical or immoral. (Nazi’s)
• We use different kinds of mechanisms to express, teach, inculcate, and enforce laws and ethics.
• Laws are often expressed in highly technical and complex jargon, and we often need specially trained people---lawyers and judges---to interpret them.
• Ethics and morals tend to be less technical and complex.
• The society uses the state’s coercive power to enforce laws on individuals. Those who not abide by the law can be fined, imprisoned or executed in some countries. Whereas those who have violated ethical or moral standards do not face these kinds of punishments unless their action also violates a particular law. The punishment for disobeying moral or ethical obligations is by usually the disapproval of their colleagues, temporary or permanent suspension from their vocation.
• However, in some countries some ethical problems have been in cooperated into the law by the legislature. E.g. Human tissue transplantation act.
Basis of Medical Ethics
How does a doctor decide an action he is going to take is ethically right? The moral values, which govern the day to day interaction of the human beings in society is obviously not enough given the complexity of medical ethical problems.
There are many theories that are designed for the doctor to come to a correct decision. They range from authoritarian revelatory theories (religious theories) at one extreme to existential ethics (purely subjective) at the other.
Religious Theories
Religiously-based medical ethics, although not favored by the main stream ethicists, continue to influence medical ethics. For instance, in the Christian tradition it is believed that a human life is a divine gift, which cannot be disposed by mortals and also uphold the importance of monogamous enduring marriage. This is the basis why the Christians, especially Roman Catholics, oppose abortion, euthanasia and artificial control of fertility.
Currents of Contemporary Medical Ethics
It is influenced by many philosophical theories. A few of them are mentioned here.
Consequentialist Philosophical Theories
In these theories, actions are judged as good or bad via its consequences, not by the intentions of the actor.
The best known consequentialist theory is Utilitarianismaccording to which, actions are right if they promote the greatest well-being or happiness for the greatest number of people.
It treats all people as equal, and so is democratic.
But it can be hard to anticipate consequences and to measure & establish equivalency of different forms of happiness;
What about the things, which are wrong even if they have some good consequences (e.g., killing a prisoner to harvest organs for transplant)?
Duty-based ethics, or Deontology
In these philosophical theories actions are judged in terms of set criteria (e.g., the Ten Commandments). Rules are derived by rational argument or, in earlier times, claimed to be handed down from God.
The most important deontological theory is Kant's moral theory (Immanuel Kant c.1780).
He says "Act only in a way that you would wish to see as a universal law". This means that you should always act in the same way irrespective of the result and you cannot change how you act depending on other factors. In other words your act is judged not on the result but on the act itself.
He also says "Never treat people solely as a means, but always as an end". This means that you should not treat people to achieve some other end forgetting that person’s own happiness or needs.
One problem of this theory is it often specifies what one should not do; tends to be less clear on what one should do. In situations where duties conflict, what should one do? E.g. Lying to the authorities versus betraying someone.
Virtue ethics
According to this, ethical guidelines are based on what a virtuous person (a person with high moral standard) would do in this situation. It focuses on the character of the person rather than anything else.
This approach often judges an act (e.g., abortion, or killing someone in self-defence) in terms of the motives underlying it, rather than the act itself, as would be the case with duty-based ethics (deontological).
It brings in ‘motives’ that may be omitted from other approaches to ethics and focuses attention on the characteristics of a good doctor. But the basis for defining virtue is not clear (and may require other ethical approaches!). Moreover, definition of virtue tends to be tied to cultural norms. In difficult situation it does not indicate a clear path of action.
Communitarianism
This philosophical theory says that we should act as responsible as members of a community.
The common good establishes the criterion for what is right. Hence, smoking bans are appropriate, even though they inhibit liberty and happiness of some people. However, it is different from ‘utilitarianism’ as it focuses not only on the greatest good for the greatest number of people forgetting the minor, which would be unhappy, but also on the well-being of even the minorities.
Intuition
Intuition is the ability to understand something immediately, without the need for conscious reasoning. This may have only a limited role as a basis of medical ethics but it cannot be totally dismissed. Sometimes it may point to the direction of value which cannot be properly articulated.
Four Principles of Medical Ethics
The "four principles plus scope" approach provides a simple, accessible, and culturally neutral approach to thinking about ethical issues in health care. The approach, developed in the United States, is based on four common, basic prima facie moral commitments-
1. Respect for autonomy,
2. Beneficence,
3. Non-maleficence, and
4. Justice-
(5. Plus concern for their scope of application. )
It offers a common, basic moral analytical framework and a common, basic moral language. Although they do not provide ordered rules, these principles can help doctors and other health care workers to make decisions when reflecting on moral issues that arise at work.
This was developed by the Americans Beauchamp and Childress.
It claims that whatever our personal philosophy, politics, religion, moral theory, or life stance, we will find no difficulty in committing ourselves to four prima facie moral principles plus a reflective concern about their scope of application.
Respect for autonomy
Autonomy literally means self-rule. An autonomous person can make his own decision after deliberation. Respect for autonomy is the moral obligation to respect the autonomy of others, which is their ability to take decisions on behalf of themselves, which is also called ‘self-determination’. (This should be compatible with the equal respect of the autonomy of all especially those who are affected by the decision. If respecting autonomy of one person cannot violate autonomy of the others.)
In health care, this moral obligation has many implications such as:-
Informed consent
Medical confidentiality
Keeping promises
Not deceiving each other
Respect for autonomy even requires us to be on time for appointments as an agreed appointment is a kind of mutual promise.
The autonomy of the patient gives them the right to:-
to choose the doctor (Private sector/government sector)
to choose the type of treatment (Surgery, palliative, rehabilitation)
for a second opinion
to refuse the treatment or change treatment (Religion-Jehovah witness)
to die with dignity (No resuscitation orders at terminal stage)
to make donations of his/her body tissues during life (Blood, tissues-bones, sperms and organs)
to make donations of his/her body tissues after death (Cadaveric donation & beating heart donations) Acknowledge a person’s right to make choices,
to hold views, and to take actions based on personal values and beliefs
However, it should be remembered that only a ‘competent’ person can have ‘autonomy’. The minors (children), mentally retarded or psychiatrically ill person may not have the capacity to have ‘self-determination’.
Beneficence and non-maleficence
Non-maleficence (do no harm) is an obligation not to inflict harm intentionally; In medical ethics, the physician’s guiding maxim is “First, do no harm” “Primum Non Nocere”.
Beneficence (do good) provide benefits to persons and contribute to their welfare. This refers to an action done for the benefit of others.
As the principles of beneficence and non-maleficence are closely related, they are usually discussed together. Beneficence involves balancing the benefits of treatment against the risks and costs involved, whereas non-maleficence means avoiding the causation of harm. As many treatments involve some degree of harm, the principle of non-maleficence would imply that the harm should not be disproportionate to the benefit of the treatment.
Sometimes these two principles conflict with autonomy when a patient refuses a treatment, which the doctors see as benefiting for the patient. In western societies the patient’s wishes are always respected. But in some other societies beneficence takes precedence over autonomy.
In cases where the patient lacks legal competence to make a decision, medical staff are expected to act in the “best interests” of the patient. In doing so, they may take into account the principles of beneficence and non-maleficence.
Justice
Justice is treating others equitably and distributing benefits/burdens fairly.
It is often regarded as being synonymous with fairness and can be summarized as the moral obligation to act on the basis of fair judgment between competing claims.
In health care ethics justice can be subdivided into three categories:
1. Fair distribution of scarce resources (distributive justice)
2. Respect for people's rights (rights based justice)
3. Respect for morally acceptable laws (legal justice).
It should be remembered that doctors should not impose their own personal or professional views about justice on others.
Doctor Patient Relationship
Doctor’s obligations of medical ethics start with commencement of the ‘doctor-patient’relationship. As soon as the doctor accepts a person as his/her patient in the private sector or the patient is registered in the ward in cases of inward patient doctor patient relationship is considered to be started.
If the patient is to get the maximum benefit out of this relationship it should be based on mutual trust and respect. If it is to be based on formality and excessive caution as seen in most of the other ordinary transactions of life the doctor patient relationship cannot be for the patient’s interest if each sees the other is a potential adversary.
Today the doctor is seen as a ‘servant of the public, which is more or less informed of the medical matters. The society is conditioned not to trust the paternalistic attitude of the doctor. On the doctors’ part they no longer wish to be seen as paternalistic.
On the other hand a particularly sinister concept has emerged in many countries, which sees the doctor as ‘producers’ and patients as ‘consumers’.
Although our national health services are relatively immune to new culture of seeing doctor patient relationship in the light of ‘producer –consumer’ relationship the private sector seems to have not been immune to this trend. In some worse cases the development of medical care along ‘business lines’ appear to have led to dubious practices such as costly over-investigations and unnecessary referral and sometimes treatment options.
Doctor’s rights
Refusal of Treatment
A doctor can refuse treatment
1. When the doctor does not have the specialization required by the patient’s ailment
2. They may also refuse to treat a close relative if they believe there may arise a conflict of interest or that their own judgment might be compromised.
3. Non-compliance of the patients to doctor’s orders or advice. They should inform the patient using a reliable and verifiable source and cannot abandon a patient in the middle of an operation or treatment.
4. Doctors who are out of their office and "off duty" are not required to treat strangers and should definitely not attempt to treat a patient's ills when they lack the necessary expertise to treat them.
Personal Beliefs and Medical Practice
1. Doctor must treat their patients with respect, whatever their life choices and beliefs.
Doctor must not unfairly discriminate against patients by allowing your personal views to affect adversely their professional relationship with them or the treatment they provide or arrange.
If a procedure or advice conflict with the doctor’s religious or moral beliefs, and this conflict might affect the treatment or advice they provide it should be explained to the patient and tell them they have the right to see another doctor. If it is not practical for a patient to arrange to see another doctor, they must ensure that arrangements are made for another suitably qualified colleague to take over.
The doctor must not express to their patients their personal beliefs, including political, religious or moral beliefs, in ways that exploit their vulnerability or that are likely to cause them distress.
Patients’ personal beliefs
Patients may find it difficult to trust the doctor and talk openly and honestly with them if they feel the doctor is judging them on the basis of their religion, culture, values, political beliefs or other non-medical factors.
For some patients, acknowledging their beliefs or religious practices may be an important aspect of a holistic approach to their care. Discussing personal beliefs may, when approached sensitively, help the doctor to work in partnership with patients to address their particular treatment needs.
The doctor must respect patients’ right to hold religious or other beliefs and should take those beliefs into account where they may be relevant to treatment options. However, if patients do not wish to discuss their personal beliefs with the doctor, they must respect their wishes.
References
1. Law & Medical Ethics; Mason & McCall Smith, 5the Edition, Buttorworths, London 1999
2. General Medical Council, UK, Good Medical Practice http://www.gmc-uk.org/guidance/good_medical_practice.asp
3. Medical ethics: four principles plus attention to scope; Raanan Gillon http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2540719/pdf/bmj00449-0050.pdf
No comments:
Post a Comment