From nucleus - Freshers' Edition 2019 - medical ethics for beginners
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Giles Cattermole explains the basis of medical ethics
It's easy to think that prescribing antibiotics is a 'scientific' decision, without the need for ethics or 'value judgments'. But if the patient is foreign, unconscious, terminally ill, with life-threatening pneumonia, and if the antibiotics are very expensive with nasty side-effects, all sorts of ethical considerations become apparent: consent; entitlement to NHS treatment; and how good and bad outcomes ought to be balanced. Value judgments are intrinsic to medicine. 'Patient' implies a particular relationship of duty and care. Medicine presupposes that disease is 'bad' and health is 'good', and that doctors 'ought' to help people from disease to health. These are value judgments; this is ethics.
Ethics is about deciding what is morally right and wrong, what we should or shouldn't do. It relates to obvious issues like abortion, cloning, and euthanasia. But also, what life is and what a person is; our attitudes to disability and mental illness; justice and rationing; confidentiality, consent, truth-telling, professionalism and much more.
Morality was once generally accepted to be 'revealed'; God tells us (in the Bible or in nature) what is right and wrong. Enlightenment Deism saw morality as 'discovered'; there is moral truth 'out there', but God won't tell us what it is; we must work it out for ourselves. Postmodernity says that there is no absolute moral truth; morality is 'chosen'. Ethics becomes no different from aesthetics.
Some philosophers use the categories of 'factual' and 'value' judgments. Factual judgments concern scientific truth (determined empirically) and logical truth (self-evident). Value judgments concern aesthetics and ethics.
Wales is west of England — scientific truth, observed on a map
2 + 2 = 4 — logical truth, assuming the rules of mathematics
Coffee is nicer than tea — aesthetic judgment, 'true' for some but not all
Murder is wrong — ethical or moral judgment
For some, value judgments are matters of personal preference. But in practice few people consistently live as though there is no moral truth at all. Just ask them whether rape or racism are acceptable. Instead, most people still think that some actions really are 'right' or 'wrong', even if they disagree about which are which. They operate according to some sort of moral framework, even if they don't know it.
There are three major theories.
Virtue ethics are concerned with the character of the moral agent. By becoming the 'right' sort of person one will naturally behave correctly. Many people think this too vague and incomplete for practical use, yet there is still an assumption that doctors and nurses should be competent, compassionate, altruistic people.
Duty-based ethics are concerned only with the rightness or wrongness of an action itself, not with its outcomes. Some things are universally right, some universally wrong. The Hippocratic Oath is a list of duties. But many people object to the idea of absolute duties without exceptions: would you lie to prevent murder?
Consequence-based ethics look to the outcome of any action to determine whether it is right or wrong. The end justifies the means. A common form is 'utilitarianism' — the greatest good for the greatest number. Yet, one can never be sure that an action will achieve its desired end. Even if it did, it's difficult to measure 'happiness' and 'sadness' for each individual. This sort of thinking is also very dangerous for individuals and minorities.
For many, virtue ethics were too vague and duty-based ethics were too absolute. The driving ethic became more utilitarian as governments took over the role of providing healthcare and sought to maximise efficiency.
Virtue, duty and utility-based ethics are ethical theories, from which principles and rules can be derived for practical decision-making. Beauchamp and Childress (4) famously promoted the idea of 'principles' of medical ethics: most people, of any religious or cultural background, tend to agree on certain basic ethical principles. The standard four principles they described were: autonomy (respect for a person's choices); beneficence (doing good); non-maleficence (not doing harm); justice (fair distribution of resources).
Beneficence is what clinicians have always wanted: to bring healing. Non-maleficence was Hippocrates' first aphorism: primum non nocere (5) (first do no harm). This is the attitude that safety comes first. These two principles can be put together as 'balancing risks and benefits'. People want fairness, even if they don't agree how it's best defined. But autonomy is sometimes criticised as being too Western and individualistic. Another problem with this approach is that sometimes the principles conflict. Autonomy is often assumed to trump the others.
In practice, decision-making involves 'blended ethics', using different theories and principles to support an argument, or to suit different circumstances. What seems to be an attempt to discover what is really the right thing to do (as the Enlightenment philosophers intended), becomes instead an exercise in justifying one's own preferences. Ethics becomes relative, a matter of personal choice.
Our starting point must be God. He has told us what is good. But we also need to recognise that human nature is sinful, in rebellion against God.
Secular ethical approaches take no account of sin. Utilitarianism ignores God's concern for the weak and helpless. Duty ethics fail to recognise that we cannot rely on 'virtuous' clinicians, because we are sinful. Similarly, autonomy assumes that we can determine what is right and wrong ourselves. Rights and autonomy are essentially selfish; we prioritise our own needs over others. Autonomy is not the solution to ethical dilemmas; it's the cause of the problem!
But there is at least a glimmer of truth in these approaches too.
The result we're concerned with is God's glory — our decisions should seek to maximise this. We can trust God because he is glorified in his actions and is concerned with each individual. God has given us duties. But they are not a mechanical checklist. Despite our sinfulness, they are in response to Jesus' work on the cross and God enables us to obey him by the power of the Spirit. Finally, Christian ethics seek to be those of Jesus. As we become more and more like him, we will act in the way that is most pleasing and glorifying to God.
Giles Cattermole is an Emergency Medicine Consultant and is UCCF London Team Leader
1. Aristotle. The Nicomachean Ethics. London: Penguin, 2004. MacIntyre A. After Virtue. 2nd ed. London: Duckworth, 1985
2. Kant I. The Moral Law. 2nd ed. London: Routledge, 2005
3. Mill JS, Bentham J. Utilitarianism and other essays. London: Penguin, 2000
4. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 6th ed. Oxford: OUP, 2008
5. Hippocrates. Hippocratic Writings. London: Penguin, 2005