Welcome to the first in a new series of articles that will focus on ethical issues in Medicine today. In these articles, we will examine topical issues in order to inform and familiarise you with how to tackle these often complex situations.
Being able to work through an ethical issue in a confident, logical and balanced way is a critical aspect of success – both as a medical school candidate and medical practitioner. (And we also hope they will be interesting to read, too!)
In this first article, we will discuss the conceptual framework that underpins medical ethics and examine how these concepts can be put into practice in a clinical setting. Of course, we should state that in real life situations can rarely be put into neatly defined boxes, so while this framework is an excellent and powerful tool for unpicking ethical issues, we still need to use discretion and judgement when deciding on a course of action.
The Four Pillars of Medical Ethics
There are four pillars of medical ethics:
Each of these pillars represents an entire realm of considerations that need to be considered when faced with an ethical dilemma. As we will see over the course of this series, not every issue will require us to consider every single pillar in this framework. But having the full framework in mind ensures that we never miss an area of examination – and it also provides a universal and logical structure for discussing ethical issues in interviews or with colleagues.
We’ll explore each of these pillars in turn and get a sense for what they mean and how we can use them. First up…
The patient has ultimate decision-making responsibility for their own treatment. This means that a medical practitioner cannot impose treatment on an individual for whatever reason – except in cases where that individual is deemed to be unable to make autonomous decisions (see Mental Capacity Act and Emergency Doctrine).
To modern sensibilities, the principle that a patient has the right to choose what happens to their body seems pretty straight-forward. But it’s important to remember that historically this has not always been the case, and even today some patients defer all decision-making to the “wise doctor” – even if they do not feel comfortable with their treatment plan. And so, it is more important today than ever to bear the autonomy of the patient in mind and ensure patients are actively involved in their diagnosis and treatment.
How to approach a scenario with respect to autonomy
In our everyday practice then, the principle of autonomy demands that we consider the following:
Have we explained fully the patient’s medical condition, their options for treatment and the advantages and disadvantages of those treatments?
Is the patient able to retain this information, evaluate their options and arrive at a decision?
Has the patient provided informed consent for our actions?
These principles apply to all medical interventions, from a physical examination to major surgery. If a medical practitioner fails to obtain consent, it is known as a battery – a legal term that means “an infliction of unlawful personal violence.”
It is helpful, therefore, to think of autonomy as a limiter on how far a clinician can intervene in a patient’s care. If the patient does not consent to an action, we cannot intervene even if it will result in death.
Let’s look at an example:
A 26 year old male has been involved in a high-speed collision in which he sustained blunt force trauma to his head as his head hit the front windscreen of his car. He did not lose consciousness, he is fully responsive and has no indications of neurological damage. He does, however, have a significant head wound which is bleeding continuously. This patient has refused treatment on the grounds that he feels “fine” and is refusing to have sutures to close his head wound. He would like to leave the Department.
Even though the best interests of this patient would be served by undergoing a CT scan and having sutures, as he is an adult with full mental capacity, we must respect his autonomy in choosing to leave the Department. We cannot prevent him from leaving, and if we did it would be unlawful detainment.
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As we will see, things can get very complicated indeed once you start to apply these principles to real-world situations. We’ll also find that there are other non-official principles that we need to consider in certain cases.