This principle states that when considering whether an action is ethical or otherwise, we must consider whether it is compatible with the law and the rights of the individual, and whether it is fair and balanced from a societal perspective.
The final point about societal justice is particularly relevant to us in the UK because we operate a universal health system. This means that decisions about what treatments to provide to whom need to be taken extremely carefully.
It also means that we must ensure that no one is unfairly disadvantaged when it comes to access to healthcare. This is the reason why the NHS has certain entitlements, such as free prescriptions for lower income individuals.
How to approach a scenario with respect to justice
Justice in medical ethics can be an extremely complex pillar to consider. Everyone’s concept of fairness tends to differ. But, in general we should consider the following aspects:
Is this action legal?
Does this action unfairly contradict someone’s human rights?
Does this action prioritise one group over another?
If it does prioritise one group over another, can that prioritisation be justified in terms of overall net benefit to society or agree moral conventions?
Let’s take a look an example:
Patients suspected of having cancer are prioritised within the NHS with the maximum waiting time for referral being two weeks (as opposed to eighteen weeks for non-urgent referrals). Patients diagnosed with cancer are entitled to a range of treatments including radio- and chemotherapy. These treatments are expensive and treat a small, but significant proportion of patients.
First, let’s analyse the counter-arguments to prioritisation of patients with suspected cancer. One could argue that the prioritisation of these patients over others perhaps infringes the universal right of all patients to receive timely access to healthcare services – in particular access to GP services.
One could also argue that the public expenditure on radio- and chemotherapy treatments could be spent on less expensive treatments that would treat a greater number of people, such as an increase in statins for those at risk of cardiovascular disease.
Regardless of whether you agree or disagree with these two points morally, they are valid points nonetheless and need to be considered from a neutral position.
Remember to consider both sides
On the first point about waiting times, one could argue that as cancer patients are referred to specialist oncology centres, their urgent referral actually liberates other services (such as General Practice) and therefore increases access for non-cancer patients.
We could also point to the clinical evidence that shows that early diagnosis and treatment of cancers not only increases survival rates, but also reduces the cost of treatment. Therefore, urgent referrals actually optimises the distribution of resource across the health service.
The second point is a bit more muddied and relates to what is known as the “distribution problem”. In short, do you offer the treatment that maximises the number of years of life, regardless of how many people benefit, or do you offer the treatment that treats the maximum number of people, regardless of how many more years those people will live as a result? Arriving at a morally acceptable answer to this distribution problem is particularly tricky in a system which is publically funded (i.e. almost everyone has paid into the system).
But let’s assume for argument’s sake that British culture is such that we believe in attempting to save the lives of anyone, no matter the cost, because that is the morally right thing to do. We could bolster our counter-argument further by saying if we fail to treat a patient suffering from cancer, we will ultimately spend more money on treating that patient for the co-morbidities associated with the cancer itself. Therefore, unless we are prepared to remove all rights to treatment for that patient, it is ethically and objectively better to treat them early.
Now, it’s important to note that while treating patients with suspected cancer is hard to argue with, we cannot simply say that it’s a “no brainer” without going through the pro’s and con’s of the medical ethics involved. You must be able to justify your ethical position by first having considered all sides of the argument!
As we will see, things can get very complicated indeed once you start to apply the principles of the four pillars to real-world situations. We’ll also find that there are other non-official principles that we need to consider in certain cases.
Now that we’ve established and explained the four pillars, watch out for more blogs in this series exploring current hot topics.
Watch this space, and get ready to improve your interview performance!