You do not need to be an expert in medical ethics or law in order to respond constructively to the ethical dilemmas you encounter in practice. Here we introduce approaches to decision making and the concepts likely to be engaged when you think about ethical dilemmas.
Outlining some key concepts
The purpose of medicine is to help patients. Health is universally regarded as a good thing and doctors seek to maximize the health of their patients. Medicine is therefore an ethically driven practice.
During your medical training you begin to learn the skills that will enable you to provide high quality care. The provision of appropriate clinically-indicated care or treatment to patients who consent to receive it is at the heart of good medical practice and is seldom ethically problematic. Difficulties can arise though because health is one value among others. People who take up risky sports for example, or join the army are clearly willing to accept some risk to health in order to pursue other goods.
Doctors do not need to be experts in medical ethics or law in order to respond constructively to the ethical dilemmas they encounter in practice.
There are a variety of different approaches to ethical decision-making
- Giving priority to the principles that should guide decisions.
- Focussing more on the outcomes or consequences of decisions.
- Giving priority to the inner dispositions or virtues of the decision-maker.
Although a great deal of academic ink has been spilt on the pros and cons of these approaches, when it comes to concrete decisions they frequently – though not always – result in similar conclusions.
We do not promote any particular ethical framework. Your developing sensitivity to ethical problems is more important than wrestling with the pros and cons of different ethical systems. In providing practical advice to doctors and students we use a variety of approaches that include widely accepted general ethical principles, professional guidelines and previously settled legal cases.
Concepts likely to be engaged when confronting ethical dilemmas in medical practice
The ability to decide and to act for oneself, sometimes referred to as ‘autonomy.’ The most obvious expression of self-determination is the right of competent adults to refuse any proposed medical intervention even where the decision may result in death. The only exception is compulsory treatment under mental health legislation. This is discussed in a little more detail on the next page.
Capacity or competence
Not a principle itself but a key concept in medical ethics. The capacity or competence to make a decision is ordinarily a prerequisite for a decision to be respected. A decision by someone lacking capacity to refuse life-sustaining treatment can be overridden.
A respect for the confidences of patients is central to good medical practice. The right of adult patients to control their private information is linked to the principle of self-determination. The consequences of not respecting confidences could include patients withholding relevant information and a loss of trust in the medical profession.
Honesty and truth-telling
The communication of information in ways that are believed to be truthful and that are not intended to deceive the recipient. It can be thought of as a virtue in health professionals and also as a prerequisite for a respect for patient self-determination.
Benefit and harm
To do good and avoid harm are among the oldest exhortations in medicine. Often in medicine though the good can only be achieved at the risk of harm. Medical interventions are ordinarily justified where the anticipated benefits exceed the harms. There can be disagreement about how benefit and harm are interpreted. A patient can be harmed for example by having life-saving treatment that she rejects being imposed upon her.
Fairness or equity
A range of issues here. People should be treated fairly – people with equal needs should be given equal consideration – and should not be discriminated against in the provision of health services. On a wider level, health services should also be distributed according to good moral reasons and not arbitrarily.
In addition to relevant legal rights, such as the right to refuse treatment, these also point to the idea that human beings have certain moral rights which relate to basic human interests or entitlements that simply cannot be taken from them, irrespective of how much benefit may accrue to others.
Useful names and addresses
There are many professional organisations who can provide advice and support on ethical issues. Some are listed below.
Department of Health
Telephone: 020 7972 2000
General Medical Council
Telephone: 020 7189 5404
Fax: 020 7189 5401
Royal College of General Practitioners
Telephone: 020 7581 3232
Fax: 020 7225 3047
Royal College of Nursing
Telephone: 020 7409 3333
Royal College of Obstetricians and Gynaecologists
Telephone: 020 7772 6200
Fax: 020 7723 0575
Royal College of Paediatrics and Child Health
Telephone: 020 7092 6000
Fax: 020 7092 6001
Royal College of Physicians
Telephone: 020 7935 1174
Fax: 020 7487 5218
Royal College of Physicians and Surgeons of Glasgow
Telephone: 0141 221 6072
Fax: 0141 221 1804
Royal College of Physicians of Edinburgh
Telephone: 0131 225 7324
Fax: 0131 220 3939
Royal College of Psychiatrists
Telephone: 020 7235 2351
Fax: 020 7245 1231
Royal College of Surgeons of Edinburgh
Telephone: 0131 527 1600
Fax: 0131 557 6406
Royal College of Surgeons of England
Telephone: 020 7405 3474
Fax: 020 7831 9438
- Ashcroft R et al – Principles of Health Care Ethics