Medical ethics is the foundation of how doctors practise medicine in the NHS and is a huge field of study. This is a basic introduction to the topic that will give you an idea of the basic concepts in medical ethics. These will be important when you are reflecting in things you have seen on work experience but also when writing your personal statement and in your interviews.
The topics covered here are:
The four pillars provide an ethical framework for doctors to make decisions about patient care where each pillar needs to be considered and can be weighed against each other to decide if an action for a patient is ethical or unethical.
The pillars are:
Respect for autonomy
Literally meaning self-rule, this is the idea that all patients have the right to make their own decisions and from this, there is both a legal and moral obligation to uphold the decision of a patient (1,2). In healthcare, there are a number of practicalities that are associated to ensure that a patient’s autonomy is respected such as ensuring the patient has capacity, informed consent has been gained (see later) and patient confidentiality is maintained.
Confidentiality (keeping information between a patient and their healthcare professional private) is a direct implication of autonomy whereby a decision is made by the patient to keep their information confidential and thereby, an agreement is reached between the doctor and the patient to keep their information private.
To respect this decision (and thereby respect the patient’s autonomy), the healthcare professional should not divulge any information to any other parties unless the patient has given permission to do so (there are exceptions to this which will be covered in a later article).
Beneficence is defined as the ‘act of doing good’. In day to day situations, this can be as simple as doing some random kind act but in healthcare, this is the idea that any intervention carried out on a patient must have some kind of benefit to the patient (i.e. there must be some good reason for why you are doing something). This is again, a moral and legal obligation and should be considered for all patients(3).
An example of this is the use of warfarin in patients at risk of stroke. Warfarin is an anticoagulant medication which works to stop blood clotting, and thereby prevents clots forming which travel to the brain and stops strokes from occurring. The benefit here is the reduction in the rate of strokes for those taking warfarin.
This literally means ‘to do no harm’(4). From an ethical point of view, this is the idea that any medical procedure or intervention has a risk of harm, no matter how small, and the role of a healthcare professional is to minimise this risk in all ways possible and justify any remaining risk.
Applying the principles of non-maleficence is to consider these risks, understand the individualised risks these may have to a patient and possibly consider alternative paths to overcome any risks to the patient.
Thus, as warfarin is an anticoagulant, too much anticoagulation can lead to side effects such as easy bruising and an increased risk of brain bleeds. Whenever a clinician prescribes warfarin, they should weigh up whether this risk of harm is outweighed by the potential benefit of preventing a stroke.
A clinician may also consider using an alternative medication e.g. apixaban, which is a different type of anticoagulant, works equally well in stopping strokes but has a lower rate of side effects compared to warfarin.
In a medical context, this provides the idea of fairness. An example of this is having an independent and objective adjudication between two or more treatment options from multiple perspectives e.g. cost and other resource implications, legal barriers and the rights of a patient (1). This is part of the role of NICE (National Institute for Clinical Excellence).
Following on from the example above, considering warfarin vs apixaban, although they are equally as effective in prevention of strokes, apixaban is about four times more expensive than warfarin. Is this a justifiable spend to decrease the rate of side effects with such other funding shortfalls affecting all other areas of the NHS?
Capacity is the patient’s ability to make an appropriate decision about their own care. In order to have capacity, a patient must be able to meet all of the following requirements:
Understand information given to them
Retain the information
Weigh up the pros and cons
Communicate their decision to the doctor
[Section 2,1] Mental Capacity Act 2005 (2)
All reasonable measures should be taken to ensure a patient can exercise their capacity (e.g. if the patient doesn’t speak English, therefore may not be able to understand or communicate with the healthcare team, an interpreter can be used to overcome this barrier).
Capacity is also time dependent, and should be reassessed for each decision made.
But if a patient does not meet all of these criteria, they are judged to not have capacity, in which case, a family member or friend who has a lasting power of attorney (2) over the patient or the leader of the patient’s healthcare team may need to make a decision for them in their best interests. (This will be covered in more detail in a later article).
The decision of whether a patient does or does not have capacity is not taken lightly but deeming a patient lacks capacity may be the most appropriate course of action at times. For example, many patients with advanced neurodegenerative diseases such as Alzheimer’s disease may not be able to understand what is happening in their local surroundings, let alone make a complex decision about their care.
However, just because a patient has Alzheimer’s disease does not mean doctors should assume patients do not have capacity. The legal position is all patients are presumed to have capacity to make decisions about their care until proven otherwise with a formal capacity assessment.
Consent means a patient gives permission to their health care team before a test, examination or treatment is carried out. This must be given voluntarily with no coercion from the healthcare team, friends or family to make a decision.
Consent must be informed, meaning the patient must understand the pros and cons of the treatment or procedure (5). If the consent they have given is not informed, then the consent is invalid. Therefore the patient’s autonomy could be being violated as they may not understand the full extent of what is happening to them.
For example, if a patient and a doctor discussed starting warfarin to reduce the risk of a stroke in a patient, then the doctor is legally obligated to ensure the patient is aware of the side effects of warfarin. These include an increased risk of bruising and increased risk of a brain bleeds etc..
If the doctor does not ensure the patient was aware of the side effects, the consent to starting treatment is invalid. This could make the doctor vulnerable to litigation proceedings. This is in addition to the decision being unlikely to be the best for the patient.
Ensuring all steps taken by healthcare teams are ethically justified improves patient safety and patient care.
It is everyone’s responsibility to protect patients rights and ethical frameworks help you do this.
The ‘four pillars’ approach is a useful structure that you can use to answer ethical dilemmas in your interviews and beyond.
References and further reading
You are not expected to know the level of detail cited in the articles below. They are only provided if you are interested.
1. R.Gillon. Medical ethics: four principles plus attention to scope. The British Medical Journal. 1994; 309: 184-188. DOI: 10.1136/bmj.309.6948.184
2. Mental Capacity Act 2005. [cited 14.12.2020]. Available from: https://www.legislation.gov.uk/ukpga/2005/9/section/3
3. Kinsinger.F.S. Beneficence and the professional’s moral imperative. Journal of Chiropractic Humanities. 2009; 16: 44-66. DOI: 10.1016/j.echu.2010.02.006
4. R.Gillon. “Primum non nocere” and the principle of non-maleficence. The British Medical Journal. 1985; 291: 130-131. DOI 10.1136/bmj.291.6488.130
5. General Medical Council. Consent: patients and doctors making decisions together. 2018 [cited 14.12.2020]. Available from: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/consent