Applied medical ethics
Dr. Deepthi Edussuriya
A man without ethics is a wild
beast loose upon this world
Albert Camus
At the end of this lesson you should
be able to…
….solve ethical dilemmas, using a
framework for making good ethical
decisions, in order to obtain the best
possible outcome
How do we make decisions?
• Gut reaction/feelings
personal/emotional
tends to be one of 2 things
not bad as it informs us of
how our community might
react
feelings may tell us not to do
the right thing if it is hard
• Religion
advocate high ethical
standards
may not address all
types of problems we face
• Culturally accepted norms
cultures can become corrupt -or blind
to certain ethical concerns (USA to
slavery)
• Science
just because something is scientifically
or technologically possible, it may not
be ethical
• Rule obedience
tell us how to react to things
one rule fits all approach might
be unethical as it fails to
consider the specific
interests of those involved
can become ethically corrupt,
designed to serve the interests
of narrow groups
difficulty in designing/enforcing
slow to address new problems
• Guidelines
tells us how we are expected to react
decision based on reflection/reasoning
more than one perspective
made to ensure good practice
guidelines issued by medical
professional bodies should always be
considered
since guidelines may change in the light
of experience/new evidence it is
necessary to be aware of any changes
A framework for making good ethical
decisions is necessary because…
• ethical decision making is a skill
• a skill needs to be practiced
• when practiced regularly, the method
becomes so familiar that we work through
it automatically without consulting the
specific steps
The framework
1.
2.
3.
4.
5.
Recognition of an Ethical Issue
Get the Facts
Evaluate alternative actions
Make a Decision and Test It
Act and Reflect on the Outcome
Making good ethical Decisions
requires…
• Recognition of an Ethical Issue
A clue that an action or situation needs an
ethical rather than simply a business
judgment is that the action/situation could
- be damaging to someone
- violate what is generally consider
right/good
- be more than what is legal/most
efficient
• Get the Facts
- What are the relevant facts of the
case? What facts are not known? Can I
learn more about the situation? Do I
know enough to make a decision?
- What individuals and groups have an
important stake in the outcome? Are
some concerns more important? Why?
- What are the options for acting? Have
all the relevant persons and groups
been consulted? Have I identified
creative options?
• Evaluate alternative actions by asking the
following questions:
- Which option will produce the most good
and do the least harm? (Utilitarian
Approach)
- Which option best respects the rights of
all who have a stake? (Rights Approach)
- Which option treats people equally or
proportionately? (Justice Approach)
- Which option best serves the community
as a whole, not just some members?
(Common Good Approach)
- Which option leads me to act as the sort of
person I want to be? (Virtue Approach)
• Make a Decision and Test It
- Considering all approaches, which
option best addresses the situation?
- If I told someone I respect of the
option I have chosen, what would they
say?
• Act and Reflect on the Outcome
- How can my decision be implemented
with the greatest care/attention to
concerns of all stakeholders?
- How did my decision turn out and what
have I learned from this specific event
Approaches to making ethical
decisions
• Utilitarian Approach
Common Good Approach
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•
•
•
•
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Deontological approach
Rights Approach
Casuist approach
Fairness/Justice Approach
Virtue Approach
Putting the Approaches Together
Utilitarian theory
 the choice that yields the greatest benefit
to the most people is the choice that is
ethically correct
 founded on the ability to predict the
consequences of an action
 provides a logical and rationale argument
for each decision and allows a person to
use it on a case-by-case context
Example
A baby born prematurely at 24 weeks
gestation is put in intensive care.
However she is not thriving and scans
suggest she has profound brain
damage.
She
cannot
breathe
unassisted and the care team believe
she is suffering and it is not in her
interest to keep her alive. The parents
do not agree. What should the clinician
do?
Utilitarian
• Greater benefit to more people if life
terminated as the medical staff and
facilities will be freed even at the
expense of the parents happiness
Flaws
• Based on predicting the future. No human
being can be certain that his predictions will
be true and this uncertainty can
lead
to
unexpected results
• Necessity to compare the various types of
consequences against each other on a similar
scale. Eg., money vs happiness
• Not
always
concerned
with
justice/
beneficence/autonomy for an individual, if
oppressing the individual leads to the solution
that benefits a majority of people.
• Possibility of conflicting benefits/risks
What is ethically right for a surgeon who is
running late for his list?
to drive breaking traffic rules to arrive
at his surgical list on time because the
fasting patients benefit from this
decision
follow the traffic law because this
benefits an entire society
• A group for whom there is a risk of harm may
not be the group likely to receive any benefit clinical research trials.
Common good approach
• Ideal derived from utilitarianism
• Community members are bound by the
pursuit of common values and goals
(Affordable
healthcare,
Unpolluted
environment)
Flaws
• Individualism (Individual freedom goals &
interests
• “Free-rider problem”
Available to everyone even those who
don’t do their part. Therefore if more free
riders common good will be destroyed
• Pluralistic society
Different people have different ideas.
Impossible to agree on one social
system.
Deontological theory
• States that people should adhere to their
obligations and duties when analyzing an
ethical dilemma
• A person who follows this theory will produce
very consistent decisions since they will be
based on the individual's set duties
Flaws…
• No rationale for deciding an individual's duties.
Eg., an MOH may decide that it is his duty to
always
be on time to meetings. What is the
rationale for
this? Not to keep others waiting
or to the fact that he has to always sit in the same
chair
• Does not provide guidance when there are
conflicting obligations
Eg., a person who must be on time to meetings is
running late, how is he supposed to drive? Is he
supposed to speed, breaking his duty to society
to uphold the law, or is he supposed to arrive at
his meeting late, breaking his duty to be on time?
Is lying right or wrong?
• Utilitarian/Consequentialist may argue
that lying is wrong because of the
negative consequences produced by
lying. However a consequentialist may
allow
that
certain
foreseeable
consequences
might
make
lying
acceptable
• A deontologist might argue that lying
is always wrong, regardless of any
potential "good" that might come from
lying
Casuist theory
• Compares a current ethical dilemma with
similar ethical dilemmas and their
outcomes
• Allows to determine the severity of the
situation and to create the best possible
solution according to others' experiences
Flaws
• There may not be a set of similar
examples for a given ethical dilemma. eg.,
is new and unexpected
• Assumes that the results of the current
ethical dilemma will be similar to results
of the previous experience
Rights theory
• Human rights of the individuals set forth by
society are protected and given the highest
priority
• Rights are considered to be ethically correct
and valid since a large or ruling population
endorses them
• Examples of Rights to be adhered to :
right to the truth/privacy/not to be
injured/what is agreed
Example
• A couple with primary subfertility were
tested
for
STD
before
assisted
reproduction. The man was diagnosed
with STD. He requested their doctor not
to disclose his diagnosis to a third party
including his wife. He even threatened
with suicidal intention and denial of
treatment. How should the doctor deal
with this situation?
Flaws
• Conflicting rights
Right to privacy vs right to truth
Duty vs right
Fairness & Justice Approach
Everybody needs to be treated equally. If
individuals, can’t be treated equally then
they need to be treated properly based
on some criteria/standard. This means
that the communities or people affected
by your decisions can’t be favoured or
benefit from an unfair advantage.
Virtue theory
• Act after judging a person by his
character rather than by an action that
may deviate from his normal behavior
• It takes the person's morals, reputation
and motivation into account when rating
an unusual and irregular behavior that is
considered unethical.
Example
A person plagiarized a passage that was
detected by a peer
The judgment will be based on whether the
plagiarizer normally follows the rules and has
good standing amongst his colleagues, if so the
peer may judge his friend more leniently.
(Perhaps the researcher had a late night and
simply forgot to credit his or her source
appropriately). Conversely, a person who has a
reputation for scientific misconduct is more likely
to be judged harshly
Flaws
• Does not take into consideration a
person's change in moral character. Eg.,,
a scientist who may have made mistakes
in the past may honestly have the same
late night story as the scientist in good
standing. Neither of these scientists
intentionally plagiarized, but the act was
still committed. On the other hand, a
researcher may have a sudden change
from moral to immoral character may go
unnoticed until a significant amount of
evidence mounts up against him or her
Decision-making process
• Although all of the ethical theories
attempt to follow the ethical principles in
order to be applicable and valid by
themselves, each theory falls short with
complex flaws and failings.
• However, these ethical theories can be
used in combination in order to obtain the
most ethically correct answer possible for
each scenario.
• a utilitarian may use the casuistic theory
and compare similar situations to his
real life situation in order to determine
the choice that will benefit the most
people.
- the deontologist and the utilitarian who
are running late for their list may use the
rights ethical theory when deciding
whether or not to speed to make it to
hospital in time. Instead of speeding,
they would slow down because the law in
the rights theory is given the highest
priority, even if it means that the most
people may not benefit from the decision
to drive the speed limit.
Ethics is knowing the difference between
what you have a right to do and what is
right to do