Medical Ethics and Law
Introduction
Dr Gordon Linklater
Medical Ethics and Law system
2013
am
pm
Mon 17th
Ethics Introduction
Medicolegal part 1
Tue 18th
Community course
Moral theories/ reasoning
Wed 19th
Beginning of life
Thu 20th
Anatomy
Fri 21st
Research/ human rights/
resource allocation
Mon 24th
End of life
Mental health/ complaints
Tue 25th
Children
Debate: assisted suicide
Wed 26th
Medicolegal part 2
Thu 27st
Fri 28nd
Debate: abortion
Social media
Assessment
Morality and Ethics
Two traditions:
1. Duties, “right” & “wrong” actions, absolute
values
2. Look at benefits and harms to individual
and society; look at the consequences.
Two traditions:
1. Duties, “right” & “wrong” actions, absolute
values
DEONTOLOGY
2. Look at benefits and harms to individual
and society; look at the consequences.
UTILITARIANISM (a type of consequentialism)
Hippocratic tradition
• “as to diseases, make a habit of two things
– to help and not to harm.”
• “I will never give a poison to anyone to
cause death, not even if asked.”
Hippocratic tradition
• “into whatever houses I enter, I will enter
to help the sick, and I will abstain from all
intentional injustice and harm, especially
from abusing the bodies of man or woman,
bond or free.”
Kant
•
Immanuel Kant
(1724 – 1804)
–
Categorical
Imperative
•
–
Act only in such a way
that you would be
happy for it to become
an universal law
Treat people as ends
in themselves, never
just means
Religion
• e.g. the ‘sanctity’ of human life
http://www.gmc-uk.org/guidance/good_medical_practice.asp
Doctors are powerful
•
•
•
•
We get to look at you naked
We can cut you open
We might tell you that you are going to die
We can decide what is in your best
interests
Doctors are trusted
• Trust to tell the truth
%
– Doctor
– Teacher
– Professor
– Judge
92
88
80
80
– Journalist
– Politician
22
13
MORI poll 2009
Deontology
• Good points
– Gives you some certainty
• Duty not to kill
– Defines behaviours
• Duty of care
Deontology
• Bad points
Consequentialism
• The moral worth of an action is determined
by its outcome
Utilitarianism
• Jeremy Bentham
(1748 – 1832)
• The greatest good for
the greatest number
(maximising pleasure/
happiness and
minimising pain/
unhappiness)
Utilitarianism
• Classic
– Judges the consequences of a particular act
• Rule
– Judges the consequences of particular rules
• Preference
– Maximising choice rather than pleasure
Utilitarianism
• Good points
– Flexible
• Can adapt to the particular circumstances of a
decision
– Avoids need for a belief system
– Measurable
• Do you want a nice doctor or an effective doctor?
Utilitarianism
• Bad points
Ethics and clinical decisions
• Duties
• 4 Principles
• Ethics grid
Duties
• Having watched a caesarean section
whilst on my medical elective in Kwa-Zulu
Natal I thought, ‘that looks fun – I’ll have a
go on the next patient’
• A young woman comes to your surgery
very distressed. She tells you she had
unprotected intercourse last night whilst
drunk. She does not want to get pregnant.
She asks if there is anything that can be
done…
4 Principles
•
•
•
•
Respect for Autonomy
Non-maleficence
Beneficence
Justice
4 Principles
• Respect for Autonomy
– Promote the right to self determination
• Non-maleficence
• Beneficence
• Justice
4 Principles
• Respect for Autonomy
• Non-maleficence
– The avoidance of harm
• Beneficence
• Justice
4 Principles
• Respect for Autonomy
• Non-maleficence
• Beneficence
– To do good
• Justice
4 Principles
•
•
•
•
Respect for Autonomy
Non-maleficence
Beneficence
Justice
– Fairness/ equality
– Individual vs population
Which chemotherapy?
• Mr Jones has non small cell lung cancer
Chance of
benefit %
Chance of
death %
Cost £
Chemo A
10
2
1 000
Chemo B
50
33
1 500
Chemo C
60
10
100 000
Chance of
benefit %
Chance of
death %
Cost £
Chemo A
10
2
1 000
Chemo B
50
33
1 500
Chemo C
60
10
100 000
•
•
•
•
Autonomy
Non-maleficence
Beneficence
Justice
Chemo C
Chemo A
Chemo C
Chemo B
Chance of
benefit %
Chemo A
Chemo B
Chemo C
Chance of
death %
10
50
60
2
33
10
Cost £
1 000
1 500
100 000
• Justice
– you cannot use chemo C
• Non-maleficence
– you must not use chemo B
• Beneficence
– chemo A is better than nothing
• Autonomy
– Patient can chose either chemo A or nothing
• Should we use data from medical
‘research’ carried out in the concentration
camps of Nazi Germany?
– Specifically research into the effects of
hypothermia on the human body
A synthesis of ethics and the current UK law
• Duty of care, right to life, sanctity of life
– If in doubt, doctors have a duty of care to save life and preserve function
– Euthanasia and physician assisted suicide are illegal
– Doctors must not intend to hasten death, but may in certain
circumstances administer treatment that will hasten death (Doctrine of
Double Effect)
– Not keeping alive versus killing (usually not considered equivalent)
• Autonomy, justice
– Patient autonomy allows the refusal of any treatment, even if refusing
the treatment will result in their certain death
– Patients cannot demand a treatment that a doctor does not consider
indicated (but they can get a second opinion)
• Also remember that healthcare is rationed. Treatment may be indicated but
not affordable
– Family members cannot make medical decisions for patients (unless
they have been legally appointed proxy decision maker)