Ethics

Consequentialism

Consequentialism judges acts to be right or wrong according to the results/consequences produced. An act leading to a positive outcome is morally more acceptable than one that produces a negative outcome. According to critics of consequentialism no act is, therefore, non-permissible. Consequentialists can argue back that if abhorrent acts are allowed and generalized there would be less overall benefit to people.

A positive outcome depends on what value is being optimized, e.g. pleasure, happiness, wealth, etc. A hedonist will always act in such a way as to maximize pleasure over other values, such as, say, honesty. Often, in consequentialist arguments, a calculation needs to be made to determine the net benefit, taking into account the benefits and negative effects of any action. Utilitarianism, a form of consequentialism, aims to maximize the overall utility in the world that an action can bring about. The utilitarian ‘greatest happiness principle’ suggests that one should always act to provide the greatest happiness to the greatest number. Consequentialism is popular as it is practical. Logically, it is analogous to ‘evidence-based medicine’. It allows the application of judgement in the form of a calculation to justify any action – nothing is universally forbidden. Consequentialism, however, is not without drawbacks. Expensive therapies with low probabilities of success do not fare well against the utilitarian yardstick. For example, intensive care is resource hungry, with high levels of mortality (especially in adults) and morbidity. Public education programmes about chronic disease management, such as asthma and diabetes, in comparison may be more cost effective in reducing long-term morbidity and mortality and utilitarians would prioritize the latter over the former. However, if intensive care provided the only chance of survival for a critically ill child, would any parent favour the utilitarian argument? Furthermore, it is unclear how the utilitarian argument can be limited – closing hospitals in the UK or decreasing national spending on nuclear weapons and redistributing the savings to the lowest income countries in the world might arguably yield greater happiness for a greater number.

Deontology

Unlike the outcome-based approach of consequentialism, deontology provides a rule-based approach. Morality is based on the intentions of actions, not the consequences. Actions are therefore:

• Obligatory – must be carried out, e.g. resuscitation of a patient in the event of an unexpected cardiac arrest

• Permissible – neither obligatory or forbidden, e.g. the treatment of ‘colic’ with gripe water

• Supererogatory – morally praiseworthy if performed, e.g. donating a kidney to a relative

• Forbidden – not permissible under any circumstances, e.g. actively killing a patient.

Immanuel Kant, the major proponent of deontology, formulated what is known as the categorical imperative – according to Kant, it is an absolute duty to act morally. If any action is immoral, then we ought not to perform it. The two formulations of the categorical imperative that are important in medical ethics are:

• The formula of the universal law – to act only if the principle of the action can be applied universally to all. For example, lying to a patient to provide false reassurance about their prognosis cannot be applied universally – if all doctors lied to their patients about prognosis, patients would not trust their doctors and therefore would not be reassured by what they said.

• The formula of the end in itself – when any action involves a person, to never treat the person only as a means to an end, but always at the same time as an end. For example, administering a placebo to a child to reassure their parent is not morally acceptable, unless the child was benefiting from the treatment at the same time.

The doctrine of double effect is the converse of the above example. An action can be justified even if it causes serious harm, if the harm is a side effect of bringing about a good end. The use of high doses of opiates to alleviate the pain of a terminally ill patient could be deemed moral, even though it could lead to respiratory depression and death.

Virtue ethics

Unlike deontology and consequentialism, virtue ethics does not focus on acts per se , but on the character of the moral agent, i.e. the person morally responsible for the act. Having a given virtue predisposes a person to act in a certain way – for example, a generous person is likely to donate towards charity. Virtues are defined by the person's actions, but also their attitudes and internal values. Therefore, actions are morally appropriate if they conform to a virtuous individual's habits of valuing, assessing and acting according to the virtue in question. In other words, an action is honest if it is consistent with the actions of an honest individual.

It is worth noting, however, that individuals are unlikely to be able to always act according to a given virtue. Negative desires may be a result of circumstances and context. The virtuous will attempt to fight the negative desires and perform the right act accordingly. Virtue ethics therefore accepts the complexity of practical situations, which duty- or consequence-based theories may not.

Feminist ethics or ethics of care

This approach is often contrasted with other classic approaches in its communitarian, contextual and caring approach. Some have argued they are perfect for child health dilemmas ( ) as they focus less on individualistic rights-based solutions, but rather view the child in its true context as part of a family with parents, brothers and sisters, of a community with family and friends and of a society of other co-dependent people. However, there is a need to ensure the child is not merely considered as the property of its parents. The influential Gillick case clearly established that ‘parental rights are derived from parental duty…and…exist only so long as they are needed for the protection of…the child.’ ( ).

Indeed, for paediatricians, one also needs to clarify the law surrounding decision-making for children. (Further details can be found by reference to GMC and BMA guidance and healthcare law textbooks.) Parents or those with parental rights are privileged to make healthcare decisions (e.g. consent) for their children, as long as they are acting in that child's best interests. If they are not, such as refusing radiotherapy for a treatable brain tumour, the courts will ensure treatment occurs.

Over the age of 18 years, children become autonomous adults and can decide for themselves. Treatment without consent constitutes the tort of battery – unless they can be shown to lack capacity. Young people between 16 and 18 years are presumed to be able to consent, but cannot refuse medical treatment held to be in their best interest. Their parents can consent, though clinicians would be wise to seek help from the courts before treating if the situation is not an emergency, and even then rapid decisions to treat have recently been made ( ).

It is possible that many involved in child health might consider the ethical aspects at variance from the stark legal situation, given attempts to intro­duce ‘assent taking’ from children un-/not yet able to consent in both research and clinical practice.

Although the decision in the Gillick case was limited to provision of contraceptive advice, Lord Justice Scarman's reasoning has become influential to the extent that children deemed Gillick-competent can now consent to treatment at any age, though in reality such maturity is generally only attained over the age of 13 years. He stated:

As a matter of law, the parental right to determine whether or not the minor child below the age of 16 will have medical treatment terminates if and when the child achieves sufficient understanding and intelligence to understand fully what is proposed. Lord Justice Scarman

Any paediatricians faced with ethical dilemmas involving young people must have a clear understanding of and the ability to test for both capacity and the child's competence to consent to what is pro­posed. Certainly, one place where ethics and the law coalesce is in children of any age having a right to be involved in decision-making about their healthcare ( ).

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Respect for autonomy

Autonomy is the ability to self-govern. In order to possess autonomy, an individual must be able to have desires, be able to formulate options that can realize those desires and be able to select the most appropriate option. Autonomous actions should be intentional, fully understood and devoid of controlling influences. In order to exercise autonomy, a patient must be able to express the problem for which they wish to have treatment, understand the various treatment options and consent to the most appropriate option. Consequently, it would be unethical to treat a patient against their wishes, fail to present the available treatment options to them, or influence or disregard their consented option. For children, this might be the relative autonomy (if that can exist) of a Gillick-competent child, or the autonomy of parents to decide for their children – restricted by the need to act in the child's best interests, however this might be determined.

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