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Professional and ethical responsibilities
Introduction
Ethics is a term derived from the Greek word ethos, defined by the Oxford English Dictionary as being ‘the moral principles that govern a person’s behaviour or the conducting of an activity’. Ethics does not always provide the right answer to moral problems. For many ethical issues, it is acknowledged that there is not a single right answer but instead a set of principles that can be applied to specific cases, giving those involved some clear choices.
Thomas Percival, an English physician, was central to the formalisation of medical ethics at the end of the 18th century, during a time when divisions between the healthcare groups threatened the stability and development of the medical profession. Percival went on to inspire modern codes of medical ethics, the first being the Code of Ethics of the American Medical Association in 1847.
His codes of conduct were very much related to developing harmony between conflicting factions within a medical institution. Modern codes have outdated this and address not only safeguarding professionals but, just as importantly, patients.
Principles of Medical Ethics
Beauchamp and Childress developed an approach to medical ethics based on four prima facie moral principles. Prima facie means that the principle is binding unless it conflicts with another moral principle, and if it does, we have to choose between them. The four moral principles, comprising respect for autonomy, benevolence, nonmaleficence and justice, should be compatible with all political, philosophic, religious and moral beliefs.
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Summary
Gillon R. Medical ethics: four principles plus attention to scope, BMJ 309:184–188, 1994.
Autonomy
Autonomy is Latin for ‘self-rule’. We have a duty to appreciate the autonomy of an individual, that is, to respect the decisions made by individuals concerning their own lives. In medical practice, this autonomy is generally expressed as the right of competent adults to make informed decisions about their own medical care. This principle is the basis of the requirement to gain the informed consent of the patient before any investigation or treatment takes place.
Generally, a decision is regarded as autonomous when the individual has sufficient information to make the decision, has the capacity to make this decision and does so voluntarily—informed consent. In this situation, even if a patient refuses life-sustaining treatment, the person has the right to autonomy, and their decision must be respected.
Beneficence and nonmaleficence
It is important to begin all discussions around medical ethics with the fundamental and essential principles of nonmaleficence, meaning ‘do no harm’, and beneficence, meaning ‘do good for the patient’.
For the physician, this should be the guiding principle in the care of the patient, firstly to do no harm and provide benefit, contributing to a person’s health and well-being.
Justice
Justice is the concept that there should be fairness and equity in the distribution of healthcare and allocation of treatments. Decisions on the distribution of healthcare are often made on the background of limited resources, both financial and related to capacity and ensuring scarce resources are distributed fairly.
This can be in the context of deciding how best to use a limited budget. Should a large proportion of funds be spent on a drug that will prolong a patient’s life for a limited period of time (e.g., chemotherapy) or on a treatment that will improve the quality of life of a patient (e.g., joint replacements)? Should limited theatre capacity be taken up for one operation over a period of 5 hours (e.g., pancreatic resection) or for five individuals who will require only 1 hour of surgical time each (e.g., cataract surgery)?
This concept also arises in the allocation of donor organs. The availability of such a scarce resource does not sit easily with the number of patients requiring transplantation.
With limited resources, the principles to consider are as follows:
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Need
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Benefit
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Utility
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Need: This assigns treatments to those patients who are most likely to die without such interventions. This may be at the expense of utility because these patients who are at the greatest risk of death may also be at the highest risk of death posttreatment.
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Benefit: This seeks to minimise mortality in the patient population as a whole by prioritising patients based on the lifetime gained as a result of treatment.
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Utility: This would ensure treatments are received by patients with the lowest chance of death posttreatment. However, patients with the best treatment outcomes may also have the best waiting-list outcomes.
It is also important to appreciate that medical care is not just intended to improve survival but also quality of life.
It is difficult to determine the operative priority between a patient requiring a joint replacement for intractable pain and reduced mobility resulting from severe arthritis and the patient with pancreatic cancer who, despite surgical resection, has the prospect of a less than 20% 5-year survival.
Patients’ care should also not be dependent on geography and socioeconomic status. Justice includes ensuring that there is no significant variation in medical treatments available to patients across the country. For example, in some areas, there may be ready access to clinical trials or advanced radiologic interventions, whereas such access is not available in more remote and rural areas.
Informed consent
Consent to treatment is the principle that a person must give permission before they receive any medical examination, test or treatment. This should be informed, based on sufficient information provided on which the patient can make their decision. Consent is a process; it results from open dialogue and not, as traditionally perceived, from the act of obtaining a signature on a form.
Consent is required in every aspect of medical care, from giving a patient a tablet, intravenous fluid or blood while they are awake to performing procedures under sedation, such as colonoscopy or day-case surgery (e.g., hernia repair under general anaesthesia), to major surgery with the potential risk of significant morbidity and mortality (e.g., cardiac surgery).
Consent can be undertaken in the elective setting ahead of any intervention or may be required as an emergency with little time for the patient to absorb information and discuss with family. Each of these situations is very different; however, they should all follow the same principles and standards.
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