Introduction to ethics in medical practice

1. Introduction to ethics in medical practice Anna Smajdor Lecturer in Ethics University of East Anglia a.smajdor@uea.ac.uk http://www.bbc.co.uk/news/health/

2. What medical ethics teaching can’t do • Tell you what’s right and wrong • but it might help you to understand ethical issues and think more deeply about them • Make you a good person • but it might help to make you a better person, and a better doctor, through thinking about and understanding ethical issues

3. What your medical ethics teaching is for • Recognise common areas of ethical dispute in medicine • Recognise ethical beliefs & assumptions (your own and those of others) • Recognise the impact of your ethical beliefs on your practice • Be able to articulate and evaluate your ethical beliefs • Recognise and understand the ethical viewpoints that conflict with your own beliefs • Participate in the resolution of ethical conflicts that arise in practice And (pragmatic considerations) • To fulfil government requirements • To help you pass your exams

4. The evolution of ethics Maeterlinck says ants are ethical because they are altruistic. What assumption(s) does this imply? Ants – Maurice Maeterlinck argues that ants behave ethically, because they are altruistic Can animals behave (un)ethically? • fthat ‘altruistic’ equals ‘ethical’ • that ants can choose to do this

5. ‘Ethics’ in animals

6. What about human beings? Ethical norms probably part of evolutionary history as a social species. To this extent, humans perhaps not qualitatively different from other animals. BUT – with the ability to debate ethical problems, and construct new ethical codes, it’s no longer a question of instinct. We can deliberate about our actions to ensure we make the ‘ethical’ choice. The question is: how?

7. Ethics is about right and wrong: what ought one to do? – Socrates Some common fallacies: Ethical questions CAN’T be answered simply by referring to a) empirical facts, b) the law, c) religion, d) majority views. • EG: ‘is euthanasia wrong?’ A1: euthanasia will always happen whatever we think about it A2: Euthanasia is legal in the Netherlands A3: The Catholic church forbids euthanasia A4: Most British people think euthanasia is acceptable. None of these is valid as the sole answer to an ethical question.

8. Theory and argument: approaches to ethical reasoning In the Western philosophical tradition, ethical questions are explored through philosophical reasoning. Consideration of ethical theory may help in recognising and constructing arguments • Relativism/Subjectivism • Virtue ethics • Consequentialism • Deontology • Four principles Applying ethical approaches – sample question: is euthanasia wrong?

9. Moral relativism & subjectivism • Relativism: ethics dependent on social context Euthanasia is OK if you live in Switzerland but not in the UK • Were the Nazis right to send 6 million Jews to their deaths? They lived in a place where it was ‘OK’ to do so • Was slavery a good system? It was widely accepted at the time • Subjectivism: ethics is a matter of personal opinion Euthanasia is OK if you think it’s OK • But - our values/choices affect others • Am I entitled to my personal view that slavery is OK? • Or that Jews should be killed?

10. Aristotle (384 BC – 322 BC) Virtue ethics – balancing between extremes Courage Cowardice Compassion Selfishness Diligence Laziness Temperance Greed WISDOM Would a virtuous doctor perform euthanasia? Would a virtuous patient request it? What sort of person would he/she be?

11. Only outcomes count • The greatest good for the greatest number • No absolute prohibitions • Ends justify the means • ‘…the only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others.’ • Euthanasia is OK if overall benefit results - could mean killing those who are unprofitable to society? Consequentialism/Utilitarianism Famously associated with John Stuart Mill (1806-1873)

12. Deontology • Morality is about following rules - consequences are not important. • Some acts are intrinsically wrong. So they are wrong in ALL circumstances. EG, killing. • Means and ends – never treat another human being solely as a means, but always as an end in him/herself. Famously associated with Immanuel Kant (1724-1804) Euthanasia is wrong, as it is the killing of another human being

13. Core concepts – four principles Autonomy:Greek origin, literally means “self-rule”. “The capacity to make reasoned decisions and act on them” (The New Dictionary of Medical Ethics) . Contrasts with paternalism - assumption that doctor knows best. Respect for autonomy means that the patient’s choices decisions and values are key. Non-maleficence – not doing harm Beneficence – doing good Justice – treating people fairly, without discrimination Does euthanasia respect autonomy? Does it harm the patient? Or benefit them...?

14. What does respect for autonomy entail? • Respect for people’s mental & physical integrity: • No treatment without consent. • Patients assumed competent unless evidence otherwise • Consent must be freely given & fully informed • Provision of accurate & relevant information • Absolute right to refuse treatment, even if death will result (but no right to demand treatment) • Confidentiality: doctors must not divulge facts about their patients

15. A critique of autonomy-focussed medicine Degrees of autonomy – gradually attained as children grow older; sometimes gradually lost as adults grow older Critics of autonomy: individualistic, ignores society, disregards relationships, downgrades the doctor’s role?

16. Ethical conflicts in medicine • Autonomy vs paternalism refusal of treatment • Individual vs society allocating scarce resources • Beneficence vs non-maleficence screening programmes – greater harm than good? • Acts vs outcomes euthanasia, abortion • Objective vs subjective values best interests; quality of life; futility judgements

17. Ethics is about right and wrong: what ought one to do? – Socrates Ethical questions can’t be answered simply by referring to a) external facts, b) the law, c) religion, d) public opinion. Q: Is euthanasia acceptable?

18. Challenging an ethical argument Claim: ‘euthanasia is wrong’ Arguments (an argument is a conclusion supported by one or more reasons): • It is wrong to harm people • euthanasia harms people Conclusion: euthanasia is wrong DISAGREE? Show where the argument is flawed…. Potential challenges: ‘Harming people is not always wrong’ – rejects 1st claim ‘Euthanasia does not harm people’ – rejects 2nd claim ‘Euthanasia is not wrong because it harms people, but for other unrelated reasons’ – accepts that the argument is flawed, but suggests the conclusion is justified on separate grounds: need to draw up new argument

19. Reflective equilibrium GMC: “You are personally accountable for your professional practice and must always be prepared to answer for your decisions and actions” [GMC Good Medical Practice, p1] Where there is an ethical issue, you need to show you’ve a) recognised that there’s a potential problem b) thought through the relevant options c) selected a course of action based on careful, conscientious analysis of the problem

20. Conclusion Van Rensselaer Potter: need to create professionals with the ‘knowledge of how to use knowledge’[Potter 1971] • Values are diverse + disputed – no factual answers • Moral theories can help but not always conclusive • Reflective equilibrium offers a way of addressing ethical questions, identifying + evaluating ethical assumptions + engaging in ethical debate • Ethical issues extremely broad + cover a wide spectrum of social, ethical + scientific questions • Need to connect scientists & doctors with social & ethical values

21. References and further reading General Medical Council. Good medical practice. 4th Edition. 2007. London: General Medical Council Beauchamp T L, Childress J F. Principles of Biomedical Ethics. Oxford University Press. 2001. Boyd, Higg, Pinching (eds). The new dictionary of medical ethics. BMJ. 1997. Rawls J. A theory of justice. OUP. 1999 O’Neill O. Autonomy and Trust in Bioethics. Cambridge: Cambridge. University Press, 2002, 30, 83–5. Hope T, Savulescu J et al. Medical ethics and law: the core curriculum. Churchill Livingstone. 2nd Edition. 2008. Potter, V.R. 1971. Bioethics, A bridge to the future. Englewood Cliffs: Prentice-Hall. Daniels, Norman, "Reflective Equilibrium", The Stanford Encyclopedia of Philosophy (Fall 2008 Edition), Edward N. Zalta (ed.), URL = <http://plato.stanford.edu/archives/fall2008/entries/reflective-equilibrium/>