Medical Ethics: the Principles Used by Doctors to Make the Toughest Decisions
About the author
Robert Cronshaw is a Medical student at Jesus College, Cambridge.
In this article I will discuss medical ethics, an important topic for anyone hoping to study medicine.
But what is “ethics” and why is it important to medical practice? Ethics is defined as a branch of philosophy that involves recommending and defending concepts of right and wrong conduct. This is important in medical practice as there will be situations where the ethical course of action may not be immediately obvious or clear. In these situations if you have a reasonable understanding of ethical systems you can apply their principles to the dilemma at hand and use them to try to decide what the right thing to do is.
Understanding ethics is useful to a prospective medical student as it is likely that in medical school interviews you will be asked about an ethical dilemma. In these situations many candidates are tempted to answer with a “gut feeling” answer about what is right, without any consideration. Of course, the interviewer’s next question will always be “why do you think that?” An interviewer is never really interested in your opinion on assisted dying or abortion; they want to investigate your ability to think and come to rational conclusions. Having said this, if you do answer with a very bizarre or controversial opinion it is much more likely to hinder than help your chances. Remember that your interviewer will be considering whether they want you to be a doctor who could be treating them in 10 years’ time and they will not think of you as particularly compassionate if you start suggesting compulsory euthanasia. So how is it possible to be rational about your moral judgements and be able to look at an ethical problem systematically? This is essentially what ethics has been trying to do and while it is rare that ethics will produce a conclusive answer to a dilemma, it at least provides a means for examining a situation.
The Categorical Imperative
As there are far too many ethical systems to successfully describe them all, I will focus on a small number of historically important ones and then move on to discuss the most modern and relevant system, the “Four principles” approach. The first system to examine is that devised by Immanuel Kant, one of the most important European philosophers since antiquity. His moral system is entirely based around logic and rationality and is meant to transcend any kind of subjective ideas of what is good or right. The basis for this is called the “Categorical Imperative”, defined as “Act only on the maxim through which you can at the same time will that it be a universal law”. In other words, behave in a way that everyone could behave. Take as an example a doctor who decided to start promising patients they would recover when they wouldn’t. If this were universally applied by doctors trust would break down so that this doctor could no longer falsely promise patients recovery, as they would simply disbelieve him. It is important to realise that Kant is not saying that making a false promise is wrong because of the unpleasant effects it could have on the patient and their family, but because it cannot be applied universally. While this is a useful way of removing any subjective bias from morality it is also very stern and inflexible; you are acting out of a sense of duty as opposed to a desire to increase happiness. For example, while Kant rejects the making of false promises it is possible to envisage a scenario where you could use deception to protect someone vulnerable from harm.
There is a somewhat less strict interpretation of the Categorical Imperative which leads to the “Formula of the End in Itself”, that no person (another or yourself) should be treated simply as a means but always at the same time an end. Another way to put it is that no person should ever be used simply as a tool but also as a person to be respected and left with the power to act for themselves. Kant thought that using another was not limited to doing something the other does not want or consent to, but also doing something which they could not consent to, such as being deceived (where the deceit makes consent impossible). The idea of consent is crucial in medicine and is also important in cases such as drug trials, where it becomes all too easy to view participants as experimental tools and not as individuals to be respected. While Kant manages to bring a rational basis into morality which often does adhere with our instinct for what is “right” it is not necessarily the case that what is rational is also moral. His approach seems a little too theoretical and strict to be usefully applied in day to day life.
Utilitarianism: the greatest happiness for the greatest number
An alternative ethical system is a type of Consequentialism known as Utilitarianism. This contrasts well with Kantian ethics, as instead of using very stern and fixed maxims for every situation you instead judge each situation individually. The principle on which Utilitarianism is founded is that we know fundamentally that happiness is good and suffering is not good. Therefore if we attempt to maximise happiness while minimising suffering we will be doing something that overall is good. This can all be summed up by attempting to achieve “The greatest happiness for the greatest number”. While Utilitarianism is useful at a community wide scale, it can be less useful at a smaller scale and can appear to suggest decisions which most would call immoral, which is investigated in a thought experiment. Imagine that you had a great aunt who was very wealthy, but unfortunately unwell and in constant pain. You are her only surviving relative and if she dies you stand to inherit all of her money. You are also the only person who sees her and you don’t enjoy seeing her because her illness has made her bad tempered. It seems as if there is a strong Utilitarian argument for killing your aunt, especially if you decided to donate some of the wealth you inherit to the poor and needy as you would create a very large overall increase in happiness not only for yourself but also for others, as well as relieving your aunt’s suffering. This example really highlights the most significant drawback of Utilitarianism, that what creates the greatest happiness for the greatest number of people isn’t necessarily right. Morality is not necessarily the same thing as trying to make a net gain in happiness.
Virtue Ethics: acting like the person you wish you were
Recently there has been a revival of an ethical system that was originally proposed by Aristotle. This system is known as virtue ethics and revolves around the central concept of good character. Modern virtue ethics developed partly as a reaction to the somewhat impractical Kantian ethics and Utilitarianism. If you think about a person who is particularly moral or ethical, the chances are their decisions have nothing to do with some kind of utilitarian calculation or Kantian rationality, but instead the kind of person they innately are. Virtue ethics says that we should strive to have a good character, both by thinking about the kind of person you want to be and also by looking at what virtues those we admire have and attempting to copy them. In essence virtue ethics says that if you focus on making who you are an admirable character, what you do will be right. When posed with an ethical dilemma virtue ethics wants you to ask “what would someone I aspire to be like do?” While somewhat vague and quite difficult to apply it does at least acknowledge the complexity of morality and does not require any rules to be rigidly adhered to. Unfortunately, we often turn to ethics in a situation where we don’t know what to do and the character that we have made for ourselves is unable to come up with a solution. In these cases it is the question “what should I do?” that we want answering, the question that virtue ethics ignores in favour of the less clear concept of “character”.
The Four Principles Approach
The most modern ethical system I will discuss is the one which is easiest to apply to an ethical dilemma and will also give you a range of perspectives to weigh up in your decision. It is known as the “Four Principles approach” and is based on the concept of analysing a situation from the perspective of four different principles to ensure a balanced approach. The four principles are: Beneficence, Non-maleficence, Justice and Autonomy. Beneficence and non-maleficence are essentially two sides of the same coin, with beneficence being actions that promote the well-being of patients and non-maleficence being avoiding actions which bring about the harm of patients. Justice is concerned with the distribution of finite health resources and autonomy is the recognition that patients have the right to choose for themselves what treatment they receive. Unfortunately, it is not always possible to adhere to all of these principles at the same time and this is usually where an ethical dilemma occurs. A very basic example would be a patient who wants to receive a very expensive course of chemotherapy. While a doctor wishes to respect their right to choose (autonomy) and also to help them (beneficence) they must also bear in mind the fair distribution of healthcare resources (justice). If a million pounds is spent on this treatment it is a million pounds which cannot be spent on many other people who would receive more benefit from the money spent.
Beneficence could also come into conflict with non-maleficence in the context of chemotherapy, where patients often experience harmful side effects in order to be treated. These examples seem to put the usefulness of the four principles approach in doubt; what is the point if it does not provide any useful answers? This approach is a powerful tool because it produces questions, not answers. The questions generated are then an excellent starting point for a discussion of an ethical dilemma in the context of a medical school interview. When confronted with a difficult problem you can pause and weigh up each principle in turn, allowing you to come to a well-reasoned conclusion. Of course different people will always place a slightly different focus on the importance of certain principles. For example, as medicine has modernised there has been a shift from a main focus on beneficence to greater importance being placed on autonomy, with patient choice becoming a key part of modern healthcare systems such as the NHS. This is a reaction to the traditional “paternalistic” attitude of doctors, that they knew best and that the most important thing was what would provide the best outcome for the patient, not what the patient wanted. It is interesting to note that the four principles approach appears to integrate different parts of different ethical systems, with justice in particular being closely related to utilitarianism. There is in fact a system for deciding the allocation of healthcare resources based on maximising the greatest benefit for the greatest number. It uses a unit of measurement known as a “quality adjusted life year” (QALY) to decide which drugs the NHS will fund. A new drug will be evaluated by how many years it is likely to extend someone’s life, as well as the quality of life they will gain and is compared against an older drug to see if it is a worthwhile expenditure, with one QALY generally being worth at most £20,000-£30,000.
Ethical Dilemmas and how to approach them
Having provided a very brief introduction to these ethical systems (hundreds of thousands of words have been written about each one) I will give examples of situations that could be asked about at interview and examine them in order to demonstrate how this is done. One question that is posed in an attempt to catch students out with a poorly considered answer is this: “Would you give a liver transplant to someone injured playing rugby instead of someone who had damaged their liver due to a chronic drinking problem?” Most students reply they would give it to the rugby player with little thought and then struggle to justify why. Both patients want the treatment, so there is a conflict of autonomy where one patient’s autonomy must be disregarded. As only one patient can receive the transplant beneficence will only be able to be used for one person, so again this principle provides no method of distinction. It could be argued that the rugby player is less likely to suffer from associated health problems and will therefore make better use of the transplant, with it extending his life more than the alcoholic’s. Therefore there is an argument of justice for the rugby player receiving the transplant. However, this is suggesting that the health of the alcoholic is less valuable than the health of the rugby player, which is a very serious judgement to make and one that you must be prepared to justify. Using the concept of QALYs it is possible to justify this stance, but many candidates will simply suggest that the alcoholic does not “deserve” a transplant as it is “their fault”. It is unlikely that someone becomes an alcoholic without a traumatic life event and is it not as much a rugby player’s fault for engaging in a sport that they know carries a risk? In a sense the rugby player has more of a choice than an alcoholic suffering from a chronic addiction, as they do not have a powerful biochemical draw to continue the potentially harmful behaviour.
Another example is a patient who is requesting assistance with their suicide. They are suffering a great deal and have a very poor prognosis, so should the doctor respect their autonomy? This question really comes down to beneficence and non-maleficence and there really is no right answer. It all depends on whether you believe that by assisting someone in dying you are being beneficent or maleficent and in an interview it is not really important which side of the line you come down on, as long as you can analyse the situation well. Clearly if you believe you are doing good by assisting the patient’s suicide then you are also aligned with their autonomy, which adds weight to your argument, but in this case the seriousness of the potential maleficence could outweigh the autonomy argument. This question also brings up the distinction between claim rights and liberties. The word “rights” can have two meanings, either something you are free to do, such as “I have the right to remain silent” (a liberty) or something which someone has a duty to give you, such as “I have the right to an education” (a claim right). This distinction has confused the assisted dying debate, with the phrase “right to die” being thrown around. Of course people have the liberty to die if they wish to, but this is not the same as having a claim right to die, where a doctor is obliged to assist you.
Remember, if someone poses you an ethical dilemma, resist the temptation simply to blurt out your instinctive response. As a minimum talk your way through the four principles and then identify where they may come into conflict or where their interpretation may cause a dilemma. Once you have done this it does not matter too much what conclusion you come to, as long as you have arrived at it through reasoning. There is very rarely such thing as a correct answer in ethical dilemmas, as otherwise they would not be considered a dilemma.