Ethical Principles

Question 1

What are the 4 pillars of ethics?

Answer 1

. Beneficence
. Non-maleficence
. Autonomy
. Justice

Question 2

What does beneficence mean?

Answer 2

Beneficence means all medical practitioners have a moral duty to pick the course of action that is in the best interest of the patient. Doctors have to rank options for the patient from best to worst and decide which outcome suits the patient and their expectations the most.

Question 3

Questions doctors ask themselves that show beneficence

Answer 3

. Will this option resolve the problem?
. Is it proportionate to the scale of the medical problem?
. Is this option compatible with the individual’s circumstances?
. Do the treatment and outcome match up with the patient’s expectations?

Question 4

Limits of beneficence

Answer 4

. Doing good depends on the circumstances at hand, sometimes you can’t give the best outcome for the patient due to external situations
. Only applies if it outweighs non-maleficence

Question 5

Example of beneficence - walkthrough.
An eight-year-old child has been admitted to the hospital with a significant open fracture to their left leg. The limb is deformed with significant bleeding and the patient is extremely distressed. The parents are demanding immediate action be taken.

Answer 5

. There are significant risks like heavy bleeding, infection and a severely damaged limb.
. One treatment consideration would be amputation
. Although amputation would resolve all the issues, it is by no means the best course of action as it will affect the patient physically and mentally for the rest of his life.
. it is not a proportionate treatment and doesn’t consider the patients expectations or how it will affect them.
. Alternate treatments like reducing the bleeding, reducing the fracture or giving surgery are much more beneficent.

Question 6

What is non-maleficence?

Answer 6

Non-maleficence states that a medical practitioner has a duty to do no harm and allow no harm to occur to a patient through neglect.

Question 7

How is non-maleficence different to beneficence?

Answer 7

. It’s a threshold for treatment, if a treatment causes more harm than good to a patient, it shouldn’t be considered. Beneficence is about considering all options for the patients ranked from best to worst

. We tend to use beneficence in certain situations, but non-maleficence is something doctors have to do constantly

Question 8

Questions doctors ask themselves that show non-maleficence?

Answer 8

. What are the associated risks with this intervention?
. Do I possess the required skills and knowledge to perform this?
. Is the patient being treated with dignity and respect?
. is the patient being put directly at risk through other factors?

Question 9

Example of non-maleficence - walkthrough
A 52-year-old man collapses in the street complaining of severe acute pain in his right abdomen. A surgeon happens to be passing and examines the man, suspecting that he is on the brink of rupturing his appendix. The surgeon decides the best course of action is to remove the appendix in situ, using his trusty pen-knife.

Answer 9

. From a beneficence perspective, operating him would improve the patient’s outcome as it would stop his appendix from bursting
. From a non-maleficence perspective, this would cause a lot more harm than good
. It isn’t a sterile environment so there is a huge risk of infection
. There are no other staff members of extra blood if needed, the patient isn’t anaesthetised
. Might be decontextualised as the patient isn’t on the operating table

Question 10

What is autonomy?

Answer 10

Autonomy means that a patient has the ultimate decision-making responsibility for their own treatment. A doctor can not impose treatment on a patient for whatever reason unless the patient is unable to make autonomous decisions. It’s important that patients are actively involved in their own treatment.

Question 11

Questions doctors ask themselves that show autonomy

Answer 11

. Have you fully explained the patient’s medical condition, treatments available and the advantages and disadvantages of these?
. Is the patient able to obtain this information, evaluate their options and arrive at a decision?
. Has the patient informed consent?

Question 12

What happens if a clinician doesn’t gain consent for a procedure?

Answer 12

If a clinician carries out a procedure without consent, it is called battery which means ‘ infliction of unlawful personal violence’. If a patient doesn’t consent, you can’t intervene even if it results in death.

Question 13

What is the term for a patient being in a position to understand information?

Answer 13

Patient competence

Question 14

What is justice?

Answer 14

When considering an action, it has to be fair and balanced, compatible with the law and the patient’s rights. it also means no one can be unfairly disadvantaged in the NHS e.g. low-income people get cheaper prescriptions

Question 15

What are some limitations of autonomy?

Answer 15

. Patients can’t demand treatments, they can only pick from the ones outlined to them.
. If the parent is giving consent for their child, beneficence can outweigh autonomy if the treatment is in the best interest of the child.

Question 16

What is Gillick competence?

Answer 16

Whether a child under 16 can consent to treatment without their parents permission. Children under 16 have to be assessed for this before they can have treatement

Question 17

Example of autonomy- walkthrough
A 26-year-old male has been involved in a high-speed collision, in which he sustained blunt force trauma to his head as his head hit the front windscreen of his car. He did not lose consciousness, he is fully responsive and has no indications of neurological damage. He does, however, have a significant head wound that is bleeding continuously. This patient has refused treatment on the grounds that he feels “fine” and is refusing to have sutures to close his head wound. He would like to leave the Department.

Answer 17

Even though it would be in his best interest to get a CT scan and have sutures, he is a competent adult and can have the autonomy to refuse treatment. He would have to be let out of the hospital, or it would be unlawful detainment.

Question 18

Questions doctors ask themselves that show justice?

Answer 18

. Is this action legal?
. Does this action unfairly contradict human rights?
. Does this action prioritise one group over the other?
. If it does prioritise a group is this because of net benefit or because of moral conventions?

Question 19

What is the 5th pillar and why?

Answer 19

Confidentiality is the 5th pillar and it is the duty of a medical practitioner to keep a patients information private within the healthcare team apart from specific circumstances.

Question 20

What are the exceptions for confidentiality?

Answer 20

. When the patient consents to their information being shared
. When not sharing information puts the patient or others in danger
. When the patient lacks capacity and sharing the information is for the good of the patient

Question 21

What is another name for justice?

Answer 21

Equity

Question 22

Why is confidentiality so important?

Answer 22

It is essential for building trust in a doctor-patient relationship. A patient is much more likely to under-share symptoms or not seek medical help if they think their information is being shared without consent. This is at a disadvantage to the patient and also makes it harder to treat patients.

Question 23

How does confidentiality apply to beneficence and non-maleficence?

Answer 23

. Consider whether breaking confidentiality could put a patient at risk with the police for example or cause avoidable distress
. Find out if you can try and gain consent
. Advise a patient to tell the right people about their situation

Question 24

Example of justice - walkthrough
Patients suspected of having cancer are prioritised within the NHS, with the maximum waiting time for referral being two weeks (as opposed to 18 weeks for non-urgent referrals). Patients diagnosed with cancer are entitled to a range of treatments including radio- and chemotherapy. These treatments are expensive and treat a small, but significant proportion of patients. Think of arguments for both sides.

Answer 24

. One argument is that prioritising cancer patients means you’re limiting the availability of healthcare to other patients who may have been waiting a long time with a disease just as serious
. A counterargument is that referring cancer patients to oncology units are freeing up space for other services
. Another argument would be that spending money on chemotherapy is taking away from less expensive treatments that benefit more people
. It could be argued that treating cancer early would actually reduce the cost of the cancer treatment overall.

Question 25

How does confidentiality relate to autonomy?

Answer 25

.Breaking a patients confidentiality also breaks their autonomy . Breaking confidentiality undermines a patients trust and they may be hesitant or avoid healthcare professionals in the future . If children are Gillick competent, they should be respected and have the same autonomy as an adult.

Question 26

How does confidentiality relate to justice?

Answer 26

. If confidentiality is continuously broken unjustifiably, it damages the publics perception of healthcare professionals and their reputation . If the publics perception is damaged, they will withhold information. . A doctors job is to decide how their actions impact society as a whole

Question 27

Questions to consider before breaking confidentiality

Answer 27

. Is it likely that anyone will be harmed as a result of this info? . What impact will revealing this information without consent have on the patient? . Is there anything else that can be done before breaking confidentiality?

Question 28

What are ethical frameworks?

Answer 28

They are guiding idealogies that help decision making in medical ethics. They are not as constant as the 4 pillars as they are more philosophical.

Question 29

What is consequentialism?

Answer 29

. It means that an actions morality is dependent purely on it's consequence. . As long as the action has an overall benefit, the morality of any other aspect of the action doesn't matter

Question 30

An example of consequentialism

Answer 30

There is a limited drug supply on the ward and you have the choice of giving it to 1 really sick patient or 5 not so sick patients. A consequentialist would argue that the drugs should go to the 5 patients as that does the greatest good. the one sick patient is therefore disregarded

Question 31

What is deontology?

Answer 31

. This is duty based ethics and means that actions all depend on duty and the morality of that action depends on the way you got the result, not the actual result itself . It is in direct contrast of consequentialism

Question 32

An example of deontolgy?

Answer 32

A patient going into a really long surgery asks the doctor if they know the outcome of the surgery. The doctor has no idea. . A consequentialist would think it's ok to lie to the patient if the end result turned out ok . Based on deontology, this would be immoral as lying is wrong. They would tell the patient the truth

Question 33

What is utalitarianism?

Answer 33

. It means the best action is the one that provides the most good . The best decision is the one that benefits the most people

Question 34

What are virtue ethics?

Answer 34

. It means an actions morality is dependent on the motivations behind their actions . Aim to be good and actions will automatically be moral . Doctors need to have 5 characteristics to be moral: compassion, discernment, trustworthiness, integrity, conscientiousness

Question 35

What is a diadvantage of virtue ethics?

Answer 35

Someone else is dictating what is moral and what isn't which can be an issue if you are trying to figure out your own moral compass so you can't develop it. you might not be able to apply these principles at times.

Question 36

What is principlism?

Answer 36

. These are the 4 principles of medical ethics which you use to guide you when making decisions . There isn't a framework for which of the decisions prioritises the others, there may be circumstances where you support one pillar but go against another

Question 37

What is a disadvantage of deontology?

Answer 37

There is no room for flexibility which is a problem in a field like medicine which is so dynamic and unpredictable

Question 38

How to approach ethical questions?

Answer 38

. Acknowledge the ethical implications of the scenario . State which frameworks you are going to use and explain it . Provide a balanced argument using your chosen framework . Reach a balanced conclusion using the frameworks in your answer

Question 39

What is capacity?

Answer 39

Capacity is the ability to give consent. It relies on a patient being able to assess the risks and benefits of a situation and weigh them up to make a decision

Question 40

How is capacity assessed?

Answer 40

It is assumed everybody over the age of 18 has capacity unless proven otherwise and this is dictated by the Mental Health Act of 2005

Question 41

Who might lack capacity?

Answer 41

``` People who have: . dementia . a severe learning disability . brain injury . mental illness . stroke ```

Question 42

What happens if somebody lacks capacity?

Answer 42

You as a doctor have to be beneficent which means you have to find the least restrictive course of action. Try all other alternatives like postponing decisions if they could regain capacity. Contact their relatives and their power of attorney if named. They could also have a medical proxy or an advanced directive.

Question 43

How do you know consent is valid?

Answer 43

. It's voluntary - it's decided solely by the patient and not influenced by any relatives or anyone else . It's informed - the patient is given all the information including : the benefits, the risks and what would happen if it didn't go ahead . The patient has to have capacity

Question 44

What is consent?

Answer 44

Consent is when a patient gives permission for any sort of medical treatment administered to them

Question 45

Why is consent important?

Answer 45

It's really important because it ensures the patient is in agreement and is allowing everything to happen to them. It also enables healthcare workers and patients to work closely and maintain a good relationship

Question 45

What does the Children Act 2004 state?

Answer 45

That adulthood is reached when someone turns 18 and from that point, they can give their own consent

Question 46

What does the Mental Health Act of 2005 state?

Answer 46

. A patient has to be able to understand information presented to them . They have to be able to retain the information for a long enough period . They have to be able to evaluate the information in order to make an informed decision . They have to be able to communicate what their decision is

Question 47

When might consent not apply?

Answer 47

. In an emergency lifesaving situation where the patient is incapacitated . Additional emergency procedures during an operation . Under the Mental Health Act 1983, if there is need for hospitalisation like if a competent patient is suicidal or refuses treatment, they can be kept in hospital as long as 2 doctors have assessed them. Relatives also have to sign and make an application . If there is a wider risk to public health

Question 48

When might consent not apply?

Answer 48

. In an emergency lifesaving situation where the patient is incapacitated . Additional emergency procedures during an operation . Under the Mental Health Act 1983, if there is need for hospitalisation like if a competent patient is suicidal or refuses treatment, they can be kept in hospital as long as 2 doctors have assessed them. Relatives also have to sign and make an application . If there is a wider risk to public health

Question 49

How does autonomy apply to consent?

Answer 49

. If a child can make a decision about their health, it should be respected . if a child doesn't understand a procedure and it's risks or benefits, they cannot consent. . Only those able to make informed decisions to promote health and avoid harm should have autonomy

Question 50

How does beneficence apply to consent?

Answer 50

. If a child is able to make a decision in their best interest, it should be respected and they can be deemed competent . If a child under 16 lacks the cognition to understand the implications of treatment and are refusing treatment that could be in their best interest, it can be overruled by a parent or a court of law

Question 51

How does non-maleficence apply to consent?

Answer 51

. If preventing a child from receiving a treatment they are willing to consent for causes them harm, then accepting their consent is the right thing . If a child is participating in illegal or dangerous behaviour, it is arguable their parents should be informed

Question 52

How does judgement apply to consent?

Answer 52

. The Gillick Test was created to test if children are capable of making their own decisions . Legal guidelines usually encourage the autonomy of children, but it's down to clinical judgement

Question 53

An example of consent - walkthrough A 15-year-old girl comes in alone and tells her GP that she is sexually active. She also states that she would like to start taking contraception.

Answer 53

. If you refuse to give out contraception without parental consent, her physical and mental health would suffer. She could also end up with unwanted pregnancy or STDs. She could also be forced to tell her parents she is sexually active which would harm her emotionally . On the other hand, she could be having sex with an inappropriate adult in which case giving her the contraception would allow this to continue and keep it a secret from her parents. . The Gillick competence test will help the doctor understand if sexual abuse is taking place and the Fraser Guidelines will help with the decision