The murky world of medical ethics

The murky world of medical ethics

Medical ethics exist to protect us and they’re part of the more interesting side of modern medicine. When can we pull the plug? When does a mother’s autonomy override the baby’s right to life? How do ethics develop as cultural morals change?

As a system of moral principles, medical ethics are a determined set of values that can be referred to whenever a case gets complicated. Separate to the Hippocratic Oath, medical ethics encompasses the practical application of ethical philosophy in clinical settings and is hotly debated as it continues to develop and change. Ethics boards and committees reside in hospitals, medical schools teach the core tenets, and clinician ethicist is now a professional role.

In its most simple form, medical ethics comprises four principles: respect for autonomy, beneficence, non-maleficence, and justice. The patient has the right to choose or refuse treatment; the professional must act in the best interest of the patient; the professional must not do harm or must promote more good than harm; and resources must be distributed ethically—no principle can supersede another as all are weighted equally.

These pillars form the basis of medical ethics, but there’s a murkier side of things to be found in the articles submitted to journals like the British Medical Journal’s Journal of Medical Ethics and when we consider the state of national healthcare services like the UK’s NHS. Things that include using oestrogen treatments to prevent girls growing too tall, the emergence and subsequent proliferation of artificial intelligence, and the access to healthcare afforded to migrants.

Medical ethics is trying to do the right thing and achieve the best outcome for the patient but balancing the four principles can lead to debate and controversy—while offering oestrogen treatments to young girls to save them the social consequences of being ‘too tall’ may seem to be in the best interest of the patient, it may flout the patient’s right to autonomous decision: in most cases covered in the article in the Journal of Medical Ethics, the mother tends to make this decision for her child and informed consent can come into question. The healthcare provider needs to make sure the patient understands their condition and the options for treatment, but this combines with age of consent, a parent’s right to care for their child, and the ethical implications of determining what is ‘too tall’ for a woman. It should be very clear that ethical principles may be fine in theory but putting them into practice requires a case-by-case approach. Perhaps the most controversial cases seen regularly by medical ethics boards are abortion cases where autonomy and nonmaleficence come into conflict. Where does the woman’s autonomy end and the foetus’ right to nonmaleficence begin?

Cultural differences also create different medical ethics problems and some cases have no straightforward answers. Medical professionals are not held to a particular medical ethics code; rather there are principles and the understanding that the professional uses these to guide their decisions. Morals and standards are not the same around the world and the course of action is ultimately decided by the professional. Ethicists can be consulted, opinions may be gathered, the patient contributes their thoughts—but the professional uses their morals to make their choice of treatment. Often, this is spur of the moment, such as in emergency rooms or trauma theatres—cases may be debated by ethics boards afterwards, but the professional called the shots in the moment. In 1998, two surgeons from Bristol were found guilty by the General Medical Council of continuing to operate on children with heart defects when they knew their death rates were ‘unacceptably high’; a doctor manager was also found guilty of failing to stop the operations once he had been alerted to the high mortality. The surgeons clearly thought the operations were in the patients’ best interests—one professional’s interpretation of ‘unacceptably high’ will differ from another’s, even when a standard has been set. Did these surgeons decide they had the responsibility to help, despite the risk—that they were acting in the best interest of the patients? Don’t forget; this ‘unacceptably high’ death rate is the rate of patients who died on the surgeon’s table; is this truly poor performance or pure chance? Would these patients have died anyway, regardless of who operated, or would they have suffered more had they been refused the chance of an operation? What should the doctor manager have done differently with the staff shortage that has plagued the NHS for decades? Little is clear cut in medical ethics; it’s simple to understand but a challenge to implement.

Even in seemingly simple cases, medical ethics appear in surprising ways. Consider a person having a pacemaker implemented: by consenting to having an implantable device placed, the patient is indirectly giving up the right to autonomous control of the device. Therefore, the patient forfeits the right to request removal of the device without due cause; should they simply change their mind after informed consent, the doctor should not remove a perfectly functioning pacemaker keeping the patient alive. In such a case, the patient has exercised their autonomy to waive their future right to autonomy—beneficence and non-maleficence hold the sway in the future. Turning off a pacemaker in a patient could be very similar to euthanasia—another hotly contested topic in medical ethics.

Ethics are a uniquely interesting topic precisely because of their proliferation in all areas of life: if you find money on the pavement, do you keep it? Do you tell your partner their outfit isn’t flattering if it’ll upset them? Do you lie to your parents about where you were last night? Ethics are personal and medical ethics are no different. And with social ethics developing rapidly, doctors are likely to face controversial issues on a regular basis.