Foundation of bioethics for MBBS student

1. The Foundations of Bioethics

2. ●
4 Modules:
●
Introduction to Bioethics
●
3 case based discussion modules
●
Emphasis on Autonomy & Decision making

4. The Foundations of Bioethics
Small Group Session: 2 hours

5. What is ethics?
•Ethics is the branch of study dealing with what
is the proper course of actions for individuals
interacting with each other.
•-It is the study of right/ wrong in human
endeavors
•- it answers the question what should I do?

6. Medical ethics is the branch of ethics that
pertains to doctor patient relationship
Medicine asks,
“ what can be done for the patient”
Ethics asks:
“what should be done for the patient”

7. Ethical vs Legal Obligations
•Medical ethics & the law are not the same
•Legal regulations represent broad categories of
action
•Breach of ethical obligation may not necessarily
mean breach of law

8. Stages of Moral Thought
•Child- defines what is right and wrong in terms of
what authorities say.
•Adolescent defines what is right and wrong in
terms of group loyalty (friends, family, gang, nation)
•Adult views what is right and wrong from universal
standards of justice, human rights and human
welfare.
•Education is what stimulates moral growth
through these levels.

9. Father of Western Medicine- Hippocrates
The Oath in the
Hippocratic Corpus can be
seen as “pioneering
Modern medical ethics
with the Universal and
Humanitarian appeal.”

10. Fundamental Problem
•On what do we base our ethical standards?

11. Train Problem

15. ●
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17. Ethical Theories: Overview
•Agent Act Consequences
•Modern ethical theories ask the question:
• “Is this action ethical?”
•Consequences of the Action- Utilitarianism
ethics
•The Act itself- Deontologic ethics
•And Agent itself: “is the acting agent/physician
a virtuous person?”

18. Utilitarian Ethics
Consequences alone determine right/wrong
action
“the greatest good for
the greatest number of
people”
- JS Mill
Seeks to maximize
aggregate well being of
society as a whole
Problems:
●
How to define aggregate
welfare?
●
How do we define
“good”?
●
- happiness? pleasure?
other measures?
●
Principle of utility is open
to the objection that it
sacrifices the rights of the
minority for the sake of
the happiness of the
majority.

19. Deontologic ethics
some acts are intrinsically right regardless of the
consequences
●
Duty based ethics
●
Right vs Good
●
Deontologists deny that what ultimately
matters is an action’s consequences.
●
Claim that what matters is the kind of
action it is.
●
Certain’ acts’ have right- making
characteristics and it is our duty to
adhere to these acts.
●
Duties: honesty, fidelity, do not kill, do
not steal and respect for autonomy.
Kant

20. The Virtue Approach
•Focuses on attitudes, dispositions or character
traits that enable us to be and to act in ways to
develop our human potential.
•Examples: honesty, courage, faithfulness,
trustworthiness, integrity etc.
• States: “What is ethical is what develops moral
virtues in ourselves and our communities.”

21. Principles Approach
•Principles of medical ethics
- autonomy
- beneficence
- non-maleficence
- justice (Distributive)
Veracity (truth telling)
Proportionality
• 1 & 4 are deontological
• 2 & 3 are consequentialist
• Identifies the main principles in conflicts in a case and
attempts to “balance” the principles and determine which
principle is more important in that particular setting or ethical
dilemma.

22. Why are medical ethics important
Medical ethics guide our decision making and our
interactions and conduct with patients. It is an important
part of medical professionalism, which is always expected.
Violation of medical ethics can threaten job, medical license, or even
constitute a crime
Ethics provide us a moral compass to use in situations
that may not be straightforward.

23. Autonomy
Patient’s autonomy refers to the patient’s right to make
decision for themselves according to their own system of
morals and beliefs
Patient education and informed consent are important elements of
proper autonomy
Confidentiality loosely fits under the umbrella of autonomy
When is autonomy challenged?
Incompetence: patient is legally deemed unable to make rational
decision for themselves. Often due to dementia & MR
Incapacity: patient is clinically determined to be unable to make a
rational decision for themselves. May be due to transient conditions
such as lack of consciousness, delirium. So use good clinical sense.
Check for durable power of autonomy
Threat to self or others- Usually in psychiatric settings

24. Paternalism is the practice of making decision
for the patient without seeking their inputs.
It does not mean pt. gets his way all the time.

25. Beneficence
Beneficence is a value in which provider takes
actions or recommends courses that are in patient’s
best interest.
- It is not covering or manipulating the patient into making
a decision against their values even though it may
objectively the best decision for the health.
- Is euthanasia just?
Keep the individual patient in mind- beneficence is not
the same in all situations.
When patient autonomy is compromised (e.g.
Incapacity) beneficence must be the guiding ethics.

26. Non-maleficence
Non-maleficence is closely related to
beneficence.
It is abstaining from any action that may bring
harm to the patient. “Do no harm”.
Beneficence is what you do, Non-maleficence is what
you don’t do
Refusing to prescribe opioids when deemed not necessary
Non-maleficence and beneficence can conflict :
patient or proxy input can help

27. Unintended medical consequences are acceptable if the
intended consequences are legitimate & harm is
proportionately smaller than the benefit
Removing an organ or limb that is causing disease
Providing high dose analgesic to a hospice patient even though
it may unintentionally shorten life.
 Performing an abortion to save the life of mother
Caveat
Principle of double effect

28. Veracity (truth telling)
•Veracity is honesty.
•Most important part of truth telling is revealing
all pertinent details of a patient’s medical
condition(s) to them as well as the risks &
benefits of a procedure and prognosis (if
known).
• Also includes informing a patient of any
mistakes that have been made during care.
•Critical element of informed consent.

29. Distributive Justice
Distributive justice is the proper allocation of
resources in a manner that is fair and just
Not necessarily equal allocation of resources
Triage is a common example of distributive
justice. The first person through the doors of the ER
is not necessarily attended first (ankle sprain vs
acute M1)
Spending more time with a very ill patient than
with less ill patients
When is distributive justice challenged?
 - VIP patients

30. Proportionality
 Ensures a medical treatment or plan is
commensurate with the illness & with the goals
of treatment
Ensuring the benefits outweigh the risks
•Benefits are maximized (beneficence)
•Risks are minimized (non-maleficence)
Often plays a role when ethics may be
legitimately compromised or when two or more
ethics conflict

31. Summary
Ethics are the cornerstone to the proper and
professional practice of medicine, although what is
ethical in one situation may not translate exactly to
another
Autonomy: patient’s right to make decisions for
themselves
Paternalism : Making decision for the patient
without their input
Beneficence: Doing or recommending actions in
the patient’s best interest
Non-maleficence: Refraining from actions that are
harmful to the patient

32. Summary contd.
● Veracity (truth telling): Revealing all
information to a patient especially when
requested
● Distributive justice: Allocation of resources
in a manner that is fair and just, though not
necessarily equal
● Proportionality: Ensuring that the benefits
outweigh the risks

33. Ethical principles may conflict with one another.
For test taking purpose, autonomy usually
trumps when there is conflict but autonomy may
be compromised in certain situations.

34. Autonomy vs. Beneficence.
•Who determines the good of the patient?
• How do we know that patient is able to make
decisions?

35. •As we go through these modules we will
provide many different cases with these
dilemmas and will revisit many of the concepts.
Till then keep thinking….