Ethics in medicine practice

1. MEDICAL ETHICS
© 2022 WILSON ZIMBA.ALL RIGHTS RESERVED

2. UNIT ONE: THIS SESSION OUTLINE
• Present philosophical foundations and
ideologies of ethics.
• Present practical case studies related to linking
theory and medical dilemmas.
• Present and discuss general ethics principles

3. INTRODUCTION
• The job of a doctor is to save lives and enhance the
quality of life.
• In doing so, sometimes a conflict might arise between
saving lives and protecting the rights of other people.
• When this happens, the doctor faces an ethical
dilemma.

4. PHILOSOPHICAL FOUNDATIONS
• The important principle of ethics, in general, is the recognition of inherent disagreement
among well-meaning men about what may be morally right or morally wrong.
• In this regard, there exist fundamental philosophical beliefs of what might constitute ethical
or unethical behaviour, namely: egoism, Kachanism, deontology, skepticism, consequentialism,
and utilitarianism.
• Over decades, these beliefs have formed the philosophical foundations of ethics and
doctrines for various professions and their practices, especially in human services.
• Thus, what might be considered ethical by utilitarians might not sit well with deontologists,
but skeptics might be apprehensive about the views of deontologists.

5. ETHICAL EGOISM
• Ethical egoism is the view that people ought to pursue their own self-interest, and
no one has any obligation to promote anyone else’s interests.
• It is thus a normative or prescriptive theory: it is concerned with how people ought
to behave.
• Thus, ethical egoism is quite different from psychological egoism,
• Psychological Egoism postulates that all our actions are ultimately self-interested.
• Thus, psychological egoism is a purely descriptive theory, describing a basic fact
about human nature.

6. EGOISM: HISTORICAL BRIEFS
• In principle, egoism argues that pursuing own self-interest is the
best way to promote the general good and therefore everyone
ought to do so.
• This argument was made famous by Bernard Mandeville (1670-
1733) in his poem "The Fable of the Bees" and by Adam Smith
(1723-1790) in his pioneering work on economics, "The Wealth
of Nations."

7. EGOISM: HISTORICAL BRIEFS, CONT’D.
• Smith wrote that when individuals single-mindedly pursue
“the gratification of their own vain and insatiable desires”
they unintentionally, as if “led by an invisible hand,” benefit
society as a whole (Trickle-down effect).
• Core Belief: people generally are the best judges of what is in
their own interest, and are much more motivated to work
hard to benefit themselves than to achieve any other goal.

8. EGOISM: HISTORICAL BRIEFS, CONT’D.
• Obvious objection: egoism doesn’t really support the common good.
• The assumption is that what really matters is the well-being of society as a
whole, the general good.
• However, ethical egoism then claims that the best way to achieve this end is
for everyone to look out for themselves.
• But what if the selfish pursuit of self-interest doesn’t, in fact, promote the
general good, then what is ethical about egoism?

9. AYN RAND'S OBJECTIVISM
• Ayn Rand's complaint is that the Judeo-Christian moral tradition, which
has fed into modern liberalism and socialism, pushes an ethic of altruism.
• Altruism means putting the interests of others before your own.
• People are routinely praised for doing, encouraged to do, and in some
circumstances even required to put the interest of others before their own
such as to support the needy.
• According to Rand, no one has any right to expect or demand that I make
any sacrifices for the sake of anyone other than myself.

10. SUGGESTED FLAWS IN ETHICAL EGOISM
• An obvious problem is the egoistic assumption - that there is generally a
conflict between pursuing your own interests and helping others.
• In fact, though, for most people these two goals are not necessarily opposed at
all; they complement one another.
• For instance, one student may help a housemate with her homework, which is
altruistic. But that student also has an interest in enjoying good relations with
her housemates. She may not help everyone in all circumstances, but she will
help if the sacrifice involved is not too great. Most people behave like this,
seeking a balance between egoism and altruism.

11. MORE OBJECTIONSTO ETHICAL EGOISM
• Ethical egoism is not a very popular moral philosophy for going against certain
basic assumptions that most of us regard as ethical.
• Two objections seem especially powerful.
1) Ethical egoism has no solutions to offer when a problem arises involving
conflicts of interest.
• Where there is a conflict of interest between two parties, ethical egoism advises
that both parties actively pursue what they want.
• It doesn’t suggest any sort of resolution or common sense compromise.

12. MORE OBJECTIONSTO ETHICAL EGOISM,
CONT’D.
2) Ethical egoism goes against the principle of impartiality.
• A basic moral assumption is that we should not discriminate against people on
arbitrary grounds such as race, religion, sex, sexual orientation, or ethnic
origin.
• On the other hand, ethical egoism holds that we should not even try to be
impartial; we should distinguish between ourselves and everyone else, and
give ourselves preferential treatment.

13. To many, egoism contradicts the very essence of morality
whose golden rule underpinning major religions of
Confucianism, Buddhism, Judaism, Christianity, and Islam —
says we should treat others as we would like to be
treated. One of the greatest moral philosophers of modern
times, ​
Immanuel Kant (1724-1804), argues that the
fundamental principle of morality (the “categorical
imperative,”) is that we should not make exceptions of
ourselves. According to Kant, we shouldn’t perform an
action if we cannot honestly wish that everyone would
behave in a similar way in the same circumstances.

14. KANTIAN ETHICS & DEONTOLOGY
© 2022 Wilson Zimba.All rights reserved

15. KANTIAN ETHICS: HISTORICAL NOTES
• Kantian ethics or Kantianism is named after Immanuel Kant, a
German Philosopher (1724-1804) - one of the most influential
intellectuals in the field of political philosophy.
• His philosophy provides a single set of moral principles that can
be used to design just institutions and to govern society
perfectly.
• Today, the justice systems in (Western) democracies are
fundamentally based on Kant’s writings.

16. KANTIAN ETHICS: HISTORICAL NOTES, CONT’D.
• The United Nations is one such institution that
is largely based on his vision of an international
government that binds nation-states together
to maintain peace.

17. KANTIAN ETHICS
• As stated, Kantian ethics form a set of universal moral
principles that apply to all human beings, regardless of
context or situation.
• These principles he called Categorical Imperatives.
 Unconditional moral obligations that are binding in all
circumstances and are not dependent on a person's
inclination or purpose.

18. KANTIAN ETHICS, CONT’D.
• The core idea of Kantianism is that human beings are not mere
objects—they are persons worthy of respect, and must be treated as
such.
• In particular, other persons must not be treated as mere tools in
the pursuit of one’s own goals.
• Kantianism is the most commonly-cited version of deontology, and
many people use the term “Kantianism” to refer to deontology
generally.

19. KANTIANISM, CONT’D.
• Kantianism places an ethical obligation on all officials to treat all
persons with respect.
• Respectful treatment is considered obligatory regardless of what
one’s goals and mission are.
• A desire to achieve a particular outcome, such as to make a profit,
cannot override the obligation to treat people fairly and with respect.
• Kantianism even insists that the desire to achieve outcomes that you
think are ethically good cannot justify actions that, incidentally, fail to
treat people with respect.

20. KANTIANISM & DEONTOLOGY
• Kantianism forms a key foundation of the broader ethical perspective known as
deontology.
• Deontology asserts that there are certain absolute (or nearly absolute) ethical rules that
must be followed.
• For example, the rule that we must respect people’s privacy, and the rule that says we
must respect other people’s right to make decisions about their own lives should be
considered absolute.
• This implies that certain actions (perhaps including lying, and killing people) are
absolutely prohibited.

21. DEONTOLOGY
• The word deontology derives from the Greek words for duty (deon) and
science (or study) of (logos).
• It is a moral philosophy regarding which choices are morally required,
forbidden, or permitted.
• Deontology is a moral theory meant to guide and assess our choices of
what we ought to do (deontic theories).
• Deontologists stand in opposition to consequentialists.

22. DEONTOLOGY, CONT’D.
• Deontology is also known as “duty-based ethics” - the ideology states that the
correct course of action is dependent on what your duties and obligations are.
• It means that the morality of an action is based on whether you followed the
rules, rather than what the consequence of following them might be.
• This is in direct contrast with consequentialism and utilitarianism.
• Example: If your terminally ill patient asks if they’ll be ok after surgery, if they’re
unlikely to survive, a deontological approach would suggest you don’t lie to
comfort them. That’s because according to this concept, lying isn’t morally
acceptable because it’s our obligation not to lie – no matter the consequences.

23. CONSEQUENTIALISM
• Consequentialists hold that choices—acts and/or intentions—are to be morally
assessed solely by the states of affairs they bring about.
• To consequentialists, the desired states of affairs that are intrinsically valuable are
collectively referred to as “the Good.”
• Consequentialists assert that whatever choices increase the Good, that is, bring about
more of it, are the choices that are morally right to make and to execute.
• The Good in that sense is said to be prior to “the Right.”

24. CONSEQUENTIALISM, CONT’D.
• Consequentialists do differ widely among themselves.
• Utilitarians, as a special form of Consequentialists, for example, identify the Good
with pleasure, happiness, desired satisfaction, or “welfare” in some other sense.
• Other consequentialists are pluralists in regard to the Good.
• Some of these pluralists believe that how the Good is distributed among persons (or all
sentient beings) is itself partly constitutive of the Good, thus advocating the wide
distribution of the good.
• Conventional utilitarians merely add or average each person’s share of the Good to
achieve the Good’s maximization.

25. SENTIENT BEING
• Sentient beings include every conscious creature.
• These include humans and all species - be they
mammals, birds, fishes, or insects.
• Plants are the only living thing excluded from
consideration as sentient beings because people do
not see them as conscious.

26. CONSEQUENTIALISM, CONT’D.
• Moreover, there are some consequentialists who hold that doing or
refraining from doing, certain kinds of acts are themselves intrinsically
valuable states of affairs and therefore constitute the Good.
• For example, working for the rights of others not to be violated is part of
the Good to be maximized (Nozick 1974).
• An action would be right only insofar as it maximizes the Good.

27. CONSEQUENTIALISM, CONT’D.
• Whatever their differences, they all agree that the morally right choices
are those that increase (either directly or indirectly) the Good.
• Moreover, consequentialists generally agree that the Good is “agent-
neutral” (Parfit 1984; Nagel 1986).
• That is, valuable states of affairs are states of affairs that all agents have
reason to achieve without regard to whether such states of affairs are
achieved through the exercise of one’s own agency or not.

28. CRITICISM OF CONSEQUENTIALISM
• Consequentialism is criticized for what it seemingly permits.
• It seemingly demands (and thus, of course, permits) that in
certain circumstances innocents be killed, beaten, lied to, or
deprived of material goods to produce greater benefits for others.
• Consequences—and only consequences—can conceivably
justify any kind of act, for it does not matter how harmful it is to
some so long as it is more beneficial to many others.

29. BOTTOM LINE ON CONSEQUENTIALISM
• Example: Your patient has a terminal illness and is not likely to survive the
operation she is about to undertake. Just as she is about to be
anaesthetised, she asks you: “Doctor, will I be okay?” A consequentialist
ideology supports that lying in this circumstance is acceptable, even
though lying itself is not a moral action.

30. UTILITARIANISM
• Utilitarianism says the best action is that one that brings about the best
increase in utility (or benefit). The utility is generally considered on a broad
scale, often taking into consideration wider society and not just the patient in
question. It’s a form of consequentialism.
• Example: You have a sum of money to either fund a very expensive
treatment for one patient with a rare disease or five patients with a very
common and easy-to-treat disease. Utilitarian ethics dictates that treating
the five patients is morally superior as a greater overall benefit is achieved.

31. BROAD-BASED GENERAL ETHICAL PRINCIPLES
• Informed Consent: Informing clients about a medical procedure
before it is carried out and seeking their express consent
• Purpose is to protect the clients from violations of their privacy
and other rights.
• Parents or legal guardians stand in for children or mentally
impaired persons and give or withhold consent.

32. GENERAL PRINCIPLES, CONT’D.
• Confidentiality: Certain information about a client cannot be
divulged to third parties.
• Avoid coercion, deception, physical and mental stress
• Common Courtesy: Keep to schedule and time and treat
clients as people and not cases

33. Ethics
Coercion
Confidentialit
y
Informed
consent
Invasion of
privacy
Physical or
psych. harm
Deception

34. ETHICS IN MEDICINE
• Medical ethics describes the moral principles by
which a doctor must conduct herself.
• Note that medical ethics is a changing ideal.
• Something considered ethical in the past may not
be today – and what we think is ethical right now
may change in the future.

35. WHY IS MEDICAL ETHICS IMPORTANT?
• Medical professionals frequently find themselves facing moral
questions and ethical dilemmas in their line of work.
• Medical ethics provide a framework to help them make judgements
that are morally sound and right for the patient in question.
• It’s essential for aspiring doctors to have a good moral compass and
a solid grasp of medical ethics so they can consistently do what is
best for their patients.

36. UNIT TWO
FOUR PILLARS OF MEDICAL ETHICS

37. SESSION OUTLINE
• Discuss four pillars of medical ethics
• Present applicable medical dilemmas related to each
pillar.

38. FOUR PILLARS OF MEDICAL ETHICS
• The four pillars of medical ethics are:
1.Beneficence (doing good)
2.Non-maleficence (to do no harm)
3.Autonomy (giving the patient the freedom to choos
e freely, where they are able)
4.Justice (ensuring fairness)

39. MEDICAL ETHICS: BENEFICENCE
• Beneficence means that all medical practitioners have a
moral duty to promote the course of action that they
believe is in the best interests of the patient.
• Often, it’s simplified to mean that practitioners must do
good for their patients – but thinking of it in such a
simplistic way can be problematic.

40. BENEFICENCE, CONT’D.
• beneficence is the process of ranking the available options for the patient from
best to worst, taking into consideration the following aspects:
• Will this option resolve this patient’s medical problem?
• Is it proportionate to the scale of the medical problem?
• Is this option compatible with this patient’s individual circumstances?
• Is this option and its outcomes in-line with the patient’s expectations of treatment?
• You will notice that several considerations are concerned with the patient’s expectations
or circumstances. This is also known as holistic or patient-centric care.

41. Beneficence is the process of ranking the available
options for the patient from best to worst, taking into
consideration the following aspects:
• Will this option resolve this patient’s medical problem?
• Is it proportionate to the scale of the medical problem?
• Is this option compatible with this patient’s individual
circumstances?
• Is this option and its outcomes in line with the patient’s
expectations of treatment?
You will notice that several considerations are concerned
with the patient’s expectations or circumstances. This is also
known as holistic or patient-centric care.

42. BENEFICENCE, CONT’D.
• When ranking treatment options, we are not simply
referring to what is medically good for the patient, but also
what is acceptable to the human being we are treating.
• Consider individual circumstances and remember that
what is good for one patient may not necessarily be great
for another.

43. The Case of Ethical dilemma
An eight-year-old child has been admitted to 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.
There are a number of options for treatment here, but let’s take an extreme one –
amputation.
If the bleeding is life-threatening, the limb sufficiently injured and the risk of
infection extremely high, then amputation could be a treatment option. It would be
“good” for the patient in as much as the injury would be resolved and the threat to
life from bleeding or infection somewhat reduced.
But let’s consider the implications of amputation. The treatment would result in a
life-changing injury and the risks of infection or massive bleeding aren’t
proportionate. The limitations to their physical movement also carry other future
risks that could inadvertently result in further physical and mental health issues.
Most important of all, there are other interventions available to us that have better
outcomes attached. Using blood products to manage the bleeding, reducing the
fracture if possible and orthopaedic surgery if necessary will have better outcomes
for this patient. That course of action is “more good” than amputation.

44. DISCUSSING BENEFICENCE
• When talking about beneficence, you should think
about the following things:
• Have you thoroughly considered every option and
weighed up what the best course of action is for
the specific patient in the scenario?
• Does the best course of action align with patient
expectation?

45. MEDICAL ETHICS: NON-MALEFICENCE
• Non-maleficence states that a medical practitioner has a duty
to do no harm or allow harm to be caused to a patient
through neglect.
• Any consideration of beneficence is likely, therefore, to involve
an examination of non-maleficence.
• Hence, Non-maleficence is considered a sister to beneficence.

46. • Non-maleficence differs from beneficence in two major
ways.
• First of all, it acts as a threshold for treatment. If a
treatment causes more harm than good, then it should
not be considered. This is in contrast to beneficence,
where we consider all valid treatment options and then
rank them in order of preference.
• Second, we tend to use beneficence in response to a
specific situation – such as determining the best
treatment for a patient. In contrast, non-maleficence is a
constant in clinical practice. For example, if you see a
patient collapse in a corridor you have a duty to provide
(or seek) medical attention to prevent injury.

47. EXAMPLE
• One of the best ways to understand the difference between non-
maleficence and beneficence is by looking at an ethical example:
• 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.

48. • From a non-maleficence perspective, the Doctor has to examine the
potential harms to the patient including:
o The environment is unlikely to be sterile (as is that manky pen-
knife) and so the risk of infection is extremely high
o The surgeon has no other clinical staff available or surgical
equipment meaning that the chances of a successful operation
are already lower than in normal circumstances
o Assuming that the surgeon has performed an appendectomy
before, they have almost certainly never done it at the roadside
– and so their experience is decontextualized and therefore not
wholly appropriate
o Unless there isn’t a hospital around for miles, this is an
incredibly disproportionate intervention.

49. MEDICAL ETHICS: AUTONOMY
• In Medicine, autonomy means that a patient has the ultimate
decision-making responsibility for their own treatment. A medical
practitioner cannot impose treatment on a patient.
• The only exception is in cases where the patient is deemed unable
to make autonomous decisions, e.g., under Emergency Doctrine.
• For an adult patient, nobody other than the patient herself can
give valid legal consent to medical treatment, even if she is
unconscious or mentally incapacitated .

50. AUTONOMY, CONT’D.
HTTPS://DOI.ORG/10.1136/BMJ.316.7144.1608
• In an emergency, the patient may be treated without consent
under the doctrine of necessity, as long as there is a necessity to
act when it is not practicable to communicate with the patient and
that the action taken is no more than is immediately necessary in
the best interests of the patient.
• Hence, it would clearly be legally permissible to perform medical
treatment including surgery if the doctors consider it immediately
necessary and that a simpler procedure is unlikely to be effective.

51. Autonomy Example: 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 ward.
Even though the best interests of this patient would be served by undergoing a CT
scan and having sutures, he is an adult with full mental capacity, and so we must
respect his patient autonomy in choosing to leave. We cannot prevent him from
leaving, and if we did it would be unlawful detainment.

52. AUTONOMY, CONT’D.
• In considering autonomy , you need to think about the
following things:
• Have you explained fully the patient’s medical condition, their
options for treatment and the advantages and disadvantages of
those treatments?
• Is the patient able to retain this information, evaluate their
options and arrive at a decision?
• Has the patient provided informed consent for our actions?

53. JUSTICE
• Justice is the principle that when weighing up if something is
ethical or not, we have to think about whether it’s compatible
with the law, the patient’s rights, and if it’s fair and balanced.
• It also means that we must ensure no one is unfairly
disadvantaged when it comes to access to healthcare. Justice is
one reason why certain groups have certain entitlements, such
as free prescriptions for lower-income individuals.

54. MEDICAL ETHICS: JUSTICE
• 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.
• This raises a couple of dilemmas for justice, and it’s important you can
think of arguments on both sides of the issue. For example:

55. JUSTICE, CONT’D.
• It could be argued that prioritising cancer patients means you’re limiting the
ability of other patients to access healthcare
• A counter-argument might be that by referring these patients to specialist
oncology centres, you’re actually freeing up other services
• It could also be argued that spending public money on radio- and
chemotherapy on a smaller group of people is taking budget away from less
expensive treatments that would benefit a greater number of people – for
example, an increase in statins for those at risk of cardiovascular disease
• A counter-argument would be that early treatment increases survival rates
and actually reduces the cost of cancer treatment

56. RFERENCES
• Westacott, Emrys. (2020,August 28).What Is Ethical Egoism? Retrieved from
https://www.thoughtco.com/what-is-ethical-egoism-3573630