Having a good sense of medical ethics is one of the most important parts of being a good doctor, but it is not emphasized as often as it should be. Proper medical ethics help support a proper doctor-patient relationship in which there are mutual trust and respect. However, many people have different views and values when it comes to what is ethical and what is not, making medical ethics quite complicated. In this post, we will explore the basic tenets of medical ethics and cases regarding them.
The key principles of medical ethics are autonomy, beneficence, non-maleficence, and justice. While they may seem extraordinarily simple at first sight, we must unpack them to reveal their complexities. Autonomy refers to the patient having full choice over their medical decisions. This entails telling the patient all of the medical details, not lying or leaving anything out no matter how bad it may be, so the patient can make an informed decision. For example, the doctor must tell their patients what is wrong with them, what their treatment options are, and what the associated risks of treatment are among other things. Doctors cannot force what their thoughts upon the patient; although, they can offer their professional opinion if asked. This makes sense because patients should have control over their health and be able to do what they want to. Where this gets complicated is when dealing with people who may not be able to make decisions for themselves like children or the mentally ill. Then, you must turn to family, but what if family members disagree among themselves? Moreover, what if this child or this mentally ill patient chooses a treatment option or lack thereof that opposes the choice made by the family? Do you respect that or not? These questions have extremely difficult answers that can only be addressed on a case-by-case basis. For sure, autonomy is a more complex pillar than it first might appear. The next major pillar of medical ethics is beneficence, which is to do things that work to benefit the patient. Doctors must always keep the patient’s welfare in their mind. This also can be applied to a doctor’s obligation to medically help people even outside of the hospital whether this is through supporting public health initiatives or providing help in the event of a medical emergency on an airplane for example. However, sometimes, the idea of beneficence may be harmful as doctors do treatment plans that carry a negligible benefit, if any at at all, for their patients, causing these patients to pay unmanagable premiums or costs out of their own pocket. Thus, beneficence must be balanced with practicality. The next principle of medical ethics, nonmaleficence, is often closely related to beneficence. Nonmaleficence means to do no harm for the patient because a doctor’s job is to make the patient feel better, not worse. Part of this is that doctors should not offer false hope nor give treatments that are scientifically ineffective. A common thought-provoking question regards if you should give chemotherapy, which is excruciatingly painful, to a patient with Stage 4 Cancer even if they have a poor prognosis either way. Proper acknowledgment of nonmaleficence means the doctor weighs both the benefits and risks of the treatment, making decisions with that in mind. Justice is the last major part of medical ethics. In short, doctors must treat all patients equally regardless of their age, gender, socioeconomic status, religion, and sexuality among other things. This one is probably one of the simplest to understand, but it is also one of the hardest to implement. Doctors have inbuilt unconscious bias, which leads them to discriminate between patients, sometimes unknowingly. For example, doctors are significantly more likely to view patients with substance use disorder more unfavorably than patients with mental health issues despite their both being chronic illnesses that are often outside of the patient’s control. Autonomy, beneficence, nonmaleficence, and justice all are great principles to live by in medicine, but it is important to note taht the questions associated with them prove that medical ethics is extraordinarily complicated.
Dr. David Elkins is a psychiatrist who works at UCSF who told me a little about medical ethics. First, he told me about an interesting ethical case that he was a part of. There a woman in her 40s who refused a C-section, despite clear evidence that her baby was in danger, because she did not believe in Western medicine and wanted a natural birth. Her husband also wanted a natural birth but agreed that the doctors should do a C-section because the baby was in danger. Nevertheless, she would not relent despite the doctors trying to explain that the baby was going to die otherwise. Should these doctors respect patient autonomy or force her to have a C-section in the name of beneficence for the baby? Legally, a fetus is not a person until it comes out of the womb, so it was all up to the mother’s choice. Dr. Elkins was called in to do a mental health evaluation of the women in order to make sure she was psychologically able to make this decision, and Dr. Elkins found that she was psychologically able. Under increasing pressure, she finally agreed to the C-section, so that part worked out well. After the delivery, the baby needed antibiotics, but the mother said that she did not want the baby to be given antibiotics because it was again Western medicine. Nevertheless, the doctors gave the baby antibiotics since the baby now was a separate living entity, and his life was at stake. They needed to prioritize his beneficence. Dr. Elkins also brought up a thought experiment to imagine a world where drugs, alcohol, motorcycles, and guns are all banned. There is constant monitoring, and privacy is limited in such a world. The world becomes a much safer place at the cost of our freedom. Would you want to live in a world like that? Beneficence is present, but autonomy is lost. Justice is harsh in the name of promoting non-maleficence. Many rational people have drastically different answers to that question, making it one worth considering. Medical ethics can get confusing at times, and it is necessary to consider all sides of the equation before making a decision.
Some of the most well known ethical codes in regards to medicine are the Hippocratic Oath and the Declaration of Geneva. A modern version of the Hippocratic Oath written in 1964 by Mr. Lasagna, the academic dean of Tufts Medical School, includes the principles of working together with other physicians, being able to admit when you need help, treating the patient and not the disease, seeking to always prevent disease rather than just treat it, and remembering the importance of patient confidentiality among other things. The Declaration of Geneva was adopted by the World Medical Association in 1948 and has been revised multiple times since then. Some of the principles it discusses are serving humanity, maintaining the honor of the profession, not discriminating against the patient on any basis, and respecting human life among other things. These codes reinforce the pillars of medical ethics that all doctors must abide by. With great power comes great responsibility; doctors have the power to save a patient’s life, but they also have the responsibility of doing right by this patient.
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