Medical Ethics for GPs
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Principlism
The philosophy of Principlism argues that any medical ethical dilemma can be reduced to these four basic principles. In any situation one or two principles are likely to take precedence over the others:
Beneficence – doctors should only do good to their patients
Non-maleficence – doctors should do no harm to their patients
Autonomy – all patients should have self-determination over their decisions. A fully autonomous decision should be informed, competent and not made under coercion
Justice – scarce healthcare resources should be shared fairly (whatever that means)
This has been widely taught over the last 30 years (most of us will have heard of it at Medical School!), and it is still a useful approach to most ethical problems, although it does have its critics. In our current Western society, autonomy is being seen as being increasingly important with the basic human rights of the individual being emphasised and delineated ever more clearly. The emphasis on social justice (very important in the post-war years) seems to be on the wane.
Moral theories
What are the roots of ethics, and why do we have them? There are four theories about them:
Theory of virtue – this describes innate character attributes (good or bad). In a GP such attributes might be perseverance, caring, desire for excellence etc
Theory of duties – this describes rationally based rules of moral conduct – for doctors in the UK codified into the GMC regulations
Theory of utility – this describes what is morally good in terms of the greatest good to the greatest number
Theory of rights – this describes social relationships between people such that some have an obligation to provide a service to others (eg in the UK everyone has the right to be registered with a GP, but they don’t have a right to demand any treatment they want)
The doctor’s role
The GMC sets out various duties of GPs (which are compulsory under GMC rules, but are not laws):
- Confidentiality
- Being non-judgemental and non-discriminatory
- Competency
- Honesty and informed consent
- Accessibility and availability
There may well be times when the “professional ethics” (i.e. what we are obliged to do legally) clash with the “medical ethics” (i.e. what may be best for our patients) – can you think of any examples to discuss in the groupwork? Which takes precedence – the professional ethics or the medical ethics?
A few other concepts
Relativism – the idea that there are no absolute rights or wrongs, and the morality of any action depends on the circumstances/culture.
Doctrine of double-effect – an action that has both good and bad effects may be justifiable (eg opiates in terminal care)
Ordinary and extraordinary means – some treatments may not be justifiable because of the degree of intervention required (eg antibiotics for an infection in end-stage respiratory failure may be justified, but ventilation may not be).
Futility – if an outcome is going to be poor anyway, any intervention or treatment needs to be judged in this light
Wants and needs – Fair resource allocation demands an objective assessment of needs. How can this be done? Is rationing on this basis appropriate?
Do you agree or disagree with the philosophy behind any of these ideas?
The Tavistock principles
Some of these ideas have been pulled together to form the Tavistock principles, largely for use in the field of commissioning and purchasing healthcare. The Tavistock principles are:
- Rights - People have a right to health and health care
- Balance - Care of individual patients is central, but the health of populations is also our concern
- Comprehensiveness - In addition to treating illness, we have an obligation to ease suffering, minimise disability, prevent disease, and promote health
- Cooperation - Health care succeeds only if we cooperate with those we serve, each other, and those in other sectors
- Improvement Improving health care is a serious and continuing responsibility
- Safety - Do no harm
- Openness - Being open, honest, and trustworthy is vital in health care
For more details on this see: Refining and implementing the Tavistock principles for everybody in healthcare BMJ 2001; 323: 616-620 (15 Sept)
For the groupwork session, please bring an ethical problem that you have been faced with yourself, and try to apply the above principles, theories and concepts. If all else fails, your group’s course organiser will suggest some clinical scenarios to discuss!
Happy reading!
Martyn Hewett
NB some of the above derived from J Spicer: Ethical reasoning in An insider’s guide to the MRCGP oral exam.
PS The topic of Advance Directives (Living Wills) often seems to come as an area
that people want to discuss: if you want to do some background reading then
these articles are still the best summaries on the subject, even though they are
a bit old now:
1. Advance directives in the UK: legal, ethical, and practical considerations for doctors BJGP 1998; 48: 1263-6 (May)
2. Making an advance directive BMJ 1995; 310: 236-8 (28 Jan)
Written by: Martyn
Last updated: 29 August 2007