You do not need to be an expert in medical ethics or law in order to respond constructively to the ethical dilemmas you encounter in practice. Here we introduce approaches to decision making and the concepts likely to be engaged when you think about ethical dilemmas.

Outlining some key concepts

The purpose of medicine is to help patients. Health is universally regarded as a good thing and doctors seek to maximize the health of their patients. Medicine is therefore an ethically driven practice.

During your medical training you begin to learn the skills that will enable you to provide high quality care. The provision of appropriate clinically-indicated care or treatment to patients who consent to receive it is at the heart of good medical practice and is seldom ethically problematic. Difficulties can arise though because health is one value among others. People who take up risky sports for example, or join the army, are clearly willing to accept some risk to health in order to pursue other goods.

Doctors do not need to be experts in medical ethics or law in order to respond constructively to the ethical dilemmas they encounter in practice.

There are a variety of different approaches to ethical decision-making

• giving priority to the principles that should guide decisions;
• focussing more on the outcomes or consequences of decisions; and
• giving priority to the inner dispositions or virtues of the decision-maker.

Although a great deal of academic ink has been spilt on the pros and cons of these approaches, when it comes to concrete decisions they frequently – though not always – result in similar conclusions.

We do not promote any particular ethical framework. Your developing sensitivity to ethical problems is more important than wrestling with the pros and cons of different ethical systems. In providing practical advice to doctors and students we use a variety of approaches that include widely accepted general ethical principles, professional guidelines, and previously settled legal cases.

Concepts likely to be engaged when confronting ethical dilemmas in medical practice

Self-determination

The ability to decide and to act for oneself, sometimes referred to as ‘autonomy’. The most obvious expression of self-determination is the right of adults with capacity to refuse any proposed medical intervention even where the decision may result in death. The only exception is compulsory treatment under mental health legislation. This is discussed in a little more detail on the next page.

Capacity or competence

Not a principle itself but a key concept in medical ethics. The capacity or competence to make a decision is ordinarily a prerequisite for a decision to be respected. A decision by someone lacking capacity to refuse life-sustaining treatment can be overridden. Although these terms are often used interchangeably, we tend to use ‘capacity’ when referring to those aged 16 or over and ‘competence’ when referring to those under 16.

Confidentiality

A respect for the confidences of patients is central to good medical practice. The right of adult patients to control their private information is linked to the principle of self-determination. The consequences of not respecting confidences could include patients withholding relevant information and a loss of trust in the medical profession.

Honesty and truth-telling

The communication of information in ways that are believed to be truthful and that are not intended to deceive the recipient. It can be thought of as a virtue in healthcare professionals and also as a prerequisite for a respect for patient self-determination.

Benefit and harm

To do good and avoid harm are among the oldest exhortations in medicine. Often in medicine though the good can only be achieved at the risk of harm. Medical interventions are ordinarily justified where the anticipated benefits exceed the harms. There can be disagreement about how benefit and harm are interpreted. A patient can be harmed for example by having life-saving treatment that they reject being imposed upon them.

Fairness or equity

A range of issues here. People should be treated fairly – people with equal needs should be given equal consideration – and should not be discriminated against in the provision of healthcare services. On a wider level, healthcare services should also be distributed according to good moral reasons and not arbitrarily.

Rights

In addition to relevant legal rights, such as the right to refuse treatment, these also point to the idea that human beings have certain moral rights which relate to basic human interests or entitlements that simply cannot be taken from them, irrespective of how much benefit may accrue to others.

Useful names and contact details

There are many professional organisations who can provide advice and support on ethical issues. Some are listed below.