Medical Ethics - an overview.Medical Ethics - an overview.

Dr Jeffrey Brennan FRACS

Ethics Ethics

• Concept of doing good

• What is good?

Ranking a patient’s goodRanking a patient’s good

WHO Constitution 22 July 1946.

• Ultimate good - the “good of last resort”

• The good of the patient as a human person - “right to choose”

• The patient’s particular good - the choice

• Biomedical good

Ethics Ethics

Concept of doing good

Influences the examination of problems of:-

• Moral worth

• Blameworthiness, and

• Community

Moral worthMoral worth

• Defined by capacity to suffer (ie to be able to be benefited or harmed)

• Primary– Sentient person

• Secondary– Family

– Organ donor

• Symbolic– Flag

Moral worthMoral worth

• May be dynamic

• Move from primary to secondary and symbolic– Vegetative state

BlameworthinessBlameworthiness

• “morally acceptable” or “praiseworthy” option may not exist– Hemiplegia and allowing to die

• Choice becomes the “least objectionable”, or least “blameworthy”

CommunityCommunity

• Micro versus macro resource allocation

• When does one supervene the other?

Erich LoewyErich Loewy

We are a crisis oriented society - the very same patients who had no access to routine health care, who could not afford often …. food or warmth, are the object of vast …. efforts when they are found critically ill or …. dying from starvation or exposure.

Problems of the Care of the Terminally Ill

Textbook of Medical Ethics

Plenum Publishing, New York, 1989

Ethics - modelsEthics - models

• Utilitarian - outcome is what counts– Consequences– John Stuart Mill (1806-1873)

• Deontological - rule-oriented– Intentions– “categorical imperative”– Immanuel Kant (1724-1804)

Ethics - modelsEthics - models

• John Dewey - pragmatist– Appropriateness of specific actions to achieve

specific goals– Rejects the notion of “intrinsic right” or “good”

• Situation ethics– Fletcher– Each situation on its own merits

What is death?What is death?

• Homeric tradition– Death is terrible and unconquerable– Shadows and waifs

• Orthic-Pythagorean (& later Christian)– Immortal or resurrected soul– Plato, Socrates (hemlock), Jesus Christ

What is death?What is death?

• Genetic (or species) survival– Life continues through offspring– Aristotle

• Epicurean and Stoic– Personal extinction– +ve or -ve experiences constitute life

Attitudes to maintaining lifeAttitudes to maintaining life

• Vitalist

• Non-vitalist

• Refusal to examine

VitalistVitalist

• Life is good regardless of anything else

• Where to draw line?

Non-vitalistNon-vitalist

• Life is a means, not an end in itself

• An “instrumental” good

• Life is a condition for experience– A bridge to an end beyond itself

• When do experiences become only -ve?

• When does hope for future +ve disappear?

Non-vitalistNon-vitalist

• Quality of life issues

• Difficulty in avoiding paternalism

• Problems of setting external standards

• “Surrogate judgements”– Those closest to patient make decisions

• “Substitute judgements”– When no surrogates available or are unreliable

Non-vitalistNon-vitalist

• Physician judging patients quality of life for them is often wrong– Pearlman, Speer. Quality of life considerations

in geriatric care. J Am Geriatric Soc 31:113-30, 1983.

Refusal to examineRefusal to examine

• Technology is its own sufficient reason for use– “because we can”

• Physicians become technologists

DutyDuty

• Duty to relieve suffering is a much more ancient and enduring duty of medicine than is the duty to prolong life– Amundsen DW. The physician’s obligation to

prolong life: a medical duty without classical roots. Hastings Center 8:23-31, 1978.

Decision to limit treatmentDecision to limit treatment

• Obligation to refrain from causing suffering

• Obligation to sustain life

• Wish to avoid “therapeutic belligerence”

At least four considerationsAt least four considerations

• The immediacy of the treatment

• The relievability of the suffering caused by the disease

• The suffering entailed in the treatment

• The patient’s ability for sustained understanding and cooperation with treatment

Talking to patients and familiesTalking to patients and families

• Sick people are not simply well people carrying “the knapsack of disease”– Eric Cassel 1976.

• Defies a stereotypic approach

Talking to patients and familiesTalking to patients and families

• Should be gently led to bad news

• Human understanding needed more than technical knowledge

• Effort to “size-up the patient / family” and deliver a judgement as to capacity for receiving news

Descartes 1637Descartes 1637

…..I am sure there is no one, even among those who practise it, who does not admit that what is known of it is almost nothing compared to what remains to be known, and that we could free ourselves of an infinity of illness…...if we knew enough about the causes and all the remedies with which nature has provided us.