Medical Ethics Series- #1 An Introduction- The 4 pillars

This blog post series will give you a solid understanding of medical ethics and go beyond the ‘need to know’ facts that nearly all applicants will have. Using this guide you will hopefully be well equipped to tackle any ethical scenario or role play they throw at you in a considered, mature and thoughtful way. 

We will cover topics such as consent, capacity, confidentiality, as well as how to best approach nuanced ethical dilemmas. Stay tuned for an interview question bank and with model answer points too.

Let’s get started. This week will be an introduction to the basics of medical ethics: the four pillars.

Where did medical ethics come from? Why is it needed? 

It had become apparent how difficult it is to decide what to do in morally uncertain situations. We could use different schools of thought from different philosophers such as utilitarianism (greatest happiness for the greatest number idea), virtue ethics (based on developing a moral character) or deontology (based on strict good or bad actions- not outcome),  but these frameworks are often conflicting and there became a need for a standardised framework in medicine. 

Beauchamp and Childress put together a treatise for medical ethics consisting of 4 principles. This was a distillation of other schools of thought but applied specifically to medical dilemmas. 

This week we will begin with the basics. The 4 pillars of medical ethics. 

1. AUTONOMY

  • This is the recognition that the patient has the ultimate control over whether they receive treatment or not- It is the right to self-determination
  • They can refuse or accept 
  • A key factor for this to apply is that the patient must be competent.
  • They must understand and process the information to make an informed decision
  • Doesn’t mean a patient can demand a treatment e.g when it is not effective or not in their best interests
  • But when there are several options with equal benefits the options should be presented equally
  • Moves away from paternalistic medicine and treats patients as capable autonomous adults.

E.g For example a competent patient may refuse a specific treatment due to religious/ cultural views

2. JUSTICE

  • Probably the most complex of the 4
  • It regards ‘fairness’ across the population 
  • Patients in the same position should be considered in the same way- we can only discriminate based on clinical need 
  • Benefits, risks and costs should be spread fairly 
  • Must take into account costs/ short supply
  • May try to quantify this using QALYs- Quality Adjusted Life Years 

E.g. Transplant organ allocation

3. BENEFICENCE

  • To do good
  • To act in the best interests of the patient

4. NON-MALEFICENCE

  • To do no harm 
  • To act in a way that does not harm patients, whether it is actively or by omission/ neglect 

When given a scenario or ethical dilemma to discuss at an interview these ethical principles can be interleaved into your answer. Although you could structure your answer solely on the ethical principles a better approach is to think of the scenario practically, what would you do as a doctor, e.g sit down with the patient, how would you raise a concern etc.

 The fifth element is confidentiality. What is it, why is it important? Is it absolute? When can confidentiality be broken? This will all be covered in depth in the next blog post.  

Here are some scenarios for you to consider: 

Try linking the above principles and explain the best course of action.

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Doctors are in the cafeteria discussing a night out with the public around, their feet are on the chairs and they are dropping crisps on the floor. Discuss the issues here and an appropriate course of action.

Think about confidentiality, beneficence, public confidence…

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You are a GP and see a 16 -year-old girl who has revealed that she is being abused by her parents, she has fresh burns and begs you not to tell anyone. Discuss your approach to this issue.

Think about confidentiality, beneficence, her age, advisory bodies..

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An elderly lady is refusing medication for a heart condition, you are her doctor, discuss this situation.

Think about autonomy, non-maleficence, beneficence, your responsibility…

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The next blog post will include the structure and points needed to address these scenarios well. 

For some further reading, you could check out Tony Hope’s ‘Medical Ethics: A very short introduction’

And to go even further here’s a great article on the four pillars https://ethics.org.au/big-thinkers-thomas-beauchamp-james-childress/

Let me know what you think of the post in the comments below and any requests for future posts you would like.

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