Overview
This lecture introduces ethics as a discipline, connects it to the practice of medicine, and introduces the ethical concepts used in ethical reasoning. It moves from a general account of what ethics is and where problems in it arise, through the specific relationship between ethics, medicine and law, to a worked case (the ‘Vitamin C’ case) used to introduce a set of core ethical concepts.
What is ethics?
- Ethics is about “how we should live”. It concerns the sense that some things are “right” and others “wrong”.
- These ideas are universal: part of being human.
- A pragmatic answer to “how should we live?”: our sense of right and wrong reflects our values, the things we regard as important, so working out how to live starts with identifying our values.
- Values come from a variety of sources: family/upbringing, culture and society, history, identity, religion, past decisions, our basic nature, intuitions, and one’s profession.
- A good life, ethically speaking, is one that is consistent with the values one holds.
Ethical problems
- You need to think about ethics only if you encounter ethical problems.
- Ethical problems arise from three sources:
- Somebody neglects important values.
- A new situation is encountered.
- There is a conflict in values.
- Such problems often arise in medicine. Problems of the first type (neglect of values) are explored in an IPE tutorial on ‘Professional Ethics’; other tutorials focus more on types 2 and 3.
- Ethics as rational dialogue is the process for resolving ethical problems: reasoning together with others, as illustrated by the classical image of philosophers in discussion. Dialogue can be difficult and sometimes breaks down, but it is always better to try than not to.
Ethics and medicine
- Medicine as currently practised and taught is built around certain common values.
- Upholding those values can be difficult, and medical practitioners encounter a range of distinct and contentious ethical problems.
- Part of being a medical professional is being responsible for upholding the values inherent to the profession.
- ‘Bioethics’ spans a broad historical scope, illustrated by: the Hippocratic Oath, everyday clinical care, research-ethics abuses (e.g. the Nuremberg trials), and social-justice/rights movements connected to health.
- A real-world example given is a controversial neurosurgeon (Dr Charlie Teo) whose conduct and complaints against him raised professional/ethical controversy.
Medical ethics in New Zealand
- The Cartwright Inquiry was the first public scrutiny of medical practice, research and institutions in New Zealand (the “unfortunate experiment” at National Women’s).
- It led to the establishment of the Health and Disability Commission and the development of the Code of Health and Disability Services Consumers’ Rights, which sets out patient rights including respect, fair treatment, dignity and independence, proper standards, communication, information, the right to decide, support, and the right to complain.
Ethics and law
- Ethics and law are related but not the same.
- The law should reflect our ethics, but does not necessarily do so.
- It is not possible to legislate for everything.
- Ethics is grounded, ultimately, in individual conscience.
- Laws establish authorities and powers that may administer punitive measures when a person does wrong, irrespective of their individual conscience.
- Both ethical views and laws can change over time.
Ethics and professional ethics
- Ethics in the general sense can relate to anything and everything.
- Professional ethics is concerned with how people in a given profession should act, and typically refers to laws and standards (e.g. the Student Code of Conduct).
Ethical concepts and reasoning
- A concept is a general idea that enables understanding of particular things. Ethical concepts are general ideas that enable understanding of, and thinking through, particular ethical problems, and are used to generate ethical reasons.
- Concepts (or one’s grasp of them) can vary in clarity and depth. A clear and nuanced understanding of the relevant concepts allows one to more quickly apprehend the important features of a case; arriving at the “right” answer to a problem requires thinking through the relevant concepts.
The ‘Vitamin C’ case
Allan Smith, a 56-year-old man with swine flu (H1N1) infection, was admitted to Auckland ICU with intractable pneumonia and placed on ECMO life support for 20 days. Specialists judged he was going to die and that the family should agree to withdraw life support; he had “whiteout” pneumonia (no visible air entry on X-ray). The family requested treatment with mega-doses of vitamin C, for which there is no reliable evidence of benefit. [slide poses this as a discussion question for students rather than giving a resolved answer]
Concepts identified as relevant to this case:
- Beneficence (helping the patient)
- Non-maleficence (not harming the patient)
- Autonomy (the patient’s right to decide), including proxy decision-making
- Respect
- Professional integrity
- Distributive justice
- Patient dignity
Key ethical concepts
- Respect is “Right 1” in the Code of Patients’ Rights and is arguably foundational to ethics. It involves recognising a person as valuable and their perspective as worthy of consideration.
- Other key ethical concepts introduced: informed consent, competence, trust, confidentiality, sanctity of life, dignity, social accountability.
Summary: the ethics module
Doctors are held to certain standards based on a set of broadly agreed values. As a medical student you need to:
- Be aware of what these standards and values are.
- Think about what is required of you to uphold them.
There are areas of medicine where it is unclear what should be done and people hold conflicting views. As a medical student you need to learn to:
- Be sensitive to what these situations might be.
- Reflect on your own ethical response to those situations.
- Practise discussing such situations with others, in preparation for discussing them with patients and colleagues.
- Learn ethical concepts to improve your understanding of such situations and your ability to discuss them.
An IPE tutorial in March on ‘Professional Ethics’ will focus on these aims.
Self-test
- Define ethics, and explain in what sense the underlying ideas about right and wrong are said to be “universal”.
- Describe the pragmatic account given of “how we should live”, including where our values are said to come from.
- List the three sources from which ethical problems arise, and give the type of problem to which “conflict in values” belongs.
- Explain what is meant by “ethics as rational dialogue”, and describe what the lecture says about difficulty and dialogue breakdown.
- Distinguish ethics from law, listing at least three points of difference given in the lecture.
- Distinguish “ethics” in the general sense from “professional ethics”.
- What was the Cartwright Inquiry, and what did it lead to?
- In the Vitamin C case, list the ethical concepts identified as relevant and briefly say what each concerns.
- Explain why respect is described as foundational to ethics, and identify its place in the Code of Patients’ Rights.
- List at least four other key ethical concepts introduced besides respect.
Answers
Reveal answers
- Ethics is about “how we should live”; it concerns the sense that some things are right and others wrong. These ideas are universal in that they are part of being human.
- Our sense of right and wrong reflects our values (the things we regard as important), so working out how to live starts with identifying our values. Values come from family/upbringing, culture and society, history, identity, religion, past decisions, our basic nature, intuitions, and our profession.
- The three sources are: somebody neglects important values, a new situation is encountered, and there is a conflict in values. “Conflict in values” is the third type.
- Ethics as rational dialogue is the process of resolving ethical problems through people reasoning together, illustrated by the image of philosophers in discussion. Dialogue can be difficult and sometimes breaks down, but it is always better to try than not to.
- Ethics and law are related but not the same: the law should reflect our ethics but will not necessarily do so; it is not possible to legislate for everything; ethics is grounded ultimately in individual conscience, whereas laws establish authorities that may punish wrongdoing irrespective of conscience; and both ethical views and laws can change.
- “Ethics” in the general sense can relate to anything and everything, while “professional ethics” is concerned specifically with how people in a given profession should act, typically referring to laws and standards (e.g. the Student Code of Conduct).
- The Cartwright Inquiry was the first public scrutiny of medical practice, research and institutions in New Zealand (the “unfortunate experiment” at National Women’s). It led to the establishment of the Health and Disability Commission and the Code of Health and Disability Services Consumers’ Rights.
- Beneficence (helping the patient), non-maleficence (not harming the patient), autonomy (the patient’s right to decide, including proxy decision-making), respect, professional integrity, distributive justice, and patient dignity.
- Respect is described as arguably foundational to ethics because it involves recognising a person as valuable and their perspective as worthy of consideration; it is “Right 1” in the Code of Patients’ Rights.
- Informed consent, competence, trust, confidentiality, sanctity of life, dignity, social accountability (any four).