A Primer for Health Care Ethics

Ethical Principles

Brig. (Retd) Maqsood ul Hassan

MBBS, MCPS, DPH, MSc, MSLP, CHPE, PGD(PE & TM), LMPC
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What is Ethics?
Ethics is derived from Greek work “ethos”
meaning the distinctive character spirit and
attitude of a cultural group.
A set of principles that distinguish between
acceptable and unacceptable behavior or
way of conducting a task.
Various ways of understanding and
examining the moral life (moral
philosophy).
A theoretical discipline
Ethics
the mission for, and the understanding of,
the good life, living well, a life worth
living.
putting every action and goal in its place,
knowing what is important doing and
what is not.
Elegido (2000)
Ethics
 How ought one live?
 The foundation of centuries of debate concerning the philosophy of
ethics
 Writers from every country across every generation have discussed,
dispelled and posited their thoughts on without yet reaching a
consensus.
 The idea of good and evil has been filtered through multitudinous
perspectives, allowing for questions not only on the goodness of
actions but the use, rightness, morality, ad justness of actions.
 Changes in ethical philosophy over the years reflects sociological
shifts.
 At a very base level, ethics strives for a cohesive society.
 Whether the source of ideal cohesion rests in the individual on the
community at large has yet to be determined.
Bioethics
The application of ethical principles and processes
to health, including, but not limited to, health
services, systems, policies, and technologies
Focused on clinical issues of the doctor-patient
relationship, rather than issues of social justice or
population health.
Beyond the individual patient and the medical
relationship and to address the broader issues of
health disparities, public health, allocation of
limited resources, and social determinants of
health.
Meta-Ethics: What does “Right” mean?
 Meta-ethics is concerned with the epistemology of ethics,
posing conceptual questions to define the origins and
limitations of ethical statements.
 Challenging the use of moral predicates.
 Concerned with the inherent existence and man’s
understanding of “goodness”
 Meta-ethics attempts, in various ways, to provide the
necessary parameters in order that a valid ethical
conclusion be reached.
 Is the source and meaning of human values.
 Objectivists: vales and innate
 Relativists: values we attribute to things are defined
differently, depending upon the environment of the definer
Normative Ethics: How ought people to
act?
Universality of values is accepted and a
rational justification for these is sought
A prescriptive manner, establishing moral
absolutes by which society should live.
The “Golden Rule” is an ideal
representation of normative application
Normative ethics can be further broken
down to four theories.
Ethical theories
 For thousands of years of human experience, people
have looked for ways to differentiate right conduct from
wrong.
 The search for methods of identifying the right conduct
has led to the development of more complex theories of
ethics.
 Traditionally, ethical theories tend to be reductionist;
that is, they offer one idea as the key to morality, and
attempts to reduce everything to that one idea
 Concept of social contract
 Ethics is based on religion or on the concept of natural
law
 Martin Luther King Jr. reasoned that ethical conduct is
based on natural law
Ethical Theories
existing ethical issues are not always clear
and understandable.
ethical theories to explain what is right
and what is wrong
relativism theory, utilitarianism theory,
egoism theory, deontology theory, the
divine command theory, and the virtue
ethics theory
 Ethical Theories
Ethical Theories

Utilitarian Theory- Egoism Theory- Virtue Ethics Divine

Deontology
greatest good for (Aristotle's Command Relativism
focus only on your Theory (Kant’s
greatest self theory) theory) Theory Theory

Consequences
Duty is the basic
theories -the
moral category, and
right action is
that is independent
the one that
of
produces the
consequences
most benefit

Category basis Action Character Religion Culture

What kind of “Morality

What kind Follow
right” if
Meaning of actions person religious
beliefs and “specific
should we should we
principles society”
perform? be? accepts it
Common Moral Law
Theory Main Idea

This theory focuses on what makes a

Virtue good individual or person rather
ethics than what makes a good action.
theory There are specific virtue traits that
every person must have such as
civility, cooperativeness, courage,
fairness, friendliness, generosity,
honesty, justice, loyalty, self-
confidence, self-control, modesty,
fairness, and tolerance.
 Common Moral Law

Theory Main Idea

Ethics are relative to a particular
environment. Different societies
Relativism
may have different ethical codes.
theory
There is no universal truth in
ethical principles that can be held
by all peoples at all times.
Consequentialism

Theory Main Idea

Utilitarian “Ethically right” means the action

theory results in a greater number of utilities
than could be achieved by any other
actions.
 Consequentialism
Theory Main Idea

A person must always perform in

Egoism his/her own interest. An action is
theory considered to be ethically right only
when it promotes a person’s self-
interests.
Non Consequentialist

Theory Main Idea

“Ethically right” means
Divine “commanded by God”, and
Command “ethically wrong or unethically”
theory means “forbidden by God”.
Religion is the only standard to
identify ethics.
 Non-consequentialism
Theory Main Idea

It underlines the duty as a basis of

Deontology moral category which can be seen as
theory a right or wrong judgment. It does
not look at the consequences of
action. And, there are universal
ethical actions that everyone must
accept.

Kant (1724 – 1804)

- An action might be wrong even if results in good consequences
- The ends do not justify the means.
Principilism
Itis based on a set of ethical principles
Principlism is pluralistic
The moral duties represented by those
principles are not absolute but rather apply
prima facie, or at first glance
Prima facie moral duties are based on
“commorality theory
A common-morality theory takes its basic
premises directly from the morality shared in
common by the members of a society.
Potential problems
Are these global??
Are these useful in helping individuals &
organizations in the health system to do
the right thing??
Problems of divine law
Natural law
Social contract terms, agreement, breach
Ethical dilemma in Medical Practice??

• Individual judgment, Peer sanction

social expectation and laws.
• Unequal Doctor patient relationship
• Codes of Ethics
• Belief, values and context
Ethical dilemma in Medical Practice??

Individual reasoning
Situation, wishes of
patient, available
resources.
Difficult to prescribe
the right action for each
ethical dilemma.
Two questions when faced
with a dilemma:
• Behavior: What should I do?
• Motivation: Why should I do it?
UNIQUE FEATURES OF MEDICAL
PRACTICE
Intense discomfort or emotional
stress of illness
Prospect of disability or even death.
Patient has largely a passive role in
decisions.
Patient is subjected to acutely
uncomfortable, intimidating or even
traumatic handling.
What Are Ethical Principles,
and How Do They Help With
Decision Making?
• Four principle approach
• Practical bridge between
ethical theories and
common morality.
• Cut across divisions
• Prima facie value
Ethical Principles

Autonomy
Nonmaleficence
Beneficence
Justice

◦ (Beauchamp and Childress

1979)
 Autonomy
The freedom to make decisions about oneself
The right to self-determination “Deliberated self
rule”
Healthcare providers need to respect patient’s
rights to make choices about healthcare, even if the
healthcare providers do not agree with the patient’s
decision.
◦ Privacy
◦ Veracity
◦ Informed consent
◦ Confidentiality

(Contd…)
Autonomy
Impact of Individual choices on actions of
others
Balance reason & emotion, legal rights
and customs.
Relative value is socially and culturally
determined.
Constraints on autonomy
 Nonmaleficence
(Primum Non Nocere)

Requires that no harm be caused to an

individual, either unintentionally or
deliberately “Above all do no harm”
This principle requires health care providers
to protect individuals who are unable to
protect themselves
◦ Research ethics – Human subject research
◦ Competence expertise of physician
◦ Benefit versus Injury??
 Corner stone of health care – practices and
legislation
 Negligence & malpractice
 Beneficence
This principle means
“doing good” for others
Health care Professional
need to assist clients in
meeting all their needs
◦ Provide appropriate
intervention
◦ Intervention provided
produces greater benefit.
 Beneficence & Non maleficence

Net medical benefit to patients with

minimal harm. Opposite ends of
continuum
Definition of harm or good.
Prima facie obligations:
◦ Professional
◦ Risk & probability
 Empowerment !!
 Justice
Equitable distribution of benefits, burdens and
duties.
Every individual must be treated equally:
◦ Horizontal equity
◦ Vertical equity
Four ways to conceive
what is fair & equitable
◦ Justice as a fairness
◦ Comparative justice
◦ Distributive justice
◦ Compensatory justice
 Ethical Dilemmas

Occur when a problem

exists between ethical
principles
Deciding in favor of one
principle usually violates
another
Both sides have
“goodness” and “badness”
associated with them
Why Employ Ethical Principles?

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Respect for the Individual

In our pluralistic society individuals often

misunderstand each other.
Even when they do understand each
other, it is possible for them to disagree.
The Healthcare arena, in common with
every other segment of society has
found it necessary to find ways to create
understanding and agreement.

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 How to Create Understanding
and Agreement?
 Common ground must be created or found.
 A function of Ethics, in our society, is to make
agreement possible.
 As healthcare professionals and patients meet,
they meet as strangers from diverse
backgrounds therefore, their ways of looking at
and approaching the world are usually quite
different.
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 Application of principles of ethics in
patient care

Beneficence, Clinical assessment

Non-maleficence Nature of illness (acute, chronic, reversible,
terminal)?
Goals of treatment?
Treatment options and probability of success
for each option?
Adverse effects of treatment and does benefit
outweigh harm?
Effects of no medical/surgical treatment?
If treated, plans for limiting treatment?
Stopping treatment?
 Application of principles of ethics in
patient care

Respect for Patient rights and preferences

autonomy Information given to patient on benefits and
risks of treatment? Patient understood the
information and
gave consent?
Patent mentally competent? If competent, what
are his/her preferences?
If patient mentally incompetent, are patient’s
prior preferences known? If preferences
unknown, who is
the appropriate surrogate?
 Application of principles of ethics in
patient care

Beneficence, Quality of life (QOL)

nonmaleficence, Expected QOL with and without treatment?
respect for Deficits – physical, mental, social – may have
autonomy after treatment?
Judging QOL of patient who cannot express
himself/herself? Who is the judge?
Recognition of possible physician bias in
judging QOL?
Rationale to forgo life-sustaining treatment(s)?
Application of principles of ethics in
patient care
Distributive External forces and context
justice Conflicts of interests – does physician benefit
financially, professionally by ordering tests,
prescribing
medications, seeking consultations?
Research or educational considerations that
affect clinical decisions, physician orders?
Conflicts of interests based on religious beliefs?
Legal issues?
Conflicts of interests between organizations
(clinics, hospitals), 3rd party payers?
Public health and safety issues?
Problems in allocation of scarce resources?
Integrated model of patient care
Thank you