Medical Ethics Part 1: The Four Pillars

The four main pillars of Medical Ethics are: 

1. Beneficence (doing good) 
2. Non-maleficence (not doing bad) 
3. Autonomy (given the patient the freedom to choose freely, whenever they are able) 
4. Justice (ensuring fairness) 

 

1. Beneficence

 

Beneficence is the ideology of always acting in the best interest of the patient. When thinking of beneficence, it is important to consider all of the medical options a patient has, ranking them, and identifying which of them does the most ‘good’ for the patient. This means that the benefits of a treatment outweigh the harm. For example, a surgery may cause harm to a patient. It may require anaesthesia, carry a risk of infection, and cause physical pain to the patient. However, not carrying out the procedure may result in severe complications or death. Thus, the doctors acted in the best interest of the patient.

 

Example: A young boy is admitted with a significant open leg fracture. The limb is deformed and the patient is losing a lot of blood. An extreme course of action here would be amputation. If the bleeding is life threatening and the risk of infection is extremely high, amputation would be ‘good’ for the patient as it reduces the risk of infection and the chance of death due to blood loss. Of course, this is an extreme measure that is not proportionate to the medical problem, and it will result in a life changing injury that will cause long term physical and mental health issues. A ‘better’ course of action would be to replace the lost blood via a blood transfusion and to consider orthopaedic surgery. Therefore, beneficence asks as to promote a course of action, but also to de-promote certain options. 

 

Other examples of medical beneficence, in which harm may be caused to the patient are: 

• Resuscitating a drowning victim (Requires breaking ribcage and may result in long-term brain damage to the resuscitated patient)
• Providing vaccinations (Very low risk of negative side effects; painful procedure)
• Lifting side rails on a patient’s hospital bed to prevent falls (May remove a patient’s autonomy) 

 

 

2. Non-Maleficence 

 

Non-maleficence comes hand in hand with beneficence. It states that a practitioner has a moral duty to do no harm and allow no harm to be caused to a patient through neglect. Non-maleficence acts as a threshold for treatment, so that a treatment cannot be considered when it causes more harm than good. It is important that non-maleficence is constant in medical practise. For example, if patient collapses in the corridor, you have the duty to seek or provide medical attention to prevent injury. 

 

Example: A man collapses on the street with acute pain in the abdomen and a passing surgeon believes his appendix is on the brink of bursting. The surgeon believes he can remove the appendix with a pen-knife to prevent this. From a beneficence perspective, this would improve the patients life. However, from a non-maleficence perspective, this procedure has the potential to cause serious harm to the patient. The material and environment are not sterile and the surgeon doesn’t have assistance from other clinical staff. This intervention would be incredibly disproportionate unless there wasn't a hospital anywhere within reach. 

 

 

 

3. Autonomy 

 

Autonomy is the idea that a patient has the ultimate right to decide over their own body, such as in receiving or rejecting treatment. This means that a medical practitioner cannot impose treatment on an individual, except in the cases where the individual is deemed unable to make autonomous decisions (Mental Capacity Act and Emergency Doctrine).  

 

Capacity is a person’s ability to decide over their own body. This is different to a decision that may be made by a patient (who lacks capacity). Thus, it is important for a practitioner to: 

• Fully explain the medical condition to the patient, as well as their treatment options and their advantages/disadvantages; 
• Consider whether the patient is able to retain this information, evaluate the options and arrive at a decision;
• Make sure the patient provides informed consent for an action. 

When a medical practitioner fails to obtain consent, it is known as a battery or an infliction of unlawful personal violence.

 

Example: A patient has had an accident and hit their head. The patient is conscious and responsive. It would be in the patients best interest to undergo a CT scan, however, if the patient refuses the treatment, we must respect his autonomy and cannot prevent him from leaving. If we did, it would be unlawful detainment. 

 

 

 

4. Justice 

 

Justice is the idea of treating patients with fairness and equality. This includes the awareness that not everyone's needs are the same, and whether a treatment is balanced in the perspective of society. The NHS is a universal health system, therefore, decisions about what treatments to provide and to whom need to be taken extremely carefully. 

 

Example: Patients suspected with cancer are prioritised within the NHS with maximum waiting time for referral being two weeks. For non-urgent referrals it is 18 weeks.

CONS: Prioritising these patients over others infringes the universal right of all patients to receive timely access to healthcare services. Additionally, radio- and chemotherapy treatments are expensive and the money could be used to treat a greater number of patients, such as in increasing statins for those at risk of cardiovascular disease. 

PROS: Urgent referral to specialist oncology centres may actually liberates other services (e.g. GPs) and therefore increase access for non-cancer patients. Additionally, early diagnosis and treatment of cancer not only increases the survival rate, but also reduced the cost of treatment, enabling greater distribution of the budget across the health service.

 

 

Post-code lottery is the term used to describe the fact that a person’s health is impacted by where they live. Someone's post-code can affect their access to services, the number of people requiring the same treatment, and the money provided to the hospital for the service. For instance, there are stories of patients being unable to receive a round of chemotherapy and dying from cancer due to the underfunding for that service in their local hospital. If the patient had lived 3 doors down, they may have been saved.