Author: Holly B

Third-year medical student

Medicine as an ethically driven profession

Ethics is the theory of moral behaviour and deals with the concepts of ‘good’ and ‘bad’ (1). Medicine is an ethically driven profession due to the trust placed in doctors to do good for their patients and the responsibility that this brings. It is therefore paramount that medical ethics provide a high moral standard to which doctors must adhere.

Medical ethics are also needed to guide doctors through difficult decisions regarding patient care and to ensure they are always acting in accordance with the wishes and best interests of their patients (2).

The Hippocratic Oath

The moral responsibilities of being a doctor have long been recognised. The Hippocratic Oath, which dates back to at least 400 BC, is considered the earliest expression of medical ethics and reflects some of the pillars of medical ethics used today (3). The four basic pillars of medical ethics are beneficence, non-maleficence, justice, and autonomy (4). At a glance, these principles appear simple, and there are many examples of clearly unethical medical decisions. Yet ethical dilemmas are common within medicine, and there is not always an agreed-upon ‘right’ decision.

4 pillars of medical ethics

The pillar of beneficence

The pillar of beneficence is about promoting the good of others. In medicine means acting in a way that helps your patients. The most obvious example of this is providing up to date, evidence-based treatments to your patients with the aim of reducing their symptoms or treating their illness (4).

Tuskegee Syphilis Trial

An extreme example of the principle of beneficence being neglected is the Tuskegee Syphilis Trial. It was carried out by the US Public Health Service from 1932 to observe the natural history of syphilis. In this trial, hundreds of African Americans who were found to have syphilis were told that they had ‘bad blood’. They were offered free meals, health care and burial insurance if they took part in the trial. They were not fully informed that they had syphilis and were not offered any treatment even when penicillin was found to be effective in 1947.

The trial was only stopped in 1972 when an advisory panel found it unethical (5). These patients were known to have a disease that if untreated, can cause serious damage to the heart, nervous system and brain and can even cause death and were not given a known effective treatment. The doctors involved failed to help their patients, instead focussing on their research goals which was a gross betrayal of research ethics and beneficence.

The pillar of non-maleficence

Non-maleficence refers to not causing harm to your patients (6). This principle spans a range of applications such as doctors maintaining medical competence and not giving patients treatments where the risks outweigh the benefits. It seems obvious that doctors would not want to harm their patients, yet there are countless examples of when this principle has been disregarded.

Examples of the principle of non-maleficence being neglected

Harold Shipman was an infamous GP in England who qualified in 1970 and was found guilty and sent to prison for killing 15 of his patients and is suspected of killing hundreds more. He targeted elderly and vulnerable patients and gave them high-dose opiates ending their lives (7).

The Gosport War Memorial Hospital faced a similar scandal that involved the shortening of hundreds of lives starting in the late 1990s. Patients were again given high-dose painkillers without clinical indication (8).

These examples are incredibly shocking to all in the medical profession but demonstrate the need for systems to protect patients from doctors who fail to uphold the ethical standards that they should. Non-maleficence and beneficence are usually balanced in that the risks or side effects of treatment should not outweigh the benefits (6). It is surprising how conflicting helping and not harming your patient can be.

A widely debated example of this is euthanasia and assisted dying for suffering patients who have no hope of a cure. Both are illegal in the UK (9). To end a patient’s suffering may be considered as being beneficent, yet taking action to end their life prematurely can also be considered as harming a patient. It is unlikely that there will ever be a universally accepted, morally right or wrong decision about this (10).

Euthanasia as a medical dilemma

A widely debated example of this is euthanasia and assisted dying for suffering patients who have no hope of a cure. Both are illegal in the UK (9). To end a patient’s suffering may be considered as being beneficent, yet taking action to end their life prematurely can also be considered as harming a patient. It is unlikely that there will ever be a universally accepted, morally right or wrong decision about this (10).

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The pillar of justice

The principle of justice refers to fairness within medicine and equal distribution of resources. It can be considered in terms of equality and equity of healthcare across patients (11).

Health equality and health equity

Health equality refers to equal opportunity to access healthcare and means patients should not be discriminated against. Patients should be treated fairly regardless of groups such as gender, socioeconomic class, ethnicity, age etc. (11). Patients who are all provided with the same services may still experience different outcomes due to barriers to certain patient groups accessing those services.

Equity refers to the fairness of outcome and means that those who are at a disadvantage to start with should be given greater support to compensate (11). Examples of health equity would include providing transport to a hospital for patients from low socioeconomic groups or improving staff training for treating people with disabilities. It could also involve identifying, for example, higher rates of smoking in certain geographical areas and thus providing more smoking cessation services in these areas. 

Health inequality and health inequity

Inequity within healthcare services tends to mean that those most likely to need healthcare are those that will struggle the most to access it. Health inequalities are unfair differences in health across groups in the population (12). There are many examples of health inequalities, but one example is the ‘social gradient’ of health in England, where life expectancy increases as the level of social deprivation decreases (13).

The pillar of autonomy (self-determination)

The final pillar is autonomy and refers to a patient’s right to make their own healthcare decisions. This is also known as self-determination. It means that patients can decide their own healthcare priorities, and it includes their right to refuse treatment. Doctors should inform and advise patients according to medical evidence; however, the final decision should always lie with the patient even if it goes against medical advice (14).

Examples of the pillar of autonomy

A common example is a Jehovah’s Witness who may refuse a blood transfusion on religious grounds. This may seem medically unwise, but the patient has a right to refuse this treatment (15). Autonomy brings together many ethical challenges, including the areas of consent and capacity.

Consent to treatment

For a patient to consent to treatment, they must be fully informed. For example, before surgery, patients must be informed of what the surgery involves. That includes all the potential complications of the surgery, including the chances of death. On the other hand, they must also be informed of what the risks are of not having surgery (14).

The capacity to consent

To consent, patients also need to have the capacity. Capacity is about a patient’s ability to make their own decisions by understanding, retaining and using information and then communicating a decision. It can vary over time, for example, a patient under the influence of drugs or with a disease that causes cognitive decline may have impaired capacity at different points (16). It is always assumed that patients have the capacity and is only questioned if they demonstrate a reason for you to suspect they do not have the capacity (17). The Mental Capacity Act 2005 enables decisions to be made on behalf of someone without the capacity, and doctors, in this case, will act in the patient’s best interest (17).

Final thoughts

The four pillars of medical ethics appear to be good moral standards for doctors to stand by. However, medical ethics are not always clear cut. Debate and disagreement around the end of life care, abortion and treating people without the capacity, for example, are likely to always exist. Knowing which option is the best for your patient is not always obvious.

As well as this, there are countless examples where medical ethics have unquestionably been broken and doctors have betrayed the trust placed in them by their patients. For these reasons, medical ethics must continue to be explored and debated. Moreover, doctors must continue to be held to the highest of standards to ensure that they are deserving of the trust placed in them.

Resources and references

  1. Ethics: a general introduction. BBC; 2014. www.bbc.co.uk/ethics/introduction/intro
  2. Markose A, Krishnan R, Ramesh M. Medical ethics. J Pharm Bioallied Sci; 2016; 8 (Suppl 1). doi:10.4103/0975-7406.191934
  3. The Editors of Encyclopaedia Britannica. Hippocratic Oath. Encyclopaedia Britannica inc; 2019. www.brtiannica.com/topic/Hippocratic-oath
  4. Jahn WT. The 4 basic ethical principles that apply to forensic activities are respect for autonomy, beneficence, nonmaleficence, and justice. J Chiropr Med; 2011; 10(3):225-226. doi: 10.1016/j.jcm.2011.08.004
  5. Centers For Disease Control and Prevention. The Tuskegee Timeline; 2020. www.cdc.gov/tuskegee/timeline.htm
  6. Beneficence and Nonmaleficence. Alzheimer Europe; 2009. www.alzheimer-europe.org/Ethics/Definitions-and-approaches/The-four-common-bioethical-principles/Beneficence-and-non-maleficence
  7. Jackson T, Smith R. Harold Shipman. BMJ; 2004; 328(7433):231
  8. Gosport hospital deaths: Families await police review. BBC; 2019. www.bbc.co.uk/news/uk-england-hampshire-48093941
  9. Euthanasia and assisted suicide. NHS; 2020. www.nhs.uk/conditions/euthanasia-and-assisted-suicide
  10. Euthanasia and physician assisted suicide. BBC; 2014. www.bbc.co.uk/ethics/euthanasia/
  11. Justice. Alzheimer Europe; 2010. www.alzheimer-europe.org/Ethics/Definitions-and-approaches/The-four-common-bioethical-principles/Justice
  12. Definitions for Health Inequalities. NHS England; 2015. www.england.nhs.uk/ltphimenu/definitions-for-health-inequalities
  13. Public Health England. Chapter 5: Inequalities in Health. Gov.UK; 2017. www.gov.uk/government/publications/health-profile-for-england-2018/chapter-5-inequalities-in-health
  14. The Medical Porter. Medical Ethics Explained: Autonomy. The Royal Society of Medicine; 2016. www.themedicportal.com/blog/medical-ethics-explained-autonomy
  15. Norfolk D. Jehovah’s Witnesses and blood transfusion. TSO; 2013. www.transfusionguidelines.org/transfusion-handbook/12-management-of-patients-who-do-not-accept-transfusion/12-2-jehovah-s-witnesses-and-blood-transfusion
  16. Mental Capacity. Mental Health Foundation. www.mentalhealth.org.uk/a-to-z/m/mental-capacity
  17. General Medical Council. Part 3: Capacity Issues. General Medical Council: Ethical Guidance. www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/consent/part-3-capacity-issues

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