Lecture-6:

Ethical Issues in
Health Care

Scientific Ethics and

Safety
ENGR / SCI 304
Sherif H. El-Gohary , Phd
Assistant Professor,Biomedical Engineering
shamdy@zewailcity.edu.eg
Exam Sample
• Select True or False for the following statements
Preservation Ethic means unspoiled nature should be
protected for its own inherent value ( )

• For each Question, Choose the correct answer from

the multiple-choice list
• The study of moral standards, general principles,
concepts, values, and theories, we called it:
a) Normative Ethics
b) Applied Ethics
c) Metaethics
Classify the responses to this dilemma according
to Kohlberg‘s stages
Lydia‘s parents often become
angry when she gets bad grades.
She has not been doing very
well at school recently and is
considering cheating on an
upcoming test.
Should she cheat?
A = Stage 3
B= Stage 1
C= Stage 4
D= Stage 5
E= Stage 2
A. Yes, if she cheats and does well, her
parents will think she is a good daughter
and will be proud.
B. No, because if she gets caught she will
be punished.
C. No, because cheating is against school
rules.
D. No, because cheating is unfair to
other students . A person should
complete her own work.
E. Yes, because if she cheats and gets a
good grade on her test, she may hey a
reward.
Doctors are trusted
• Trust to tell the truth %
• Doctor 92
• Teacher 88
• Professor 80
• Judge 80

• Journalist 22
• Politician 13

MORI poll 2009

The oldest code of medical ethics:
Hippocratic Oath (4th Century BC)
Several parts of the oath have been revised
over the years, e.g. -
• ―To consider dear to me, as my parents,
him who taught me this art; to live in
common with him and, if necessary, to
share my goods with him…‖
• ―Nor will I give a woman a pessary to
procure abortion;‖
• ―I will not cut for stone, even for patients
in whom the disease is manifest; I will
leave this operation to be performed by
practitioners, specialists in his art.‖
Hippocratic tradition
• ―as to diseases, make a habit of two
things – to help and not to harm.‖

• ―I will never give a poison to anyone

to cause death, not even if asked.‖
Patients‘ rights
Right to Medical Treatment
Right to Information
Right to Choices
Right to Privacy
Right to Complaint
WHO: Patient rights can
vary in different countries
World Health Organisation (WHO):

• Patients' rights vary in different countries and in

different jurisdictions, often depending upon
prevailing cultural and social norms.
• Different models of the patient-physician
relationship—which can also represent the
citizen-state relationship—have been developed,
and these have informed the particular rights to
which patients are entitled.

http://www.who.int/genomics/public/patientrights/en/
WHO: Patient rights can vary
in different countries

World Health Organization (WHO):

• Patients' rights vary in different countries and in

different jurisdictions, often depending upon
prevailing cultural and social norms.
• Different models of the patient-physician
relationship—which can also represent the citizen-
state relationship—have been developed, and these
have informed the particular rights to which patients
are entitled.

http://www.who.int/genomics/public/patientrights/en/
Code of Professional Conduct
Example (Hong Kong Medical Council)

• Medicine as a profession is distinguished from

other professions by a special moral duty of care
to save lives and to relieve suffering.
• Medical Registration Ordinance (Cap. 161)
confers upon the medical profession considerable
freedom of self regulation, the profession is
obliged to abide by a strict code of conduct which
embodies high ethical values, protects patients‘
interests, and upholds professional integrity.
• Trust is essential to the practice of medicine.
There can be no medicine in the absence of trust.
The patient‘s trust imposes upon the doctor a
corresponding duty to be trustworthy and
accountable.

http://www.mchk.org.hk/code.htm
Paternalistic model:
Strengths and Weaknesses
• Paternalistic model: The doctor is the
professional. He/she gives the order, the
patient obeys.
• Strengths: Emphasizes the expertise and
knowledge of the doctor
• Weaknesses:
• Ignores the autonomy of the patient
• Ignores non-health related but morally
legitimate values of the patient
Contractual model:
Strengths and Weaknesses
• Contractual model: The doctor and patient "contract"
for each other's mutual benefit; the patient determines or
agrees to the doctor‘s decisions.
• Strengths:
• Highlights the autonomy of both patient and
physician
• Acknowledges cooperative/shared aspects of medical
decision-making
• Weaknesses:
• No "contracts" developed or signed in real doctor/
patient relationships
• Model doesn‘t allow for at trusting relationship
 Fiduciary model:
Strengths and Questions
• Fiduciary model: The patient confidently entrusts his/her health care to
the doctor, who takes on the obligation of working for the benefit of the patient
(Fiduciary: relates to a holding of something in trust for another)

• Strengths:
• Preserves the freedom and autonomy of both patient and physician
• The legitimate role of physician knowledge
• The important role of trust in the doctor/patient relationship

• Questions raised by skeptics:

1. Patient trust may be manipulated for further economic gain.
2. Patient trust may undermines consumer‘s awareness of need for self-
protection
3. Serious illness and fear of death diminish patient autonomy and power
to contract any relationship.
 ‘The Four Principles’ in Medical Ethics
Beauchamp & Childress (2001)

The Four Principles in Medical

Ethics Respect for (Patient)
Autonomy

Non-Maleficence

Beneficence

Justice
Respect for Patient Autonomy
Autonomy literally means ‗self-rule‘ or ‗self-
governance‘.
An individual‘s capacity to make decisions about
their health care needs and to consent to or refuse
treatment depends on their ability to think, decide
and act, freely, on the basis of such thought and
decision.

Two essential conditions for autonomy:

Liberty
Agency
 Respect for Patient Autonomy

• Such respect is not simply a matter of attitude, but a

way of acting so as to recognize and even promote
the autonomous actions of the patient.

• The autonomous person may freely choose loyalties

or systems of religious belief that may adversely
affect him

• The patient must be informed clearly the

consequences of his action that may affect him
adversely.
 ‘The Four Principles’ in Medical Ethics
Beauchamp & Childress (2001)

The Four Principles in Medical

Ethics Respect for (Patient)
Autonomy

Non-Maleficence

Beneficence

Justice
Non-Maleficence
We should avoid doing harming to others.
‘Primum non nocere’ – [trans. first (or above all) do no
harm] – this would make medicine a very difficult
pursuit!
It is an extremely important principle to avoid harming
others, but cannot take priority and be expressed as an
absolute principle. Must be considered in the context
of the obligation in medicine of the principle to do
good for our patients (beneficence), e.g cancer
surgery.
Also balance required with the principles of autonomy
and justice, e.g. involuntary isolation.
 ‘The Four Principles’ in Medical Ethics
Beauchamp & Childress (2001)

The Four Principles in Medical

Ethics Respect for (Patient)
Autonomy

Non-Maleficence

Beneficence

Justice
Beneficence
The obligation to do good / promote what is best
for the patient.
Sometimes conflict may arise between doctor's
judgement of what is in the patient‘s best interests
and his desire to respect the patient‘s different but
autonomous decision.
Must be balanced with the principles of respect for
autonomy, non-maleficence and justice (e.g..
rights and needs of others).
 ‘The Four Principles’ in Medical Ethics
Beauchamp & Childress (2001)

The Four Principles in Medical

Ethics Respect for (Patient)
Autonomy

Non-Maleficence

Beneficence

Justice
 The Ethical Principle of
Justice
 Social justice: the principle that all persons are
entitled to have their basic needs met regardless
of economic status, class, gender, race, ethnicity,
religion, citizenship, age, sexual orientation,
disability or health. (PHN Scope and Standards, 2007)
 Distributive justice- resources should be given
first to those who need it the most
 Egalitarian justice- equal distribution to everyone
regardless of need (Socialism)
 Restorative justice – payback those previously
harmed by injustice-i.e. Native Americans
Which chemotherapy?
• Mr Jones has non small cell lung cancer
Chance of Chance of Cost £
benefit % death %

Chemo A 10 2 1 000

Chemo B 50 33 1 500

Chemo C 60 10 100 000

 Chance of Chance of Cost £
benefit % death %
Chemo A 10 2 1 000
Chemo B 50 33 1 500
Chemo C 60 10 100 000

• Autonomy
• Non-maleficence
• Beneficence
• Justice
 Solution
Chance of Chance of Cost £
benefit % death %
Chemo A 10 2 1 000
Chemo B 50 33 1 500
Chemo C 60 10 100 000

• Autonomy Chemo A or B or C
• Non-maleficence Chemo A
• Beneficence Chemo C
• Justice Chemo B or A
The Big Four Principles
These principles are widely used as a
starting point for practical decision making
in clinical professions dealing with
individual cases (biomedical):
Autonomy- free choice
Beneficence-doing good
Nonmaleficence- do no harm
Justice- fairness

Beauchamp & Childress Principles of Biomedical Ethics

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