Introduction to Ethics and

in Healthcare
Aims today
• Overview of module
• Overview of assignment and ethical reasoning
• Overview of (some!) ethical principles relating to healthcare and
decision making
 Module
• 6 days
• Introduction to ethical and legal issues in healthcare
• On successful completion of this module students will be able to:
1. Demonstrate knowledge and understanding of one or more ethical
theories/approaches
2. Outline the relationship between theoretical ethics and professional
practice
3. Discuss how an understanding of theoretical ethics informs health and
social care.
4. Begin to evaluate both your own ethical understanding and your
contribution to ethical practice

• Interactive and participatory

 Assignment
• You are required to select a case study of a patient or service user you have
cared for in practice where an ethical dilemma has presented itself. Using at
least two different theoretical ethical approaches, discuss the ethical
dimensions of the case study. Compare and contrast how the differing
ethical approaches could be employed to try and provide a solution to the
dilemma (N.B. if there are a number of ethical issues in the case study, you
may just want to focus on one). Analyse and evaluate the how useful these
approaches may be in providing practical solutions in relation your
professional practice. Discuss how an understanding of relevant moral
theory can inform and support your future professional practice.

• The word limit is 2,500 words. This includes in-text references, but excludes
title pages, references in the list, and bibliography
 Support
• The materials and support you get (especially) from the accelerated learning module
will help you develop your critical thinking and writing skills for this assignment.
• On the final day of the module you will be asked to do a presentation of your proposed
assignment- this is not marked- it is formative and will help you develop your work;
• Present a brief outline of your (anonymised) case study
• Highlight the main ethical issues
• If there are several, pick one main dilemma you wish to explore further
• Compare different ethical approaches that could be applied to support the decision-making process
(and consider referring to relevant professional and legal literature as well as ethical theories)
• Evaluate the advantages and disadvantages of the differing approaches in relation to your practice,
and the considerations that would need to be taken into account when attempting to resolve your
dilemma.
At the end of each presentation, there will be questions and answers, and you will receive
feedback from your peers and tutor (and will be expected to give feedback as well!).
• Can be on PowerPoint, flip chart, mind map or any other format you wish to employ.
 What is Ethics?
• System of principles to
• Guide decision-making
• Show us how to lead our lives
• Also known as Moral Philosophy
• Ethics looks at
• how to live a good life
• rights and responsibilities
• decisions - what is good and bad?
 Approaches in Ethics
• Meta-ethics – origins and definitions of morality. E.g. What is ‘good’…what is ‘bad’

• Normative ethics
• What we should do (as opposed to what we will actually do) E.g. should we tell
the truth?

• Applied ethics
• Practical application e.g. animal rights, resource allocation, abortion. E.g. will we
provide birth control to sexually active teenagers?

Normative and applied ethics look at moral actions, whereas Meta-ethics look at what
morality itself is…
We will focus on the former 2.
 Moral Absolutism v Moral Relativism
• Absolutist
• Will believe some moral rules and actions are ‘moral truths’ which are absolutely
right or wrong (what ever the situation)
• Religious ethics will often be absolutist
• Problems with this?

• Relativism
• Good and bad are contextual
• Change over time and between cultures
• What is good or bad will be what that culture / society would view as good or bad
• Respects diversity
• Problems with this?

• And so????
What is a decision?
A choice between alternatives” (Dowy 1993)
• Produces an outcome, for example an action – to
do, or not to do something
• Requires analysis and balancing of pros/cons,
cost/benefit
• Some are mundane (“shall I wake the patient to
take their blood pressure?”) and some are more
complex (“should I tell Mrs B that her husband
had a sexually transmitted disease?”)
 What is an ‘ethical issue / decision’?
• Made by a ‘moral agent’

• A judgement between right and wrong (or more right, and less wrong)

• A choice between options needs to be selected

• Evaluation of the potential impact of decisions or actions needs to be made

• Assessment of what should be done (Normative ethics)

• Decision about what will be done (or not done)- Applied ethics

• Sometimes the decision (may) seem easy….when it is difficult, this is a dilemma

 Decision-making in practice
• Almost all decisions in healthcare have an ethical (and/or legal) dimension
• How to decide?
• No magic formulas!
• We need to analyze them
• Reflect on them
• Weigh up the options
• Justify them
Or do we???

Activity
Are nurses required to explain and account for their decisions and actions?
If so, who to? And why?
Ethical / philosophical reasoning

• When writing about ethical actions/ decisions you will

need to demonstrate a reasoned argument.
• In ethics and philosophy (and other disciplines) these
should follow a pattern….
Deductive reasoning
• Conclusion logically follows on from the premises

• Premise 1: All humans are mortal.

• Premise 2: Ahmed is a human.
• Conclusion: Ahmed is mortal.

If premise 1 & 2 are correct, then the conclusion MUST be correct

HOWEVER
• Premise 1: All mammals have tails.
• Premise 2: Humans are mammals.
• Premise 3: Jane is a human.
• Conclusion: Jane has a tail???
 Inductive reasoning
• Making assumptions based on previous knowledge or
experiences

David Hume…
• Premise: The sun has risen in the east every morning up
until now.
• Conclusion: The sun will also rise in the east tomorrow.

Or
• Premise; I have liked every everything I have eaten at this
restaurant up until now.
• Conclusion; I will like the meal they serve me today (???)
Can you think of
2 Deductive arguments?

2 Inductive arguments?
Ethics- Approaches
Relating to Healthcare
In pairs discuss….
Annan Mahmoud is 24 years of age, and has cystic fibrosis -a
condition which affects the lungs (and other organs).
He is admitted to hospital with a chest infection, is on intravenous
antibiotics, high flow oxygen, and other continuous infusions, and
cannot mobilise without assistance.
He wishes to have a cigarette. This will entail a member of staff
taking him downstairs in the lift so he can smoke outside.
The ward is very busy, and one member of staff is off sick
• Question.
• Should someone take Annan for a cigarette?
• Why/why not?
Yes No
 Three senses of Ethics
Edwards 1996

•Personal ethics - may be intuitive

•Question- Where do these come from?

•Group ethics - Ethical codes e.g. NMC

•May conflict with personal ethics
•Re S (adult; refusal of medical treatment 1991 4 All ER 671)

•Philosophical ethics
•Many approaches-
•For this module, main focus is on deontology, utilitarianism/ consequentialism and
Principlism- but feel free to read around and discuss other philosophical approaches…
Philosophical approaches
• Deontology (duty based ethics)
• Utilitarianism / consequentialism
• Virtue Ethics

• Principlism
 Deontology (duty based ethics)
• ‘Deontological' comes from the Greek word deon,
which means 'duty'.
• Actions are morally right or wrong.
• Rational moral agents have a duty to do the ‘right’
thing (even if the consequences are bad- or at least
not as good as they could have been)
• i.e. You should do the right thing because it is the right thing
to do.
• You should not do the wrong thing because it is the wrong
thing to do.
• So you are doing good if you are carrying out a morally
‘right’ action
Rules
• Deontologists will have rules that should always
be followed
For example
• It is wrong to kill innocent people
• It is right to keep promises

• Can you think of any other rules that

deontologist might follow?
Deontology
• Kant (1724-1804).
• Believed we have duties to
• God
• Self
• Others
• Believed all moral actions carried out by ‘rational
beings’ could be decided through reason
• i.e. we can work out what our duties are
• Motives were very important
• Categorical imperative
• Set of rules it is rational to follow
• If an action is good, it must be good in every context
• i.e. these rules should be universalisable
 Kantian deontology
• All rational beings should be respected and valued as individuals,
and individually important.
• People are an ‘end’ in themselves…not a means to an end.
• So…
• Wrong to treat people as objects, to coerce, bully, or deceive people to
do things they would otherwise not want to do
• It is acceptable to ‘use’ people, as long as they are still treated as ‘an end’
in themselves
• E.g. You get a bus to work. Are you using the bus driver a means
to an end?
• What would make this more or less permissible?
 Rossian duty based ethics
• Tried to address problems with Kantian ethics
• Had theoretical ‘prima facie’ duties which ‘all things
considered’ should be followed
• 7 actual duties
• Fidelity
• Reparation
• Gratitude
• Justice
• Beneficence
• Self-improvement
• Non-maleficence (do no harm)
• Need to consider duties to ourselves and others
• One will need to weigh and balance these duties in
different situations to arrive at a decision.
• Problems?
 Case studies
1. Your grandmother gives you a scarf she knitted for your
birthday. You hate it! It has been in your bottom draw
since you took it home. When you see her she asks you
if you like it and have you been wearing it.
• What do you say? What would Kantian ethics say? Would a
Rossian approach give you the same answers?

2. Mrs Ramos has come into hospital and has advanced Rossian duties
pancreatic cancer. She is expected to die in the next Fidelity
couple of weeks. Her family know, but have told staff
Reparation
not to tell her. Mrs Ramos asks you what is wrong with
her and asks if she is dying. Gratitude
• What do you say? What would Kantian ethics say? Would a Justice
Rossian approach give you the same answers? Beneficence
Self-improvement
Non-maleficence
Consequentialism (Utilitarianism)
• Jeremy Bentham (1748-1832) & John Stuart Mill
(1806-1873)
• The ‘rightness’ of an action is determined by the
consequences
• Bentham – the greatest pleasure for the greatest
amount of people
• created “felicific calculus” (happiness sums )
• Mill amended the approach to the ‘greatest
good’ (or ‘utility’) rather that the ‘greatest
pleasure’
• Motives not important; the outcome is what is
matters The stuffed body of Bentham is kept
in University College London,
• So a moral action is one that maximizes the good where he is occasionally allowed to
consequences take part in college council votes!
Rule consequentialists feel there are still some overall rules to be followed
• You live somewhere where organ transplant is permitted.
• Jane is fit and healthy. She has no family, and few friends.
• Andrew, Mohammed, Shakira, Shanti and Errol (who all have large families who
are dependent on them), need organ transplants to survive (heart, lung, kidney,
liver, skin)
• Should we kill Jane and harvest her organs in order to save Andrew, Mohammed,
Shakira, Shanti and Errol?
 Problems with consequentialism
• Can be difficult to work out the weighting / value of the consequences- some
sums are hard to do!
• No credit for motives
• Can be unfair
• E.g. There is a flu epidemic. It is likely that nearly everyone who is not vaccinated
will catch flu. There is only one ampoule of flu vaccine left this year….Indeed,
every year they run out of vaccines, meaning that each year, many people are
not protected. Mrs Jones is at the front of the queue. She is
immunocompromised and will die if she catches flu, so really needs the jab…..
Mr Smith is healthy, but does not want to risk missing work if he gets sick. He
will pay $10,000 for the vaccination, which next year will pay for an extra 1000
people to get vaccinated.
What would consequentialist argument say should happen?
What are the problems with this?
Who in the health service tends to make decisions on a utilitarian basis?
• Use of different approaches can lead to quite different
decisions being made…
 Virtue ethics
• Not ‘what should I do?’ but ‘what should I be?’
• Focus on being a virtuous person.
• A virtuous person will carry out virtuous actions would
do.
• What is a virtuous action? It is an action a virtuous person
would do.
• Takes practice to work out the ‘right’ thing to do.
• Traditional virtues
• Prudence
• Justice
• Fortitude / Bravery
• Temperance
• Other suggested virtues
• Prudence
• Fidelity
• Self-care
• Justice
 Golden mean

• Virtuous actions require weighing and

balancing- too much of a ‘virtue’ can be as
bad as too little.
E.g. Bravery is a virtue
-What would you be if too brave?
-Not brave enough?
-So what is the ‘golden mean’ here?
Different ethical approaches will lead to different
actions (or sometimes the same action for a
different reason)…..
 Trolley dilemma http://www.trolleydilemma.com
• You are standing by a trolley track. There are 5 workmen on the track, and they cannot

get off. The brakes on the trolley fail and the trolley cannot slow down. There is a fork

in the track. If you pull a lever, the trolley will be diverted onto the new track thus

saving the five men on the main track. Unfortunately, there is one workman on the

other track. He also cannot leave the track, so if you throw the lever, he will die instead.

What would you do? ( after Foote 1967 & Thomson 1985).
• What would you do?
Which would you choose from below
1. Throw the switch in order to maximize well-being (five people surviving is
greater than one).
2. Throw the switch because you are a virtuous person, and saving five lives is
the type of charitable and compassionate act a virtuous person performs.
3. Do not throw the switch because that would be a form of killing, and killing
is inherently wrong.
4. Do not throw the switch because you are a Christian, and the Ten
Commandments teach that killing is against the will of God.
5. Do not throw the switch because you feel aiding in a person's death would
be culturally inappropriate and illegal.
• What would you do?
1. Throw the switch in order to maximize well-being (five people surviving is greater
than one). Consequentialist
2. Throw the switch because you are a virtuous person, and saving five lives is the
type of charitable and compassionate act a virtuous person performs.
Virtue ethics
3. Do not throw the switch because that would be a form of killing, and killing is
inherently wrong. Deontologist
4. Do not throw the switch because of your religious beliefs- your religious texts
teach that killing is against the will of God. Divine command theory
5. Do not throw the switch because you feel aiding in a person's death would be
culturally inappropriate and illegal. Relativist
 Trolley dilemma variation
• The trolley is speeding towards the 5 workmen
on a single track. Only something heavy will
stop the trolley. You see a large man minding his
own business on a bridge above the train track.
If you climb onto the bridge and push him in
front of the trolley, the 5 workmen will be
saved.
• Do you push him?
• What about if the large man was the person
who tied the workmen to the rails?
Principles approach
Beauchamp, J. & Childress, T. (2013) Principles of biomedical ethics. (7 Ed) , Oxford , Oxford University Press.

•Autonomy
•Non-maleficence
•Beneficence
•Justice

•Framework rather than a model or theory

 Autonomy
Autonomy is the right to self-rule
Healthcare provider has
•Positive obligations to
•Promote autonomy
•Promote autonomous decision-making
•Negative obligations
•Not to control or restrain autonomous decision-
making or actions
Autonomy
• What do you need to be able to make an autonomous decision?
•
•
•
•
•
 Autonomy
• Is everyone capable of autonomous decision-making?
• Who might not be?
• If you have rules (e.g. religious beliefs, laws, clinical guidelines) to follow, does
this mean your are not autonomous?

• E.g. Peter is involved in an accident and is bleeding heavily. He is brought into

the emergency department and the doctor / nurse want to give him a blood
transfusion to save his life. He refuses because his interpretation of the religious
doctrine he follows is that he should not receive any blood.
• Is this an autonomous decision?
• What is (or may be influencing) his decision?
• Does this provide a conflict for the doctors and nurses?
Non-maleficence
• Obligation to do no harm

• Inflict no harm
• Prevent harm

• So we never harm our patients….do we?

 Non-maleficence
Benefits v harm

Can you think of things we may do to harm our

patients?
In which case why do we do it?
 Non-maleficence
• Double effect
• Dr Bodkin Adams 1957
 Beneficence
A requirement to contribute to
the welfare of others
 Justice
• Distributive justice
• Retributive justice

Think about…
• To each person an equal share
• To each person according to need
• To each person according to effort/contribution
Balancing?
The four quadrants - approach
The following questions should be worked through in order.
• Indications for medical/nursing intervention - establish a diagnosis, what
are the options for treatment, what are the prognoses for each of the
options.
• Preferences of patient - is the patient competent- if so what does he / she
want? If not competent then what is in the patient’s best interest?
• Quality of life - will the proposed treatment improve the patient’s quality of
life?
• Contextual features - do religious, cultural, legal factors have an impact on
the decision?
Jonsen, Siegler and WinsladeClinical Ethics: A Practical Approach to Ethical Decisions in
Clinical Medicine (8th edition) London, McGraw-Hill
From
http://www.ukcen.net/ethical_issues/ethical_frameworks/the_four_quadrant_approach
Ethox ethical / legal framework
Case studies
• Decision making will often require you to consider
ethics AND Law (we will look at Law in a future session)
• Think about
• Consequentialism
• Deontology
• Virtue ethics (is it any help here?)
• 4 principles
Case study 1
• Marvin is 83 years old. He was living independently until 6 months ago,
but after an acute drug reaction, has sustained severe permanent
damage to his lungs. He is breathless at rest and needs full time care
• He gets a chest infection and his breathing is even more laboured than
usual. His O2 saturations are 86%. Doctors tell the family that they
would like to admit Marvin to High dependency unit (HDU) for
escalation of treatment and non-invasive ventilation.
• What are the ethical implications? How can a decision to admit him OR
not to admit him be defended?
• Imagine that he is admitted to HDU for non-invasive ventilation. After 2
days, his observations are unchanged and Marvin communicates to
staff that he does not want any more treatment. What should happen -
as if he is taken off the ventilator he will die? What should be
considered when making this decision? Discuss the ethical and legal
implications of a decision to remove his breathing support.
 Case Study 2
• You visit Akleema at home to redress her venous
leg ulcer on a Monday. During your visit Akleema
mentions that she has had two falls over the
weekend. She has commenced a new tablet for
her hypertension which she says makes her feel
giddy and does not remember falling but ‘wakes
up’ lying on the floor. She asks you not to say
anything to anyone as she is scared she might
have to go into hospital.
• Outline what your duty of care is here. What
would the different ethical approaches suggest
you do?, Justify the decisions you will make to
support this lady.
Case Study 3 (consider using 4 Quadrant or 4 Principles approach)
• Mrs Y is 56 years old and has a learning disability. She is admitted to hospital with
an ovarian cyst. The cyst is blocking her ureter and if left untreated will result in
renal failure. Mrs Y would need an operation to remove the cyst. Mrs Y has
indicated quite clearly that she does not want a needle inserted for the
anaesthetic for the operation to remove the cyst- she is uncomfortable in a
hospital setting and is frightened of needles.
• The clinician is concerned that if the cyst is not removed Mrs Y will develop renal
failure and require dialysis which would involve the regular use of needles and be
very difficult to carry out given her fear of needles and discomfort with hospitals.
The anaesthetist is concerned that if Mrs Y does not comply with the procedure
then she would need to be physically restrained. Mrs Y’s niece visits her in the
care home every other month. The niece is adamant that her aunt should receive
treatment.
• Should the surgeon perform the operation despite Mrs Y’s objections? From an
ethical discuss why / why not?
• What might the role of the nurse be in this case?

From http://www.ukcen.net/ethical_issues/ethical_frameworks/the_four_quadrant_approach
Case Study 4
• Dr Cox, an experienced rheumatologist, was called to see one of his patients (whom
he had treated for many years). As well as longstanding rheumatoid arthritis, she had
acute (and very painful) vasculitis. He administered a number of painkillers, none of
which had any effect. She was in agony, and both she and her family had repeatedly
begged the doctor to end the life of the patient life. Dr Cox gave her a large dose of
potassium chloride* and she died shortly after.
• He documented his actions, and a nurse who read the medical notes brought the
incident to the attention of the authorities.
• Was what he did legal?
• Was it morally right?
• Would it have made a difference if the drug he had used was an opiate?
• Would it have made a difference if he had given her the drug to self-administer?
• What do you think the findings of the court were?
• Would you want him to be your doctor?
• * Usually used to treat electrolyte imbalances- in large doses can stop the heart.