Introduction to Medical

Ethics
Presenter: Dr Purva Shoor
Assistant Professor
Community Medicine
Ethics
 Definition: A discipline that includes the study of
ideals for human conduct and an understanding of
the moral life, in which actions are judged as right
or wrong and persons and institutions are judged
as praiseworthy or blameworthy
 Why should one be good? Or more basically,
What does good mean?
Classification of Ethics
 Descriptive ethics
 Normative ethics
1. General normative ethics
2. Applied ethics
A. Medical ethics
B. Other professional ethics
 Metaethics
Descriptive ethics
 Describes
 Is concerned with analyses of facts obtained from
anthropological, historical, psychological, or
sociological studies
 No judgment is imposed about the relative merits
of various systems
Normative ethics
 Concerns inquiry into actions and their worth
a. General normative ethics-discusses principles of
human conduct and how evaluations are to be
effected
b. Applied normative ethics-concerns the judgments
of specific moral problems. It includes medical,
legal, business and other professional ethics
Metaethics
 It is the study of the meaning and justification of
ethical discourse and the nature of moral concepts
 Why should one be good?
 What does good mean?
Medical ethics
 It involves the study of general problems relating to
health care, health care institutions, and biomedical
research
 While many issues are difficult to resolve because of
conflicting social, political, and economic pressures,
there is considerable agreement about the general
values that buttress the health profession
Background of Medical ethics
 The teaching of modern medical ethics began in the early 1960s.
 At present, virtually every medical school and several medical
specialty boards require courses in medical ethics, largely
because of:
a. New medical technologies- genetic screening, life-support
equipment
b. Demands of public interest groups
c. Physicians and other health care professionals are concerned
about the moral climate of their own fields
Moral questions in medicine
 Virtually every contact between a patient and a
health professional contains moral dimensions
 Also, most often the values of the patient, the
health care worker, and the sponsoring institution
conform, and there is no moral conflict
 However, when values conflict, there is a need for
medical ethical reasoning
Physician’s values
 Each physician has personal values; values formed at the level of
practice, partnership, service, or hospital; and values shared with
other members of professional organizations and other general
medical groups
 At times, demands from various levels may cause the physician
internal conflict
 E.g., a physician who is opposed to abortion is a member of a
medical group that is working for abortion rights, then the resultant
pull of values between personal belief and professional loyalty is a
subject of medical ethics
Patient’s values
 If a woman comes to clinic and requests the
possibility of abortion and her parents and spouse
are against her decision, the physician although not
agreeing with hospital’s pro-abortion policy and
woman’s choice, he may feel a moral duty to
represent (both value levels-group as well as
personal values) to a spouse and parents whose
values coincide with the physician’s personal values
Professional codes of conduct
 The Hippocratic Oath: once widely subscribed to
by graduating medical students, has been revised
in favor of new interpretations of desirable medical
behavior. What still remains is:
1. Do no harm
2. Keep confidential the information learned
through one’s work
Patients’ rights

 To protection from sexual abuse and from gossip

about their situation and to choose certain
interventions considered wrong for the Hippocratic
physician (e.g., surgery, abortion, use of poisons)
have been extended
 Example of clinical ethical decision
making
 An 85-year old diabetic woman with associated renal
problems lives in her own home and conducts a part-
time telephone business. She recently developed
gangrene in her left foot and refuses to give consent
to operate, saying she is ready for death and wants to
“go to heaven a whole person”. Her two children want
the operation done immediately.
 Example of clinical ethical decision
making
 A psychiatric consult concludes that, although the
patient is oriented and generally aware of her
situation, she may be considered incompetent to
assess fully the gravity of her situation. Repeated
explanations by her physician, by the hospital
staff, and by her children have failed to change
the patient’s mind
 Clinical Event

Premise: Reasons, Justifications

Counter premise: Reasons, Justifications

Evaluation

or or
Premise accepted
Counter premise
Accepted New Premise devised

Action
Premise
 Is an action statement regarding conduct that should be
initiated or discontinued because of a moral obligation of
the physician to the patient or to an involved institution.
 When opposite choices appear attractive, a positive
action statement should be used as the original premise
 Case premise- Seek a court order to obtain medical
guardianship and then operate on the patient
Ethical argument
 It consists of reasons for the premise and justifications
for the reasons. Objections to the premise should be
held until later in the argument
 All reasons that support the premise should be listed,
with medical, legal, social, and personal reasons
separated from moral ones
 A justification should be provided for each moral reason
listed. Justifications are “reasons for the reasons” and
generally move to more abstract and general concepts
Ethical argument for the case premise
 Reason 1: The situation is life-threatening
 Justification 1:There is a duty to save life
 Reason 2: If the patient does not understand, she should not decide
 Justification 2a: Letting her decide is, in effect, doing harm by
omission
 Justification 2b: A physician should do no harm
 Reason 3:The psychiatrist has judged the patient incompetent to
make a medical decision
 Justification: The expert opinion of the consultant is respected in most
cases
Ethical argument for the case premise

 Reason 4: The children desire this medical

intervention.
 Justification 4: The children have a vested interest
in the patient’s well-being and, if she is competent,
would ordinarily make medical decisions for her
Counter premises
 For each premise, there will be one or more counter
premises
 Case counter premise: Accede to the patient’s wishes
 Case based ethical argument:
 Reason 1: The patient has the right to refuse treatment
 Justification 1a: Permitting patient’s decision respects her
as an individual
 Justification 1b: Accepting the patient’s opinion is
accepting her autonomy
Case based ethical argument
 Reason 2: If the patient understands other things,
perhaps she does understand the situation
 Justification 2: There is a need to appreciate that
she may have a different value scheme, which
should be respected
 Reason 3: At her age, she will not live long anyway
 Justification 3: Accept the fact that any intervention
will have only a short-term benefit
Evaluation
 Consists of weighing the several reasons to
determine their relative importance and to select
the most important elements
 When conflict remains, outside input (e.g., for
colleagues, other professionals, patients and their
families, ethics committees, other counselors)
may help to define the problems better
Evaluation General guidelines

 Consistency: The decision should be one that

could be supported in all similar cases
 Coherence: The decision should have internal
logic and conform to the general treatment plan
for the patient unless there is an overriding reason
for altering that plan
Evaluation
 The life-threatening aspect would lead many
physicians to proceed with the operation,
completely overriding the patient’s wishes. The
children’s preference for intervention would help to
influence this decision. It is assumed that the
physicians would have the patient’s well being in
mind
Evaluation
 Had the children agreed with the patient, it would be much
harder to override their decision, but, if the patient were a
minor and agreed with the parents to refuse treatment
e.g., on religious grounds, then the health team would
take court’s approval for the medical intervention
 The argument about age seems irrelevant, if not
prejudicial, in this case
 The decision would have been clearer if the patient came
from a nursing home and did not have a business
Action
 Medical ethical decision making is directed to an
action or to a determination not to act.
 Eventually, one may need to proceed without the
agreement of other interested parties
Action
 Proceed with the action
 In this case, surgery
Summary
 Medical ethics is a sub branch of applied
normative ethics which is nothing but based on
norms
 Norms are decided at various levels and
interference at various systemic levels like,
hospital you work in, your state or country
guidelines and foreign or external influence in a
globalized world
Summary

 Yet physician can play a paternalistic role to take

decisions (through transparent explanation to the
patient if required knowing that the patient trusts
the doctor) according to his discretion and
expertise in an ambiguous situation, he may be in
conflict with personal and institutional ethics-
remember the abortion dilemma example
Summary
 Medical science has both abstract and concrete
components. Abstract deals with intangible logics
and linguistic (semantic) understanding of various
dealings and concrete is physical and is
conceptualized empirically like body weight,
height, rheology of body fluids, blood, type of
fractures and so on
Assignment
 Write or type and send an essay of 500-750 words on any one
of the following ethical considerations in the medical field:
 Ethical considerations of new fertilization technologies –IVF
and embryo transfer/IUT/GIFT/SUZI/ICSI/zona pellucida
drilling, or
 Ethics of healthcare privatization, or
 Equity in health care resource utilization-need for universal
health coverage
 E-mail- communitymedicine712@gmail.com
Thank You!!