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Medical ethics 

Medical ethics

Chapter:
Medical ethics
Author(s):

Tony Hope

DOI:
10.1093/med/9780199204854.003.0202

November 30, 2011: This chapter has been re-evaluated and remains up-to-date. No changes have been necessary.

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date: 24 March 2017

Medicine is a moral enterprise as well as a scientific one. It is as important to give reasons for the ethical aspects as it is for the scientific aspects of a decision. The corollary of evidence-based medicine is reason-based ethics.

Two concepts central to many ethical aspects of clinical practice are autonomy and best interests.

Mill argued that society has no right to exercise its power over individuals against their will purely for their own good. In the medical context a competent adult has the right to refuse any, even life-saving, treatment. Some conceptions of autonomy focus on competent choice, others emphasize the importance of reasons that relate to a person’s long-term interests and goals. Respecting patient autonomy can be problematic when it either harms the patient, or others, or when a patient lacks capacity.

When patients lack capacity to make their own choices they should generally be treated in their own best interests. But what does this mean? Philosophers have given broadly three answers: maximizing positive states of mind, such as pleasure; maximizing the fulfilment of desires; and maximizing aspects of life that are objectively considered valuable. The legal concept of best interests is a composite of all these.

Three of the most common issues for which doctors seek ethics support are consent, end of life, and confidentiality.

A crucial issue if a patient is refusing beneficial treatment is whether he or she is competent to refuse. The assessment of competence involves three steps. First, identify the key information relevant to the decision. Second, assess the patient’s cognitive ability: can the patient understand, retain, and weigh the key information to come to a decision? Third, assess other factors that may interfere with decision making, such as delusions. When patients lack capacity doctors must consider: patients’ best interests; whether there is a proxy decision maker; and whether the patient has made any relevant advance directive.

Ethical principles may conflict in end-of life-decisions. Different ethical approaches disagree over the significance of two distinctions: that between acts and omissions; and that between intending and foreseeing an outcome. These distinctions are important in considerations of mercy killing; the moral difference between withholding life, extending treatment, and killing; and in giving treatments that relieve distress but might shorten life. The law varies on these issues in different countries.

When should doctors breach confidentiality either for the good of the patient or to prevent harm to someone else? There are differing accounts of the most important reason for medical confidentiality: respect for patient autonomy; keeping an implied promise; and bringing about the best consequences. These different accounts can have different implications for when it is right to breach confidentiality in problematic situations.

Acknowledgements. I would like to acknowledge with thanks the valuable discussions that I have had with Judith Hendrick and Julian Savulescu.

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