As doctors, you will inevitably come across ethical problems.  But once you've identified an ethics issue, how do you resolve it?  The next two columns present two popular methods of case analysis. 

The first, and most widely known way to analyse a medical ethics case is the Four Principles approach. This approach anchors medical morality on four key principles: respect for autonomy [in brief, the obligation to respect people's ability to make choices for themselves and set their own goals], beneficence [the obligation to do good], non-maleficence [the obligation not to cause harm], and justice [the obligation to act fairly in treating people and allocating resources].

Although these principles sound appealing, they are too abstract to be helpful in a particular case. So, more specific rules can be derived from each of these principles. For example, under ‘respect for autonomy’, you will find ‘tell the truth to patients’ [because patients need accurate information to make choices], 'don’t breach confidentiality' [because patients give you information on the understanding that you’ll keep it secret], ‘obtain informed consent’ [because you should ask people’s permission before you do things to their bodies], and so on. Under ‘beneficence’, you might find ‘act in what you think is in the best interests of the patient’, ‘acquire relevant skills and maintain them’ [including by going to courses and reading medical journals], ‘communicate clearly with patients’, ‘ask for assistance if in doubt’, and so on.

When examining a case, you should go through each of those four principles. They are, in a way, a checklist. Does X respect Mr Smith’s autonomy? Is X in his best interests? Will X cause harm and, if so, will this harm be outweighed by the benefits? [note that, when the patient is competent, his views will partly determine whether a proposed treatment is in his best interests or will cause more harm and good. People hold different views about what’s desirable and undesirable for themselves]. Is X respectful of Mr Smith’s human and legal rights and is it an appropriate use of resources?  Make sure you don’t just consider the patient, but also how the principles might affect others, including the medical team and patient's relatives.

Sometimes, the principles will conflict. You will want to respect the patient's autonomy by not breaching confidentiality but your obligations of beneficence and non-maleficence towards your colleagues, other patients and society point to disclosing Mr Smith’s case of Ebola contracted on his recent trip to the jungles of the Congo. In fact, you also have a obligation to breach confidentiality (Public Health Act 1988) as Ebola is a notifiable disease.

The obligation to respect autonomy, then, is not absolute but prima facie. In other words, it is binding unless it conflicts with a weightier, prima facie obligation.  This is true for each of the four principles. None of them takes automatic priority. Their moral weight will depend on the circumstances. In the case of Mr Smith, we would all agree that the combined principles of justice, beneficence and non-maleficence [by appealing to the potentially catastrophic consequences of respecting confidentiality and the requirements of the law] outweigh the duty to respect confidentiality. 

Who said there are no right answers in ethics?

Daniel K. Sokol, Lecturer in Ethics, University of Keele, and Honorary Research Fellow, Imperial College, London.

www.medicalethicist.net

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