Ethical Approach to Practice

Understanding ethics and reflecting ethically will help you with your decision making – in terms of whether you feel you have done the right thing.  When we feel we have done the right thing, we naturally feel good about it and it is unlikely we are likely to be criticised for it if we understand precisely why we made that decision from an ethical viewpoint.   Examining circumstances through your ‘ethical eye’ is a skill in itself – and like all skills, it get’s easier the more you put effort into doing it in the first place.

So, in order to examine, reflect and write about a particular situation from an ethical perspective, you need to understand some ethical principles, values and frameworks.  Each addresses a value that arises in interactions between clinicians and patients.  Once you understand these ethical principles, values and frameworks, you can then write about your situation and link what you decided to them.

An example of how you can transform a learning log entry into something exceptional is provided at the end.

The 4 Ethical Principles

  1. AUTONOMY
    People have the right to control what happens to their bodies. This principle simply means that an informed, competent adult patient can refuse or accept treatments, drugs, and surgeries according to their wishes. People have the right to control what happens to their bodies because they are free and rational. And these decisions must be respected by everyone, even if those decisions are not in the best interests of the patient.
  2. BENEFICENCE
    All healthcare providers must strive to improve their patient’s health, to do the most good for the patient in every situation. But what is good for one patient may not be good for another, so each situation should be considered individually. And other things that may conflict with beneficence would need to be considered.
  3. NON-MALEFICENCE
    “First, do no harm”. In every situation, healthcare providers should avoid causing harm to their patients. They should also be aware of the doctrine of double effect, where a treatment intended for good unintentionally causes harm. This doctrine helps you make difficult decisions about whether actions with double effects can be undertaken.
  4. JUSTICE (=FAIRNESS)
    The fourth principle states that you should try to be as fair as possible when offering treatments to patients and allocating scarce medical resources. You should be able to justify your actions in every situation.

The 3 Ethical Values

  1. HONESTY
    Honesty is a facet of moral character.   It means being truthful and open about things (and NOT lying, being decietful or deceptive).   Honesty means being trustworthy, loyal and sincere.   Doctors are the most trusted profession in the world – and that’s beccause we are honest.   Reemember, in the words of Benjamin Franklin, ‘Honesty is the best policy’.
  2. INTEGRITY
    Integrity is about having good and strong moral principles – or moral uprightness.  It is generally a personal choice to uphold oneself to consitent moral and ethical standards.   Indeed it is related to the quality of being honest.  It comes from the Latin integer, meaning whole or complete – integrity is the inner sense of ‘wholeness’ deriving from qualities such as honesty and consistency of character.  A person is said to have integrity if their behaviour is consistent with their beliefs and principles (= core values).
  3. RESPECT
    Respect is a positive feeling and/or action.  This positive feeling or action is for a person or group of people (like a nation or religion).  Respect in our medical world means respect for patients, relatives, friends, colleagues and oneself.  Respect should NOT be confused with tolerance.  Tolerance is the practice of deliberately allowing or permitting a thing of which one disapproves.   In contrast, respect is about having due regard for someone’s feelings, wishes or rights.   Respect is a postive way of treating or thinking about something or someone.  For example, if you have respect for a teacher, you admire him or her and treat them well (as opposed to just tolerating them).

The 4 Moral Theories

  1. VIRTUE ETHICS
    This was first described by Aristotle.  He basically said that if a person has good qualities, they’re likely to behave in a similar fashion.  So, a person is likely to be ‘virtuous’ if they have good character qualities like honest, integrity, trustworthiness, humility, considerate, wholesome and so on.
  2. DUTY-BASED ETHICS
    This was coined by Emmanuel Kant who said that there are general moral rules that all people should follow.  So, a group of people who follow a set of religious views might be said to have Kantian morals.
  3. RIGHTS-BASED ETHICS
    The rights-based approach stipulates that every individual is the same and therefore has equal rights.   A good example of this is the Human Rights Act.   Another example in the medical world is where every patient is treated equal – and whether they are fellow doctors, judges or domestic cleaners should make no difference whatsoever.
  4. UTILITARIANISM (= THE PRINCIPLE OF UTILITY)
    Bentham and Mill developed this one.  Unlike the rights-based view which takes the individual’s perspective, the principle of Utility takes on a wider perspective (for example, of society).   Utilitarianism is about doing the greatest good for the greatest number.  For example, if there was a very expensive treatment for a particular condition, the rights based view would dictate that every individual person has the same right and therefore should recieve that treatment just like any other patient would do for any other treatment (irrespective of cost).   The principle of Utility would dictate that decisions should be based on doing the greatest good for the greatest number and not on the individual.   So in this case, could the money from the expensive treatment be more wisely spent on other lesser expensive treatments (thus helping lots more people) than the one treatment on the one individual?   So – when you write about being the role of a GP as the gatekeeper to NHS services (for example, controlling the number of referrals you make or the treatments you prescribe) – you are talking about ‘RATIONING’ – and rationing has it’s principles based on Utilitarianism – doing the greatest good for the greatest number.

3 Specific Medical Ethical Areas

If you have any situations that relate to consent, capacity or confidentiality, you can always link them to the ETHICAL competency.

  • CONSENT
    Consent can be implied (e.g. when they put out their arm when you say you want to take a blood sample) or explicit (when you explicitly seek permission e.g. before minor surgery or examination).  Treatment without consent could lead to the charge of battery or negligence.   Click here for capacity to consent in Children (Gillick Competency & Fraser Guidelines).
  • CAPACITY to make decisions (or consent)
    Remember, a patient has capacity to make decisions if they can

    1. Understand what is being said to them
    2. Retain that information
    3. Weigh up the pros and cons
    4. Come to an active decision
  • CONFIDENTIALITY
    Generally, a patient has the right to have their information kept confidential.   The duty of confidentiality continues after death.   Most breaches of confidentiality are inadvertent.  You can only break confidentiality if…

    1. The patient has consented to you releasing information to a particular recipient
    2. It is in the best interest of the patient (e.g. a psychotic patient)
    3. It is in the best interest of a third party like a child, partner, relative or other members of society (e.g. a patient who you think might harm others, the DVLC)
    4. They have done something involving serious crime (like terrorism or anything involving guns – in which case, you contact the police).
    5. The courts have demanded you release information (instruction from a judge or warrant from Police)

Example of how to make your log entries great

NOT A GREAT ENTRY

I went to see a patient from in a nursing home who was in fact a retired GP.  He was catheterised and often prone to UTIs.   The urologist had written explcitly in the notes that if he had signs and symptoms of a UTI that he should have his catheter changed and be admitted as he was prone to deteriorating.  I was called by the District Nurses to see him because they suspected an early UTI (dipstick positive for leucocytes and nitrates) but he refused to have his catheter changed or be admitted to hospital.   When I got there, everyone seemed in a panic about what to do.  Both DNs and the nursing staff were adamant that they wanted me to admit him because that is what the consultant had requested.

To me – the patient was not confused and generally well, but clearly frustrated that he was not being allowed to make decisions for himself.  In previous admissions, he kicked up a fuss in a hospitals and usually discharged himself in a state of frustration anyway.   I chatted to him and decided that the best thing to do was to respect his choice and leave him where he was.   I made a thorough documentation in the notes about his capacity to make decisions for himself and our final decision.  I started him on antibiotics for his UTI, encouraged fluids, told staff to keep an eye on him and call me if he deteriorated.

  • Quick question – what would you have done?   Not sure?  Sought advice?  Confused?  Apprehensive?  Worried?  Nervous?  

TURNING IT INTO A GREAT ENTRY

Now read this entry and notice how with a little tweaking we can make it into a fantastic log entry which also reminds us why we did things the way we did and reflect upon our actions.   Note that it is not much longer than the previous entry!

I went to see a patient from in a nursing home who was in fact a retired GP.  He was catheterised and often prone to UTIs.   The urologist had written explcitly in the notes that if he had signs and symptoms of a UTI that he should have his catheter changed and be admitted as he was prone to deteriorating.  I was called by the District Nurses to see him because they suspected an early UTI (dipstick positive for leucocytes and nitrates) but he refused to have his catheter changed or be admitted to hospital.   When I go there, everyone seemed in a panic about what to do.     Both DNs and the nursing staff were adamant that they wanted me to admit him because that is what the consultant had requested.

To me – the patient was not confused and generally well.   I said to him that I was not there to force him into anything but simply wanted an open discussion to do what was right for him and respect his views.   As a result we had a good open and honest  discussion (COMMUNICATION/CONSULTATION SKILLS).   He clearly understood the pros and cons of not having the catheter removed and refusing to be admitted.    He was frustrated at not being allowed to make decisions for himself.   As the patient had capacity (understood and retained what I was saying, could weight up pros and cons and make a decision), I felt that one needed to respect his views (patient autonomy) and go with his preference.  In addtion – I did not want to cause him harm (non-maleficience) – I could see from previous admissions, that he kicked up a fuss in a hospitals and usually discharged himself in a state of frustration anyway (ETHICAL APPROACH TO PRACTICE).  He was grateful to me for listening to him.   I made a thorough documentation in the notes about his capacity to make decisions for himself and our final decision (ORGANISATION, MANAGEMENT & LEADERSHIP).   I started him on trimethoprim for his UTI, encouraged fluids, told staff to keep an eye on him and call me if he deteriorated (CLINICAL MANAGEMENT).

  • Can you see how the trainee has made specific links to specific ethical principles, values and frameworks?
  • Can you also see how writing and reflecting on situations can help us see whether we made the right call?
  • Final question – how do you feel now about the decision that was made?  Even though the trainee had not spoken to consultant, do you think he made the right ethical decision?   Would it stand well in court?   How uncomfortable, apprehensive, confused, worried or nervous do you feel about the decision now?  More, less or about the same?

Further resources