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SECTION 1:  INTRODUCTION

‘The important thing . . . is not so much to obtain new facts as to discover new ways of thinking about them.' 1

   LEARNING OUTCOMES

   After reading this section of the course, you should be able to:

  •  Recognize when ethical issues arise in cases.
  •  Provide a critical analysis of ethical codes.
  •  Understand the meanings of the Principle of Autonomy, Principle of Beneficence, Principle of Non-malfeasance and Principle of Justice.
  •  Be able to recognize when appeal is being made to these principles.
  •  Have an initial understanding of the relation between ethics and the law.

   KEY POINTS


  •  The Principle of Autonomy. In certain areas an individual has a right to be self­ governing.
  •  The Principle of Beneficence. The well-being or benefit of the individual ought to be promoted.
  •  The Principle of Non-malfeasance. One ought to do no harm.
  •  The Principle of Justice. Equals ought to be considered equally.


1.1  ETHICAL ISSUES

Most people would claim that they can recognize an ethical issue. They realize that ethical questions, such as ‘ought one always to tell the truth' or ‘are abortions ever morally justifiable', are different from factual questions such as ‘how much is your tax bill' or ‘which is the quickest way from London to Edinburgh'. However, it will become apparent that we need to look more closely at these ethical questions in order that we can think more clearly about the issues involved and the ethical decisions that have to be taken in health care practice.

·        What is an ethical issue?
·        What distinguishes ethical questions from other sorts of questions

Here are three examples within which we can identify some ethical issues.

The Mother-to-be Example

A 39-year-old female undergoes an amniocentesis. The results indicate that the fetus is not suffering from certain genetic abnormalities. The mother requests to know the sex of the fetus. This information is refused on the grounds that an abortion might be requested if the fetus is not of the ‘right' sex.

In this example, questions requiring expert medical knowledge would have been raised when considering the advisability of offering this test to the patient. Medical expertise is also required to be able to interpret the results of the test. However, ethical questions also arise at both these stages. Should the life of the fetus be put at risk by undertaking this test? If the test indicates genetic abnormalities, is it justifiable to abort the fetus? Is it legitimate to withhold information gained from this test?

The Euthanasia Example

A 70-year-old widow in agony from rheumatoid arthritis decided she wanted to die. The request was judged to be competent and was agreed with by her only son. The doctor gave her an injection of potassium chloride and the widow died some minutes later. A member of the nursing staff wonders whether to report the consultant's action.

In this example, medical knowledge would be required to diagnose the woman's condition and realize its prognosis. Additionally, it raises ethical questions. Is voluntary euthanasia morally acceptable? Since it is illegal, should the consultant have agreed to the request for euthanasia? Would it be right for a member of the nursing staff to report this action?

The Pain-Killer Example

A consultant has decided that a patient has become too dependent on certain pain­killing drugs that will ultimately have harmful consequences. It is decided to wean the individual off these drugs without informing her. The nurse is required to continue this deception even though the patient is clearly distressed and asks why her pain killers are not having their usual effect.

In this example, we have a judgment based on medical knowledge that the pain killer will ultimately have harmful consequences. We also have the assessment that a weaker pain killer will be adequate to deal with the particular complaint. However, the ethical question arises of whether or not one should deceive this individual. In addition, the nurse in the health care team might not agree with this deception, so should the nurse tell the patient the truth or should she continue the deception ?

1.2 ETHICAL EXPERTS?

One of the things that these examples illustrate is that the expertise required for diagnosing, treating illnesses and caring for individuals is not the same as the expertise needed for taking ethical decisions. A skilful health practitioner is not necessarily one that is equally skilled when ethical decisions arise. It must not be assumed that, because we consult someone about a medical complaint, that person is also the one who should take ethical decisions when they arise. Our argument is that solutions to ethical problems in health care are not the prerogative of health care professionals Rather solutions to ethical problems rely on participation between the individual and the health care team. We shall be analyzing these ethical issues to assist both health care workers and other members of the community in their consideration of ethical questions.

1.3  PATIENTS' OR ‘CLIENTS’?

When discussing the sort of ethical questions illustrated in our examples, we must be careful not to beg any important ethical question in our description of the cases. In the ‘pain-killer example', the individual has been referred to as a patient. The term ‘patent' has the value implication that the relationship between this individual and other members of the health care team is one of dependence. This relationship of dependence, implied by the use of this term, might go some way towards justifying the paternalistic course of action taken in this example. We need to be able to consider the ethical questions raised by this case using terms that do not automatically favor one course of action over another.

Instead of the term ‘patient', it might be thought preferable to use the term ‘client'. This does not appear to have connotations of dependency and gives the recipient of health care more autonomy. However, if the term ‘client' is used, then this carries implications from the business field into the health care relationship which again begs important ethical questions. For example, is it appropriate that the availability of certain treatments should be based on the ability to pay just as business services are open to those who can afford them?

Therefore, we need to find a term to refer to recipients of health care which is not too cumbersome and which does not beg the question in favor of certain ethical conclusions. Accordingly, in this course we refer to the recipients of health care as 'individuals' which appears to be the most neutral term from a value point of view. In calling them individuals, no value issues governing their relationship with members of the health care team are presupposed.

1.4  ETHICAL CODES

If we return to the examples with which we started, it might be argued that we already have a way of dealing with the ethical questions that they raise. We can refer to the ethical codes of practice that apply to the different members of the health care team and argue that these provide guidance about what ought to be done in cases like these. For example, there is the ethical code produced by the United Kingdom Central Council for Nursing, Midwifery and Health Visiting. This provides a list of clauses for the conduct of nurses, midwives and health visitors in their relationship with the recipients of health care, other members of the health care team and any other relevant bodies. As an illustration, one of these states that they should:

‘Act always in such a manner as to promote and safeguard the interests and well­being of patients and clients. ' (see Appendices for Ethical Codes Governing Practice.)

However, there are a number of reasons why referring to ethical codes of this sort will not provide solutions to the type of ethical questions illustrated in our examples.

Meanings of key terms

The first difficulty is to understand the key terms used in the list of clauses. In the example given above:

·        What counts as the ‘well-being' of an individual? and
·        Who is to determine whether the individual is in this state?
·        What is meant by the distinction between ‘promoting' and ‘safeguarding' well-being and interests?

Until these terms and others like them have been explained, the meaning of the code will not be clear (see ET1008 – Section 15.3.4).

Conflicting requirements

A second problem with the codes of practice is that the requirements within them do on occasion conflict. For example, another clause from the code just quoted states that carers should:

‘Work in a collaborative and co-operative manner with health care professionals and others involved in providing care, and recognize and respect their particular contributions within the health care team.' (see Appendices for ethical codes governing practice.)

In the ‘pain-killer example' the nurse might well feel that there is a conflict between the requirement in the first clause that we quoted to promote the well-being of the individual and the clause to work in a collaborative and co-operative manner with other members of the health care team. Consulting the first clause alone might lead the nurse to think that it is right to tell the individual about the deception that is being practiced. However, the second clause would appear to advocate continued concealment on the grounds that this is what constitutes co-operative behavior with other members of the health care team.

Not exhaustive

A third problem with relying on ethical codes for the solution of ethical questions is that ethical codes are not exhaustive. They do not provide clauses to cover all the ethical dilemmas that might arise in health care. Many examples illustrate this point, but the ‘mother-to-be example' illustrates it particularly well. It is clear from the code to which we have been referring (see Appendices for ethical codes governing practice), that there are no clauses that indicate what ought to be done in this case.

·        Who, for example, is to be considered the patient/client in this case?
·        Was it in the interest of the fetus that the amniocentesis was undertaken or in the interest of the mother?
·        Whose interest is being considered when the request for information about the sex of the fetus is refused?

Even when these questions are answered, the clauses by themselves do not provide an answer to our ethical questions.

No justification

Another problem with the expectation that ethical codes might provide solutions to ethical questions is that they are just presented as lists of clauses. They provide rules for the ethical conduct of a nurse, midwife or health visitor but there is no indication of what the rationale for these rules might be.

·        What principles are being employed to arrive at these rules?
·        Are they principles with which the nurse, midwife or health visitor would agree?

Although these codes clearly provide some level of guidance, without an appreciation of their rationale they cannot be used as a substitute for making ethical decisions.

This problem is not limited to codes for nurses, midwives and health visitors. It also applies to the Hippocratic Oath and the various codes issued by the World Medical Association. Similarly, other health care practitioners, such as physio­therapists, have rules of professional conduct which are subject to the same criticisms (Rules of Conduct for Physiotherapists are issued by the Chartered Society of Physiotherapy).

Acceptability of the codes

A final problem is concerned with the acceptability of the codes. Up until now, we have been writing as though the codes might provide some guidance in ethical decision making but are by no means sufficient in themselves when dealing with complex ethical questions. However, it might be worth remembering that these codes were not devised by consulting many different sections of the community but were devised by a minority group from within the community. For example, the United Kingdom Central Council for Nursing Midwifery and Health Visiting has a committee that is responsible for the production of the code for professional conduct. Although every nurse has a right to vote for members of this council from which the committee membership is formed, this does not guarantee that the resulting codes and free from flaws. There is no reason why communities should accept uncritically codes that have been established by a minority group. Indeed, the requirements incorporated in the Hippocratic Oath (see Appendix B), for example, might come to be seen as too paternalistic and individualistic. In fact, Veatch writes:

'The Hippocratic Oath is dead. No rational person would agree to it. ' 2

1.5 CRITICAL ETHICAL APPROACH

If ethical codes do not, by themselves, provide answers to the ethical questions, we need to adopt an alternative procedure. A critical ethical approach needs to be taken. This begins by analyzing four basic philosophical principles which underlie ethical decision making. In addition, specific issues are analyzed where these principles are seen in operation.

Analysis of basic principles

If we return to the examples with which we started the course, we might be able to abstract some common principles that are being appealed to implicitly. One such principle is the Principle of Autonomy, that is, the principle that in certain areas an individual has a right to be self-governing. This is particularly evident in the ‘euthanasia example' and the ‘pain-killer example'.

In the ‘euthanasia example', the Principle of Autonomy is being respected since the woman's wish to die has been granted. Presumably, it is also felt by both the consultant and the woman's son that her well-being or benefit lies in this course of action. Thus, the action is also what is required by the Principle of Beneficence, that is, the principle that the well-being or benefit of the individual ought to be promoted.

By way of contrast, in the ‘pain-killer example' the Principle of Autonomy is overridden by the Principle of Beneficence. The action is assumed to be for the benefit or well-being of the individual being treated and it is this that justifies overriding the individual's autonomy.

In the ‘mother-to-be example', the Principle of Non-malfeasance is relevant. ‘One ought to do no harm' is a principle that is at the heart of health care. In this case, the possibility of harming the fetus is overridden in favor of what are taken to be the benefits of having the test, or the Principle of Beneficence. A Principle of Justice might also be involved in this sort of case since limited resources might raise the question of who is thought to be eligible to have this diagnostic test. A Principle of Justice that states that equals ought to be considered equally requires analysis in order that we can apply it when the question of distribution of resources arises.

In order to clarify our thinking about the ethical questions we have illustrated, we need to look at these four principles in turn to find out precisely what they mean. This involves looking at how these principles can themselves be justified (see Section 2).

Ethical analysis of specific questions

In addition to analyzing these four principles, a critical ethical approach will subject specific issues to analysis. In the ‘mother-to-be example’, the question could have arisen of whether abortion is justified in cases where the fetus is found to be suffering from genetic abnormalities. In analyzing this sort of question we shall need to consider questions such as:

·        What sort of beings have a right to life?,
·        What does it mean to have a right to life?,
·        Do fetuses have the same rights as other human beings? and
·        When does life begin?

The ‘euthanasia example' raises different issues. We shall have to look at questions such as:

·        Is any form of euthanasia justifiable?,
·        If euthanasia is justifiable, is there any moral difference between killing an individual and omitting to treat? And
·        What is to count as death?

It also raises an issue of professional practice about what to do when a colleague has performed an action of this sort.

Unlike the so called ‘big dilemmas' concerning life and death, the ‘pain-killer example' raises questions that arise in daily practice. Questions that would need to be considered are, for example:

·        Is there any justification for withholding the truth from individuals? and
·        What principles ought we to use when there is a conflict between duties owed to other members of the health care team and the individual being treated?

The law

A critical ethical approach to these issues is not restricted to what is, in fact, legally allowed at the present time. We are considering what ought to be the case and this might not be coincident with what is at present allowed by particular laws. For example, in the case of voluntary euthanasia, where an individual requests the termination of his or her life, we shall consider what principles could provide a justification for this and what principles are being employed by those who deny it is justifiable. The fact that voluntary euthanasia is illegal in the UK at the time of the publication of this course does not in itself provide an answer to the ethical question of whether or not it ought to be allowed.

Conversely, if a critical ethical analysis leads us to the conclusion that something is morally wrong, that does riot mean that it ought to be legally prohibited. It might be considered that there are certain areas of an individual's life that ought not to be within the domain of the law. Mill wrote:

'That the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others.' 3

If we take the case of voluntary euthanasia again, it could be argued that the individual wishing to die is not harming others. If this is correct, laws would not be justified in this sort of case. Even if voluntary euthanasia were shown to be morally wrong, that would not mean that it ought to be legally prohibited.

Outcome of a critical ethical approach

What will be achieved by a critical ethical approach to these issues? It would be ideal to think that as a result of this approach we could program the equivalent of an ethics computer and await the solutions to ethical problems. This is not what will be achieved. Rather, the aim is that ethical problems should be clarified by analyzing the issues. Analysis will reveal the sort of principles that are implicitly or explicitly referred to in our preliminary look at the examples at the beginning of this course. Discussion of principles such as the Principle of Autonomy and the Principle of Beneficence will not provide easy solutions to ethical questions but will assist reflection on these issues.

Arguably, a further advantage of this approach is that greater understanding of these ethical questions will enable individuals to sympathize more readily with ethical positions with which they disagree. For example, when there is a clash between their personal morality and what is required in their professional practice, a deeper understanding of the principles that could underpin positions other than their own might ease the conflict. An obvious example of this is in the area of abortion where personal commitment and professional conduct might conflict.

A secular approach

Finally, although religious perspectives on these issues are considered, the book is concerned primarily with secular ethical theories. This is not intended to devalue a religious approach but rather to reflect the fact that many individuals are now considering these problems outside of a religious framework. In addition, many of these problems cease to be problems if a religious ethic is adopted. Certain problems are solved automatically by virtue of religious principles.

LEARNING EXERCISES


1. Analyze one of the ethical codes given in the appendices highlighting any problems that it might contain.

2. A 59-year-old male needs a heart operation but he is told that he cannot have by-pass surgery until he gives up smoking. The doctor is prepared to give him the operation if it is done privately but he will not perform the operation under NHS funding. The individual cannot afford to have the operation done privately. He agrees to give up smoking but nine months later when he has arrived at the top of the waiting list and is just about to have the operation, the surgeon asks if has given up smoking. When the individual admits that he is still smoking, the surgeon refuses to operate and tells him to rejoin the NHS waiting list.

What ethical issues arise in this case and to what principles is appeal being made?

REFERENCES

1. Bragg, W.L. From Quotations For Our Time. Ed. L. Peter (1982), Methuen, London.

2. Veatch, R.M. (1981) A "Theory of Medical Ethics. Basic Books, New York, p144.

3. Mill, J.S. (1985) ‘On Liberty'. In G. Himmelfarb (ed.), On Liberty, Penguin Books, London, p68.