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Practical Guide to Clinical Ethics Support

Section C: Ethical frameworks

Introduction

If a clinical ethics committee (CEC) is to provide support on ethical issues relating to clinical practice, and to facilitate discussion of the ethical dimension of clinical problems, members of a CEC will require an understanding of the moral theories and ethical frameworks that have informed the development of medical ethics. Although not all CEC members are expected to be experts in ethics (indeed one advantage of an ethics committee is that its members bring a variety of different expertise and experience to bear on a particular issue), they will need to justify their claim to be providing ethics support and advice over and above that which could be obtained from any other committee or informal group. In this section we provide a brief introduction to some of the key moral theories and ethical frameworks that have had an important influence on health care practice, particularly in Western medicine. The section concludes with one example of a practical framework for approaching an ethical dilemma.

Definitions

Moral philosophy

‘Moral philosophy is the attempt to achieve a systematic understanding of the nature of morality and what it requires of us - in Socrates’ words, of “how we ought to live,” and why’.

Morality

Morality is usually construed as meaning what is right and wrong.

‘The term morality refers to social conventions about right and wrong human conduct that are so widely shared that they form a stable (although usually incomplete) communal consensus, whereas ethics is a general term referring to both morality and ethical theory’

Nevertheless, the words ‘ethics’ and ‘morality’ are often used interchangeably.

Ethics

‘Ethics is a generic term for various ways of understanding and examining the moral life’

‘Ethics requires us to go beyond ‘I’ and ‘you’ to the universal law, the universalisable judgment, the standpoint of the impartial spectator or ideal observer, or whatever we choose to call it’

Normative and Descriptive Ethics

Normative ethics is a systematic theory that tells us how one ought to live. An approach to ethics that is normative is one that presents standards of right or good action. An example would be deontological theory - ‘do not kill, ‘do not lie’.

Descriptive ethics reports on how people act, or what they believe, and is not committed to any particular normative ethical system.

Medical ethics / Healthcare ethics

These terms could simply be used to refer to ethical thinking in the healthcare setting.

Codes of Professional Ethics

Formal codes of medical, nursing and research ethics have been created, reflecting the application of ethical thinking to the issues arising in the relevant healthcare environment. Examples include the GMC ‘Withholding and withdrawing medical treatment’. Ethical behaviour in this context may be understood as behaviour conforming to the relevant professional code of ethics.

Ethical Theory

We may feel instinctively that a certain conclusion to a problem is ‘fair’ or ‘unfair’, but what criteria do we use to make such judgments? There are different ethical theories that can be applied to a problem to elucidate our thinking, but even so the results may not fit with our moral intuition.

There are several types of normative ethical theory including consequentialism, deontology - such as Kantianism - and virtue ethics. They can be applied in several procedures of ethical analysis, such as in analysis of cases (casuistry) and in different settings such as in a range of ‘communitarian ethics’: for example, a feminist approach or a social class based approach.

Moral or ethical theory may consider the application of rules or the consequences of actions.

Deontological theory - what one MUST do, based on duties and obligations

Teleological theory - the purpose or consequences of the moral acts

Consequentialist Theory

This is one sub class of teleological moral theory. According to consequentialist accounts of morality the moral value of an act, rule or policy is to be found in its consequences, not in intentions or motives. Utilitarianism is the most influential consequentialist theory. Jeremy Bentham in the late 18th century and John Stuart Mill in the 19th century formulated this way of thinking. Such ‘hedonistic’ utilitarians argue that the principle to judge our moral thinking is utility, that is, the maximisation of happiness, in the sense of pleasure and the minimisation of suffering, in the sense of pain. In any situation the morally right thing to do is the action that promotes the greatest happiness for the greatest number of people.

However pain and pleasure are not the only criteria that later utilitarians have used to evaluate the consequences of actions, rules or policies. Welfare-utilitarians consider the contribution to, or lessening of, human welfare. Preference-utilitarians seek to establish and satisfy human preferences.

Some key issues:

Calculate net benefit

The net benefit or dis-benefit is found by balancing the happiness and unhappiness resulting from an act or policy. If one then seeks the greatest happiness of the greatest number that may be taken to justify overriding individual unhappiness in the interests of the happiness of the greatest number

Difficulty in calculating consequences

This theory requires that the consequences of acts or policies must be calculated. However in many situations one cannot predict consequences with any certainty and therefore consequentialism is probabilistic, one forecasts the consequences to the best of one’s ability. Ethics committees using consequentialist criteria necessarily operate in an area of uncertainty.

Act and rule utilitarianism

Bentham tended to deal with the consequences of acts. However, ‘rule utilitariansim’ justifies certain rules on utilitarian grounds. For example, one might justify the general rule ‘do not lie’ on the utilitarian ground that lying produces more bad consequences than good consequences overall.

Deontological Theory

A criticism of consequentialist theory is that it is so concerned with ends that it may overlook the moral importance of means - the ways in which the ends or goals are achieved.

Deontological theory uses rules rather than consequences to justify an action or policy.

The best-known deontological theory is that of Immanuel Kant in the 18th century. ‘Kantianism’ is a modern term, referring to a Kant-like emphasis on duties and rules. Kant defended rules such as ‘do not lie’, ‘keep promises’, ‘do not kill’ on what he claimed were rational grounds. Rules should comply with the categorical imperative. The categorical imperative holds that:

  • Moral rules should be universalisable i.e. applied to all rational, moral members of the community rather than to just some
  • All persons should be treated never simply as means but also always as ends in themselves
  • Members of the moral community should take a hand in making the laws as well as living by them

Many modern Kantians, as opposed to Kant himself, are not absolutist in their application of moral rules or laws, whilst nevertheless stressing the importance of generally living by moral rules or laws.

Virtue ethics

Virtue ethics is the name given to a modern revival and revision of Aristotle’s ethical thinking. Aristotle’s ethics, while not generally thought of as consequentialist, is certainly teleological. For him, the telos, or purpose, of a human life is to live according to reason. This leads to ‘happiness’ in the sense of human flourishing. This flourishing is achieved by the habitual practice of moral and intellectual excellences, or ‘virtues’.

For Aristotle, the excellences are of two types. A moral virtue is an excellence of character, a ‘mean’ between two vices. One of Aristotle’s virtues is courage, a mean between recklessness and cowardice, which are vices. Modern virtue ethics sets itself the task of discerning the virtues for our time. In a healthcare setting what virtues would we like doctors, nurses, etc. to possess - self-control, truthfulness, generosity, compassion, discernment, integrity?

Aristotle also identified a second type of excellences, intellectual virtues, which constitute a preference for truth over falsehood and for clarity over muddle, both in pure reason and in practical affairs. Both the moral and intellectual virtues are, for Aristotle, the expression of reason.

Casuistry

Casuistry, or case based reasoning, does not focus on rules and theories but rather on practical decision-making in particular cases based on precedent. So first the particular features of a case would be identified, and then a comparison would be made with other similar cases and prior experiences, attempting to determine not only the similarities but also the differences.

So if a clinical ethics committee were asked to consider whether it was ethical for a clinician to breach his / her duty of confidence, the committee would identify key factors, like the health risks to others if information was not disclosed. It would then make a comparison with other similar cases, identifying the relative risks of non-disclosure.

Casuistry should not be divorced from consequentialism, deontology, or virtue ethics but complement them.

The Four Principles

Beauchamp and Childress’ Four Principles approach is one of the most widely used frameworks and offers a broad consideration of medical ethics issues generally, not just for use in a clinical setting.

The Four Principles provide a general guide and leave considerable room for judgement in specific cases.

Respect for autonomy:

respecting the decision-making capacities of autonomous persons; enabling individuals to make reasoned informed choices.

Beneficence:

balancing benefits of treatment against the risks and costs; the healthcare professional should act in a way that benefits the patient.

Non maleficence:

avoiding causing harm; the healthcare professional should not harm the patient. Most treatment involves some harm, even if minimal, but the harm should not be disproportionate to the benefits of the treatment.

Justice:

respect for justice takes several forms:

  • Distribution of a fair share of benefits
  • Legal justice - doing what the law says
  • Rights based justice, which deals in the language, and perhaps the rhetoric, of claimed human rights, and hence goes beyond, though it includes, legal rights.

These principles are prima facie – that is, each to be followed unless it conflicts with one or more of the others - and non-hierarchical i.e. one is not ranked higher than another. In recent years however, respect for patient autonomy has assumed great significance in the context of patient choice, underpinned by the requirement to provide the patient with sufficient information to put him / her in a position to choose.

The ‘Four Principles’ are intended as an aid to balance judgement, not a substitute for it.

We would like to thank Don Hill, Co-ordinator of Postgraduate Education, The Ethox Centre, University of Oxford for his assistance in producing this section.

The following is a practical clinical ethics framework that may be useful for a clinical ethics committee to work through in discussion of a case

1. What are the relevant clinical and other facts (e.g. family dynamics, GP support availability)?

2. What would constitute an appropriate decision-making process?

  • Who is to be held responsible?
  • When does the decision have to be made?
  • Who should be involved?
  • What are the procedural rules e.g. confidentiality?

3. List the available options

4. What are the morally significant features of each option e.g.

  • What does the patient want to happen?
  • Is the patient competent?
  • If the patient is not competent, what is in his or her ‘best interests’?
  • What are the foreseeable consequences of each option?

5. What does the law / guidance say about each of these options?

6. For each realistic option, identify the moral arguments in favour and against.

7. Choose an option based on your judgment of the relative merits of these arguments using the following tools.

  • Are there any key terms the meaning of which needs to be agreed e.g. ‘best interest’, ‘person’?
  • Are the arguments valid?
  • Consider the foreseeable consequences (local and more broad)
  • Do the options ‘respect persons’?
  • What would be the implications of this decision applied as a general rule?
  • How does this case compare with other cases?

8. Identify the strongest counter-argument to the option you have chosen.

9. Can you rebut this argument? What are your reasons?

10. Make a decision

11. Review this decision in the light of what actually happens, and learn from it.

Further discussion of approaches to ethical decision-making can be found in Appendix C1

Reading

2 and 3. Beauchamp T, Childress J. 2001. Principles of Biomedical Ethics. 5th edition Oxford University Press ISBN 0-19-514332-9

BMA . 2004. Medical Ethics Today. London, BMA Books

Boyd, K.M., Higgs, R., Pinching, A.J., (1997) The New Dictionary of Medical Ethics BMJ Publishing Group, London

Campell A, Gillett G, Jones G. 2001. Medical Ethics. 3rd edition Oxford University Press

Gillon, R., (1986) Philosophical Medical Ethics Chichester, Wiley

Glover, J., (1997) Causing Death and Saving Lives Harmondsworth, Penguin

Hope T (2004) Medical Ethics A Very Short Introduction Oxford University Press

Hope T, Savulescu J, Hendrick J 2003 Medical ethics and the law, the core curriculum. Churchill Livingston Chapters 1-3

Mautner, T., ed. (1997) Penguin Dictionary of Philosophy Penguin Books

Parker M, Dickenson D. 2001. The Cambridge medical ethics workbook: case studies, commentaries and activities. Cambridge University Press.

Parker M, Hope T. Ways of Thinking About Ethics. Medicine 2000;28:10:2-5

1. Rachels J. 1995. The elements of moral philosophy. 2nd edition Mc Graw Hill

Singer, P., ed. (1986) Applied Ethics (e.g. vi, J. Harris, The Survival Lottery) Oxford University Press

Singer, P., ed. (1991) A Companion to Ethics (e.g. Essays 10, 14, 20, 21 and 22) Oxford, Blackwell

4. Singer, P. (1993) Practical Ethics, 2nd Edition, Cambridge University Press. Page 12.

Warburton, N., (1999) Philosophy, the Basics Routedge. 3rd Edition. Introduction and Chapter 2.

Warburton, N., (1998) Philosophy, the Classics Routledge. Chapters 1, 2, 11, and 14.

Copyright of Section is held by The Ethox Centre.