Key principles of ethics for medical students

The main reason to study medicine and allied health professions is to help patients. Doctors, dentists, nurses and other professionals seek to do their best for their patients. Medicine and allied healthcare professions, therefore, are ethically driven, although you do not need to be an expert in medical ethics or law in order to respond to ethical dilemmas constructively when you encounter them in your working lives

The four pillars of medical ethics are:

• Respect for autonomy
• Beneficence
• Non-maleficence
• Justice

Autonomy:
Medicine is no longer prescriptive or paternalistic. Doctors cannot impose a treatment on a patient. The treatment offered is an option and not a demand. The principle of autonomy is paramount.

There are areas where autonomy can be overridden. If a patient lacks capacity then a doctor can, with appropriate permission in place, overrule their decision to refuse treatment as long as the doctor is acting in the best interest of the patient.

Examples of what constitutes a lack of capacity are patients who have dementia, a brain injury, or certain psychiatric conditions. If a patient is deemed to lack capacity, it is deemed that they cannot understand or weigh up the pros and cons of a treatment in order to reach a reasoned decision about their care.

Justice
In medicine, justice is the principle that governs whether or not something is ethical: whether a proposed treatment or a professional interaction is compatible with the law, is compatible with the patient’s rights, and whether it is fair and balanced.

In medical ethics, the principle of justice is often quoted in relation to the fair and equitable distribution of healthcare resources: its premise is that we must ensure no-one is unfairly disadvantaged in their access to healthcare. In the UK, the principle of justice in relation to medical ethics can be seen in the NHS, with free access for all, and free prescriptions for lower-income individuals.

Non maleficence
The principle of nonmaleficence requires that every medical action be weighed against all benefits, risks and consequences, occasionally deeming no treatment to be the best treatment. In medical education, it also applies to performing tasks appropriate to an individual’s level of competence and training.

It requires every doctor to Do No Harm.

An example of a non-maleficent action would be stopping a medication known to be harmful, or else refusing to give a medication to a patient if it has not been proven to be effective.

Beneficence
Under the principle of beneficence, patients are treated in an ethical manner not only by respecting their decisions and protecting them from harm, but also by the healthcare professional making active decisions and taking actions to secure their well-being.

Other concepts/principles in healthcare:

Self-determination
Self-determination is the ability to decide to act for oneself, and is analogous to autonomy. It includes the right of patients who are mentally competent to refuse medical treatment, even if that decision may result in harm or even death.

Capacity or competence
Mental competence or ‘capacity’ is a key concept in medical ethics. Under normal circumstances, and if a person is deemed to have capacity to make a decision, then the decision will be respected. Patients lacking capacity, however, can have decisions made for them. A recent example of this include a sexually active but mentally subnormal lady who was forcibly sterilised, in order to prevent pregnancy, as she would have been unable to care for any child she might have given birth to. More common examples involve people who become mentally unwell and are ‘sectioned’ under the Mental Health Act in order to provide a level of care that the patient would, in their current state, be unable to subscribe to.

Confidentiality
Confidentiality is central to good clinical practice. It respects the right of patients to have sensitive information remain entirely private. Failure of medical professionals to adhere to this principle may result in a breakdown in trust between patient and professional, as well as resulting in a loss of respect and trust in the medical profession.

Honesty and truth-telling
This is also central to good medical practice. Honest and truthful communication when delivering information allows the patient to make informed choices. It respects the principle of patient self-determination. Failure to adhere to this principle potentially results in patients making ill-informed decisions, putting at risk many of the other ethical principles at play in the doctor-patient relationship.

Benefit and harm
Avoiding harm is another principle that is central to good medical practice. Sometimes, this not straightforward, and the risks and benefits may have to be weighed carefully. All medical interventions must be justified on the basis that the benefit (or potential benefit) following the proposed treatment or procedure exceeds the potential harm. Harm, however, can physical or psychological, and one person’s determination of ‘harm’ is not always the same as that of the next person, so it is a principle that must be constantly assessed in patient interactions. Simply putting a cannula into a patient’s arm to administer antibiotics can cause pain and bleeding, for example. In the majority of instances, the overall benefit from delivering antibiotics far exceeds the pain and discomfort caused, but for some people, who are terrified of needles or hospitals, the potential harm in their minds exceeds the potential benefit.

Fairness or equity
Equity relates to fairness and justice and demands that everyone should have an equal opportunity to attain and maintain good health, and equal opportunities to access health care. It should be distinguished from the somewhat different concept of equality. Equality concerns the equal distribution of health care, whereby each individual receives the same amount of care. In most developed countries, the notion of equity transcends that of equality: the distribution of health and healthcare should be such that no individual or group of individuals should suffer negative discrimination.

Rights
Patients have many and varying rights: they have legal rights, they have human rights and they have moral rights. In civilised countries, these liberties and entitlements cannot be arbitrarily removed, although sadly this is not the case in all parts of the world.