The ethical theory we cover in this article is principlism, virtue ethics, deontology and consequentialism. Principlism is the most important theory to draw upon in interviews, however it is also good to be aware of the other ethical theories that preceded principlism.
Principlism - Four Principles of Medical Ethics
The most important ethical theory related to medicine is principlism. This was developed as a practical approach to ethical decision making. Rather than engaging in abstract debate about the idealistic approach, principlism is purported to offer a method of dealing with real-world ethical dilemmas.
In a free society this autonomy is considered one of the most important principles. Doctors must always gain informed consent- where people must be fully informed before you ask for their consent for any procedure. You can only breach this principle in rare scenarios where patients are not deemed to have capacity (see medico-legal section).
*Tip: to stand out for any question that asks you about the value of a treatment you can mention QALYs- Quality Adjusted Life Years. This is a measure that NICE use to allocate resources and assess whether a treatment is beneficial for the cost that it incurs the NHS. A QALY measures the number of years of life that a treatment adds to a patient adjusted for the quality of health in those years. Therefore, a QALY of 1 is a year of life in perfect health or perhaps it is 2 years of life in 50% health etc. NICE then measures the cost per QALY. In general a for cost-per QALY of £20,000- £30,000 is considered acceptable.
General considerations of Principlism
In ethical scenarios often one principle will be at odds with another. For example:
Beneficence vs non-maleficence – Often acting in the best interests of patients causes harm to them.
Every treatment has side effects, there are risks in surgery, drugs have side effects, procedures can be painful such that in reality the practice of non-maleficence seems impossible. Therefore, doctors often have to balance beneficence with non-maleficence and ask do the benefits of an intervention outweigh the risks? They must then relay this information to patients so they can make an informed decision about what to do.
Beneficence vs autonomy – Sometimes patients may decide against a treatment despite us deeming that it is in their best interests.
Doctors are moving away from the paternalistic approach to medicine which involves the ‘doctor knows best’ mindset. It is the duty of doctors to act in the best interests of patients by fully informing them of the costs and benefits of different treatments. They must then respect a patient’s autonomy to make a decision based on this information. Occasionally the two principles may be at odds with each other if the patient declines what we deem as best interests e.g Jehovah’s Witness denying a blood transfusion. As long as the patient is competent then autonomy trumps beneficence.
Beneficence vs justice – In the current NHS doctors want to do the absolute best for each patient but realise that it is not possible with limited resources such as money and time.
For example, you may want to give your patient their optimal treatment, however, this may be expensive and not covered by the NHS. A junior doctor working in A&E may find that it is in the best interests of the patient with abdominal pain to be seen quickly, however they have one patient in a cardiac arrest, and another having an acute asthma attack, therefore doctors must prioritise to act in the best interests of all patients.
Non-maleficence vs justice – In the process of prioritising and resource allocating, doctors risk directly harming patients.
Doctors have to prioritise resources so that they cause as little harm as possible for the highest number of people. The trade-off is that some people e.g. the person with abdominal pain, may still be harmed if not seen quickly enough. This is the unfortunate tale of the NHS where services are being put under more and more pressure.
Non-maleficence vs autonomy – It is important to know that patients must give consent for, but cannot demand treatments that would harm them.
Sometimes a patient may demand a treatment that could be harmful to their health e.g. antibiotics for a viral infection. In this situation you would directly cause harm by giving a treatment and with limited resources patients cannot demand treatments that they are not eligible for.
Other ethical theories to be aware of
In an interview situation if you are given an ethical dilemma, reason your thoughts on it using the 4 principles of medical ethics. You should also be aware of the ethical theories- virtue ethics, deontology and consequentialism. They offer idealistic approaches to different situations.
- This is the ethics where it is the character of the person that is important rather than the actions or consequences of the individual.
- Beauchamp and Childress (founders of principlism) have considered five virtues that every medical student and doctor should have: trustworthiness, integrity, discernment, compassion, and conscientiousness. It is not focussed on the outcome of an action or on developing hard and fast rules for anything.
- Deontology focusses on actions in themselves which are either right or wrong regardless of the consequence.
- This focusses on hard and fast rules (thou shalt- and thou shalt not). This includes things such as respecting autonomy, dignity and rights.
- This is where the consequences of any given action determine whether what you have done is good or evil.
- Utilitarianism is where an outcome is optimal where there is the greatest happiness for the greatest number of people. This could require a minority suffering for the greater good of many.