August 27, 2006

Ethical Principles

The other day, we had a special guest come in to speak with us about Medical Ethics. I perked up upon hearing this; after all, it is a special interest of mine (and one that has been sadly neglected on this blog.)

This doc was very engaging, very funny and very Chinese. He's a doctors as well as a lawyer, so he's well versed in the legalities and professionalism of medicine. He made a quadrant on the board with an ethical principle in each section:
  • Non-maleficence -- Do no harm. ("Primum, non nocere" was nonsensical to him, since it is Latin (and Hippocrates was Greek.)
  • Beneficence -- Do good.
    • Confidentiality -- To gain the trust of a patient, we must keep it.
    • Truth-telling -- To learn the truth from a patient, we must tell it.
  • Autonomy -- The Patient has a Right to Decide.
  • Distributive Justice -- This was a new one for me. I had never thought of correcting health disparities as a guiding principle, but as we grow in power learning more about ourselves and how we can save lives, it makes sense that we shouldn't reserve it just for the rich and powerful.
The Bates' Guide to Physical Examination listed the principles of a London conference in 1998 in Tavistock Square called the Tavistock principles:
  • "Rights: Patients have a right to health and health care.
  • Balance: Care of the individual patient is central, but the health of populations is also our concern.
  • Comprehensiveness: In addition to treating illness, we have an obligation to ease suffering, minimize disability, prevent disease, and promote health.
  • Cooperation: Health care succeeds only if we cooperate with those we serve, each other, and those in other sectors.
  • Improvement: Improving health care is a serious and continuing responsibility.
  • Safety: Do no harm.
  • Openness: Being open, honest and trustworthy is vital in health care."
We ended the session discussing how conflicts arise between quadrants; autonomy can become an issue with minors cannot provide informed consent under most situations; confidentiality must be broken if the life/lives of innocents are endangered (legally, they must be named). A point of distributive justice bothered me the most.

We were posed the question: what would you do if a convicted felon needed a heart transplant? Would you pass him/her over on a transplant list to give it to someone more "deserving?"

We tried to wiggle out of it with qualifying factors: what crime did the prisoner commit? (Someone countered with 'Does it matter?') Is the prisoner a perfect match? Is there someone who is closer to the hospital? What about age?

A girl behind me in class was obviously disgusted with the idea of giving the heart to someone who was obviously heartless. "What if you did the heart transplant and the prisoner escaped the next day and killed your mom? How would you feel?" she asked me.

"That would make me feel bad." I replied. An emotive answer, then a rational one. "But it does not make sense to use that as a reason to deny someone a heart. 'Sorry, but I'm afraid you might escape and kill my mom.' That is a fear reaction. Hopefully it doesn't become a regrettable reality... but it is our job to care."

It is tempting to take a utilitarian POV here and deny the prisoner the valuable organ because he/she is not valuable to society. It is easy to rationalize why they shouldn't get it by looking at an assortment of biological factors. It is nice to hide behind this sort of "objective" rationale...

Which makes me wonder how often these hard decisions are made and who makes them. Do we still have "God Squads" who decide which person lives and which one dies? Do courts injunctions demand one ruling over another?

Just so we aren't left in a sticky situation of ending with difficult rhetorical questions, I'll end with this thought. Ethics are high ideals that we aspire to. Laws are just the baseline of things that can be enforceable. Most of us are stuck somewhere in between.

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