Goldenberg, Solomon, Journal of Continuing Education Topics & Issues
Every health worker justifies his role in the health industry by laying claim to the original ethical principles of Autonomy, Beneficience, Non-maleficence and Justice (1). To these four, two more principles have recently been added: Dignity and Truthfulness with Honesty. But how many of us know what these terms really mean?
Historically, medical ethics dates back to Hippocrates and form the basis of the Hippocratic Oath. Maimonides, Catholic moral theologians and Islamic physicians have also contributed to our understanding of medical ethics. Perhaps the first book dedicated to medical ethics was written by a Muslim physician, Ishaq Bin ali Tahawi who wrote The Conduct of a Physician. In the 18th century, a British doctor, Thomas Percival (1740-1804) of Manchester, England, wrote about "Medical Jurisprudence" and coined the phrase "Medical Ethics." In 1847, the American Medical Association adopted its first Code of Ethics based largely upon Percival's work.
When moral values are in conflict, such as in the case of treatment of HIV illness or the rights of an octuplet mother, the result may become an ethical dilemma or crisis. Similarly, conflicts may arise between health care providers and protectionism from legal issues and religious doctrines. More recent issues of research, resuscitation and stem cell treatment have aroused heated arguments among politicians, health care professionals and theologians.
The principle of autonomy recognizes the right of the individual to self-determination. It relies on having the ability to make informed decisions about personal matters. Consider the case of a 22 year old patient who has been admitted to hospital 14 times following a bone marrow transplant 14 times. She now comes in with a chest infection and renal failure and her condition continues to deteriorate. She has a cardiac and respiratory arrest. Her parents are keen that all resuscitative measures should be taken, but her husband produces a signed living will that she does not wish to be resuscitated. Should the health worker pursue Kant's moral Deontological principle (2) of respect for each other's autonomy or should he attempt to resuscitate her into a vegetative state, thus following the Utilitarian Ethical theory3 of maximizing the greatest good for the greatest number in the community? Kant believed that one must never treat any individual as a means to an end. In exercising one's autonomy, the principle must conform to the requirement of rationality.
Situations involving informed consent are founded on the principle of autonomy. If the patient is incapacitated such as an Alzheimer's patient or mentally subnormal individual, a next of kin or court appointee should also be informed. How much information for the patient constitutes "enough?" If the individual is not sufficiently informed, then his autonomy is impaired. Other situations of undertaking risky treatment in a life-threatening episode that may jeopardize the patient's life may conflict with the patient's autonomy if the risks are not adequately explained before the procedure.
Consequentialism, however, justifies the rightness or wrongness of actions according to the outcome of the procedure. In these cases, autonomy is best valued if the treatment yields the best outcomes.
In some clinical situations, unilateral paternalistic intervention by clinicians may appear to conflict with autonomy. "If you do not have this test, I cannot treat you" or "I should know best, I am your doctor." Split-second decisions are sometimes made to save a person's life. A teenager came in for a routine termination of a mid-trimester pregnancy but the procedure resulted in profuse hemorrhaging. The surgeon had no alternative but to perform an immediate hysterectomy to save the young girl's life. This young female was deprived of her maternal right of procreation. Was this risk clearly explained to her and her parents in the pre-operative consent form? …