Medical Ethics And Deontology Pdf

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Kantian Ethics — Allen W. The word Deontology or deontological ethics also comes from Greek, more precisely from the word deontos which means 'duty'.

Application and Implications of Deontology, Utilitarianism, and Pragmatism for Medical Practice

McCormick, D. Ethical choices, both minor and major, confront us everyday in the provision of health care for persons with diverse values living in a pluralistic and multicultural society. In the face of such diversity, where can we find moral action guides when there is confusion or conflict about what ought to be done? Such guidelines would need to be broadly acceptable among the religious and the nonreligious and for persons across many different cultures.

Due to the many variables that exist in the context of clinical cases as well as the fact that in health care there are several ethical principles that seem to be applicable in many situations these principles are not considered absolutes, but serve as powerful action guides in clinical medicine.

Some of the principles of medical ethics have been in use for centuries. Similarly, considerations of respect for persons and for justice have been present in the development of societies from the earliest times.

However, specifically in regard to ethical decisions in medicine, in Tom Beauchamp and James Childress published the first edition of Principles of Biomedical Ethics, now in its seventh edition , popularizing the use of principlism in efforts to resolve ethical issues in clinical medicine. In that same year, three principles of respect for persons, beneficence, and justice were identified as guidelines for responsible research using human subjects in the Belmont Report Thus, in both clinical medicine and in scientific research it is generally held that these principles can be applied, even in unique circumstances, to provide guidance in discovering our moral duties within that situation.

Intuitively, principles in current usage in health care ethics seem to be of self-evident value and of clear application. For example, the notion that the physician "ought not to harm" any patient is on its face convincing to most people. Or, the idea that the physician should develop a care plan designed to provide the most "benefit" to the patient in terms of other competing alternatives, seems both rational and self-evident. Further, before implementing the medical care plan, it is now commonly accepted that the patient must be given an opportunity to make an informed choice about his or her care.

Finally, medical benefits should be dispensed fairly, so that people with similar needs and in similar circumstances will be treated with fairness, an important concept in the light of scarce resources such as solid organs, bone marrow, expensive diagnostics, procedures and medications. One might argue that we are required to take all of the above principles into account when they are applicable to the clinical case under consideration.

Yet, when two or more principles apply, we may find that they are in conflict. For example, consider a patient diagnosed with an acutely infected appendix.

Our medical goal should be to provide the greatest benefit to the patient, an indication for immediate surgery. On the other hand, surgery and general anesthesia carry some small degree of risk to an otherwise healthy patient, and we are under an obligation "not to harm" the patient. Our rational calculus holds that the patient is in far greater danger from harm from a ruptured appendix if we do not act, than from the surgical procedure and anesthesia if we proceed quickly to surgery.

Further, we are willing to put this working hypothesis to the test of rational discourse, believing that other persons acting on a rational basis will agree. Thus, the weighing and balancing of potential risks and benefits becomes an essential component of the reasoning process in applying the principles. In other words, in the face of no other competing claims, we have a duty to uphold each of these principles a prima facie duty.

However, in the actual situation, we must balance the demands of these principles by determining which carries more weight in the particular case. Moral philosopher, W. Ross, claims that prima facie duties are always binding unless they are in conflict with stronger or more stringent duties.

A moral person's actual dutyis determined by weighing and balancing all competing prima facie duties in any particular case Frankena, Since principles are empty of content the application of the principle comes into focus through understanding the unique features and facts that provide the context for the case.

Therefore, obtaining the relevant and accurate facts is an essential component of this approach to decision making. Four commonly accepted principles of health care ethics, excerpted from Beauchamp and Childress , include the:. Respect for Autonomy Any notion of moral decision-making assumes that rational agents are involved in making informed and voluntary decisions.

In health care decisions, our respect for the autonomy of the patient would, in common parlance, imply that the patient has the capacity to act intentionally, with understanding, and without controlling influences that would mitigate against a free and voluntary act. See also Informed Consent. Case 1 I n a prima facie sense, we ought always to respect the autonomy of the patient.

Such respect is not simply a matter of attitude, but a way of acting so as to recognize and even promote the autonomous actions of the patient. The autonomous person may freely choose values, loyalties or systems of religious belief that limit other freedoms of that person. For example, Jehovah's Witnesses have a belief that it is wrong to accept a blood transfusion.

Therefore, in a life-threatening situation where a blood transfusion is required to save the life of the patient, the patient must be so informed.

The consequences of refusing a blood transfusion must be made clear to the patient at risk of dying from blood loss. Discussion In analyzing the above case, the physician had a prima facie duty to respect the autonomous choice of the patient, as well as a prima facie duty to avoid harm and to provide a medical benefit. In this case, informed by community practice and the provisions of the law for the free exercise of one's religion, the physician gave greater priority to the respect for patient autonomy than to other duties.

By contrast, in an emergency, if the patient in question happens to be a ten year old child, and the parents refuse permission for a life saving blood transfusion, in the State of Washington and other states as well, there is legal precedence for overriding the parent's wishes by appealing to the Juvenile Court Judge who is authorized by the state to protect the lives of its citizens, particularly minors, until they reach the age of majority and can make such choices independently.

Thus, in the case of the vulnerable minor child, the principle of avoiding the harm of death, and the principle of providing a medical benefit that can restore the child to health and life, would be given precedence over the autonomy of the child's parents as surrogate decision makers McCormick, See Parental Decision Making.

The Principle of Nonmaleficence The principle of nonmaleficence requires of us that we not intentionally create a harm or injury to the patient, either through acts of commission or omission. In common language, we consider it negligent if one imposes a careless or unreasonable risk of harm upon another. Providing a proper standard of care that avoids or minimizes the risk of harm is supported not only by our commonly held moral convictions, but by the laws of society as well see Law and Medical Ethics.

This principle affirms the need for medical competence. It is clear that medical mistakes may occur; however, this principle articulates a fundamental commitment on the part of health care professionals to protect their patients from harm. Case 2 In the course of caring for patients, there are situations in which some type of harm seems inevitable, and we are usually morally bound to choose the lesser of the two evils, although the lesser of evils may be determined by the circumstances.

For example, most would be willing to experience some pain if the procedure in question would prolong life. However, in other cases, such as the case of a patient dying of painful intestinal carcinoma, the patient might choose to forego CPR in the event of a cardiac or respiratory arrest, or the patient might choose to forego life-sustaining technology such as dialysis or a respirator.

The reason for such a choice is based on the belief of the patient that prolonged living with a painful and debilitating condition is worse than death, a greater harm. It is also important to note in this case that this determination was made by the patient, who alone is the authority on the interpretation of the "greater" or "lesser" harm for the self.

Discussion There is another category of cases that is confusing since a single action may have two effects, one that is considered a good effect, the other a bad effect. How does our duty to the principle of nonmaleficence direct us in such cases? The formal name for the principle governing this category of cases is usually called the principle of double effect. A typical example might be the question as to how to best treat a pregnant woman newly diagnosed with cancer of the uterus.

The usual treatment, removal of the uterus is considered a life saving treatment. However, this procedure would result in the death of the fetus. What action is morally allowable, or, what is our duty? It is argued in this case that the woman has the right to self-defense, and the action of the hysterectomy is aimed at defending and preserving her life. The foreseeable unintended consequence though undesired is the death of the fetus. There are four conditions that usually apply to the principle of double effect:.

The reader may apply these four criteria to the case above, and find that the principle of double effect applies and the four conditions are not violated by the prescribed treatment plan. The Principle of Beneficence The ordinary meaning of this principle is that health care providers have a duty to be of a benefit to the patient, as well as to take positive steps to prevent and to remove harm from the patient.

These duties are viewed as rational and self-evident and are widely accepted as the proper goals of medicine. For example, the good health of a particular patient is an appropriate goal of medicine, and the prevention of disease through research and the employment of vaccines is the same goal expanded to the population at large.

It is sometimes held that nonmaleficence is a constant duty, that is, one ought never to harm another individual, whereas beneficence is a limited duty. A physician has a duty to seek the benefit of any or all of her patients, however, a physician may also choose whom to admit into his or her practice, and does not have a strict duty to benefit patients not acknowledged in the panel.

This duty becomes complex if two patients appeal for treatment at the same moment. Some criteria of urgency of need might be used, or some principle of first come first served, to decide who should be helped at the moment. Case 3 One clear example exists in health care where the principle of beneficence is given priority over the principle of respect for patient autonomy.

This example comes from Emergency Medicine. When the patient is incapacitated by the grave nature of accident or illness, we presume that the reasonable person would want to be treated aggressively, and we rush to provide beneficent intervention by stemming the bleeding, mending the broken or suturing the wounded. Discussion In this culture, when the physician acts from a benevolent spirit in providing beneficent treatment that in the physician's opinion is in the best interests of the patient, without consulting the patient, or by overriding the patient's wishes, it is considered to be "paternalistic.

Here, the duty of beneficence requires that the physician intervene on behalf of saving the patient's life or placing the patient in a protective environment, in the belief that the patient is compromised and cannot act in his own best interest at the moment. As always, the facts of the case are extremely important in order to make a judgment that the autonomy of the patient is compromised. The question of distributive justice also seems to hinge on the fact that some goods and services are in short supply, there is not enough to go around, thus some fair means of allocating scarce resources must be determined.

It is generally held that persons who are equals should qualify for equal treatment. This is borne out in the application of Medicare, which is available to all persons over the age of 65 years. This category of persons is equal with respect to this one factor, their age, but the criteria chosen says nothing about need or other noteworthy factors about the persons in this category.

In fact, our society uses a variety of factors as criteria for distributive justice, including the following:. John Rawls and others claim that many of the inequalities we experience are a result of a "natural lottery" or a "social lottery" for which the affected individual is not to blame, therefore, society ought to help even the playing field by providing resources to help overcome the disadvantaged situation. One of the most controversial issues in modern health care is the question pertaining to "who has the right to health care?

Medicaid is also a program that is designed to help fund health care for those at the poverty level. Yet, in times of recession, thousands of families below the poverty level have been purged from the Medicaid rolls as a cost saving maneuver. The principle of justice is a strong motivation toward the reform of our health care system so that the needs of the entire population are taken into account.

The demands of the principle of justice must apply at the bedside of individual patients but also systemically in the laws and policies of society that govern the access of a population to health care. Much work remains to be done in this arena. The four principles currently operant in health care ethics had a long history in the common morality of our society even before becoming widely popular as moral action guides in medical ethics over the past forty-plus years through the work of ethicists such as Beauchamp and Childress.

In the face of morally ambiguous situations in health care the nuances of their usage have been refined through countless applications. Some bioethicists, such as Bernard Gert and colleagues , argue that with the exception of nonmaleficence, the principles are flawed as moral action guides as they are so nonspecific, appearing to simply remind the decision maker of considerations that should be taken into account. Indeed, Beauchamp and Childress do not claim that principlism provides a general moral theory, but rather, they affirm the usefulness of these principles in reflecting on moral problems and in moving to an ethical resolution.

Gert also charges that principlism fails to distinguish between moral rules and moral ideals and, as mentioned earlier, that there is no agreed upon method for resolving conflicts when two different principles conflict about what ought to be done. Further, bioethicst Albert Jonsen and colleagues claim in their work that in order to rigorously apply these principles in clinical situations their applicability must start with the context of a given case.

See Bioethics Tools.. This article is intended to be a brief introduction to the use of ethical principles in health care ethics.

Utilitarian and deontological ethics in medicine

Two strands of thought exist in ethics regarding decision-making: deontological and utilitarian. In brief, deontology is patient-centered, whereas utilitarianism is society-centered. Although these approaches contradict each other, each of them has their own substantiating advantages and disadvantages in medical practice. Over years, a trend has been observed from deontological practice to utilitarian approach leading to frustration and discontentment. Health care system and practitioners need to balance both these ethical arms to bring congruity in medical practice. Ethics is a crucial branch in medicine guiding good medical practice. They are based on four fundamental principles, i.

McCormick, D. Ethical choices, both minor and major, confront us everyday in the provision of health care for persons with diverse values living in a pluralistic and multicultural society. In the face of such diversity, where can we find moral action guides when there is confusion or conflict about what ought to be done? Such guidelines would need to be broadly acceptable among the religious and the nonreligious and for persons across many different cultures. Due to the many variables that exist in the context of clinical cases as well as the fact that in health care there are several ethical principles that seem to be applicable in many situations these principles are not considered absolutes, but serve as powerful action guides in clinical medicine. Some of the principles of medical ethics have been in use for centuries.

Utilitarian and deontological ethics in medicine

Contemporary medicine has unique challenges that render principlism inadequate as a sole paradigm for medical ethics education. Shortcomings of this ethical system include the often contradictory nature of the principles, difficulty with integration and internalization of the principles, and the inadequate treatment of moral relativism. The ethics of Immanuel Kant is offered as a potential helpful addition to medical trainee ethics curricula. However, the nineteenth and twentieth centuries saw no shortage of systemic ethical and empathetic shortcomings which undermined the public trust in the physician-patient relationship. At the same time, American medicine has experienced a rapid paradigm shift to a medical system characterized by bureaucratic educational hierarchies, corporate-based medical practice, and the electronic medical record which have generally contributed to a dehumanization of the medical profession.

Medical ethics mainly deals with behavior of physician and the decisions they have to make rather than how to treat patients. We will not be able to understand medical law without understanding the ethical tensions in play. MRC Ethics Guide: Medical research involving children MRC Ethics Guide: Medical research involving children 6 7 zThe purpose of the research is to obtain knowledge relevant to the health, wellbeing or healthcare needs of children. This is the first publication of guidelines on research ethics by the National Health Research Ethics Committee. Since its adoption at the founding meeting of the American Medical Association in , the AMA Code of Medical Ethics has articulated the values to which physicians commit themselves as members of the medical profession..

Ethical theories help to shape both the conscious and subconscious background of our ethical considerations. In what follows I shall discuss the classic deontological and utilitarian theories which have been used in dealing with ethical problems and argue that they are problematic because inflexible. I suggest, as an alternative, an instrumentalist or pragmatic ethic similar to that advocated by John Dewey.

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