By Dr Samarendra Barman

 

The term Ethics means moral philosophy, a discipline which is concerned with morality and moral obligation. The concept of ethics is applicable in every profession to deal with issues like good, bad, right and wrong, etc. Medical ethics is an applied branch of ethics that is based on a set of moral values that guide medical professionals during their professional service. Medical ethics has a long history from the days of the Hippocratic Oath to the present days of the International code of medical ethics. The concept of ethics is a dynamic ideal and has been evolving with time. What was good ethics in hundred years ago may not be so today. They are more fluid and debatable across different cultures.

The system of medical ethics is based on four principles or values also known as “four pillars of medical ethics”. They are Autonomy, Non-maleficence, Beneficence, and Justice. These four values are not ranked in order of importance or relevance but usually carry equal weightage in issues pertaining to medical ethics. 

Autonomy: 

The principle of autonomy relates to the rights of an individual to self-determination or self-rule. In the medical profession, it is practically executed through the process of consent taking. It states that a competent patient has the right to accept or reject a medical procedure or test after getting proper information from his treating physician about the intended procedure or test. The physician must respect his decision even if he knows that the decision taken by the patient is not in his best interest. Earlier the perception among the patients and their relatives concerning medical treatment was that the doctor would know what is best for his patient and it is better to let the doctor decides for the patient. But it is not always true as different patients have different cultural, religious, or spiritual beliefs with regards to treatment and the doctor may not always be able to address those concerns effectively. Besides treating a patient against his will or consent is illegal and amounts to a penal offense. Hence, taking informed consent before performing any procedure is of paramount importance in medical practice.      

Beneficence and Non-Maleficence: 

The principle of beneficence essentially means “doing good” to people or society. In medical ethics, it states that a physician should always serve or intend to serve for the benefit of his patient. His action during his professional service must contribute to the welfare of his patient. The principle of beneficence is closely linked with the principle of non-maleficence which means “doing no harm”. In certain ethical systems, both the principle of beneficence and non-maleficence are kept under a single ethical spectrum of doing no harm and only doing good. Having said that, it must be understood that all medical or surgical procedures, investigations, drugs, etc., have inherent risks or side effects which can only be minimized by undertaking due care and proper precautions but can never be eliminated. So even under the ethical obligation of non-maleficence, a physician can never deliver a hundred percent safe or risk-free procedure or drug to a patient. That means the principle of non-maleficence in its purest meaning is impossible to follow in medical practice. At the same time, we must understand that prescribing a drug or a procedure to a patient with some side effects or complications, can certainly be not considered as a violation of medical ethics if it is firmly believed that the benefit of that drug or procedure outweighs the side effects or complications caused by the said drug or procedure. After all, the final objective of a physician should be to confer a greater benefit and lesser harm to a patient, and hence minor, acceptable, and foreseeable side effects or complications can be safely ignored. This idea is related to the principle of Consequentialism which states that the morality of an action is dependent purely on its consequences i.e. the “ends justify the means”. However, it is prudent for every physician to inform his patient about those side effects or complications well in advance and due care and precautions are to be taken to avoid them as far as possible, even if so minor or acceptable they may be for the physician. In a situation when there is a greater conflict between beneficence of a drug or procedure against maleficence caused by the said drug or procedure, striking a reasonable balance between these two ethical values would be the most realistic approach to follow. However, in those situations, most bioethicists agree that patient’s autonomy has a greater and dominant role to play than the principle of beneficence or non-maleficence.        

Justice:   

The word “Justice” is more frequently used in law than in medicine. In medical ethics, the principle of justice refers to the moral obligation of treating every patient fairly and equally. It is also concerned with making health care resources accessible to everyone but with the equitable distribution of benefits and burdens considering the scarce supply of health care resources in a demographic area. It is a complex ethical principle and its applicability in medical practice is not black and white but rather grey. To apply justice in any situation, individual factors should be examined on their own merit. Each situation is unique and should be addressed accordingly.  When evaluating justice, the health care authority must focus on four main areas: fair distribution of scarce resources, competing needs, rights and obligations, and potential conflicts with established legislation. In a distributive justice system, health care authority is expected to ensure that the distribution of healthcare resources is need-based.        

Ethical Responsibilities of Physician:    

All physicians take an oath (based on the declaration of Geneva and International Code of Medical ethics) to uphold the highest ethical standard during their professional service at the time of getting a medical licensing number. In India, physicians take the oath of medical ethics as enunciated in the Indian Medical Council (professional Conduct, Etiquette and Ethics) Regulations 2002. They are expected to adhere to those ethical standards both by letter and spirit. Ethical negligence does happen in medical practice but they are less evident unlike medical error or medical malpractice.  

When talking about medical malpractice, we often tend to think about physicians lacking basic medical knowledge, skills, and competence which leads to either patient suffers from an injury or death. But what about doctors whose professional skills are adequate but ethical values are lacking?  Deliberate ethical violations by a physician may not appear to have caused overt damage albeit they do cause harm to a patient more subtly. Sometimes, a doctor knowingly or unknowingly violates one code of medical ethics in order to uphold the other. In medical practice, it is not uncommon that physicians land up in situations where there are clashes between two different principles of medical ethics and which one to be prioritized becomes a matter of controversy, especially in a situation when the patient delegates the responsibility to the treating physician to decide about the best course of action. Allegations of ethical breaches against a doctor is easy to claim, difficult to prove, and very difficult to disprove as the intention or motive of the doctor comes under scrutiny. Nonetheless, if a doctor can firmly establish that whatever he did to a patient is in accordance with the current standard practice and done for the patient’s best interest and done with reasonable care and skill after taking proper consent from the patient, then the doctor cannot be held responsible even if there exists some amount of ethical negligence.

In general, ethical negligence is not considered as grounds for medical malpractice suits unless the patient suffers from physical or psychological injury or damage as a result of that negligence. But some ethical violations may dramatically affect the level of care for a patient and the trust between the physician-patient relationships. For example,

1. Not taking informed consent from a patient before any medical procedure.  

2. Failing to give a patient proper information that would allow him to make informed decisions about care 

3. Disclosing patient’s confidential information to a third party without taking prior permission. 

4. Revealing the identity of a patient in print or electronic media without taking prior permission.  

5. Not urgently attending a patient who is in a serious life-threatening      condition.   

This is by no means an exhaustive list. Any action taken by a medical professional that deviates from the principles of autonomy, non-maleficence, beneficence, or justice could potentially lead to ethical breaches.   

The realm of law and medical ethics is indeed a complex field and their concepts are often difficult to understand and execute practically, especially, when people have different beliefs, notions, and interests attached to their lives.  Medical ethics is not a static idea and its concepts are changing over time with changing doctor-patient relationships and with the advancement of medical science and technology. It is often seen that guidance on how to behave ethically demands more of doctors than compliance with the law. Then there are certain situations like euthanasia, artificial ventilation, abortion, etc., where many discrepancies and conflicts between law and ethics exist. In those situations, a physician often fails to understand what is right or what is wrong and what are his legal duties or ethical responsibilities.  As the saying goes “what is legal may not be ethical and what is ethical may not be legal” still holds true and the medical profession is a classic example of that old adage.              

(The writer is Assistant Professor,
Department of Forensic Medicine
TRIHMS, Naharlagun and can be reached at sam_royale@rediffmail.com)