Medical Ethics: Weighing Up the Pillars

At school we were very fortunate to hear a talk on medical ethics by Dr Mona Kooner, a lovely lady who has been a GP for a number of years. Excitingly, her new book on getting into medical school is released next month, and if she writes as clearly and eloquently as she speaks, then I can already recommend it.
Today's talk focused on Medical ethics, and by extension the extrapolation of these ethics for the BMAT exam (Biomedical Admissions Test for entry into some UK med schools) and medical school interviews. Dr Kooner introduced us to the GMC (General Medical Council, learn more here) publication "Duties of a Doctor", a guidebook of sorts that sets down the responsibilities that doctors hold. It is, in Dr Kooner's view, dry and pious; dissimilar to the varied and fascinating subject of medical ethics that she spoke about.
We learned that the four pillars of medical ethics are as follows:

1. Autonomy - the patients right of control over their own body and lifestyle.
2. Beneficence - only doing what is good for the patient.
3. Non-maleficence - not harming the patient. 
4. Justice - being fair or reasonable.

Essentially, all of these "pillars" have to be considered before a difficult decision is made, and in the BMAT exam and medical school interview, you have to prove that as a potential medical student you can do so.
So, how do they work in practice? Let us use the example that Dr Kooner used. Consider the following controversial statement:
"People that do not make an effort to quit smoking should not have unlimited access to the free healthcare that the NHS provides."

When one is sitting in a dingy exam hall, or sweating in front of a panel of medical school admissions officers, it can be hard to organise the scattered thoughts that surface when faced with such a dilemma.

As I am prone to on-the-spot nerves myself, I can see how it is times like these wherein the pillars of medical ethics would become very useful indeed. Taking our first problem, we can see that while justice falls on one side of the weighing scales, we can infer that beneficence, non-maleficence and autonomy fall on the other.

They break down like so:

• Justice - as they continue to partake in self-harming behaviour without attempting to stop, it is not fair that smokers use up precious medical resources that could be used on non-smokers.

However, this is the only one of the pillars that falls in favour of the statement, as we will see.

• Autonomy: the smokers have every right to smoke if they want to, and have no obligation to attempt to quit.

• Non-maleficence: by not providing treatment to a potentially ill  patient, you are directly harming them.

• Beneficence: similarly, if you allow the smokers full access to the NHS then you are helping them.

In this way, we can break the potentially baffling ethical dilemma into manageable chunks which allows a concrete thinking process, without the diluted, what-feels-right leanings.

In fact on that note, Dr Kooner made it very clear that whether it's in the BMAT exam, interview or your time as a doctor, your own beliefs should never affect your decision, and you have to be understanding, non-judgmental and unbiased when making decisions about patients and their care. Just another reason that I am falling in love with the field of Medicine; it is a level playing field where care comes first, which is in my opinion exactly how it should be.

Thank you for reading!

Do not resus?

My view on an article published in the Student BMJ

"Making Decisions about your Death"

Should a doctor presented with a 22 year old unconscious woman with a tattoo that reads 'Do not resuscitate' heed the order that has been inked onto her skin?
On some level, I believe they should not help the patient, it says clearly on her body that she had made this decision about the way she wanted to die, and cared so much that it be followed she had it tattooed onto her skin in case this circumstance arose.
However, a much stronger part of me argues that as a physician one simply cannot take the risk of letting a patient die if that is not exactly what they wanted in such a life-threatening situation. What they may have wanted when planning a tattoo may not cohere with their wishes in the emergency room.
Would the situation be different if the woman was 92 rather than 22? Maybe. From a legal perspective, the three letter phrase is not binding, as the article points out. Considering the situation rationally, in my opinion there is only one course of action that can be taken: to give the patient the best chance at life that a doctor could provide, and the strongest incentive for this argument is beyond the legal and social expectations, it is simply that the risk of letting a patient die who had wanted to live is far too grave a risk.

If you're interested you can read the full article in the Student British Medical Journal
2012;20;e658 Or read it here.

Thank you for reading.