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!

What would you do?

Patients have, quite rightly, a lot of choice in their treatment and their view is generally held above everyone else's. However, I've noticed in my brief time at the hospital that, quite understandably, the patients just want the safest-sounding option for their treatment. Although the facts and figures help in their decision making, ultimately to some patients they are just numbers, and they rely on their doctor for some straight talking advice. All they want to know is, if it were you doctor, what would you do?

The MDT Meeting

In my time at the Marsden I sat in three MDT meetings, and they were referred to at least four or five times a day aside from this. From this you can see how integral these meetings are to the daily workings of the hospital.

The "MDT" stands for "Multi-Disciplinary Team" meeting, and essentially it is where everyone that is associated with a patient's care comes together to discuss treatment, review objectives and eat a few biscuits.

Each patient under a consultant is talked about in depth, their latest blood count, their CT (computed tomography - learn more here) scans, their progress through treatment and their general well being is covered.  It was here that I really got a feel for how integral teamwork is to successful patient care. The amalgamation of professor, nurses, registrars, research nurses and other key team members was impressive to say the least, because for each patient a different opinion is heard, and in this way all the information is present at the same time, leading to a streamlined system of care.

However, later in the week one of the registrars and I were seeing a patient (I say seeing, what I mean is that the registrar was seeing the patient, I was mostly nodding and accidentally getting under people's feet). This out patient, I'm calling her Mrs Williams*,  had been discussed in that morning's meeting; she had pancreatic cancer, and had just finished her third cycle. In the MDT meeting it was concluded that she was responding so well, from a medical point of view, that her treatment would be extended for another one and a bit cycles. This all sounded very promising, but later that day I was there when we saw Mrs Williams in clinic (learn more here), and she told us about the side effects she was experiencing. Which I learned vary between chemo treatments, as each plan is tailored for the patient, sometimes different drugs are used, or some are left out all together - hence the diverse side effects. Mrs Williams was alarmed by the size that her ankles had swelled to as a result of the chemo, and she was in pain. The registrar, too, was concerned that there may be clotting in the left leg that was much bigger than the right, but both looked painfully enlarged (similar to in this photo), with the skin stretched uncomfortably. Furthermore, she was suffering from constipation, excess urine and nausea, all very uncomfortable conditions. An ultrasound was proposed by the registrar to make sure there were no clots in the left leg which could lead to more problems. This lady and her husband were frightened of the seemingly alarming side effects, to the point where it was only reluctantly that they agreed to carry on with more cycles of the chemo. The registrar prescribed a cocktail of drugs to deal with the side effects; which for Mrs Williams means another set of pills to take every morning.

Afterwards, the registrar was telling me that there is a major flaw in the MDT meeting set up, because discussing something in a meeting in a boardroom with colleagues and biscuits is very different to seeing the patient right in front of you with hugely swollen ankles who can barely walk. There isn't much that can be done about the problem, but it's there.

Thank you for reading, I wish the brave Mrs Williams a comfortable and speedy recovery.


*All names in my blog have been changed to respect patient confidentiality.