The doctor’s dilemma: is it ever good to do harm | Dr Gwen Adshead
Medical knowledge changes swiftly, and technological changes make new and expensive investigations and treatments possible that were only theoretical a few years ago. Life has been extended in length, but not in quality, and the debates about end‑of‑life decisions show us how much the notion of a “good life” is bound up with the absence of disease, illness and suffering.
The practice of medicine is not purely technical. It involves a relationship between a person who is seeking help, and who may be vulnerable, and a person who has the skills and knowledge to help. Relationships that involve disparities of power, knowledge and vulnerability require some degree of external oversight and regulation. Traditionally, in medicine, this oversight has taken the form of codes of ethics, starting with the Hippocratic Corpus. Today, bodies such as the General Medical Council and the Royal Colleges define the standards of good medical practice.
There has been much discussion of how we make moral choices, but what do we mean by a “moral” decision in medicine? Conventionally, we are distinguishing what is clinically and technically possible from whether it is “right” to intervene at all. For example, if a person’s heart stops, we know we can resuscitate them, but should we do so?
To answer that question, we do not expect to rely solely on numerical data and we do not anticipate getting an obvious and single answer. We are aware that there may be more than one answer to the question, and those answers may conflict with each other. We will want to get clinical information about the situation: why did the heart stop? Will restarting the heart make things better or worse for that person in medical terms? We will also want to know what the patient thinks about the situation: did they anticipate this? Do they want to be resuscitated? And if we don’t know these things, we will want to ask some questions about how best to make a complex decision if we have not heard the wishes of the person concerned.
Moral reasoning differs from those types of reasoning that are purely computational, logical or algorithmic. To answer ethical questions, we engage in a process of reflection and discussion: we begin a discourse that uses the words “ought” and “should”, as opposed to “can” and “must”. If the patient’s heart has stopped because they are losing blood, then a doctor may say: “We must give the patient more blood or his heart will stop, and we can do so because the blood is here and we know it will work.” However, that statement does not answer the question: “Should we resuscitate the patient if his heart stops?” The doctor’s statement about what can be done is not irrelevant, but it is only a part of the reasoning process involved in deciding whether it is right to resuscitate. If the patient had left instructions that they did not want to be resuscitated if their heart stopped during surgery, then the facts of successful resuscitation practice would be irrelevant to what the doctors should do.
What we are distinguishing here are facts and values – a distinction developed by David Hume in the 18th century. Hume says that it is a fallacy to think that because things are a certain way (facts), then they should be that way (values). We cannot derive values from facts, but we do evaluate facts and make moral judgments about them, and this reasoning and reflection process is crucial to medical ethical decision-making.
For centuries, it was assumed that a good decision ethically in medicine was the same as a good clinical decision
For centuries, it was assumed that a good decision ethically in medicine was the same as a good clinical decision. If the doctor did what was medically indicated to benefit the patient, then this was the ethically right thing to do. Although sometimes crudely summarised as “doctor knows best”, this approach to ethical dilemmas in medicine is (arguably) less about the doctor’s status, and more about the tensions between facts and values.
Medicine as a science utilises a method of study that focuses on consequences of actions, on causes and effects in nature. These facts about how bodies heal, or how drugs work, are sometimes confused with medicine’s ethical imperative to bring about good consequences for the patient, or at least reduce harmful consequences. Concerns tend to arise when there is friction between the facts and values.
Modern medical ethics developed out of an examination of medical authority after the second world war, partly in response to the Nuremberg trials of doctors who had used medicine to torment and kill citizens, but also in sympathy with a general increase of attention to the human rights of ordinary people which had previously been denied – people of colour, women and those made vulnerable by illness.
Legal cases reflected this change: in one famous instance (Murray v McMurchy, in 1949), while operating on a woman for another purpose, a surgeon tied her fallopian tubes without her consent, because he foresaw that becoming pregnant would be clinically dangerous for her, and that it would also be dangerous for her to undergo two surgical procedures. She sued for negligence and won: it was not disputed that the surgeon was factually correct, in clinical terms, but he had not considered that the patient’s own view of herself and her body were essential to the decision-making process. He had focused on facts, and assigned no value to the patient’s view, even though it was her body that was being operated on.
This case brings us to an important issue in moral reasoning generally, which is how we think about words like “good” or “right” or “best”, in relation to a human decision. It is not a question of whether we want doctors to make ethical decisions on a daily basis – it is a fact that this will happen in the world of medical practice. What we want is for doctors to make “good” ethical decisions, or at least the “best possible”. We want to know that they have engaged in the type of thinking that takes account of values and personal lived experience.
One of the most common criticisms of doctors is that they do not listen to the experience of the patient, or let the patient’s voice be present or important. There have been changes in this regard, and medical practitioners are encouraged to be more patient-centred. This process is helped by doctors themselves acknowledging that they will inevitably be patients at some point in their lives, that knowledge does not make them immune from suffering. Nevertheless, there are still concerns about unethical practice in medicine, and occasions when doctors do not make the best ethical decisions; or even make decisions and take actions that are deemed to be “wrong” and “bad”.
A few years ago, a medical team described how they resuscitated a woman whose heart had stopped, despite knowing that she did not want to be resuscitated. They described how they felt that they had done the right thing at the time, but they could see that, besides disrespecting her wishes, their decision had bad consequences for the woman. Although difficult to do, it is helpful if doctors can take the risk to discuss their “bad” ethical decisions in public, because it allows a learning process to take place, just as happens after other types of serious incident or accident. At present, doctors who have done “bad” things are treated as offenders, and any exploration of what happened takes place in a secret process.
Ethical reasoning in medicine has drawn on a range of theories in moral philosophy. There is obviously a close relationship between medical ethics and the utilitarianism of Jeremy Bentham and John Stuart Mill, namely that the doctor should act in such a way as to bring about the best medical consequences for the greatest number of people, or act in such a way as to minimise harmful consequences for the greatest number of people. Although it may seem unarguable that doctors should always do what is best for their patient’s welfare, it is not always clear how the assessment of welfare is to be done, and from whose perspective.
A common criticism of focusing on medical consequences is that a utilitarian approach does not help doctors and patients to weigh up different consequences, nor does it tell them what to do when doctors, patients and carers weigh anticipated consequences very differently. Ray Tallis, a physician of older age care, writes movingly of how painful it is to be accused of cruelty and ageism when he does not support treatments and interventions that will prolong an aged person’s life for a short time, but cause them more suffering before their inevitable death.
In 1979, a model of medical ethics was proposed that has become a basic starting point for discussing and teaching healthcare ethics. It proposed a set of principles that would address both consequences and duties in medicine. Doctors should respect the principle of doing good and doing no harm, but they should also have respect for the patient’s views and choices about their condition and treatment, and respect their autonomy over decisions that affect them directly. Doctors should also respect a principle of justice in healthcare, where justice implies fairness of access to treatment.
This model is known as the “four principles” approach, and is now often used as the basis of training in healthcare ethics. Possibly its greatest value is that it has enabled the study of healthcare ethics to become more central to the training and development of doctors. Doctors used to learn about ethical reasoning by watching their trainers and seniors in a purely clinical context, but the four principles gave them a structure for thinking about their ethical decisions that was based on arguments from moral philosophy, not clinical medicine. A good ethical decision in medicine could be said to be one that takes account of the clinical consequences for the patient and embodies a duty to respect the views of the patient and the justice of the process.
Respect for patient autonomyhas grown with the consideration of human rights and dignity, and developments in the law on consent and personal ownership of identity. But there is a problem with giving more weight to autonomy. Many medical conditions impair the capacity to be autonomous, even if only temporarily, which gives rise to considerable debate as to how to make good-quality ethical decisions in cases where people cannot express their views. In many cases, it will be possible to wait until the patient has regained the capacity to make their own decisions, in other cases, the patient may have left advance instructions as to how to be treated, or there are substitutes (usually family members) who can make a choice for the patient.
The problem of lack of capacity deepens where people have long-term problems with autonomy, either because they are developing it (children and young people), they have lost it through physical and mental injury (the elderly and disabled), or where it fluctuates, owing to psychological distress (which occurs in a wide variety of mental disorders).
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