[MUSIC] The four pillars of principle based ethics, in medicine, are respect for autonomy, beneficence, non-maleficence and justice. These are a common set of moral commitments that help guide our decision-making in difficult situations. Respect for autonomy, means the patient has the right to make informed decisions about their medical care, and have these decisions respected. Beneficence means that the health professional should act in the best interests of their patients. Treatments must have an inherent benefit for the patient. Non-maleficence means that health professionals will not intentionally cause harm. And justice means that all patients will be treated equally and fairly. This also encompasses distributive justice which covers the fair allocation of resources. Not just to the individual patient, but across the whole of society. These are principles which we can all agree to. However, they can often be at odds with one another. The typical example is beneficence. This is non-maleficence. For every medical intervention, the risks of harm must be balanced against the potential benefits. For example, ventilating a patient subjects them to the risks of ventilator-associated pneumonia. Ideally, the patient should be able to make an informed decision after weighing out the risks and benefits. This is respect for autonomy. It used to be that the doctor would make this decision for the patient, a system called paternalism. But ethically it is better to place the patient at the center of their own treatment. Nowadays, we strive to have a combined decision between the doctor and the patient with the emphasis on the patient making the ultimate decision. The doctor uses their experience to give informed advice about the treatment options to the patient, but ultimately the decision is the patient's to make. In cases, where the patient lacks capacity to make decisions, a person or people close to the patient would fill the role of decision maker. Advance directives and formally appointing a surrogate decision maker can help greatly to ease what can be very difficult and burdensome decisions. Respect for autonomy while being the cornerstone of modern medical ethics can conflict with the other principles and doesn't necessarily override them. For example, if a patient to their family request an inappropriate treatment, it places autonomy in conflict with non maleficence. In end of life treatment decisions, doctors are not legally obligated to do what the patient or family requests if it is inappropriate. Legally, the court will side with what is reasonable as per accepted medical opinion. Autonomy and beneficence can also conflict with distributive justice, when devoting intense medical resources to a single patient, or possibly benefiting that patient can deprive treatment from other patients with a better chance of survival. Allocating scarce resources such as ICU support is challenging. Allocating equally between everyone, for example allocating everyone five days in ICU in their lifetime is technically fair. This will however not lead to equal outcomes for everyone because of differences in need. The reality is that resources are limited and rationed to some degree wherever you are in the world. Allocating on first come first serve basis is also technically fair, but very inefficient if your aim is to maximize positive outcomes with a finite resource. Utilitarianism is an ethical theory that looks specifically at maximizing utility for the benefit of the majority. We must do things for the greatest good for society as a whole. This is a consequentialist ethical theory where actions are judged by their outcomes. This is the opposite of deontological, or duty based ethics, where the focus is that one must do the right thing If such a thing exists, regardless of the consequences. Take for example the following philosophical thought experiment. It is called the trolley problem, and there are many variations. The basic premise is there is a runaway trolley barrelling down the railway tracks. Ahead on the tracks, there are five people, tied up and unable to move. The trolley is headed straight for them. You're standing some distance off in the train yard next to a lever. If you pull this lever, the trolley will switch to a different set of tracks. However, you notice there is one that isn't tied up on the side track. You have two options. One, do nothing and the trolley kills five people on the main track. Two, pull the lever, diverting the trolley on to the sidetrack but it would kill one person. What would you do? The majority of people will pull the lever. In an alternation of this problem, you are standing on the bridge under which the trolley will pass. You can stop it by putting something very heavy in front of it. As it happens, there is a very overweight man next to you. You only way to stop the trolley is to push him over the bridge and onto the track. Killing him to save the five. Would you push the man off the bridge? In this version, the majority of people will not push the man onto the railway track. Ethical theories do not always provide all the answers and ambiguity as to the correct course of action may still exist. For different people the correct course of action can be very different. This is why we have moved to a system which is patient-centered. Ethically we must always assess the manner in which we achieve our goals, actions, as well as what our goals are, the outcomes. The two are intrinsically linked but what we must always be clear about is our intentions. These must always be pure and clear of co-founders. The Doctrine of Double Effect is used in end of life care to justify doctors prescribing pain relieving medication that may have the consequence of shortening the patient's life. Aiming to relieve suffering is morally good, but can have a morally bad side effect. This is acceptable only when relief of the suffering cannot be achieved in any other way, and the good effect is independent of the bad effect. The good effect must come first and be the primary intention of the treatment. To recap, ethical theories do not provide us with a magical algorithm to come up with a single correct answer. They provide us with a framework to reason out our decisions. Religion and culture also help provide such a framework. Whatever our choices are, we must take responsibility for our actions be they passive or active and their outcome. [MUSIC]
