Ethics

At the end of life or in caring for someone nearing the end of life, a host of ethical questions can arise. Some of them are abstract and enduring, such as, “Did I live a good life?” “What will my legacy be?” Other questions are more specific to being in the healthcare system. These latter questions and concerns are addressed in this section.

 

Doctors and other medical staff that you encounter in hospitals and other healthcare settings are subject to professional training in medical ethics, and they are bound to these ethical standards. Medical ethics is traditionally thought of as four basic principles: patient autonomy, justice, non-maleficence, and beneficence.

 

Non-maleficence and beneficence are two sides of the same coin. The former refers to “do no harm,” which is part of the oath that doctors take. The latter, beneficence, is the positive corollary: do increase well being. Beneficence itself is a principle of medical ethics that requires that patients benefit from the care they receive. That may seem obvious, but there are times when a patient undergoes care that actually benefits another person exclusively or significantly more than it benefits themselves. For example, being a living organ donor requires surgery that does not benefit the donor, but rather it benefits the recipient. For this reason, there is much conversation around the ethics of living organ donation.

 

Patient autonomy refers to the idea that patients get to make their own decisions about their care. As a patient, you have control over your own body and medical decision making. In order to make your own decisions, you have to have decisional capacity. All patients are assumed to have decisional capacity unless there are indications of medical or mental impairment, or if the patient is under the age of 18. In order to make decisions, you must be informed about your health and the medical options that you have. Medical professionals, especially doctors, are required to inform you and get consent for treatment. This process of being informed, selecting treatment, and consenting is referred to as informed consent. The takeaway is that you, the patient, get to pursue the course of treatment that you choose rather than what the doctor decides is best for you.

 

In medical ethics, the principle of justice refers to treating patients equally and using resources well. This particular principle is more context dependent than the others. How resources are used depends on the level of resources a given institution has and the needs of its patient population. Moreover, the just use of resources depends on a number of prior ethical commitments that will vary from person to person. For example, should resources be used to treat the largest number of people or should they be used to treat the sickest people? There is no universal answer to this question. In fact, it has been debated in one form or another for centuries. Unlike beneficence, non-maleficence, and autonomy, the principle of justice can often remain abstract in patient care settings.

 

Justice can come into conflict with patient autonomy. Imagine that the best course of treatment for an individual patient requires a scarce resource. How that resource is used comes under scrutiny and the patient’s needs may not be met. In that instance, you could say that the patient’s autonomy has been violated, or at least that it has been eclipsed by greater concerns for justice at a communal level. In short, patient autonomy and justice reveal the tensions that always exist between individuals and communities.

 

In a hospital or other healthcare setting, there will be ethics committees and ethics consultations. Ethics committees are comprised of staff in the hospital who are interested in ethics, and they provide education and debriefing on hard cases. Each institution is required by law to have an ethics committee, but its composition and function are determined by the institution. Ethics consultations are also available and can be initiated by the patient or the patient’s family. Ethics consultations are often sought when a situation is complex. Usually, any staff person can help you get that process started. These consults are not punitive, but rather seek to bring clarity to difficult situations. Often, chaplains are on the ethics committees and know the process of beginning an ethics consultation. They can be a first line of inquiry into how to handle many ethically difficult situations.