The Pillars of Medical Ethics and

the Ethical Basis for Law

Charles Ellington, MD, JD
SIU School of Medicine
Decatur Family Medicine Residency
 Objectives
• Describe the pillars of medical ethics,
including non-maleficence, beneficence,
autonomy, and justice
• Explain their limitations and clinical
application
• Discuss basic legal principles that flow
from the above, including informed
consent
 Pillars of Medical Ethics
• Non-Maleficence
• Beneficence
• Autonomy
• Distributive Justice
 Non-Maleficence
• Primum non nocere: First do no harm
• Hippocratic oath: “I will use treatment to
help the sick according to my ability and
judgment, but will never use it to injure or
wrong them.”
 First rule of ethics
• Many argue overrides all other ethical
concerns
• Clinical Case
– A transplant surgeon kills a death row inmate
so he may harvest his heart and liver, thus
saving two lives. Is this ethical?
 First rule of ethics?
• An oncologist gives chemotherapy to a
woman with breast cancer in hopes of
curing her cancer. Unfortunately, she
develops congestive heart failure as a
result of her treatment. Is this ethical?
 Negligence
• The concept of medical malpractice or
negligence is related to the duty no to
harm
• Medical negligence occurs when a
physician breaches a duty and as a result
of that breach, harms a patient
                                                                                      

                                                                         
 Beneficence
• An action done to benefit others
• Hippocratic Oath: physicians will “come for
the benefit of the sick”
• Differs from non-maleficence in that
beneficence is a positive requirement for
action, whereas non-maleficence is a
negative prohibition against action
 Is Beneficence Obligatory?
• A physician is driving down the street and
sees an automobile accident. Is the
physician morally obligated to respond?
• What if the physician is an opthalmologist?
• Are there times when beneficence is
required by ethics? By law?
 Required Beneficence
• Specific beneficence: directed at specific
parties such as children, patients, etc.
• General beneficence: directed to society in
general
 Required Beneficence
• What are some specific positive actions
the law requires of physicians or others?
 Physician-Patient Relationship
• Is created when a patient requests and a
physician agrees to provide medical care
• Creates special obligations for physician
– Provide medical care in accordance with
standard of care
– Not abandon patient (provide care if needed
until relationship properly terminated)
 Paternalism
• Deciding what is best for another person
and overriding their preferences or choices
• At tension with autonomy
 Paternalism
• At a routine visit, you notice a 55 year-old
patient of yours has never had a mammogram.
On questioning, the patient says she prefers not
to have one—that they are uncomfortable and
she does not see the need. You explain
mammograms save lives, and instruct your
nurse to schedule a mammogram as soon as
possible. Is this ethical? What if you simply
handed her an order and told her to make the
appointment?
 Paternalism
• A 68 year-old male patient of yours suffers
from alzheimer’s dementia. He develops
hemoptysis, hoarseness, and weight loss.
CT scan shows suspected late stage
bronchogenic carcinoma. The patient’s
wife pleads with you not to tell her
husband the suspected diagnosis because
she is concerned he may kill himself if he
finds out. What should you do?
 Autonomy
• Principle of self-rule or self-governance
• Based on respect for individual and value
of a person as an end in itself
• Also influenced by humility—it is difficult or
impossible to know what is best for
someone else
 Preconditions for Autonomy
• Liberty or freedom to choose
• Agency or capacity to choose
 Rules Flowing from Autonomy
• Truth telling
• Confidentiality and privacy
• Informed consent
 Informed Consent
• A communication process between the
physician and patient whereby a fully
informed patient can participate in
healthcare decision-making
 Legal Duty
• A physician has a legal duty to inform the
patient of the condition, differential
diagnoses, the purpose of tests, treatment
options, risks, alternatives, prognosis and
expectations
Canterbury v. Spence, 464 F.2d 772 (D.C.
Cir. 1972)
 Preconditions
• Patient must have capacity to consent
– If at issue, document process for determining
if someone has capacity
• If a patient lack capacity, a surrogate
decision-maker must provide informed
consent
 What Must Be Disclosed
• Nature of treatment or procedure
• Expected outcome and likelihood of
success
• Reasonable alternatives
• Material risks
 Material Risks
• Risks that are very slight or rare do not
have to be disclosed
• Some states require any risk that would
impact a patient’s decision be disclosed
• Alternative treatments that carry fewer
risks must be disclosed
 Legal Standard Applied
• Professional disclosure standard (majority
including IL): Was the disclosure or non-
disclosure consistent with the community
medical practice
 Special Cases
• Pediatric patients
• Emancipated minors
• Mature minors
• Pregnant patients
• Minors seeking certain care (STD
treatment or birth control; drug, ETOH, or
psychiatric treatment)
• Emergencies
 Exceptions
• Therapeutic privilege
• Patient asks not to be informed
• Common knowledge
• Emergency
 Informed Refusal
• Corollary to informed consent
• Places a duty on physician to disclose
material risks for refusing to undergo low
risk procedure (e.g. pap smear)
Truman v. Thomas, 165 Cal Rptr. 308,
611 P.2d 902 (1980).
 Distributive Justice
• Fair, equitable, and appropriate
distribution of resources
• Especially relevant for healthcare
– 45 million Americans uninsured
– Significant healthcare disparities
• Distribution of scarce resources always
requires hard choices
 Theories of Justice
• Utilitarian: the greatest good for the
greatest number
• Libertarian: focuses on protecting liberty
and property
• Communitarian: focuses on responsibility
of the community to the individual and
based on pluralism
• Egalitarian: basic equalities among
individuals
 Is healthcare a right?
• What is the scope of the right?
• Against whom is this right asserted?
• What are the responsibilities of those
possessing such a right?
• Is the right to healthcare a positive or
negative right?
 Clinical Case
• You’re a physician serving on a state healthcare
reform task force. One issue that has arisen is
whether the state will pay for liver transplants for
alcoholic related end stage liver disease. One
proposal is not to pay at all. Another proposal is
to pay for it, but place these patients below
those without alcohol related disease. What will
you recommend and what programs are you
willing to cut to pay for it?
 Summary
• The four pillars of medical ethics provide
important guidance for physician behavior
• Non-maleficence is considered the first
principle of medical ethics but cannot be
viewed as isolated from the other
principles
• Beneficence requires acting in the best
interest of another but can become
paternalistic
 Summary-Cont.
• Autonomy is grounded in respect for the
individual and serves as the basis for
several ethical rules including informed
consent
• Informed consent requires a physician
disclose the nature of the proposed
treatment or procedure, expected benefit
of proposed treatment and liklihood of
success material risks, and alternatives
 Summary—Cont.
• Distributive justice seeks to make and
equitable distribution of scarce resources
but always requires hard choices
• Ethical theories often overlap and not
always separable