A VERY BRIEF GUIDE TO MEDICAL ETHICS
By Deniz Kaya
Within this article, I’ll be aiming to cover a bit about the ethical side of medicine and some of the main dilemmas that doctors will commonly experience within their career. It’ll basically be a quick look into how to act correctly, with common sense and to the benefit of your patient. I’ve done this by selecting 3 different problems which are especially common within interviews.
The first is the problem of Jehovah’s Witnesses. The question is that given a circumstance in which blood transfusion was necessary for a person who was a Jehovah’s Witness, let’s say they’ve had a car accident and an injury has resulted in a situation where they lost a large amount of blood, would you consider it acceptable to transfuse them with a quantity of blood even though their religion may have rules that forbid them from accepting it?
The second will be the problem of a patient that has been diagnosed with HIV. Namely, if a patient has HIV but is doing everything within their power to make sure that they are safe near other people, implying that they are abstaining from sex and being under close review at a nearby hospital, should you tell their partner that they have contracted the disease?
The third is the problem of vaccination, which I thought may be relevant to bring up due to the recent outbreak of measles that has been publicized within Europe. I’d like to extend this one a little bit by referencing a smaller case study with similar circumstances that occurred just a few years ago, and to make parallels between that and the situation faced currently. The question here is should we forcibly vaccinate people, so likely anti-vaxxers, in order to make sure that themselves and people in contact are safer around them, despite them not giving consent?
Before we begin it is important to note the 4 pillars under which medical ethics acts. This is important because it is with the consideration of these 4 pillars that doctors and those within the medical profession act when presented with a medical dilemma.
Autonomy - which is defined as respect for the patient’s right to self-determination. Within law this would be reflected under the principles of consent, confidentiality or privacy.
That is to say that whether or not a patient provides you with consent to perform an action or to tell or not to tell people certain details, is an exercise of their autonomy.
Beneficence – the duty to ‘do good'. Legally, this would be reflected under the Negligence Law.
So that is to say that the duty to do good would be reflected under not being negligent towards your patient and thus treating your patient to the best of your ability.
This was solidified in the case of Schloendorff v. Society of New York Hospital.
Mary Schloendorff was admitted to New York Hospital to evaluate and treat a stomach disorder. Some weeks into her stay at the hospital, the house physician diagnosed a fibroid tumor. The visiting physician recommended surgery, which Schloendorff adamantly declined. She consented to an examination under ether anesthesia. During the procedure, the doctors performed surgery to remove the tumor. Afterwards, Schloendorff developed gangrene in the left arm, ultimately leading to the amputation of some fingers. Schloendorff blamed the surgery and filed a case against them.
Would performing a surgery to the patient’s benefit without their consent be seen the same way as a crime which constitutes around 6 months in prison or a fine?
Non-Maleficence – the duty to ‘not do bad’
Criminal Law and Negligence Law Regulation reflect this. So, obeying the law and not being negligent would come under non-magnificence.
And finally, Justice – to treat all people equally and equitably.
That is reflected under Anti-discrimination law, that is to not discriminate against any type of person. Recently, we have seen this with the areas of the medical profession as using gender neutral pronouns,
And of course, it is important to note that this applies to people that are not only of different orientations or beliefs, but also murderers, rapists, and any other type of criminal. You have a duty to treat these people as well.
First starting off with the problem of blood transfusions, the problem is that Jehovah’s Witnesses see blood transfusions as being sacrilegious, that is to say that the blood transfusion is
“Considered a great disrespect of the source of life,” and the official faith’s website says that abstaining from blood is
“As important as abstaining from sexual immorality and idolatry.” So there is obviously the problem of consent. You’d likely go around this by finding methods to follow the rules and hence obey patient consent but doing so taking into account the restrictions that are present.
This is done through many methods one of which is cell salvage. That is taking blood of that person before it is needed, putting it through a machine that ‘cleans’ it and makes it suitable to be reintroduced into the body. In this way, if the blood is ever needed although it is a blood transfusion it is not technically considered to be against the faith.
This is because as long as the patient is able to view the tubing that their blood will be passed in before it is transfused as simply an extension of their body, that is to say that anything the blood is kept in, then technically the sanctimony of their own blood is maintained and no rules are broken.
Another more interesting way includes giving them cell fractions instead. While accepting transfusions of whole blood is out of the question for Jehovah’s Witnesses, the faith does give members some leeway regarding ‘blood products’ like plasma, platelets, and red or white blood cells.
The Jehovah’s Witness publication, ‘The Watchtower’, addresses the questions of whether blood fractions are okay to accept since they’re not, “Whole blood.” The organization’s answer basically boils down to: “We cannot say. The Bible does not give details, so a Christian must make his own conscientious decision before God.”
Taking this into account, it is your duty under being beneficent, meaning that in order for your patient to make the best possible decision you must inform them of as much as you can, including the risks and any concerns that they may have.
Secondly, we move onto HIV and the issue of confidentiality, namely that if your patient doesn’t give their consent for you to tell their partner that they have HIV, what do you do?
Although this is a very complex issue, it essentially boils down to the circumstance and if there is a legal obligation or a greater public interest to disclose the circumstance of a patient. That is to say that even though you are taking the best effort possible in order to follow the rules of patient consent, you need to take into account that the lesser of two evils would be the discomfort of one patient in telling others about their circumstance, when there are others at risk from this decision.
To clarify, a document from the NAT or National Aids Trust, which has a role in protecting the rights of its patients, also has a viewpoint in patient confidentiality, where they express the same sentiment. Although they also mention that in the case of our initial question, anyone under the category of a ‘sexual partner’, a doctor would almost certainly inform them despite the lack of consent.
The BMJ or British Journal of Medicine, expresses the same point, although they mention that the degree of harm needs to be significant if the doctor wishes to disclose to the general public. Rather than doing this with HIV, they instead recommend that this is done with highly infectious diseases instead or those that pose a significant risk. For example, if your patient told you that they would continue to have sexual intercourse despite having the disease, you have the duty to do everything in your power to stop them from doing so, including bypassing patient confidentiality.
Some other viewpoints to consider would include these questions:
The fact that some may consider the lack of keeping patient confidentiality as treating them different towards others, which goes against the principle of equality.
That doctors should take more into account that there is a stigma around HIV and that the doctor should do their best to help the patient overcome this.
And the idea that public health should always be valued over patient confidentiality. It could be seen as negligence if you do not do this.
For the issue of vaccination and anti-vaxxers, I’d like to relate this to a case study and to the recent outbreak of measles within Europe.
It has resulted in around 70 deaths within the Philippines, for which ‘anti-vaxxers’ have been blamed.
It has also increased in number of reported cases by around 50% to 2.3 million last year, affecting countries all across the world. It is important to note that the UK has eradicated all measles within the country, so it is incredibly unlikely that it will spread over here. We are also generally more educated and likely to know that vaccination is an important aspect of maintaining public health, therefore have a statistically lower number of anti-vaxxers.
This case is very similar to the measles outbreak in Disneyland a few years back. Not only was it the same disease, measles, due to the same cause, anti-vaxxers which acted as vectors for the spread of the highly infectious disease but it also originated from the same predicted country, within the Philippines. So there are some relevant similarities there.
When thinking about whether or not to vaccinate one individual it is important to take into account certain questions. Whilst we are used to anti-vaxxers being generally illogical activists that are based around false information and delusion, it is important to note that there are some valid reasons as to why certain individuals would not want themselves to be vaccinated.
This would include, for example:
An allergic or adverse reaction to a vaccine meaning that not receiving the vaccine would be safer for the patient than to have the risks associated with the contraction of that disease.
Or from the following slightly crazier reasons, cited by the BMJ:
Vaccines cause idiopathic illness,
Vaccines as poisonous chemical cocktails,
Unholy alliance for profit,
Vaccine immunity is temporary,
Vaccines are ineffective,
Healthy lifestyle alternative.
Unfortunately, unless you are legally obligated to vaccinate the child, in which case you have the precedent to bypass the consent of the parent, if the vaccination is optional and the parent has the power to reject it without going against the law, then nothing can be done on the doctor’s end.
You need to respect the decision of the parent to not vaccinate their child.
However, there are alternative actions that one could take, which are interesting:
Relating back to the Disneyland Case Study, the state of California has now taken approaches to make sure that vaccination of children is within law:
Various charities have started programmes to make vaccination cheaper so that more parents are able to vaccinate. Keep in mind, this is in the US where they don’t have the NHS.
And improving education and improving access to education. Though there are various education schemes that have started as a result of this outbreak, the case of a Reddit user getting vaccinated after asking online, tells us how not only education can help but also making this type of information and advice more widely available.