Ethics of medical care

Question 1
In your own words, explain what you understand by each of the ‘four principles’.


The four principle approach to ethics in healthcare, provides a comprehensive and versatile group of principles to guide and inform our decision making process with respect to patient treatment and rights. These principles are; Respect for autonomy, beneficence, non-maleficence, and Justice. Respect for autonomy defends the personal rights and freedoms of the patient; their right to truthful information, their right to make decisions about their treatment, their right to confidentiality. Beneficence describes the application to maximize “good” outcomes, to seek a solution that always maintains the best overall outcome in situations where compromises may have to be made or there is a conflict of concerns. Non-Maleficence describes the principle of abstaining from causing harm to the patient. It also extends to situations where harm can be done, by not taking action. In Justice, multiple issues such as fairness, entitlement, and allocation of resources, is looked at in a larger context. It relates the practical matters of treatment (access to medications, professional’s time, cost of treatment etc) with the merit of the patient, their worthiness of the resources etc.


Question 2
In the modern health service, resources are such that priorities for treatment need to be established. There are some people who are persistent users of the health service and whose conditions are (arguably) the result of choices they have made: heavy drinkers, heavy smokers, people who have very bad diets, and so on. Imagine you are responsible for the decision as to whether or not patients such as these should be treated differently from other patients. 1 Outline some issues relevant to your decision under each of the four principles. 2 Use these issues to justify a decision as to whether or not to treat those patients differently.


In a perfect world all patients would have equal access to treatment, medicines and resources, and no bias would be invoked when deciding priority of treatment from patient to patient. However, as resources are a finite quantity, with practical and financial concerns constantly setting limits on their distribution, it is an eventuality that health care services will be impelled to look at whether they should adopt a more penalizing policy to those that abuse the service. The question of whether patients should be considered for treatment according to their lifestyle is one that is brings out the whole spectrum of colours from the argument of ethics. On the one hand, all human beings are equal and should receive equal treatment, irrespective of their lifestyle choices. On the other, consideration must be given to the fact that health is something that exists outside of the hospital or clinic, and we can’t expect the doctor, the taxpayer and indeed other patients to bear the responsibilities of our choices. To attempt to provide my conclusion on this I shall consult the four principles turn by turn and analyze how they relate to this case.




AUTONOMY

Autonomy refers to a patient’s right to have control and information on their care, and as such is not particularly relevant in this situation as it deals with protection of individual rights and powers, not with interrelationships between patients, or the policies of large scale care providers.



BENEFICENCE

Beneficence is a little less easy to conclude clearly; to try and project the outcomes of such a scheme would quickly place us in the realm of hypothetic ethics. There is no doubt that establishing priorities would deal with the resources issue surely enough, however it is impossible to predict -and perhaps even measure- the effects of that decision on health standards. Though certain to allow more room for compromise in the “constant offender” patients, perhaps even to the point of causing deaths, it may also encourage some of these patients to change their ways, thus it is unlikely we will be able to find out how these balance.


NON-MALEFICENCE AND JUSTICE

The obvious active principles in this case are those of non-maleficence and justice. The potential of doing harm (through less effective treatment of some patients) places it in conflict between the practical considerations which could be advocated by the principle of justice. While the amount of overall care available will not change, (only the distribution of that care,) the fact that certain patients will be put at a clear disadvantage goes purely against the natural instinct to not allow harm. The interesting point to note about this though, is that it is not the amount of maleficence, (which remains the same whether the scheme is allowed or not) but its allocation to a certain group which offends, this perhaps calls into question how we interpret the Non-maleficence principle, and indeed whether it is even relevant.

Justice also seems to be similarly ambiguous and confounded by variations in how it is read. For example, is limiting someone’s access to health care, encroaching on their equal share, or have they already exceeded their share by placing excess demands on the service as a result of their lifestyle? A common defense from those that are frequently in hospital from drinking or smoking related illnesses, is that the high rate of taxation on alcohol and tobacco “pays” for their treatment costs. This is hard to prove, but it is definitely true that the taxation offsets to some level their subsequent medical costs. So perhaps they’re entitled to the extra share they elicit from the extra contribution. Where the justice principle is clear in this case though is that the merit of those that have put effort into maintaining their health should be considered.



As it is not possible to reach clear conclusions using the other three principles, I will be coming to my decision using the principle of justice. Although there is some confusion as to its recommendation with regards to equal share and contribution, I believe ultimately, it justifies implementing a priority based system. People who look after their health are taking responsibility, not just for themselves but for the services they use. This should be rewarded, and not negated through compromised healthcare due to the effects of those that do not look after themselves, this isn’t fair and clearly goes against justice due to merit and effort. To maintain fairness to the patients who are persistent and unrepentant drinkers, smokers, drug users, or eaters of unhealthy foods, I would use a system that; explains to them the results of their lifestyles, on themselves and the services, offers rehabilitation and full care but only on the condition that they change their ways. If they continue to show no responsibility or care over their health or its effect on the system, then they will forfeit their rights to priority and be treated as a lesser class of patient.