Core principles of medical ethics

This topic gathers the ten points of the medical ethics exam notes, plus the WHO Health for All targets that close them.

Four ideas hold it together.

Medicine has four goals, and prevention comes first. Preventing disease and promoting health is the first goal, then curing disease, then helping patients cope with pain and suffering, then preventing premature death and helping the terminally ill to a good death.

Chronic disease changes the job. About half of all disease is linked to lifestyle, and after the age of 45 almost everybody has two or more chronic diseases. These cannot be cured, only managed, so the doctor works in a team and in partnership with the patient.

Informed consent is a procedure with four steps: establish that the patient is competent, give enough information, make sure it has been understood, and let the patient consent freely.

Ethics is practised through structures: ethics committees, guidelines for good medical practice with their four domains, the consent procedure, and the UNESCO declaration's 15 principles of bioethics and human rights.

Medicine in the 21st century has four goals, listed here in order.

First goal: prevention of diseases and promotion of health

According to the World Health Organization (WHO), health is a state of full physical, psychological and social wellbeing, and not just the absence of disease.

Health has to be promoted at every age, from young children to the elderly, to keep the person healthy. This is done through education about a healthy lifestyle and the correct choices, using language that is easy to understand.

Prevention works at three levels:

• Primary prevention aims to prevent the disease, for example through prophylactic treatment. Wealthy countries have a high standard here, but they carry a higher level of chronic disease than of infectious disease. Preventive medicine will only be effective if 50% of doctors are working within primary healthcare.
• Secondary prevention aims to stop the progression of the disease.
• Tertiary prevention aims to return the patient to their daily life and their community.

Holistic medicine and chronic disease

Holistic medicine is a form of medicine that considers the person as a whole, rather than as a disease to be cured. It is the key to managing chronic disease and its lifestyle causes, such as:

• obesity
• smoking
• drinking
• a sedentary lifestyle
• depression

70% of financial resources could be saved if the prevention of chronic diseases could be achieved. The most expensive conditions are:

• obesity
• diabetes
• Alzheimer's disease and dementia (neurodegenerative disease)
• chronic pain (degenerative disease of the muscles and bones)

Second goal: cure diseases. Where medicine cannot cure a disease at the moment, it still cares for the patient: this is palliative care for people with a terminal illness.

Third goal: coping with, and dealing with, the pain and suffering caused by disease.

Fourth goal: preventing premature death, and helping patients to have a good death if they are terminally ill. The doctor makes sure they are comfortable and not in pain. This includes searching for new models to promote palliative care: comfort, pain relief, and withholding machines when the patient is near death.

Ethics is put into practice through several structures and procedures.

• Ethical committees, in hospitals and in professional organisations. Examples are the Bulgarian Medical Association, the Irish Medical Council and the General Medical Council.
• Research ethics committees.
• Guidelines with rules for good medical practice.
• The procedure for receiving informed consent from the patient, both to participate in the treatment process and to take part in health research. It involves:
  • identifying the competency of the patient: who tested it and how (was it a professional, or someone who is not, such as the family), and considering any possible third-party interests
  • the doctor's obligation to give the patient enough information about their health status, and to educate the patient so that treatment is effective
  • the doctor making sure the patient has understood the information given
  • the patient giving consent for treatment freely
  • offering an alternative way of treatment
• Respect for the principles of publicity and dialogue.

Good medical practice is described in four domains.

Informed consent is obtained in four steps, in this order.

1. Identify whether the patient is competent, and understand how they are or are not competent.
2. Give enough information. The doctor is obliged to give the patient enough information about their health status, and to educate them so that treatment for chronic disease is effective.
3. Make sure it has been understood. The doctor must be sure the patient has understood all the information given.
4. Free consent. The patient must give consent for treatment or research freely, and must sign the documents themselves. They must not be pressured into a decision.

There are three models.

• Paternalistic relationshipthe old model, in which the doctor decides for the patient.
• Autonomy modelthe doctor explains everything to the patient, and the patient makes the decision. This can lead to an error in the decision, because it can be made without professional guidance. This is no longer the case.
• Patient partnershipthe new model. Doctor and patient work together for the best outcome for the patient, and each respects the other. The doctor works in a team with other healthcare professionals, but is the leader of that team, because he is responsible for his patient.

Preventive medicine has three aims.

Primary aim: prevent disease

A healthy lifestyle, both emotional and physical, and healthy living conditions contribute to developing health.

Doctors need to speak their patients' language. Preventive medicine is effective when 50% of doctors are working in primary healthcare.

70% of the financial resources the state gives to the healthcare system would be saved if there were effective preventive systems. The argument for this is that the most expensive direct costs of the healthcare system are obesity, diabetes, neurodegenerative diseases (Alzheimer's disease, dementia) and chronic pain and suffering caused by the muscles and bones. Fibromyalgia is given as a very expensive example.

Secondary aim: stop the progress of the disease

Chronic diseases cannot be dealt with by the doctor alone; teamwork is needed. Holistic medicine is a new speciality, because many psychosocial problems can be treated this way, and doctors should be the leaders of this team approach to treatment.

50% of chronic diseases are connected with the patient's way of life: smoking, drinking, stress, obesity, lack of exercise.

Tertiary aim: recover the patient

The tertiary aim is for the patient to recover and to succeed in fulfilling their social function.

The chain of reasoning

When 50% of doctors work in primary care, the primary aim is met and preventive medicine is effective, which saves 70% of the financial resources provided by the state. Because 50% of chronic diseases are related to lifestyle, the GP must educate the patient and help them manage the risks in their lifestyle.

The latest WHO report says that doctors have an obligation to take their decisions based on both evidence and values. This is because of the uncertainty in medical practice around technology, resources and capacity. Life is the highest value: saving life comes first.

Human rights must be respected, because rights and responsibilities are interdependent. Patients have responsibilities, such as self-care, and therefore they have rights.

Chronic diseases (CD) raise several challenges.

• About 50% of diseases are due to a person's lifestyle.
• After the age of 45, almost every individual has two or more chronic diseases. These cannot be cured, only managed, so the doctor must teach the patient how to live with them.
• Doctors must work in a team, and in partnership with patients, to manage chronic disease.
• Patients have their own expectations and often prefer treatments doctors do not recommend, which causes conflicts.
• New medical technologies give the doctor many possible treatment options, and he has to choose the most appropriate way of acting.
• In a patient with more than one chronic disease, the treatment of one may have side effects on another.
• Patients move between different hospitals and health settings, leaving gaps of information. Good communication between settings is needed, and the lack of information causes uncertainty.

In the model of ethical decision making, the responsibility of healthcare professionals is examined through these questions:

• Are there differences of opinion between physicians, other healthcare professionals, patients and their families about what should be done?
• Is it possible to solve the conflict by choosing a particular plan of treatment and care?
• Has there been sufficient consultation between the healthcare professionals involved?
• Have their responsibilities been made sufficiently concrete?
• How do the healthcare professionals deal with confidential information?
• Has the case given rise to tension within the team?
• Can the suggested policy be accounted for in relation to other patients?
• Should the healthcare providers take into account the interests of a third party?
• What are the relevant guidelines of the healthcare institution?

Two special circumstances change how a decision is made: an incompetent patient, and a child.

Incompetence

• How, and by whom, has the incompetency been established?
• In what way is the patient incompetent, and is it temporary or permanent?
• Is there a prospect of the patient recovering competency?
• Is it possible to postpone decisions until the patient regains competency?
• What is known about the values the patient holds?
• Is there a competent representative of the patient's interests?

When the patient is a child, the questions are:

• Has the child been given enough attention?
• Is the child capable of deciding for itself about treatment?
• Which way of acting is most in keeping with the parents' set of values?
• What are the consequences for the child if the parents' view is, or is not, adhered to?

The UNESCO Universal Declaration on Bioethics and Human Rights, adopted in 2005, sets out 15 principles:

1. Respect for human dignity and human rights
2. Benefit and harm
3. Autonomy and individual responsibility
4. Consent
5. Persons without the capacity to consent
6. Respect for human vulnerability and personal integrity
7. Privacy and confidentiality
8. Equality, justice and equity
9. Non-discrimination and non-stigmatisation
10. Respect for cultural diversity and pluralism
11. Solidarity and cooperation
12. Social responsibility and health
13. Sharing of benefits
14. Protecting future generations
15. Protection of the environment, the biosphere and biodiversity

The notes close, under the heading Risk management, with the WHO Health for All strategy, which they call "Health for all 2020". It sets 21 targets.

1. Solidarity for health in the European Region: closing the health gap between countries.
2. Equity in health: closing the health gap within countries.
3. Healthy start in life: for example, policies should create a supportive family, with wanted children and good parenthood capacity.
4. Health of young people: young people in the region should be healthier and better able to fulfil their roles in society.
5. Healthy ageing, reflected in increases in life expectancy, in disability-free life expectancy, and in the proportion of older people who are healthy and living at home.
6. Improving mental health.
7. Reducing communicable diseases.
8. Reducing non-communicable diseases.
9. Reducing injury from violence and accidents.
10. A healthy and safe physical environment.
11. Healthier living: healthier behaviour in fields such as nutrition, physical activity and sexuality, and an increase in the availability, affordability and accessibility of safe and healthy food.
12. Reducing harm from alcohol, drugs and tobacco.
13. Settings for health: people in the region should have greater opportunities to live in healthy physical and social environments at home, at school, at the workplace and in the local community.
14. Multisectoral responsibility for health.
15. An integrated health sector, with better access to family- and community-oriented primary healthcare, supported by a flexible and responsive hospital system.
16. Managing for quality of care, by focusing on outcomes.
17. Funding health services and allocating resources: sustainable financing and resource allocation for healthcare systems, based on the principles of equal access, cost-effectiveness, solidarity and optimum quality.
18. Developing human resources for health, so that health professionals and others have acquired the knowledge, attitudes and skills to protect and promote health.
19. Research and knowledge for health: health research, information and communication systems should better support the acquisition, effective use and dissemination of knowledge.
20. Mobilising partners for health, including governments, professionals, non-governmental organisations, the private sector and individual citizens.
21. Policies and strategies for health for all, at country, regional and local levels.

• The four goals of medicine: prevention and health promotion; cure (with palliative care where cure is impossible); coping with pain and suffering; preventing premature death and helping the terminally ill to a good death.
• Prevention is primary (prevent), secondary (stop progression) and tertiary (return the patient to daily life). It works when 50% of doctors are in primary care, and effective prevention would save 70% of healthcare resources.
• 50% of chronic disease is lifestyle-related, and after 45 almost everyone has two or more chronic diseases.
• Informed consent: competence, information, understanding, free consent.
• Good medical practice has four domains: professional integrity (knowledge, skills, performance), safety and quality, communication and teamwork, maintaining trust.
• Doctor-patient models: paternalistic (old), autonomy, and patient partnership (new, with the doctor as team leader).
• Special circumstances are incompetence and children.
• The UNESCO declaration of 2005 has 15 principles, from human dignity to the protection of the environment.