1 Chapter 1 Understanding Ethics
“Every k over is a killer.” It’s quite memorable. There is some alliterative pleasure drawn from the k for killer message in relation to speeding. But, what does it mean? If an individual drives 1km per hour over the speed limit, are they more likely to perpetrate homicide? Is driving more than 1 km per hour over the speed limit a guarantee all lives of all occupants in a car will be extinguished? Or is it a plea to engage in morally acceptable conduct on the roads? Just how many speeding offences are committed daily? How many speeding offences are punished? How many go unpunished? Irrespective of culpability, is all speeding a criminal offence? Killing is, so syllogistically speeding is when contrasted with the criminal act of homicide. Following this corollary, for every km per hour you drive over the speed limit the risk of you killing yourself or another is a natural consequence. So how on earth is it ever acceptable to claim an exemption from the speed limit? To borrow from another well-used road safety message: speed kills. Based on these two public safety messages, it is never acceptable to speed… ever! So how is it ethically and legally permissible for emergency services to drive faster than speed limits allow?
At the conclusion of this chapter you will:
- Acquire the basic concepts of ethical theory
- Interpret ethical theory as it applies to paramedic and health professional practice
- Distinguish between conflicting theories to address and problem solve ethically
- Explain aspects of moral conduct and paramedic health professional practice
- Justify treatment and course of action based on accepted ethical theory
1.2 Ethical Theory
According to Lawrence Kohlberg’s Model of Moral Development, ethical behaviour is dependent on our ability to engage in acts of moral reasoning. As a student, your engagement with learning has altered over time. The same is true in the development of your moral character. I am certain at some point in all your lives, every one of you told a lie to the person who was your primary care provider. I’m going to guess it had something to do with chocolate. Despite clear evidence contrary to your persistence that – I dunno, it just… disappeared – you committed to the lie until the episode reached its natural (and inevitable) conclusion. Now when you did this, it was likely you were sitting at stage 1 or 2 of Kohlberg’s Model of Moral Development. Of course, by now you have evolved moral character. Not only are you legally competent, you have high regard for moral obligations. Right! Right? This unit is beginning to appear redundant already.
Back to speeding. How can 61kph in a 60kph zone be more of a threat than 60kph or lower. You’ve broken the law. Whether you agree with the underlying message or not is irrelevant. Is it ever acceptable to go faster than the permitted speed limit? In what cases? Who decides? How did they arrive at that decision? Surely, 59kph is safer than 60kph? Why not drive at 59kph? Not all laws and moral obligations apply to everyone, all the time and with good reason. Like laws, morals can’t be arbitrary. They must undergo some sort of ongoing process that demonstrates they have legitimacy. Perhaps moral reasoning and driving faster than the speed limit permits are more closely related than they first appear.
We have met Immanuel Kant (1724-1804) already. He is responsible for telling us that duty or rules are more important than consequences in determining action. If Kant was the chief executive or commissioner of your ambulance service, no speeding or treating red lights as give ways for you. According to Kant, the morality of a given act lies in its universality. Engaging in a certain act is only permissible if it can be universally applied. We are all are own moral agents. The morality of treating a red light like a give way lies in the moral universality of everyone treating a red light like a give way. It’s not workable. Getting effective help to people is usurped by the morality of the rule or act, rather than its intended consequence. The same can be said for lying.
However, there is lots to admire in Kant’s approach to moral conduct. It directs us to introspection and focus on what is our duty and what is the right thing to do. How do we know what is right? Simply put, the morality or immorality stems from universal acceptability: murder is never acceptable and lying is never acceptable based on the principle of universality. If an individual commits murder, then it becomes universally morally acceptable to commit homicide. I’ve never seen The Purge; I don’t think I’m the audience the producers are aiming at, but for those of you who have, and there must be many as they keep making sequels, the premise of these films raise interesting aspects of the duality and fluidity of our nature given threats to our existence. According to Kant, The Purge wouldn’t be an annual event. It would be permitted to happen each day. So, by accepting individually that murder is wrong, the immorality of murder is universalised thereby eradicating murder in society. This is called the Categorical Imperative. It is entirely objective, absolute and authoritative. Its formation is wedded to the Golden Rule. You could say that this theory forms the basis of our own Human Rights Act 2019 (Qld). Furthermore, deontology is a defining characteristic of the principle of autonomy or right to self-determination, which will be discussed in more detail in this chapter.
Deontology proposes that human rationality is principal. Kant is not mucking around with ethical theory. He is ardent in his application that morality exists within us. All humans can exact morally acceptable conduct based on sapience and human’s ability to engage in rational thought. In short, while we are on this earth, we must treat one another fairly and equally with equal respect. For Kant, humans are not a means to an end. Favourable outcomes cannot be traded if unfavourable consequences impact on individuals. It is our capacity to comprehend value and weight of what is right or wrong that determines our moral growth. Like we’ve already heard: Do unto others…
Critics of deontology find Kantian ethics too rigid a tool to help resolve nuanced moral dilemmas. This is especially true where conflict arises. Contemporary issues have shown us that in some cases moral rules and duty must be overridden. For example, should resuscitation be commenced on all people irrespective of the circumstances? How would Kant have felt about voluntary assisted dying (VAD)? Ten people need ventilatory support, but there are only five ventilators available; how would Kant’s theory of deontology allocate resources? I’ll stop now. But you get the point. It is unlikely Kant, in the 18th century would have contemplated contemporary life support machines. Were he alive today, his concept and definition of death would be challenged. What constitutes not clinically dead today was not possible in Kant’s time. People in post-coma unresponsiveness would have been considered as dead as a doornail. Then, just for fun, instead of talking about jobs, placement and all the usual CS43 and HL19 malarkey with your peers, start a conversation on Kant and the permissibility of organ donation. Here’s a starting point: section 20 Transplantation and Anatomy Act 1979 (Qld).
In case you’re wondering who is responsible for, if you’re ever involved in a road traffic collision, why you must always stop, check to see if everyone is alright and exchange insurance (another Kantian influence) details, it’s Kant. Of course, it is.
Look, if your understanding of deontology is still a bit fuzzy, I’m going to leave it to S Peter Davis and CollegeBinary to explain. But don’t watch with children around. You’ve been warned. (By providing this warning I think I have breached Kant’s Categorical Imperative; whoops.)
1.2.2 Consequentialism and Utilitarianism
In the section on deontology, I posted a video describing two answers in response to a question posed by a patient. The answers given by the deontologist and the consequentialist (or to be more precise an act utilitarian) are somewhat binary and polarised. Before I talk more about that, I want to tell you who or what a consequentialist is. A consequentialist is a person who subscribes to the ethical belief that the moral worth in response to a vexed dilemma is what outcome favours the greatest good for the greatest number of people. The answer to that question provides for the ethical justification for decisions. Utilitarians, a branch of consequentialism – look at the social utility of a response to determine the best response to any conflict. For deontologists, the right thing is regardless of the consequence. For consequentialists, doing the right thing is based on outcome and it is the outcome that has the best consequences for the greatest number of people determines whether the conduct is ethical. The act or rule is only ethical if the consequences are also ethical.
Returning to our patient on the stretcher asking will she die. Dr Deontology is correct to answer “Yes”. It’s true, she will die. It’s an inevitable consequence of living. However, Dr Consequentialism is also correct to say, “No, not today”. Dr Consequentialism understands nuance and the context the patient is asking her question. This is a question you will be asked several times by the patients you care for during your career. In the grander scheme of things, Dr Consequentialism is lying. The different responses underpin the fundamental difference between consequentialism and deontology. Like the opening track from Radiohead’s Kid A: Everything in its Right Place. Unlike deontology, where the end does not justify the means; consequentialism permits achieving the best outcome in ways and means that are unconscionable to Kant but to Jeremy Bentham and John Stuart Mill, perfectly fine because the purpose of morality is to make the world a better place. And if that means a few of us are lost along the way, but it’s all for the greater good, then away we go. This point is poetically revealed by Sylvester Stallone in a quieter moment during Rambo: First Blood Part II. I am unable to recommend any other part of this film, however. Rocky IV, on the other hand, is all gravy. Rocky IV, followed by Creed II. Is there a better filial double-bill? No need to answer. I know the answer.
Another distinction between deontology and consequentialism to aid in our understanding is deontology applies to the individual, whereas consequentialism applies to any entity, individual or otherwise. How can we measure the overall good? Measuring the worth of decisions is like the Schrödinger’s cat thought experiment. Outcomes simultaneously exists and don’t exist. Look at Robert Frost’s poem, The Road Not Taken. For one outcome to exist, the other outcome must have to exist in the metaphysical world, albeit briefly. If it didn’t there would be no moral dilemma to evaluate in the first place. Believe me, Frost’s poem isn’t about what you think it’s about.
According to Jeremy Bentham:
“Nature has placed mankind under the governance of two sovereign masters, pain and pleasure. It is for them alone to point out what we ought to do, as well as to determine what we shall do. On the one hand the standard of right and wrong, on the other the chain of causes and effects, are fastened to their throne. They govern us in all we do, in all we say, in all we think: every effort we can make to throw off our subjection, will serve but to demonstrate and confirm it. In words a man may pretend to abjure their empire: but in reality he will remain subject to it all the while. The principle of utility recognizes this subjection, and assumes it for the foundation of that system, the object of which is to rear the fabric of felicity by the hands of reason and of law. Systems which attempt to question it, deal in sounds instead of sense, in caprice instead of reason, in darkness instead of light.”
Bentham’s quantifiers to measure the overall good are split between Hedons (good feelings) and Dolors (bad feelings). He relied upon criteria that included intensity of feeling, duration of feeling, certainty of one over the other and quantity of people to whom the criterions apply. Experiences are relative. Few lives are untouched by troughs of despair and crests of elation. One person’s primrose path is another’s slippery slope to sorrow. Focussing on the quantifiable elements of pleasure are perhaps too crude a measure to determine the morality of an outcome.
Yes, it is too crude a measure. In a world scaffolded by choice architecture and philosophies of big and little government, we are not encouraged to yield our choices of what makes us happy or unhappy to administrative institutions. We have responsibility to inform ourselves and not to be so passive we don’t participate in the pursuit of the greater good within society. John Stuart Mill went so far to say:
“It is better to be a human being dissatisfied than a pig satisfied; better to be Socrates dissatisfied than a fool satisfied. And if the fool, or the pig, are a different opinion, it is because they only know their own side of the question.”
A contemporary quote from Austrian filmmaker, Michael Haneke reveals the importance of an engaged and informed audience:
“I give the spectator the possibility of participating. The audience completes the film by thinking about it; those who watch must not be just consumers ingesting spoon-fed images.”
So, who are we? What entertainment do you seek out? When there is so much competition for your attention. Including this Pressbook. Oh, bring back lectures, Stephen. This is deplorable. I don’t even know what solipsist means, but I suspect you are one. Or is it sophist or casuist? Oh, I don’t know. Why can’t I just cannulate and practice loading and unloading the stretcher? Why can’t I just do that? Okay, fair enough. I’ll stop. But being informed and engaged anchors our intellect. It is work; I know. The work, hard as it is, benefits society as we pursue loftier goals for our intellect and development as a species.
184.108.40.206 The Act/Rule Dispute
There are two main forms of consequentialism/utilitarianism (look, can we just call it utilitarianism). One is Act Utilitarianism (AU) and the other is Rule Utilitarianism (RU). AU looks at the consequences of each individual act and calculate utility each time the act is performed. It is situational. RU looks at the consequences of having everyone follow a rule and calculates the overall utility of accepting or rejecting the rule. It is universal and has its roots somewhat in deontology. Adherents to AU believe that following a rule in a case when the overall utility demands that we violate the rule is just rule-worship. AU proponents believe that if the consequences demand it, it is justifiable to violate the rule. Advocates of AU claim they can follow rules of thumb. Formed from accumulated wisdom based on historical outcomes. They will only engage in individual calculation when there is a pressing reason. Proponents of RU argue that subscribers of AU can justify disobeying important moral rules and violating individual rights. RU proponents believe it takes too much time to weigh the merits of each and every act in AU. It is a waste of effort and energy that could be better spent on measuring the outcome based on a different and streamline decision-making method.
1.2.3 Virtue Ethics
If I have understood Aristotle correctly, I need never have been told it is wrong to murder. Possessing virtue prevents me from ever getting to the point that I would murder. Being told not to murder another person is already too late a warning to heed. If I was a virtuous individual I should never I found myself in the state or position to take another person’s life. Being virtuous means that I have achieved a state of character, a balance, if you like, that prevents me from arriving at a precipice where I am considering killing. If I was virtuous, I would never contemplate, let alone achieve the psychological state required for me to murder.
Virtue ethics, unlike deontology or utilitarianism, focusses on character beyond and before contemplation of the ethics of a certain act or rule begins. According to Aristotle, possession of a virtuous disposition marshals us toward ethical conduct. This example of ethical theory is sometimes referred to as aretaic ethics, which translates from the Greek to mean excellence. It’s easier to understand how Bill and Ted led humanity to a utopian future. Imagine, if Bill and Ted had met Immanuel Kant. They would have been guided by very different set of principles. The story would be devoid of any humour. I may be making this up, but I’m sure Kant was never one for slapstick, one-liners or quasi-smut.
Instead of us asking: what is the ethical thing to do? Virtue ethics implores us to ask: what sort of person should I become? Virtue, deontology and utilitarianism frame the unethical (never mind illegal) conduct of murder differently. A deontologist has a duty not to commit murder. A consequentialist believes that murder is wrong because it produces undesirable consequences that outweigh desirable consequences. Consider a deontologist’s take on capital punishment and a utilitarian’s take on capital punishment. A virtue ethicist asks what sort of person would execute another in the name of justice? Virtue ethicists recognise that the path to ethical behaviour is governed by roles and leadership. It recommends a way of behaving that reinforces in others the acceptability of their own behaviour and subsequent conduct. The answers may be similar, but the frameworks are different.
Like Act or Rule utilitarians, there is an arbitrary nature in the measurement of individual behaviour. Measuring intrinsic qualities are nebulous. The adage: the proof of the pudding is in the eating is notably absent in virtue ethics. We can all claim to be virtuous; unless our virtue is tested. How will we ever know if our character meets the full-time, no half measures, work hard-play hard, all or nothing unyielding principles of virtue?
Like an Australian back-yard swimming pool at the height of summer, Aristotle is all about balance. Instead of the balance between acidity and alkalinity, virtue fixes its gaze on the balance between excess and deficiency. Extremes are not welcome in virtue ethics. An equilibrium is sought. This is the Golden Mean. Aristotle identified 3 dominant characters:
- The Akratic Person
- The Temperate Person
- The Continent Person
Aristotle talks of harmony and the unity of virtues. This means that virtues must co-exist as a collective. To be virtuous, you must be virtuous in every area according to Aristotle’s teachings. The exhibition of courage is its mean, or the balance between recklessness and cowardice. Contemporarily known as feeling the fear but doing it anyway. To achieve temperance, an individual must fulfil the needs of their soul and their body. Discretion and self-restraint are key to temperance. Generosity refers to the mean between excess and deficiency. Generosity ought not to know boundaries and generosity must be endowed with egalitarian principles. Pride is harder to pin down. Pride is used often in a pejorative context. Pride, in the sense of virtue, refers to being noble in character and not in relation to vanity. Aristotle also requires us to be gentle in our behaviour. It is the mean between anger and lacking spirit. A person should not be unfair with anger, but neither should they be servile and incapable of assertiveness. Friendship applies equally to friends and strangers and the one aspect of Aristotle’s virtues closely related to the Golden Rule. Wishing ill on another is unvirtuous. Finally, truthfulness. Truthfulness here refers not just to truthfulness with others but foremost truthfulness with ourselves. It is the mean between boastfulness and self-deprecation.
Virtue ethics in recent decades, unless it is related to hoarding toilet paper, has made a resurgence. As we increasingly fragment, virtue ethics might provide a cohesive approach to behaving in complex, pluralistic and secular societies. Virtue ethics emphasises internal traits. Not for Aristotle are wealth, status and power. Instead hard work and efficiency that benefits all equally are the basis of a resilient and prosperous society. I wonder what U.S. senator Joseph McCarthy would have made of Aristotle and his ethical theory of Virtue.
1.2.4 Ethical Egoism
The final ethical theory discussed in this chapter is ethical egoism. Like libertarian paternalism, each word is at odds with the other. Simply put, acting in self-interest will by default benefit others. Ethical egoists do not believe they are obligated to help others. Others are helped by result of their self-interest. Ethical egoism shares some foundational origins with consequentialism. Instead of emphasising happiness of the majority to determine the ethical nature of the conduct, ethical egoism emphasis the happiness of the individual.
By now, you have seen distinct ethical theories treat people in polarised ways. People have intrinsic values and it is acceptable to treat individuals as an end in themselves. People also have instrumental value and according to utilitarianism can be treated as a means to an end. Ethical egoists believe that (1) humans always act out of self-interest and (2), a normative view, we should act selfishly. Ethical egoism can be subdivided further:
- Personal Ethical Egoism
- I am going to act only in my own interest, and everyone else can do whatever they want
- Individual Ethical Egoism
- Everyone should act in my own interest
- Universal Ethical Egoism
- Each individual should act in his or her own self interest
Friedrich Nietzsche (1844-1900) struggled with the concepts of altruism and further, the Judaeo-Christian concepts of charity, piety, restraint and meekness. He was scathing of altruism, believing it was demeaning. He felt altruism was a power imbalance between the giver and the receiver. According to Nietzsche, selfless concern for the well-being of others, often at your own expense, forces the receiver of services to submit, and makes the individual a slave to the help. This sentiment is expressed in the proverb:
Give a man a fish and you feed him for a day; teach a man to fish and you feed him for a lifetime.
If you are familiar with Nietzsche, you may be tempted to attribute Hitler’s rhetoric to his philosophy. To do so does Nietzsche a disservice and we should park this philosophical association for a moment to examine Nietzschean philosophy at a distance from Nazism. Nietzsche encourages people to be the best they can. He advocates individual will, ambition, achievement and individuals maximising their potential as a societal driver. He pursued the concept of the Übermensch. He felt earthly rewards should be sought on earth, not wait to be received in an after-life. He advocated striving for achievements in personal life and not reward through serving others. Nietzsche believed that everyone is the best person to author their own interests based on the premise of sapience and self-awareness. He also eschewed the practice of helping others, this, leads to dependence and ultimately harms individual growth and subsequently, overtime, society. Individual improvements lead to collective improvements. Our aspirations drag people up with us. However, for Nietzsche it wasn’t all sunshine and lollipops. His regard for the proletariat wasn’t too hot, regarding most of us as the bungled and the botched. We, the great unwashed, do not pursue loftier goals, he believed. This pursuit instead is left to the lauded 1% of the population. And the other 99% dwell in poorly lit noxious societal mediocrity.
Nietzsche holds some merit despite lacking in popularity and continues to be admired globally. In more recent decades, ethical egoism has undergone revaluation and development. Enlightened self-interest claims that individual will benefit more from cooperation than non-cooperation. Society is built upon cooperation between interests: roads, schools, institutions etc. all result from enlightened self-interest. In her opus published in 1957, Ayn Rand wrote:
“For centuries, the battle of morality was fought between those who claimed your life belonged to God and those who claimed that it belongs to your neighbours – between those who preached that the good is self-sacrifice for the sake of ghosts in heaven and those who preached that the good is self-sacrifice for the sake of incompetents on earth … And no one came to say that your life belongs to you and that the good is to live it.”
You know what, I’m going to make a bold claim and state that everyone in this unit is an ethical egoist. Everyone who wants to be a HCP is an ethical egoist and I will call trot if you say different. And here’s the Goldilocks zone informed approach to getting interviewed to become a HCP if you are an ethical egoist, which, of course, *goes without saying* you are:
So, it’s possible to be an ethical egoist and benefit society. Like all the other ethical theories introduced here, it’s not without detraction. Here are a couple of probing questions to test the merits of ethical egoism:
- What happens to fair play?
- o Assumes a world full of strangers, indifferent towards each other
- What would love or friendship look like?
- o Moral insensitivity
There are many others, of course. We’ll leave them for tutorials. Or perhaps we won’t. It’s up to you.
1.3 Ethical Decision Making
There are a variety of approaches that HCPs may use to identify and respond to ethical dilemmas arising in their practice. The information presented below is one way to approach these issues but is not the only way. Ultimately, each HCP must reflect about ethics and ethical decision-making and take responsibility for integrating ethics into their professional practice. Ethics is not a black and white subject – it involves reflection, communication, discussion and debate. It is an area where well-intentioned people can, and do, legitimately differ as ethical problems are complex. For all health professionals, ethics might be experienced as: ethical violations (incompetent or deliberate wrong-doing in care); ethical dilemmas (arising from a situation where there may be opposing, but equally morally legitimate approaches to resolve a dilemma); or ethical distress (moral distress (guilt, concern, distaste) arising from action or inaction imposed upon a person by another health professional, organisation or government).
The following sections will guide you how to resolve ethical dilemmas. You will be helped as you develop the skills of critical analysis and appraisal. Building on the work of others, the following sections will use the 3 ‘C’s to understand and appreciate alternative arguments better. From the mixed premise of cogency, coherence and congruence we will examine arguments, expose flaws and be able to put forward strong ethically reinforced justifications for our acts and omissions in nuanced contextually complex (feel free to add another 2 ‘C’s to the 3 ‘C’s suggested prior) situations.
1.4 The Four Principles of Bioethics
We’ve seen that the study of ethical behaviour has a long history. Surprisingly perhaps, medical and bioethics have a significantly shorter history. For one, the first edition of Tom L Beauchamp and James F Childress’ seminal Principles of Biomedical Ethics was published just over forty years ago. According to the authors, the four principles of Autonomy, Beneficence, Nonmaleficence and Justice do not exist in a hierarchy but stand horizontally, equal to one another. The next four sections outline briefly each of the principles. If you want to know more, the library has a copy of the most recent edition of their seminal work. Like with the topics discussed already, there are strengths to the principlism (the collective term for the for principles of bioethics) discussed here and there are weaknesses. Some of these will be relative to your own experiences and understanding, which will change over time. Okay, ready? Strap in, let’s go.
Autonomy can apply in any sense, from buying a car, to purchasing life insurance, to getting a tattoo. People with capacity (chapters 4 and 5, from memory so don’t worry too much at this stage) can make choices irrespective of whether those choices are rational or irrational judged by objective standards. We’re only going to talk about autonomy, or the right to self-determination as it is sometimes known, in relation to healthcare. It means that patients have the right to be informed and they can make a choice between ingesting the blue pill, ingesting the red pill or not ingesting any pills. Patients have the right to question our motives and seek more information before making an informed choice. Although it’s not exclusive to autonomy, and is applicable to the other principles of bioethics, respect is a key feature. Upholding autonomy requires us to adopt a virtuous approach to caring for patients. This is seen in codes of conduct. We owe many professional obligations to our patients, and this list is not exhaustive: communication, confidentiality, truthfulness, promise keeping, and so on are just a few. Autonomy and human rights share a common bond. It is worth knowing that whenever a person claims a right to something, this creates an obligation in another to ensure that right is upheld. What happens if claims are contested? What happens if expectations cannot be met?
There are two conditions essential for autonomy: Liberty, an independence from controlling influence; and Agency, a capacity for intentional action. The autonomous person acts intentionally, with understanding and without controlling influences determining outcomes. Sorry to keep mentioning capacity when I haven’t explained fully what capacity is, but I need to allude to it one more time. If you need more information, head over to chapter 5 and there will be a section on capacity. In the meantime, autonomy, like capacity, is not a fixed state. It sits on a continuum. Wholly present at one extreme of the continuum and wholly absent at the other end of the extreme, with acres and acres of real estate in between. For autonomy to be present, criteria need to be met. To be held to be autonomous, a person needs to possess a level of understanding and be free from constraint.
Beneficence requires us to conduct ourselves in a way that benefits others. HCPs need to contribute to patient’s overall well-being. Beneficence focusses on commission. Beneficence requires us more often than not to do something, rather than refraining from doing something to provide collective benefit. I could refrain from assessing you at the end of semester, and you could argue that will be of benefit to you. Isn’t it incumbent upon me to cater to the greater population? Surely, I need to set standards that need to be reflected in the care you provide. Assessment is just one method to determine adequacy. By all means, it is not the only way. Y’know, growth, mind-set, that sort of stuff is important too. You will be familiar with the phrase commonly misattributed to Abraham Lincoln’s administration: You can please some of the people all of the time, you can please all of the people some of the time, but you can’t please all of the people all of the time. As a university lecturer, I am certainly familiar.
Despite the obvious challenges of meeting everyone’s expectations all the time, certain obligations relative to the demands of any profession are incumbent. How do we know which obligations to meet? Institutional requirements dictate some obligations to benefit others. HCPs have specific obligations to benefit patients in their care. As we will learn in chapter 4, there is no legal duty to rescue another whom you do not owe a duty of care. There may be a moral duty to rescue but this is discretionary and therefore not an enforceable duty. Moral culpability is in proportion to obvious limitations. If I have a mobile phone within range of a telecommunications mast, and I witness a person collapse and I do nothing (and there is no external force influencing my ability to call the emergency services on my mobile phone). I have failed in my moral duty to do good. Contrast this with this scenario: I witness a person fall overboard from a boat. I am not obliged to jump in after them. The personal risks are too great. I am, however, obliged to inform the person in charge of the craft so they can take steps to help them. Beneficence is relative and obligations can be broken down into constituent parts. There is general and specific beneficence and in addition, there is obligatory and discretionary beneficence.
Unlike beneficence, non-maleficence is the moral principle that requires HCPs to not engage in harmful conduct. You are probably familiar with the Hippocratic Oath. If not all of it, then probably the following ethical standard:
Do no harm
Harm can be caused to patients in several ways that are not limited to: failure to provide care to the best of my ability; to act in a way not condoned by my profession’s code of conduct; exploit patients; self-report and report others to the (regulatory) authority if serious harm has occurred, is occurring or at risk of occurring.
Of course, it is impossible to do good in healthcare without causing harm. Intravenous analgesia is delivered following venepuncture; lifesaving drugs are often administered this way. An inflated sphygmomanometer isn’t especially comfortable but finding out about hypertension early could save your life. And if you read the side effects of most all drugs, death is usually found there. The benefit outweighs the risk. We will return to non-maleficence in chapter 5 when we discuss the law of negligence and when we look at laws on voluntary assisted dying (VAD).
Justice, the final of the four principles addresses concepts of fairness and equality. Captured in this one term, is a threefold duty to ensure fair distribution of limited resources (distributive justice); respect patient rights (rights-based justice) and respect morally acceptable laws and to be accountable and transparent in your actions and omissions as a HCP (legal justice). The area that we will focus on most here is distributive justice and the work of John Rawls. In terms of healthcare, it is not advised to contemplate justice too narrowly. In a fair and just society where everyone’s behaviour is beyond moral reproach all things ought to be equal. We now know that’s a load of codswallop. Distributive justice means that services should be distributed evenly. What happens when demand outstrips resources. What if there are 10 intensive care beds, 10 ventilators and 20 patients are needing to be ventilate? Should the resources be distributed like a lottery? Or should other factors be considered? Should the patients only be assessed based on survivability? Does it matter if the patients have dependent children or not? What if 10 patients are unemployed and 10 have jobs, should this make a difference? What if 10 of the patients were working on a human vaccine to COVID-19 and the other 10 sold military hardware for a living? Oh, I could go on, but I won’t.
Perhaps it is a basic human right to access basic healthcare, but what is basic healthcare? Wherever you go in the world this will look very different. I’m going to take a wild guess and say, in Brisbane, there are more community defibrillators than there are public telephones. It’s a bold claim and I’m happy to be proved wrong. Do you think this is reflected throughout the world? In some countries, yes but in many, nopey nopey no no. Why do you think this is? Knowing the importance of early compressions and early defibrillation is to cardiac arrest survival, shouldn’t there be a fair and equal distribution of defibrillators throughout the world? How you answer this question is determined by your own horizon. And is it a horizon on the edge of a big or a little sky?
According to Rawls, “the most reasonable principles of justice are those everyone would accept and agree to from a fair position”. Like autonomy and capacity, this statement reveals that belief how goods and services should be distributed sits on a continuum and can change based on pollical uncertainty. Forgive the pessimism, but I sometimes wonder if whether it is the pinches in peoples’ pockets that influence a willingness to accept equal and fair distribution of goods. Or perhaps, if not the pocket then in the event people are just plain misinformed, could prejudice influence the distribution of essential goods and services.
Consider an obstetric surgeon. She is performing an emergency caesarean section because the unborn child’s heartrate dropped dramatically and suddenly. The emergency dictates that the pregnant woman will have to have her baby delivered under general anaesthetic. There is no time to lose. After successfully delivering the mother of her baby our surgeon begins the process of suturing the mother. On close inspection of the patient’s uterus our keen-eyed surgeon identifies an abnormal growth on the wall of patient’s uterus. She suspects that the abnormal tissue is a tumour and removes not just the tumour but the women’s uterus entirely. The surgeon has just saved the patient’s life. Histological pathology reveals cells in the tissue were cancerous. The patient is now the mother of a healthy baby, she is cancer free and as a result of the hysterectomy incapable of further pregnancies. Consider these questions:
- How does the mother feel about this?
- Sure, lifesaving treatment was provided but did she consent to a hysterectomy if her life was in imminent danger?
- What about autonomy and self-determination?
- Were there less intrusive methods that could have eradicated the cancer and prevented its spread?
- But the surgeon acted quickly and saved her life. She had a responsibility to benefit her patient and not do harm. Doesn’t this trump her patient’s claim?
- Do you think the surgeon acted in the patient’s best interests?
- Does necessity always override consent?
- Should identification of future harm be a principle that informs a decision to undertake additional surgery?
Perhaps you think this is the stuff of legend and put here to deliberately provoke a reaction. Perhaps not.
1.5 Using a Framework Approach to Resolve an Ethical Dilemma
Ethical theory is all well and good. But they are just theories. Theories carry different weight. Some theories are a slow burn or go through periods of critique, analysis, reappraisal and evaluation for contemporary application. HCPs are by necessity a practical bunch. Resolving ethical dilemmas requires a practical application and approach. I am including other authors’ works here. You are not limited to these works and you can adapt your own to suit circumstances. They are not meant to be rigid. Flexibility is key. They all offer a process that takes into consideration multiple perspectives.
The first one is adapted from QUT’s Faculty of Law, the second is from Ruth Townsend and Morgan Luck’s Applied Paramedic Law, Ethics and Professionalism, and the final one from Noel Preston’s Understanding Ethics.
I’m going to call this Old MacDonald’s Ethical Framework. I know it doesn’t work exactly but that’s what it made me think of. See what you think:
Old Macdonald had an ethical framework
Well, now that I’ve got that earworm locked in, you probably want to know what it all means.
There are many similarities between this ethical framework and the one developed by QUT’s Faculty of Law. Essentially, they are very similar, but the ethical framework suggested by Townsend, Luck & Steer is it lends itself to modification and adaptation to circumstances.
1.5.3 Preston’s Ethic of Response
Finally, I’ll provide an overview of Noel Preston’s Ethic of Response. I favour this one out from all of them because it not only provides a structured approach to resolving ethical dilemmas, it relates its structure to ethical principles that underpin the theory of what we do with why we do.
1.6 Contemporary Application of Ethical Theory
Phew, nearly at the end. I’m not going to spend too long here. We will revisit this area again in Part Two of this book. It is helpful to introduce contemporary medical ethics here broadly. In the last half a decade in Queensland we have seen changes to the law on consent, termination of pregnancy and time to debate voluntary assisted dying in Queensland has been tabled. On the 1 January 2020 the Human Rights Act 2019 (Qld) came into force. We have seen how technology can be used to limit the spread of infectious diseases and concerns its use raises in relation to privacy and restraint on personal liberty and curtailing of some freedoms.
Here are some issues in relation to biotechnology:
- Biotechnology: use of living systems or organisms to make or modify products, improve plants or animals
- o Agriculture & Medicine
- Implications are often unknown, may challenge common social understandings, may have resource implications – economies, developed/developing worlds
- Technological growth means biotechnology will continue to produce some of the great ethical dilemmas of our time
With advancement in technology comes some fundamental questions that can only be addressed through examination of ethical theory to determine acceptability of outcomes and the legitimacy of the methods used to achieve those outcomes.
1.7 Final Thoughts
1.8 Case Study
Mitchell and Farsal have been tasked to a 24-year-old female complaining of a significant per vaginam (PV) bleeding. On arrival Mitchell carries out a primary assessment of the patient and believes that the patient may be presenting with an ectopic pregnancy. Mitchell enquires more about the patient’s history and requests to examine the patient. She declines, stating that she doesn’t want to be examined or treated by a male and requests a female paramedic. Mitchell contacts his dispatch to determine whether this will be possible. Dispatch state that the closest crew to them is 45 minutes away and it is also an all-male crew. Mitchell informs the patient and she reasserts her position that she doesn’t wish to be treated by a male paramedic. From what Mitchell can determine in his limited assessment the patient’s presentation is serious and will deteriorate if intervention and transport is not commenced.
1.9 Suggested Readings
- Moritz, Dominique (ed), Paramedic Law and Regulation in Australia (Thomson Reuters (Professional) Australia, 2019) pp 17-42
- Beauchamp, Tom L & Childress, James F. Chapter 9: Moral Theories. Principles of Biomedical Ethics. Oxford University Press. 2013 pp 351-389
- Berglund Catherine. Ethics for Health Care. Oxford University Press. 2012 pp 45-70
- Preston, Noel. Understanding Ethics. The Federation Press. 2014 pp 57-70
- Kirby L, Tregenza K and Richards K, 'Every K over is a Killer: Behind the scenes' (2003) ARRB Transport Research, Limited. ↵
- http://www.sidewaysthoughts.com/blog/2014/03/speeding-tickets-and-kohlbergs-model-of-ethical-decision-making/ ↵
- “Our new Constitution is now established and has an appearance that promises permanency; but in this world nothing can be said to be certain, except death and taxes.” https://freakonomics.com/2011/02/17/quotes-uncovered-death-and-taxes/ ↵
- https://www.poetryfoundation.org/poems/44272/the-road-not-taken. ↵
- Bentham, Jeremy, The Principles of Morals and Legislation (Prometheus Books, 1988). ↵
- Mill, John Stuart and George Sher, Utilitarianism (Hackett Publishing Company, Inc., 2002). ↵
- http://www.peterboroughartscinema.co.uk/2013_02/docs/amour.pdf. ↵
- Rand, Ayn, Atlas Shrugged (Dutton, Centennial ed 2005). ↵
- this paragraph has been adapted from QUT’s Faculty of Law LWS 101 Ethics Law and Health Care unit. ↵
- Beauchamp, Tom L. and James F. Childress, Principles of Biomedical Ethics (Oxford University Press, Eighth edition. ed, 2019). ↵
- Rawls, John, A Theory of Justice (Belknap Press of Harvard University Press, Original edition. ed, 1971). ↵
- Rawls, John, A Theory of Justice (Belknap Press of Harvard University Press, Original edition. ed, 1971). ↵
- https://tinyurl.com/ycet5fz3 ↵
- Townsend, Ruth and Morgan Luck, Applied Paramedic Law, Ethics and Professionalism (Elsevier, 2nd ed, 2020). ↵
- Preston, Noel, Understanding Ethics (The Federation Press, Fourth edition, 2014). ↵
- Look, I can’t base this on fact because I know nothing about coding and app development. I footnote here just as a point of interest, but who would have thought that the software used to help people hook-up with other people nearby could be used to track and trace people infected with COVID-19? The technology must be the same. It’s just the nature and the purpose of the engine used to run such software differs. Essentially the only thing that changes is the branding and subject matter. ↵