Ethical theory John Dunn

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Ethical theory John Dunn

• Thanks for slides to
• John Gillies
• Associate Adviser
• GP Unit
• Lister Institute

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Ethics and ethical theory.

• Applied (e.g. medical) ethics aims to give
  guidance on what to do in particular moral
  problems or controversies
• Ethical theory attempts to offer general rules or
  concepts relating to how individuals,
  institutions, the NHS and government should act
  or behave

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Theoretical approaches.

• Deontological
• Utilitarian/ Consequentialist
• Virtue Ethics

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Deontological theories

• These stress the idea of duty. (Gr. deontos
  duty, logos discourse). Whether an act or policy
  is right or wrong is determined by the action
  itself, rather than the consequences. The
  intentions of the person are seen as morally
  relevant.
• May be based on divine command, on works of
  Kant, Thomas Nagels idea of deontological
  constraints.
• ONeill O. Kantian Ethics. In A Companion to
  Ethics. pp.175-185 Ed Singer P. Blackwell 1991.

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GMC duties of a Doctor

• Front page of Good Medical Practice
• How many can you name ?

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Problems

• Good intention
• Bad effect

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Deontology in Practice

• Elizabeth is dying from disseminated bone cancer
  at home. Her GP gives increasingly large doses
  of diamorphine by syringe driver to relieve her
  pain and suffering. She dies after a few days
  from a bronchopneumonia.
• The diamorphine, by causing respiratory
  depression, may hasten her death. It is a
  foreseen but unintended consequence of the GPs
  use of opiate. The action is morally justified by
  the intention of the GP to relieve pain and
  suffering

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Doctrine of double effect

• The act must be good or at least morally neutral
• The agent must only intend the good effect. The
  bad effect may be foreseen, tolerated and
  permitted but not intended
• The bad effect must not be means to the good
  effect
• The good effect must outweigh the bad effect

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Utilitatarianism Consequentialist approaches

• Based on the idea that the right action in any
  situation is that which produces the best
  consequences or outcomes
• Most influential of these approaches is
  Utilitarianism maximising utility (the good) or
  happiness
• Goodin R Utility and the good. in Companion to
  Ethics. pp.241-248 Ed Singer P. Blackwell 1991.

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Video 1

• From a deontological point if view was the Drs
  actions correct ?
• Did the Dr in the video behave in a morally
  correct way?

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Utilitarianism and EBM

• Evidence-based medicine (EBM) is at heart an
  Utilitarian approach
• Greatest good for greatest number

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Problems EBM

• Evidence is based on a reductionist paradigm--
  look at small parts of the picture and
  extrapolate-- (inherently non-holistic)
• Evidence is nearly always based on data derived
  from populations, then applied to individuals,
  (the ecological fallacy)

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Problems EBM

• Hierarchy of evidence-- the dominance of the RCT
  privileges pharmacological interventions over
  others (e.g. in hypertension)
• Much research funding comes from the
  pharmaceutical industry--more difficult to
  identify funding for psychological/ other
  interventions

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Ethics of utilitarian EBM

• Much evidence is on interventions in single
  diseases, within circumscribed age limits, in
  very well defined situations
• The content, direction and peer review of
  research is driven by the scientific community
  rather than by consumers or patients
• In GP, we treat many conditions for which
  evidence is scanty, contradictory or absent

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How should we use evidence?
The problem The facts dont tell you what to
do Erkki Vartiainen, 2003 The patient in front
of you was not in the trial Jonathan Rees,
dermatologist 2004
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Video 1

• From a utilitarian point of view was the Drs
  actions correct ?
• Did she ensure the greatest good for the greatest
  number ?

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Virtuous Doctor

• Must combine science and compassion
• How do we do this ?
• It is challenging enough to remember the science

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Edwins Doctor

• Read Edwins description of his Doctor
• What qualities did he have ?

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Perceptual capacity Virtue

• Helps you to decide what to do when you dont
  know what to do.
• This is one of the greatest challenges facing a
  GP day to day

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Video 1

• Did the Dr behave in a virtuous manner
• Did the Dr take into account the patients
  situation and concern was she emotionally
  involved ?

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Virtue in Practice

• Bob 63 diabetes ,stage 3 renal failure
  ,Hypertension, Hypercholesterolaemia,
• BP137/86
• Renal Clinic advise 5th antihypertensive to get
  BP below target of systolic 130 in line with
  guidelines
• Bob then on 16 medications doesn't like taking
  tablets
• 10 year risk of CVD event falls from 22 to 20
• NNT 10 years 50
• What do you do ?