Norwich Prof discusses heart of medical ethics
Medical ethics questions get to the heart of what it is to be human and what a human life is worth, Professor Sam Leinster, Dean of the School of Medicine at Norwich’s University of East Anglia, told a recent meeting of Churches Together in King’s Lynn. Peter Coates reports.
Sam is a Christian and member of Dereham Baptist Church. He was a surgeon in the RAF and worked in Oman. He was professor of surgery at Liverpool and he specialises in oncology, particularly breast cancer. He now works in Norwich where he is responsible for the UEA’s School of Medicine. He is a member of the Norfolk & Norwich University Hospital’s clinical ethics committee.
People tend to think of medical ethics in terms of the important issues which are written about in the press, including the beginning and end of life issues involving embryo and stem cell research, abortion, euthanasia, and assisted suicide, said Prof Leinster.
However, most of the issues dealt with by a hospital clinical ethics committee relate to everyday medicine. These issues might include confidentiality, consent, fairness and altruism. If the patient is not capable of giving consent, only the doctor is legally allowed to undertake consent for the patient, although the next of kin’s views would be considered. The law assumes that the doctor will act in the best interest of the patient.
There is no code of conduct for medical ethics. Ethics is a tool for analysis which is descriptive and not prescriptive. Responsibility, truth, honesty and integrity are some of the general component principles of ethics. Each case has to be analysed individually. What is the reasonable aim of treating a particular patient, are we primarily trying to preserve life or preserve the quality of life?
The role of the physician is to cure sometimes, help often and comfort always. Ethics questions get to the heart of what it is to be human and what a human life is worth.
One commentator and philosopher, Peter Sentence, has stated that a healthy aware dog is more valuable than a severely demented person. This view would be unacceptable to Christians because a demented patient still has a relationship with God, said Prof Leinster.
Should a woman who is over 55 years of age be allowed to have an ovarian transplant in order to have a baby? In this case we need to take into account the future needs and autonomy of the child. Or should a patient who is aged 80 be persuaded to have surgery? If the patient’s relatives ask you not to tell the patient if cancer is discovered, should the doctor follow the relative’s advice? Which of the ethical principles would be broken in this case? The answer is that the doctor would be acting against truth.
Some ethical questions are, in fact, technical, said Prof Leinster. The case in the press several years ago in which the doctors wanted to stop giving chemotherapy to baby B after the leukaemia failed to respond to three cycles. The parents took the doctors to court and the court ordered that a further cycle of chemotherapy should be given. The child sadly died shortly after the doctors complied with the court’s instructions.
Similarly, it is a technical problem if a 60-year-old, who has inoperable cancer, demands surgery. If a previously healthy seven-year-old was involved in a road traffic accident and, after being admitted via A+E, required an ITU bed, but the ITU was full. The solution would be to move an 85-year-old who was on a ventilator, and who was suffering from advanced cancer, onto a nearby high dependency ward where ventilation could continue if necessary.
More specific ethical principles are laid down in law. Euthanasia is against UK law. Abortion is governed by law and there are NHS laws. The Hippocratic Oath is no longer used but doctors are governed by the declaration of Geneva made by the World Medical Association in the 1940s. There is also a Tokyo declaration which forbids any doctor to associate with torture in any way.
If you ask a selection of medical students their views of ethics, the students may be a mixture of Christian, Muslim, atheist or other faith but they tend to come up with these same principles.
For Christians, God is the ultimate reality and God redeems and glorifies each of us. Each of us is created in the image of God who is rational, volitional, creative and relational. In the Trinity, God lives in perfect relationship. Our value is our relationship with God. The value of a human life is that God died for each of us and we constantly reflect on this altruistic God while we are gradually transformed to the image of his son. Because each individual is of infinite value to God, we must treat people equally.
The four general principles of medical ethics are: Beneficence (giving benefit); Non-maleficence (avoiding damage); Autonomy (the patient has a will of their own and doctors can only advise), and Justice (equality of treatment for all in proportion to need).
The relationship between the doctor and the patient is seen as a shared agreement in which both can put their views in the planning of management, said Prof Leinster.
Some specific ethical problems in medicine include: confidentiality, duty of care and informed consent. The problem is that if more than one ethical principle applied to a case there may be a conflict between principles. For example, if you, as a doctor, knew one of your patients to be HIV positive but you also knew that this person did not want to tell their partner, what would you do?
To tell the partner breaches confidentiality while not to tell the partner could put the partner’s health at risk. There is a conflict here between duty of care and confidentiality and duty of care must take precedence.
Similarly if a doctor discovers a crime which threatens the public’s safety, the doctor would be duty bound to discuss the crime with the police even if this meant breaching confidentiality. However, the doctor would first try to persuade the person to be truthful themselves as this would lead to the best outcome for all.
The doctor must always think of the consequences of his actions. In certain circumstances abortion is the lesser of two evils but Catholic doctors would feel completely banned from being involved in abortion. We also have to remember that some actions can lead to the slippery slope.
For example, if we were to legally allow assisted suicide it would soon become accepted practice in people’s minds and would make it easier to take the next step in euthanasia.
David Steele, who introduced the first abortion law in the UK, did not foresee that we would now be legally tolerating over 100,000 abortions per year. At the moment the authorities in the Netherlands are turning a blind eye to assisted suicide. There is also the double effect in which morphine is given with the intention of relieving pain but due to side effects on respiration it may shorten life.
How do we apply the principles of medical ethics in each individual case? First we decide what the issues are, then we decide which ethical principles apply, then we discuss with the patient and with other people and finally a decision is made, said Prof Leinster.
Pictured above is Professor Sam Leinster.