alright friends tonight we’re going to talk about medical ethics. omg sounds fun right? what better way to spend our holy shit is it friday?! night?
alright medical ethics. sounds simple right? it’s medical. it’s ethical. it’s medical ethics. just help people! right?
okay so medical ethic consists of four sometimes overlapping sometimes competing principles: beneficence, non-maleficence, autonomy, and justice. (apparently i can only spell two of those go figure.)
beneficence is like the easy obvious one. heal! help people! make better!
non-maleficence is the inverse of that. it’s the famous “first do no harm”. (which btw does not actually appear in the hippocratic oath. that’s not important to this conversation i just wanted everyone to know just in case it came up in final jeopardy one day or something.)
non-maleficence is sort of the check yourself before you wreck yourself of the medical profession. making sure that while attempting to do good you don’t accidentally do more harm. every treatment, every test, everything we do has potential complications and side effects. some more dangerous, some more common but they’re always there.
non-maleficence is why we usually don’t operate in older men with prostate cancer. yes we can cure their cancer but chances are they’ll die of something else before the cancer gets them so why not not put them through the pain of surgery? it’s why we don’t vaccinate for smallpox anymore. because while making everyone immune to a deadly disease sounds good on paper way more people would die from vaccine side effects than are ever likely to die of smallpox again. do no harm.
autonomy is all about consent. patients must must MUST consent to treatment. i cannot touch you unless you do. (exceptions: presumed consent in emergencies, psych patients deemed not to have capacity to make decisions, and i can render life-saving treatment to a child over (parental) objection.) and that consent must be informed. consent requires the communication of the risks, benefits, and alternatives of the proposed treatment. it requires that a patient understand those things, gel them together in their mind, arrive at a decision, and then communicate that decision back to me.
autonomy recognizes that patients have absolute and final dominion over their own bodies and any decisions regarding it are theirs to make with all information available.
and last justice is the big picture one. justice is doing the most good for the most number of people. justice is what allows a triage system in a mass casualty incident to pass over patients with slim but existent chances of survival in favor of those we’re more likely to save. justice is what allows us to hold people who are public health risks against their will if need be.
fun fact: while we can lock public health risks up in hospitals autonomy remains in play when it comes to actually taking their meds. i can make you stay in isolation but i can’t force you to take you medication. that just goes to show that these four concepts are in constant interplay.
so why am i even talking about this? (maybe i shouldn’t have waited to half way through this post to get to that point but.) ebola of course! because i think everyone needs to understand the medical ethics underlying the decisions of when and on whom to use these highly experimental treatments. so let’s see how they all interact.
beneficence is why anyone’s researching ebola treatment in the first place. (believe me a rare disease of impoverished african nations is not a big moneymaker for pharm. antihypertensive and lipid lowering agents are where it is at. treat the disease of rich white americans.)
so now maybe you have a potential treatment but you can’t just run out willy nilly and start giving it to people. who knows what it does? who knows if it’s safe? non-maleficence is why any potential drug is going to be heavily tested in animals first.
because what if there’s an unexpected side effect? what if the current ebola death rate is only 65% but the drug actually kills 95% of recipients? you just killed a whole bunch of people who might have lived if you haven’t given them this unknown drug. that’s not non-maleficence. that’s doing a lot of harm.
of course beneficence and non-maleficence is a balance. which is why in this case some people did get the treatment. if you’re looking a patient like “this person is going to die either way” well you can’t do much more harm then huh? that’s the grounds for what’s called compassionate release of treatments like this. you literally can’t do more harm so why not gamble on maaaaaybe doing some good.
so why not compassionate release for EVERYBODY! wouldn’t justice demand that? the most good for the most number?
because autonomy. because informed consent. because a patient has to understand fully exactly how untested and potentially dangerous a treatment is. and honestly it’s unlikely that your average ebola victim can offer that. and without that consent well you’ve just manipulated a scared and undereducated person into taking a dangerous treatment they don’t understand and thus can’t fully truly decide if they want. you’ve violated their autonomy. their right to have the last word on what goes on with their body.
one interesting comprise which isn’t the right word but i can’t find one that really works i heard offered by a medical ethicist at where i did my med school is to try to make the treatment available to infected healthcare workers. because they’re the people who would be able to actually give true informed consent. and treating them and getting them back on their feet and out there helping other victims does the most good for the most people.
so congrats you officially know everything i know about medical ethics. standard disclaimer: while medical ethics is a required course in medical school, i am fundamentally an emergency physician not a medical ethicist. if any medical ethicists want to disagree with me here i’d listen to them. ;-)
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