Ethical decision making

Dr Louise Dale, MDU medico-legal adviser, asserts that medical ethics drive every professional decision a doctor makes and advises doctors in training to start to develop their ethical shadow.

Have you ever felt that uncomfortable uncertainty that sneaks up when you have to make a decision with obvious ethical conflict? Some common examples that doctors of all grades and specialties may identify with are:

  • deciding how to resolve a patient's lack of capacity to consent to life-saving treatment 
  • whether to disclose confidential patient data to third parties, such as insurers or the DVLA
  • the validity of an apparent advance decision.

In the late 1990s, I wrote a dissertation for an MA in Medical Ethics and Law outlining my belief in an ethical dimension, or ethical shadow, that co-exists in every medical decision. This belief remains as firm as ever.

How to develop your ethical shadow infographic

The 'ethical shadow' influences a doctor's reasoning, whether consciously or subconsciously - for example, when deciding if, when and how to treat a patient. In the last 10 years, the MDU has opened over 8,700 advice files which involved some aspect of ethics or ethical decision-making, mainly regarding consent, confidentiality, end of life care and boundary issues. See infographic above.

I believe it is vital to good medical practice that all doctors develop a specific sensitivity to the ethical dimensions of every situation they encounter. This should start as a student in medical school, and continue to be honed throughout a medical career. Fortunately, teaching of medical ethics - once considered trivial, redundant or impossible (Hope, 1998) - has come a long way and is now an integral part of medical training.

Ethical strategies

What strategies are available to help doctors reconcile the ethical component of their decision making?

Medical ethicists have traditionally based their teaching on two moral philosophical theories: consequentialism and deontology.

Consequentialism is self-explanatory: it is a way of making your decision, or guiding your action, by deciding on the outcome with the best consequences, for one person, or for a group. Deontological reasoning has no concern for consequences, just for duty. For example, choosing to tell a patient the full extent of their terminal condition, on the basis that it is always right to be honest. Deontological decision-making models are often based on the four principles of professional ethical duty - autonomy, beneficence (doing good), non-maleficence (not doing harm) and justice.

Other ethical theories are very different from the impartial, apparently universal doctrines of deontology and consequentialism. They include virtue ethics, where a doctor makes a decision because that is what the virtuous, conscientious or person of integrity might do. Sometimes, you may also act in ways that favour the particular specifics of a discrete section of the community (communitarian ethics). You may sometimes act through communication with all relevant parties taking into account the particular details of individuals and their relationships with the people around them, encompassing some of the reasoning of feminist ethics. You will appreciate that these theories are situation-specific. Some contemporary medical ethicists would argue that they are more appropriate for medical decision-making.


The 'ethical shadow' influences a doctor's reasoning, whether consciously or subconsciously


In practice, you will be juggling many philosophical models to reach a decision about a patient's care, and often without realising it. Whenever there is choice, a decision must be made. So often in medicine the ethics involved in each of the options collide, and there is no absolute right answer. When you document and justify your reasoning in the records, you will be consciously or unconsciously giving voice to an ethical theory of some sort.

My work with MDU members has shown me how difficult we, as doctors, find some of the ethical dimensions of our decision-making.  But personal reflection and learning help build confidence in making difficult decisions, especially those which appear only in shades of grey.

For me, medical ethics forms the very frontier of our profession's development.  Whichever approach you choose, strong awareness of your ethical 'shadow' and sensitivity to the ethical aspects of your decision can only enrich your personal career development, as well as promoting good practice to the benefit of patients.

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