“It is not only what we do, but also what we do not do, for which we are accountable.” (Molière).
Medical ethics principles
Medical ethics is founded upon 4 moral obligations (principles):
- Autonomy: Competent adults have the right to decide what happens to them, regardless of the consequences their decisions may have upon their health and wellbeing. For example, a patient may decide to refuse treatment, even if doing so will end their life.
- Beneficence: A doctor must endeavour to achieve the best outcome for every patient and to improve the patient’s health. Attention must be given to the idiosyncrasies of the individual patient, the disease process and potential outcomes.
- Nonmaleficence: A doctor must avoid harming patients at all costs. Careful consideration should be given as to whether the risk associated with a particular course of action outweighs the benefit to the patient.
- Justice: A doctor’s decisions must be fair, transparent and defensible.
Beneficence and nonmaleficence can be viewed as opposing ends of a continuum upon which the risks and benefits of a particular course of action can be plotted. For example, considering the risk of death from general anaesthesia against the benefit of surgery to treat colon cancer, or whether commencing a patient on a third line chemotherapeutic agent known to have severe side effects outweigh the potential benefit to the patient if the expected outcome is to extend their life by three months? When considering any risk-benefit ratio, the aim should be one of an overall benefit to the patient. This is often referred to as beneficence without maleficence and whilst desirable, it may not always be achievable. Unfortunately, ethics (like much of medicine) is not always black and white, and careful consideration is necessary to navigate the grey areas.
The aforementioned principles have formed the basis of several expanded codes of ethics, which explicitly detail obligations and behavioural guidelines for doctors. These commonly cover such areas as (but are not limited to), patient care, clinical research, self-regulation and professional conduct. Examples of these can be seen in the resources listed at the end of this chapter. It is important to be aware of all guidelines produced by the licensing bodies with which you are registered, as well as those of your employer.
Ethical dilemmas commonly occur in cancer and palliative care in areas such as informed consent, treatment options (e.g. cost/benefit ratio, early phase clinical trials), disclosure of information regarding disease (e.g. communication of prognosis, whether the patient understands the information provided, or family member requests not to disclose information to the patient), the introduction of end of life care and patient “do not resuscitate” preferences. Advances in medical knowledge and discovery also give rise to discussion regarding their ethical merit (e.g. stem cell research). Issues such as cost and availability of resources place additional pressures on fair and equitable delivery of cancer care, as was recently highlighted by the limited supplies of chemotherapy agents. How does one decide who receives limited optimal treatment and who receives a (lesser) alternative? Debate surrounding the cost benefit ratio of expensive chemotherapeutic agents has been an ongoing issue of dispute for several years.
Clinical trials are commonplace in the treatment of cancer patients and the ethical conduct of human research is paramount to ensuring that the health and wellbeing of patients are maintained and protected. Whilst Albert Moll argued against the unethical clinical research on patients in the late 19th century, the basis of modern ethics in research stemmed from the results of the Nuremburg trials, which were conducted after the atrocities of World War II. In 1964 the World Medical Association published the Declaration of Helsinki, with the aim of ensuring that patients taking part in clinical research have their rights, wellbeing and safety placed ahead of the consideration of research (i.e. the patient comes first). The Declaration of Helsinki formed the basis for the development of good clinical practice (GCP) guidelines, which govern the conduct of clinical trials in Australia.
Cancer patients are often vulnerable and therefore may be emotionally dependent upon their doctor, which may influence their decision regarding treatment options, including participation in clinical trials. Ensuring that the patient fully understands the aim of the trial as well as the risks and benefits is critical to their participation. A phase I trial to evaluate the safety of an experimental drug is a far cry from a phase II trial in which its efficacy is being evaluated and patients may participate believing that the aim of the trial is to treat their cancer. Hellman and Hellman question whether the dichotomous nature of the doctor as a physician and a scientist contradict one another in the setting of the randomized control trial. The authors argue that on one side the physician has a duty of care to the patient, whilst the scientist has an obligation to the veracity of the trial. Accuracy and transparency are essential to providing good informed consent, as is evaluating whether the patient has understood the information provided to them.
Clinical trials may also raise issues in relation to frequency of imaging, which may exceed practice guidelines or hospital policy, and expose the patient to high levels of radiation. The use of non-diagnostic tissue sampling/bio-banking is another aspect of clinical trials that is often viewed as pushing ethical boundaries.
As with cancer, ethics is not restricted to one domain or area of medicine. Regardless of your future career path, ethical conduct and professionalism will underpin and influence your clinical practice, research and education, and will help define you as a doctor. Your core values, the way you interact with your patients, peers and the community all draw upon these (often unconscious) moral values, beliefs and behaviours.
Of note, the majority of disciplinary action taken against medical practitioners is for breaches of professional conduct and/or unethical behaviour. When looking at mandatory notifications in 2013, the Medical Board of Australia reported 299 notifications for all states and territories. The grounds for those reported in all states (with the exception of NSW) are shown in Table 1.
Table 1: Mandatory Notifications to the Medical Board of Australia about Medical Practitioners in 2013
|Number of Notifications||Grounds for Notification|
|138||The practitioner was placing the public at risk of harm due to practice that constituted a significant departure from accepted professional standards|
|36||The practitioner had an impairment that was placing the public at risk|
|18||The practitioner had practised under the influence of alcohol or drugs|
|19||Sexual misconduct in connection with practice|
The implications of unprofessional or unethical behaviour are severe and can lead to fines, reprimands, suspended or cancelled registration with licensing bodies, and even criminal proceedings.
A comprehensive overview of medical ethics is beyond the scope of this chapter and the following resources are recommended for further information:
- Australian Medical Association. AMA code of ethics - 2004. Editorially revised 2006. [homepage on the internet] ACT: Australian Medical Association Limited; 2004 [cited 2014 May 29; updated 2006 Nov 20]. Available from: https://ama.com.au/codeofethics
- AHPRA. Australian health practitioner regulation agency. [homepage on the internet] Australia: AHPRA; 2014 [cited 2014 May 29; updated 2014 Feb 4]. Available from: http://www.ahpra.gov.au/
- National Health and Medical Research Council. Australian clinical trials: Good clinical practice (GCP) in Australia. [homepage on the internet] Australia: National Health and Medical Research Council; 2014 Jan 1 [cited 2014 May 29; updated 2014 Jan 1]. Available from: http://www.australianclinicaltrials.gov.au/node/36
- World Medical Association. WMA international code of medical ethics. [homepage on the internet] France: World Medical Association, Inc.; 2014 May 29 [cited 2014 May 29; updated 2014]. Available from: http://www.wma.net/en/30publications/10policies/c8/index.html
- Australian Medical Students' Association. Australian medical students' association: Code of ethics. Australia: Australian Medical Students' Society; 2003 [cited 2014 May 29] Available from: http://media.amsa.org.au/internal/official_documents/internal_policies/code_of_ethics_2003.pdf
- Maehle AH. 'God's ethicist': Albert Moll and his medical ethics in theory and practice. Med Hist 2012 Apr 1 [cited 2014 May 20];56(2):217-36 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23002294.
- World Medical Association. World medical association declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA 2013 [cited 2014 May 20];Vol. 310, No. 20 Abstract available at http://jama.jamanetwork.com/article.aspx?articleid=1760318.
- Department of Health and Ageing Therapeutic Goods Administration. The Australian clinical trial handbook: a simple, practical guide to the conduct of clinical trials to international standards of good clinical practice (GCP) in the Australian context. Canberra: Commonwealth of Australia; 2006 Mar 1 [cited 2014 May 20] Available from: http://www.australianclinicaltrials.gov.au/node/36.
- Hellman S, Hellman DS. Of mice but not men. Problems of the randomized clinical trial. N Engl J Med 1991 May 30 [cited 2014 May 20];324(22):1585-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/2027362.
- The Australian Health Practitioner Regulation Agency. Regulating health practitioners in the public interest: annual report 2012/13. Brisbane: AHPRA; 2013 Jan 1 [cited 2014 May 20] Available from: http://www.ahpra.gov.au/Publications/Corporate-publications.aspx.