Healthcare relationships: How to start thinking like an ethical doctor

Is it ever okay for your doctor to intentionally hurt you? In this Wi-Phi video, we’ll ask what kinds of ethical considerations should guide medical practitioners when working with patients and others under their care. It is 1947, Nuremberg, Germany. Sentence is about to be passed in the Doctors’ Trial. Twenty-three German medical doctors and administrators have been ‘charged with murders, tortures, and other atrocities committed in the name of medical science’ between 1939 and 1945. Crimes include a secret euthanasia programme where hundreds of thousands of persons with disabilities were systemically killed across Germany by physicians, as well as medical experiments forcefully conducted on inmates of Germany’s war-time concentration camps. Sixteen are found guilty. Sixteen people intricately involved in the medical profession are found guilty of committing mass murder, torture and other atrocities. “And so, we’re all healthcare practitioners - so what ethical lessons can we learn from this case as applied to our work as clinicians or medical researchers?” ‘That’s an easy one’, pipes up a local GP. ‘An important principle of bioethics is the principle of non-maleficence: “One ought to avoid doing harm.” Members of the healthcare profession ought to avoid doing harm to those in their care, both in their clinical practice and when conducting medical research. Those doctors did no such thing.’ But is it that simple? Jo’s a dentist and after this class, she’s going to extract some wisdom teeth that will cause major problems if they stay in. It’s a standard procedure but it does involve actively creating a wound that might get infected. ‘If all that matters is avoiding doing harm,’ thinks Jo, ‘then I shouldn’t do this procedure at all, even though it will ultimately help the patient. But that can’t be right - my job is to help people!’ ‘As healthcare professionals,’ Jo explains to the class, ‘We ought to help and not just avoid doing harm. In fact, another important bioethical principle is the principle of beneficence. According to this principle one ought to take positive steps to prevent or remove harm, and to promote good. This principle captures the values at the very heart of our profession, where we look out for the overall best interests of those under our care!’ Perhaps this is where the German doctors went wrong. While the doctors certainly caused immense harm, maybe their failure specifically as 'doctors' was more a failure to promote goods like health and well-being, especially for the very people under their care? ‘But wait!’ cuts in a world-famous oncologist. ‘Sometimes promoting good may require causing quite extreme harm. When my patients undergo chemotherapy for their cancer, they can experience severe side effects. Now, I think that the potentially miraculous results I get for my patients can justify even something as harmful as chemotherapy. But couldn’t the German doctors have used the same logic to justify their horrific actions? If the Nazi doctors believed that they were removing a financial and social burden from the German state, for instance, or were conducting research to aid the German war machine, then they might have thought that they were promoting good. Ok, these were obviously terrible goals and there’s little reason to think that anything good came out of their euthanasia programme and research anyway. But imagine if it had. Some of their research was on immunisation for diseases like malaria that are still rife today. If they had succeeded, wouldn’t they have done something good for the whole world, even? ‘But even if there are benefits of the research,’ Jo retorts, ‘those benefits can’t justify just anything especially harms like murder and torture. The harms and benefits need to be balanced in the right kind of way!’ Now Jo seems to be onto something. Neither the principle of non-maleficence nor the principle of beneficence is enough by itself. We need to balance both to promote health and well-being while avoiding doing harm. But how can we determine whether the harms and goods are balanced in the right kind of way? One thing that is relevant is the person’s intention. If the person intends good but brings about a harm as a foreseeable but unintended side-effect, their action may still be morally justified – this general idea is sometimes captured by what is called the ‘doctrine of double effect’. In Jo’s case, she intends to help her patient She will reach this end by removing the wisdom teeth, but a side effect is that she will create a new and painful wound. The painful wound, while foreseen, is just a side effect and Jo will avoid it as much as she can, such as by using anaesthetics and prescribing antibiotics to ward off infection. The wound will also heal while the good effects will last. So, Jo concludes, her actions on balance can be morally permissible – at least in this case. But let’s return to those German doctors. Could they have intended to do good, where the harm may have just been a side effect? The evidence suggests otherwise: their intentions were in fact to cause harm as an actual means to their ends. As the prosecution argued in the Doctors’ Trial, the objective of the doctors had not been ‘how to rescue or to cure, but how to destroy and kill’. By focusing on intentions, the doctrine of double effect allows us to distinguish between Jo’s right way of balancing benefits and harms from the doctors’ bad way of doing so. But is this all that went wrong? Let’s imagine that another set of doctors committed exactly the same atrocities, but that, unlike the German doctors, they really did intend to rescue and cure, and even succeeded in developing a highly effective and accessible immunisation for malaria. Given this immensely beneficial payoff, and the doctors’ apparently good intentions could the same atrocities now be justified? The answer is still no. Why? Well, on top of balancing the principles of non-maleficence and beneficence, there are other ethical considerations that need to be taken into account when determining what ethical healthcare practice and research looks like, considerations such as the importance of respecting autonomy. This requires respecting someone’s choices about what to do and not forcing them into doing things that they don’t want to do. So, independent of intentions and outcomes, this second set of doctors would still be murdering people under their care and forcing or coercing others to be part of their experiments. They would be failing to respect autonomy. As Jo heads back to her clinic, her patient calls. After getting a second opinion and thinking it over, he’s decided to keep his wisdom teeth. With the class discussion in mind, Jo relents: “Okay. I think it’s a mistake, but I respect your choice.’