6. Helping the helper

‘Helping the helper’ shows how ethics support can be introduced to shape ethical understanding and good healthcare practice using an example from a care home setting where everyday care is provided to people with dementia. This case is one example of an ethical issue that arises frequently in the care of people with dementia: how to balance the person’s previous preferences and values with their current interests, when these conflict. This discussion raises some difficult philosophical questions about how a person’s identity should be understood when that person is cognitively impaired. Two concepts of personal identity are discussed: the psychological continuity account and the situated-embodied-agent account.

10. A glance into the future

The future of medical ethics, the ways in which it will develop and change, will be largely determined by the nature of the new situations that arise. ‘A glance into the future’ suggests that these are likely to be of two broad types: scientific and technological developments such as gene therapy, stem cell research, synthetic biology, and advances in information technology and artificial intelligence; and social and cultural changes as a result of the increasing international context of our lives. The challenges from both technology and globalization make it crucially important for medical ethics to continue to progress through the process of rational argument and the assessment of evidence.

9. Culture, consent, and community

Cultural differences within and across societies can also challenge our assumptions and approaches to medical ethics and require us to reconsider our ethical obligations to individuals. Medical research involving collaboration between widely varying cultures is one context that is particularly problematic. ‘Culture, consent, and community’ discusses the guidelines for medical research, which highlights four main ethical issues: respect for the autonomy of the potential participants in research; protection of participants from the risk of harm; the value and quality of the research; and aspects of justice. It then considers how to avoid the imposition of Western views and practices on non-Western countries by endorsing respectful collaboration through community advisory boards.

7. Establishing fair procedure

No healthcare system in the world has sufficient money to provide the best possible treatment for all patients in all situations. When is the extra benefit of a new, better, and expensive treatment worth the extra cost? ‘Establishing fair procedure’ explains that medical ethics can provide practical support to assist policy-makers in the allocation of healthcare resources. The medical ethicist acts as the architect of a process of fair and accountable decision-making, and also facilitates discussion about, and judges between, those ethical values that have been identified for application within this process. The rule of rescue principle is discussed along with thought experiments that support or go against it.

5. Inconsistencies about madness

‘Inconsistencies about madness’ examines the different standards used in enforcing treatment and secure accommodation for those with and without mental disorder and considers the links with criminal acts. It is argued that those with mental disorder are subject to a double injustice. Under legislation such as the UK’s Mental Health Act, they are discriminated against not only for the protection of others but also for the protection of themselves. It may be right or wrong to impose life-saving treatment on a patient who has the capacity to refuse treatment, but what is not right is to change the answer depending on whether or not the person has a mental disorder.

8. How modern genetics is testing traditional confidentiality

Medical ethics is under challenge from developments in medical science and technology, raising new ethical questions or old questions in new ways. The work of genetics clinics worldwide is forcing us to re-think the traditional ways in which we think about medical confidentiality. A genetic test from one person can provide information about a relative. ‘How modern genetics is testing traditional confidentiality’ considers the foundations of medical confidentiality and the fundamental reasons why maintaining medical confidentiality is important: respect for patient autonomy; to keep an implied promise; and to bring about the best consequences. It also discusses two models of confidentiality: the personal account model and the joint account model.

4. People who don’t exist; at least not yet

‘People who don’t exist; at least not yet’ discusses the non-identity problem by considering the analogy between the rules governing assisted reproduction and those governing adoption. It looks at the issues involved with comparing existence with non-existence, which considers the best interests of a child that is yet to be born, and then outlines the fundamental distinction between identity-preserving and identity-affecting actions. Three examples of the non-identity problem in which the actions are identity-affecting are discussed: preimplantation genetic testing, delaying pregnancy, and treating acne. It concludes that it is almost always wrong for doctors, or society generally, to refuse reproductive assistance on grounds of the welfare of the potential child.

3. A toolbox of reasoning

‘A toolbox of reasoning’ discusses a further four tools of ethical reasoning: distinguishing facts from values; reasoning from principles; thought experiments; and spotting and avoiding fallacies in reasoning. Five fallacies are discussed: the no-true Scotsman move; the ten-leaky-buckets tactic; the argument from nature; the argument from playing God; and the slippery slope argument. It also explains how the analysis of medical ethics is organized around four principles—respect for patient autonomy, beneficence, non-maleficence, and justice—and their scope of application. Ethical reasoning cannot be reduced to algorithms. Situations are complex and doing the right thing will often require flexibility. Humane medicine, in addition to rationality, requires wisdom, imagination, and creativity.

2. Assisted dying: good medical practice, or murder?

Euthanasia is one form of assisted dying. Other forms include assisting suicide and the withholding or withdrawing of life-extending medical treatment. The practice of euthanasia—killing a patient for the patient’s benefit—under some circumstances, is morally required by the two most widely regarded principles for guiding good medical practice: respect for patient autonomy and promoting patients’ best interests. ‘Assisted dying: good medical practice, or murder?’ considers four tools of ethical reasoning: defining terms, elucidating concepts, case comparison, and logic. It argues in favour of the law allowing health professionals, under certain conditions, to assist patients to die, and illustrates one common and powerful method of argument: countering the counter-arguments.

1. On why medical ethics is exciting

‘On why medical ethics is exciting’ provides an introduction to medical ethics, which deals with some of the big moral questions: easing death and the morality of killing, for example. It takes us into the realm of politics. How should healthcare resources, necessarily limited, be distributed; and what should be the process for deciding? It is concerned with legal issues. Should it always be a crime for a doctor to practise euthanasia? When can a mentally ill person be treated against his will? Medical ethics ranges from the metaphysical to the mundanely practical. It is concerned not only with these large issues, but also with everyday medical practice.