Interview Preparation: Four Pillars of Medical Ethics

Medical ethics refers to a series of principles that when considered together aim to ensure that everyone receives the same standard of healthcare and serve to guide doctors in approaching the care of their patients. While healthcare professionals must use them each and every day in carrying out their roles, they can also be examined more closely when conflicts arise to work out exactly how they should be resolved. Such cases are known as ethical dilemmas.

These ideas are loosely defined in four key values, known as the four pillars of medical ethics. In no particular order, they are Autonomy, Beneficence, Non-maleficence and Justice. This article will address each of these ideas in turn and elaborate on their meaning and consequences for the practice of medicine, which you’ll want to be aware of before your medical school interview. We’ll explore them more individually in future articles but for now here’s a primer.

The Hippocratic Oath, dating back to the 5th century BCE, outlines many principles of medical ethics which are still used today

The first, autonomy, is recognition that the patient has ultimate control over whether they receive the treatment or not - medical practitioners may not force treatment upon them under normal circumstances. The exception to this is when patients cannot be deemed able to reasonably make decisions for themselves, for example when detained under the Mental Capacity Act.

At this point you’re concerned with establishing whether you have explained all the treatment options the patient has available to them, the patient understands their choices and that they are capable of making that decision. Lastly, whatever actions need to be taken in order to deliver that treatment can only be taken if the patient has provided their informed consent - moving ahead without this consent is treated as battery, or unlawful personal violence.

Beneficence refers to the idea of having the best outcome for the patient in mind at all times, particularly when all the options available (of which there may be many) have been considered. It is the duty of medical practitioners to identify which treatment would give the best outcome and to communicate that to the patient.

Do bear in mind that this could be more complicated than it sounds, as the patient will have their own views about the treatments beyond medical statistics. There might be elements to their lives that make some methods incompatible with their situation, for example. It’s all about identifying that best outcome and discussing it with the patient.

Non-maleficence is taken together with beneficence, and is essentially a concise version of the Hippocratic Oath: Do No Harm. I highly recommend that anyone interested reads the memoir of neurosurgeon Mr Henry Marsh, who applies this principle very frequently throughout the book. The risks of an intervention should always be weighed up against the outcome of doing nothing at all.

Of course harm can come by neglect, which is where the latter case comes in. A holistic assessment of the situation is therefore necessary, to identify all possible sources of risk, be it the competence and experience of the medical practitioner, the circumstances of the patient beyond the hospital and of course any basal risks that are inherent of the treatment itself.

The last of the four pillars and perhaps the most complex is Justice, which concerns identifying whether or not an action is fair in society and within the realms of the law. As one might imagine, this is no easy feat because of the nuances and subjectivity associated with the idea of fairness.

Say you were faced with two patients who desperately needed liver transplants and would surely die without them. You have access to one liver, compatible with both patients but you may only choose one. The first patient is a middle-aged male with two young children and a morphine addiction, while the second is a sixteen year old female. In this case, do you choose the option which gives one patient more years of life, or that might result in fewer for the other but provide the two children with a more stable environment?

This is an extreme example but reflect on the point made - responsibility lies in very large part with the doctor and you must be able to live with the consequences of your choices. The four pillars serve as a way to inform these choices and ensure the best outcomes for your patients.