The Inaugural Friday Filosophy
I dropped myself in it, didn’t I? Announcing a regular posting schedule without getting any pre-written posts in hand. Now that: that was intelligent … 
Anyway …
What to do? I thought I’d start at the most simplistic, baby-steps end of medical ethics, and write a little about the four principles that have become almost reified within discussions of medical ethics – though really they’re only a place to start. These are: Non-maleficence, Beneficence, Autonomy, and Justice. I’ll discuss each in turn, and if I can get myself together enough I’ll illustrate with a vignette.
Non-maleficence:
This is also referred to with the phrase: “First do no harm”, and that’s what it really comes down to. If we are contemplating an intervention, we must consider the risk of causing harm by it. I would hope that it obviously encompasses actual deliberate harm, which is obviously unethical, but it also includes consideration of any potential harms (by action or inaction).
Beneficence:
This refers to the doctor’s duty to do good: to provide benefit for our patients. If someone is unwell in some way, the principle of beneficence says we should do what we can to assist them to get well, to feel better. Of course, our interventions (motivated by beneficence) usually carry at least the potential of harm, so the principle of non-maleficence obligates us to consider those potential harms, rather than acting solely from beneficence. This brings in the concept of a cost-benefit analysis: not (just) financial cost of course; cost in terms of any negatives that could arise.
Autonomy:
Simply put: the patient’s wishes and decisions should be respected. The “dark side” if you like, of beneficence is paternalism, where the “doctor knows best” and will determine what should be done for the patients, who will tug their forelock and take that treatment if they know what’s good for them 
We don’t think that’s a good approach now. Patients need to be informed, so they are able to make their own decisions about their treatment.
That’s the simple side of it. However, there are some wrinkles. First, to make a truly autonomous decision, someone needs information. How do they get the information with which to make their decisions about their health? People rely (mostly) on their doctor to give them the information they need. The amount of information they have to base their decision on therefore depends on what the doctor tells them. There is a tension around how much information to give. To truly give all the information about an illness and a treatment could take a very long time. Having too much information can be paralysing. Some people don’t want to make their own decisions anyway (though of course, that is their decision). The issue arises: is it ethical for a doctor to decide how much, and what information to provide his or her patients with? How much can be withheld before the patient’s autonomy is impaired?
A second wrinkle is one that arises commonly in psychiatry: people who refuse treatment that they manifestly “need” (according to us, and in fact according to the rest of society). Quite commonly people who are psychiatrically ill lose insight into their own mental state, and unsurprisingly refuse treatment. Can we compel them to have treatment? First, the legal bit: yes we can compel treatment in prescribed circumstances: around serious risk of harm to self or others generally; in NZ there’s another limb that allows a serious incapacity to care for oneself. But is it ethical? It certainly would seem to ignore that person’s autonomy. We can then combine a wider view of autonomy – taking into account the increased ability to make autonomous decisions the patient would have if effectively treated – with our earlier principles of beneficence (the person is ill, and suffering, and we can relieve that), and non-maleficence (what harm might the treatment itself cause, and what distress might be caused by the process of compulsion?)
Justice:
This is the one that seems to get the least airtime; in fact I was interested to note that this Wikipedia article on Medical ethics simply omits the principle of justice. However it’s just as important, in a number of ways. Simplistically, the main ones that occur to me in this context are: something akin to fairness (if we offer a treatment to one person, we must not then withhold it from another with the same needs); and distributive justice … we have finite resources, and seemingly infinite need What can we offer, to whom, and to how many? If we use too much resource on a few, there will be many more people not, or only inadequately, served. We have to balance our concern for, and duty towards, the individual patient in front of us, with the need to be just in the sense of distributive justice, and our duty towards all the members of our society.
… And I said this was the simple/baby steps end ….
Well, it is, really 
There’ll be more to come, but for now, let’s make up a story, and go through each of these four principles as they might apply:
Trev is a 23 year old man with a history of schizophrenia, which is complicated by daily use of cannabis, weekend binge drinking, and occasional amphetamines. He tends not to believe he has an illness, or that he needs psychiatric treatment or follow-up. He was discharged from hospital some 2 months ago, and since then has refused any follow-up visits or appointments. It seems unlikely he is taking any medication, as on discharge he was only given sufficient medication to take him through to his folow-up appointment. His parents contact the psychiatric service concerned that he has been saying increasingly odd and concerning things, and they worry what he might do. Since we have a mobile and assertive service, rather than making another appointment we are quite sure he won’t keep, we do a home visit with doctor and nurse, to assess him. Trev comes to the door. He is unshaven and generally dishevelled, wearing odd, mismatched and unwashed clothing. When the doctor and nurse introduce themselves he become irritable, and tells them (in, shall we say, no uncertain terms) to leave. Being persistent, they continue to ask to speak with him, and despite his protestations of good health, it becomes apparent that he is in fact floridly psychotic: he is formally thought disordered (thoughts jump from idea to idea without clear connection), and he makes vague reference to “them” watching and plotting against him – he is sure of this because he hears them talking about him among themselves.
While completely made up, this is a very common scenario in acute psychiatry. The question really is how to proceed. In turn, we’ll look at how the principles of beneficence, non-maleficence, autonomy, and justice, might inform our decision-making.
Beneficence:
Clearly Trev is seriously ill. From a beneficent standpoint, we are bound to treat his psychotic illness in order to improve his psychiatric health. Let me be clear: it’s not simply that we want to, but there is an ethical obligation to do so. This aspect is probably relatively simple – which is why I put it first in this discussion. The wrinkles are around how much benefit we can provide, by various different sorts of interventions (not just pills for the psychosis, but other interventions for other important aspects of the illness and its sequelae), and taking into account his previous response to treatment and so on. For this discussion though, I think the main thing that beneficence has to offer is simply the obligation to help him.
Non-maleficence:
Ok, so we want to do good. We must remember though, the potential to cause harm. For a start, if treatment involves coercion (see the next section) it will be unpleasant and possibly traumatic for Trev (there is research demonstrating that compulsory/unpleasant admissions can lead to post-traumatic stress symptoms). That’s one aspect of harm. Overriding his will in such a fashion is also quite likely to impact adversely on our chances of developing a useful therapeutic alliance with Trev, and may actually hurt his longer-term chances for good psychiatric health. Then we have to consider potential adverse effects of medications, which range from transient and annoying, to impacting on quality and even length of life: obesity, diabetes, dyslipidaemia (stuffed up cholesterol etc) … These must be balanced against the potential risks of not treating/the benefit afforded to Trev by treatment.
Autonomy:
Trev (quite explicitly) does not want the assistance we feel ethically bound to give. He has had treatment explained to him in the past, and has taken it for periods of time, but has never agreed that he needs it, and has always stopped it as soon as he is able. In most of medicine that would pretty much be the end of it, if we could not persuade him, but in psychiatry there is in some cases the ability to compel treatment. Is it justified in Trev’s case? We must consider both whether it is legally justified, and whether it is ethically justified. Let’s say that legally it is: Trev has a well-documented history of aggression/self-harm/self-neglect (take your pick) when seriously ill, and we think he is currently seriously ill. So far so fine, but is it ethically justified? We are still overriding his autonomy, and I don’t think that “because the State says I can” is sufficient ethical justification. There are justifications that can be made, however. One involves beneficence: our professional opinion is that his life will be improved with proper treatment of his illness. Another actually does involve autonomy itself: when someone is seriously psychiatrically ill it often impairs their ability to understand and process the world around them – and thereby to exercise true autonomy. In that view, treating his psychosis will in fact improve his autonomy, and ability to make decisions about himself.
There are other ethical arguments for over-riding an individual’s autonomy, but I think within these four (limited and limiting) principles that’s about it.
Justice:
Assessing and treating Trev can be unpleasant: he is verbally abusive, and even threatening at times. He doesn’t want our service, doesn’t follow through with recommendations, and uses drugs which worsen his illness. The fairly natural tendency might be to be somewhat less assertive with Trev, and put more time into someone “nicer”. That however would be unjust: Trev has a serious illness, and ethically we are obliged to provide him with the same treatment we would to the “nicer” person.
Of course, one can also talk about distributive justice, and (simplistically) the fact that Trev is disengaged, poorly adherent, and abuses drugs, means that he will use a lot of resources, for (possibly) less gain than someone who is well engaged, adheres to treatment, and doesn’t abuse drugs. Arguably, putting intensive resource into Trev’s case is not just, in that sense, as it diminishes the time and resource available for other ill people in need.
Decision time….
So … what do we do? Sorry, but I’m not going to give a single or concrete answer to that. It hinges on many factors, including: the imminence and degree of danger; how well he has responded to treatment in the past; what adverse effects he has had in the past; whether he actually develops insight when well, and becomes adherent for a time, or whether after getting well in hospital he immediately becomes non-adherent and relapses; whether he has in fact responded to adequate trials of appropriate treatment … and so on.
This is the sort of stuff we have to weigh up all the time – without spending half a day deliberating every time The most important thing is that we don’t deal with these ethical difficulties by ignoring them.
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