INTRODUCTION

The nature of the modern healthcare system means that ethical dilemmas commonly arise, and it is with this in mind that the following chapter will attempt to clarify our understanding of ethics and provide the reader with knowledge that may assist in the analysis and solution of some of the dilemmas likely to be encountered. These dilemmas may involve an individual patient or may have wider ranging societal consequences, as in the problem of whether patients should be given costly drugs or treatments at the expense of other services.

WHAT IS ‘ETHICS’?

Ethics is defined as being ‘the study of the moral value of human conduct’,¹ and whilst this definition is useful the study of ethics has evolved from purely a philosophical pursuit into a branch of philosophy which has enormous implications for healthcare practice in general. It may therefore be useful to examine the fundamentals of the study of ethics in an attempt to examine its applicability to practice.

As Box 1.1 would suggest, ethics is not to be thought of as the musings of philosophers that have no real life applicability, nor should it be regarded as simply a matter of applying common sense. Ethics provides us with a framework by which we can analyse dilemmas and hopefully this structured scrutiny will subsequently lead us to be able to resolve the dilemma we may face.

WHAT IS AN ETHICAL DILEMMA?

Before we begin to examine the applicability of ethical analysis, it is essential that the exact nature of what essentially constitutes an ethical dilemma be understood, as opposed to being faced with choices that do not really have an ethical dimension to them. As previously stated, the study of ethics can be summarised as the analysis of what is right and/or what is wrong in any given situation and it also assists us with the concept of how we ought to act at any given time. We make a lot of choices during daily life and not all of these choices necessarily have an ethical element involved with them. What we decide to wear, for example, is not normally of great moral concern. While an individual might inadvertently offend people with their terrible dress sense it would not necessarily be doing anyone any great harm, so as a result would not really be worthy of any kind of ethical/moral scrutiny or debate. If, however, this was taken a stage further and a T-shirt with a racist slogan worn, this could truly offend many individuals as they quite rightly would regard individuals from another race as being worthy of their consideration. In other words individuals, or indeed communities, matter and we should consider their feelings, whereas choosing to wear black or purple is not really of any great concern to individuals or society in general. Box 1.2 demonstrates that for a dilemma to have an ethical dimension it should encompass the following elements: 1) a moral agent; 2) a subject; 3) an action and 4) a consequence.³ All these elements have to be present before the dilemma can be defined as having an ethical dimension afforded to it.

To further qualify this statement there are also further conditions. First, the moral agent is someone who is assumed to be rational and capable of moral reasoning; then the subject must be worthy of moral consideration; the action could be good or bad, and the consequence should be of concern. Now, before readers start worrying that they have inadvertently picked up the hard core philosophy book that they leave around when trying to impress their brainy university mates, the author would just like to give an example in order to bring some clarity: If we choose to analyse a widely recognised dilemma, such as euthanasia, it soon becomes apparent that this subject more than fulfils the criteria, which results in it being arguably one of the most complex ethical dilemmas in modern medicine. In this case the moral agent is the physician who is in possession of a moral code and who can be regarded as rational. The subject (the patient) is a human being and therefore is afforded the status of being worthy of moral concern. The action is that their life is shortened by the actions of the physician, and the consequence is that they die. It is easy therefore to see that this dilemma has massive ethical perspectives.

Once we have ascertained that our dilemma has some ethical element we need to investigate the tools we have at our disposal in order to analyse and potentially come up with a solution or solutions to the problem.

BASIS OF MORAL REASONING

This analysis of ethical problems can alternatively be termed ‘moral reasoning’. Here we can look at a problem and apply our moral and/or professional values to it. We can then decide what is the right option or course of action to take. We are all in possession of our own moral code (in other words, what we perceive as being right and wrong) and it is this code that we sometimes consult when deliberating about an issue. There has been much debate regarding our moral/ethical development;⁴ however, it would seem that our moral reasoning capabilities may be influenced by a complex mixture of internal and external factors.

All the elements mentioned in Box 1.3 serve to provide us with our own set of values. These values may change as we mature or gain ‘life experience’ but they may also be supplemented by additional rules or values that come when we adopt a professional role.

Box 1.3 Basis of moral reasoning