What are Ethics?

What are Ethics?

·         Definition: A branch of philosophy concerned with moral principles, values, and conduct. It explores concepts like right/wrong, good/bad, duty, obligation, virtue, and justice.

·         Distinction from Law: Law sets minimum standards enforceable by the state; ethics often aims higher, guiding discretionary judgments and character. An action can be legal but unethical (e.g., exploiting a loophole), or potentially illegal but perceived as ethical in extreme circumstances (though this is legally risky).

·         Distinction from Policy: Policies are operational guidelines within an organisation/system; ethics are the underlying moral principles that should inform those policies and individual actions. Following policy is usually expected, but ethical reflection is needed if a policy seems to lead to an unethical outcome in a specific case.

·         Role of Values: Ethics is grounded in values – enduring beliefs about what is good, desirable, or important (e.g., compassion, honesty, fairness, respect for life, autonomy). Personal, professional, organisational, and societal values can sometimes conflict.

Key Ethical Principles (Principlism)

A dominant framework in biomedical and care ethics, particularly popularised by Beauchamp and Childress, involves four core principles:

1.    Autonomy (Self-Rule): Respecting an individual’s right to make their own decisions about their own life and body, free from coercion or undue influence. Requires providing adequate information and ensuring capacity. Underpins informed consent, confidentiality, and person-centred care. Dilemmas arise when respecting autonomy potentially leads to harm (e.g., refusing life-saving treatment, making risky choices).

2.    Beneficence (Doing Good): Acting in the best interests of the service user; taking positive steps to help others and promote their well-being. Includes providing competent care, preventing harm, and improving quality of life. Requires balancing potential benefits against risks and costs.

3.    Non-Maleficence (Doing No Harm): Avoiding causing unnecessary harm, pain, or suffering. Includes not inflicting harm and not imposing risks of harm. This principle underlies safety procedures, risk assessment, and careful consideration of interventions (e.g., side effects of medication, potential burdens of treatment). The concept of ‘double effect’ (where an action has both a good intended effect and a bad foreseen but unintended effect, e.g., strong pain relief that may hasten death) is relevant here.

4.    Justice (Fairness): Treating people fairly and equitably. In health/social care, this relates to:

o    Distributive Justice: Fair allocation of scarce resources (staff time, funding, beds, treatments). How should resources be distributed when not everyone’s needs can be met? (e.g., based on need, merit, equality, utility?).

o    Rights-Based Justice: Respecting and upholding people’s legal and moral rights.

o    Legal Justice: Ensuring fair legal processes and adherence to the law.

o    Relates closely to tackling discrimination and health inequalities.

Other Important Ethical Principles/Concepts:

·         Fidelity (Faithfulness): Being loyal and trustworthy, keeping promises (explicit and implicit), maintaining confidentiality, and acting in the best interests of those who place trust in you. Core to the professional-patient relationship.

·         Veracity (Truthfulness): Being honest and telling the truth. Underpins informed consent and trust. Dilemmas arise when truth-telling might cause significant harm or distress (though withholding information requires strong justification).

·         Dignity: Respecting the inherent worth and uniqueness of each individual, regardless of their condition, abilities, or circumstances. Involves providing care that is respectful, maintains privacy, promotes self-esteem, and avoids humiliation.

·         Compassion: A deep awareness of the suffering of another coupled with the wish to relieve it. Involves empathy, kindness, and caring.

·         Accountability: Being answerable for one’s actions and decisions. Includes professional accountability (to regulatory bodies), legal accountability (to the law), organisational accountability (to employers), and moral accountability.

 Ethical Theories

These provide different frameworks for analysing why something is right or wrong:

·         Deontology (Duty-Based Ethics): Focuses on duties, rules, and obligations. An action is right if it conforms to a moral rule or duty (e.g., ‘always tell the truth’, ‘never kill an innocent person’), regardless of the consequences. Immanuel Kant is a key figure. Supports principles like autonomy and justice. Can be rigid if rules conflict or consequences are severe.

·         Consequentialism/Utilitarianism: Focuses on the outcomes or consequences of actions. An action is right if it produces the greatest good for the greatest number of people (utility). Jeremy Bentham and John Stuart Mill are key figures. Useful for resource allocation decisions and public health policy. Can potentially justify sacrificing individual rights for the greater good, raising justice concerns.

·         Virtue Ethics: Focuses on the character of the moral agent rather than rules or consequences. Asks “What would a virtuous person do?” Emphasises cultivating virtues like compassion, honesty, integrity, wisdom, courage. Aristotle is a key figure. Provides a holistic view but can be less helpful in providing clear-cut answers to specific dilemmas.

·         Principlism (The Four Principles): As described above, seeks to provide a practical framework by balancing the four core principles. Widely used but criticised for potentially lacking a unifying theoretical base and not always providing clear guidance when principles conflict.

·         Care Ethics: Emphasises relationships, empathy, interdependence, and responsiveness to the needs of others. Arises from feminist critiques, highlighting values often associated with caring roles. Focuses on context and relationships rather than abstract principles. Particularly relevant in social care and nursing.

 Ethical Decision-Making Frameworks

When faced with an ethical dilemma (a situation with conflicting moral principles or values), a structured approach can help:

1.    Identify the Ethical Problem: What are the conflicting values or principles? Who is affected?

2.    Gather Relevant Information: Collect all factual details, understand the context, identify relevant laws, policies, and professional codes.

3.    Identify Stakeholders: Who has an interest in the outcome? What are their perspectives, values, and wishes (especially the service user)?

4.    Consider Options: Brainstorm potential courses of action.

5.    Evaluate Options using Ethical Principles/Theories: Analyse each option against principles like autonomy, beneficence, non-maleficence, justice, fidelity, veracity. Consider potential consequences (utilitarianism) and duties (deontology). What would a virtuous practitioner do?

6.    Consultation: Discuss the dilemma with colleagues, supervisors, mentors, or an ethics committee. This provides different perspectives and support.

7.    Make a Decision: Choose the option that appears most ethically justifiable, balancing the conflicting principles.

8.    Implement the Decision: Carry out the chosen course of action.

9.    Evaluate the Outcome: Reflect on the decision and its consequences. What was learned? Could anything have been done differently? Document the process and rationale.

Common Ethical Dilemmas in Health and Social Care

·         Resource Allocation: Who gets the ventilator/ICU bed/organ transplant/social care package when demand exceeds supply? How to balance individual need with population benefit and cost-effectiveness?

·         End-of-Life Care: Decisions about withholding/withdrawing life-sustaining treatment, palliative care, advance care planning, responding to requests for assisted dying (where legal or debated). Balancing autonomy, beneficence, non-maleficence, and sanctity of life views.

·         Consent and Capacity: Making decisions for those who lack capacity (balancing autonomy/past wishes with best interests), assessing fluctuating capacity, dealing with disagreements between family members or staff, managing capacitous refusals of essential care.

·         Confidentiality vs. Duty to Warn/Protect: When is it justifiable to breach confidentiality to protect the service user (e.g., risk of suicide, self-neglect) or others (e.g., risk of harm, infectious disease)? Balancing privacy rights with safety duties.

·         Truth-Telling: How much information to disclose, especially if it may cause distress? Dealing with requests from family not to tell a patient their diagnosis/prognosis.

·         Professional Boundaries: Maintaining appropriate relationships with service users and their families, avoiding conflicts of interest (e.g., accepting gifts, personal relationships).

·         Use of Restraint (Physical, Chemical, Environmental): Balancing safety (preventing harm to self or others) with autonomy, dignity, and the right to liberty. Must be legally justified (e.g., MCA best interests, MHA, common law necessity), proportionate, least restrictive, and for the minimum time necessary.

·         Whistleblowing: Reporting concerns about unsafe or unethical practice within an organisation. Balancing loyalty to colleagues/employer with the duty to protect service users and the public interest. Legal protections exist but whistleblowers can face repercussions.

·         Research Ethics: Ensuring research involving human participants is conducted ethically (informed consent, confidentiality, minimising risk, fair participant selection, independent review by Research Ethics Committees – RECs).

·         Artificial Intelligence and Technology: Ethical issues around data privacy, algorithmic bias, impact on the therapeutic relationship, accountability when AI makes errors, equitable access to technology.

Professional Codes of Conduct/Ethics

Most health and social care professions have codes issued by their regulatory or professional bodies (e.g., NMC Code, GMC’s Good Medical Practice, Social Work England’s Professional Standards, HCPC Standards of Conduct, Performance and Ethics). These codes translate broad ethical principles into specific behavioural expectations for registered professionals. They typically cover areas like:

·         Prioritising people/patients.

·         Practising effectively (competence, communication, teamwork).

·         Preserving safety.

·         Promoting professionalism and trust.

·         Confidentiality.

·         Consent.

·         Candour (being open and honest when things go wrong).

·         Maintaining boundaries.

·         Equality and diversity.

·         Record keeping.

·         Raising concerns.

Violation of these codes can lead to fitness to practise investigations and sanctions. They serve as a key guide for ethical conduct in daily practice.