The Four Pillars of Medical Ethics

Medical ethics is one of the most common topics that can come up in medical school interviews—specifically, MMIs. The basics of medical ethics are the 4 pillars. It is important to know these because they are applied almost daily in a clinical environment.

What Does Medical Ethics Mean?

By definition, medical ethics are moral principles that govern the practice of medicine. They help doctors make decisions in the best interests of the patients. There may be difficult situations where doctors need to decide what to do. This is where medical ethics will help to do what is most beneficial for the majority.

What are the Four Pillars of Medical Ethics?

There are 4 principles of medical ethics: beneficence, non-maleficence, autonomy and justice.

Beneficence

Beneficence means to do good. It means to act with kindness and mercy. Medicine is all about patient-centred care and beneficence helps in doing this. Doctors must act in favour of the patient. Sometimes, this may mean overriding the wishes of the patient’s relatives. A basic example is choosing to go ahead with taking blood even though it hurts the patient. This is because it is the most beneficial act to do and the pros weigh out the cons.

Non-maleficence

Non-maleficence means to do no harm. Whatever the action, the doctor must aim to minimise any pain and suffering to the patient. An example is preventing mental distress to a patient. This ethical pillar is sometimes confused with beneficence but they are not binary opposites.

Autonomy

Autonomy means that the patient must be given the right to make their own decisions. However, not every patient has autonomy. Only those who are competent and have the capacity, have autonomy. Read below to find out more about competency and capacity.

Justice

Justice means to ensure an equal distribution of resources. The NHS has limited resources but there is unlimited demand for them. Therefore, as a doctor, it is vital to ensure resources are being used to their utmost benefit. This ethical pillar can be applied to interview questions regarding removing life support. If the life support is only prolonging the patient’s suffering, then it may be better to remove it. This resource may then become available to other patients.

Other Medical Ethics Concepts

Informed Consent

There are 3 Cs within medicine – consent, competency and confidentiality. Informed consent means that the patient must give permission to go ahead with a procedure or treatment. The word “informed” means that the patient must be told fully what this procedure will entail. Consent can be written, verbal or shown with a simple nod.

Competence to Make Decisions

Competency is defined as a person’s ability to make decisions and communicate them back. There are 4 steps to assess the competency of a patient:

• Can the patient understand you?
• Can the patient retain the information?
• Can the patient weigh up the pros and cons of the decision at hand?
• Can the patient communicate their decision back to you?

Gillick’s competence is often used to assess if a child is mature enough to make their decisions. This applies to any young person under 16. There is no lower limit to these guidelines.

Confidentiality

Confidentiality is a crucial part of medicine as it builds trust in a doctor-patient relationship. It is defined as the patient’s right to keep their personal information from being disclosed. A patient may tell doctors things they may not even be comfortable telling their family or anyone else. This is a privilege we get as healthcare professionals. However, it is also our responsibility that we respect the patient’s confidentiality.

A medical professional must not tell anyone about the patient’s health unless required. There are 4 circumstances when confidentiality may be breached:

• If required by law
• If the patient is at risk of harm
• If there is a risk of harm to others
• If the patient allows you to tell someone (i.e. gives consent)

In any of these circumstances, only the minimum amount of information that needs to be disclosed should be. For example, if a patient is at risk of harm and a police officer needs to know what medications the patient is taking to help minimise this risk, their doctor should provide this information. However, it won’t be appropriate to then also tell the patient’s friend or neighbour about their medications without a valid reason. Likewise, it won’t be appropriate to give any more information than is needed.

Honesty

According to the GMC guidelines, it is essential to display certain qualities as a doctor and medical student. These include professionalism, honesty and integrity. Being honest will maintain the trust of patients in the NHS. In a hospital environment, it is common to make errors however, you must have the honesty to own up to your mistakes.

Beneficence vs Non-Maleficence

Beneficence means to do good whereas non-maleficence means to do no harm. Beneficence (doing good) and maleficence (doing harm) are opposites, however, doing no harm isn’t just the same as doing good. Doing no harm means to actively avoid harming a patient, and doing good means to actively do good for a patient. Often, it can be difficult to achieve both beneficence and non-maleficence. Doctors must be able to weigh out the benefits and risks of harm to a patient when making any decision.

Take the example of drawing blood for blood tests. We might test a patient’s blood to check whether infection markers are improving and the antibiotics they’re being given are effective. We’re doing good for the patient. We’re not just giving them antibiotics and leaving them be (which is appropriate in many cases). We’re going through the effort of continuing our investigations and monitoring their results to make sure they’re getting the best treatment that they need. However, blood tests involve physical harm to a patient using a needle, which would be maleficent (doing harm) and against the principle of non-maleficence (doing no harm).

The pros and cons need to be weighed up here. Is it worth the minor physical harm in order to achieve our desired result? Will the blood test results make a difference to their care? If so, then the blood test should be carried out, with consent from the patient of course. If the blood test results won’t make a difference to patient care, then the test should not be carried out in order to abide by the principle of non-maleficence.

Autonomy vs Beneficence or Non-Maleficence

The ethical pillar of autonomy may also conflict with beneficence or non-maleficence. Autonomy is the patient’s right to make their own medical decisions, which can sometimes seem to over-ride everything else. It’s not necessary for a patient to make a decision that is in line with what’s best for their health, but it’s necessary for a doctor to respect the autonomy of a patient to make their own decision (that is, as long as they have the capacity to make that decision).

An example of the conflict between autonomy and beneficence would be a Jehovah’s Witness who needs a blood transfusion. It’s important for medical school interviews to understand that Jehovah’s Witnesses cannot accept blood transfusions due to religious beliefs, so it’s common for people of this faith to exercise their autonomy in refusing blood transfusions. Many trusts have specific forms that can be signed in advance of operations and risky procedures to consent to a refusal of blood products to be very clear what the patient’s wishes are.

In a situation where a patient desperately needs blood, or may even die without a blood transfusion, it would be the beneficent thing to do to provide the blood. To refuse a blood transfusion would be maleficent. However, if the patient has the capacity to make a decision, and they refuse blood, it is not permissible to give them that blood. It’s essential that we respect the patient’s autonomy to make decisions about themselves, their healthcare and the treatments that they receive, even if refusing treatment could lead to their death.

Beneficence is not just to do with physical health. Being beneficent to your patients also means considering their spiritual wellbeing, their mental health, their social and their religious beliefs, and everything else that matters to them. To disrespect their autonomy and force your own decision on an adult with capacity would be completely against the essence of beneficence. So, although from a rough glance at this kind of example, it might seem like the only beneficent thing to do would be to offer blood and save a life, that might actually be the most harmful thing you could do. Hopefully that clarifies the true meanings of beneficence and non-maleficence, and the value of autonomy in healthcare.

Famous Medical Ethics Cases

Harold Shipman’s Case

Harold Shipman was a doctor in general practice and is now known to be one of the most horrific serial killers. He was found guilty of the certified murder of 15 patients. However, there were approximately 250 victims in actuality. The Shipman Inquiry was a 2-year long investigation started by Dr Linda Reynolds. She was concerned about the high death rates in Shipman’s patients. The bodies of most patients found lethal doses of diamorphine (heroin). This investigation also found that Shipman had forged the will of one of his patients – Kathleen Grundy. According to the will, £386,000 was assigned to Harold Shipman and not Grundy’s children. Harold Shipman was arrested on 7th September 1998 and convicted on 31st January 2000. 11 days later, he was struck off the GMC register.

This ethical case led to the Shipman Effect. This meant multiple changes in medical procedures and tighter prescribing rules to prevent overprescribing in pain medication.

Charlie Gard’s Case

Charlie Gard was born in 2016 with a rare genetic disease named mitochondrial DNA depletion syndrome (MDDS). He was admitted to the Great Ormond Street Hospital (GOSH) which is a renowned children’s hospital in London. Sadly, there is no treatment for this disease and doctors said that Charlie has limited time to live. Various doctors debated on whether prolonging the life support was beneficial or was just lengthening his suffering. The court case concluded in agreeing with the NHS’ decision to withdraw life support as this would allow Charlie to die with dignity.

This was heartbreaking for Charlie’s family, doctors and anyone who heard it. It is also a case that puts the 4 ethical pillars into conflict. What was the more beneficial act for the patient? Was the life support harming Charlie even more, and thus going against the pillar of non-maleficence?

Medical Ethics Questions

Example

Do you think abortion should be legal?

Approach

This is a typical example of a disguised medical ethics question. Interviewers may not ask you directly to explore the ethical considerations of abortion but you need to be aware of this. In this type of opinion-based question, we recommend the diamond approach. This is where you structure the answer in 4 parts:

• Introduce the topic = give the definition of abortion

• Explore the pros = 2 arguments for abortion
• Explore the cons = 2 arguments against abortion
• Give your opinion = conclude your answer

Example Answer:

Abortion is the termination of pregnancy before 24 weeks.

The positives and negatives of abortion must be considered for me to make a decision. One argument for abortion is that if it is the woman’s choice to abort, then we must respect the patient’s autonomy. Autonomy is the ethical pillar that every competent patient has the right to their medical decisions. Another argument for abortion is that an abortion may prevent any health risks for the mother. Therefore, as a medical professional, we need to always act for the benefit of our patients. Beneficence is another ethical pillar which means to “do good.”

On the other hand, an abortion may be immoral because it is putting an end to a potential life. This may be going against the ethical pillar of non-maleficence which means to “do no harm.” An abortion may also cause psychological distress for the mother.

In conclusion, I believe abortion should be allowed as it promotes patient autonomy and is in the best interests of the patient.

Here are some more medical ethics interview questions to help gain insight.

Medicine Interview Tuition

Interviews are one of the most important parts of medical school applications. For most medical schools, your interview performance will be the sole decider of whether you receive an offer or not. Having said that, ethics are part of most interviews whether it is an MMI station or in a panel interview. We recommend booking in with a medicine interview tutor to get the most realistic preparation for interviews. An interview tutor will expose you to more ethical dilemmas and give personalized teaching and feedback on the questions. This will help you to gain interview confidence and the knowledge you need to stand out. Once you feel prepared, we also advise you to practice your answers in a mock MMI circuit.