Introduction to Ethics

by Mark Hughes, MD, MA

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    00:00 So what do you think about when you think about ethics or morality? Are those terms that come easy to you? When I think about ethics, I think it's things that we learned all the way back in kindergarten.

    00:12 How to be a good person? How to be kind? How to be fair? How to treat people nicely? You know core things that all of us should have learned along the way.

    00:22 But now we're going to take those general principles and apply those to medicine.

    00:28 How to take care of patients, patients who are sick, who are ill and need our help.

    00:33 We have to take those general concepts of ethics and now apply it to the person before us.

    00:39 So what is ethics? It's a branch of moral philosophy which systematically investigates human actions.

    00:46 So when we're thinking about human beings performing actions, we can consider them actors or moral agents.

    00:53 They have the agency, the ability to choose how to perform their actions, how they're going to conduct themselves in the world.

    01:00 And we can think about those actions in terms of good or bad, right or wrong, what should or should not be done.

    01:10 And when we're thinking about ethical inquiry, we can think about it at three levels.

    01:15 There is first of all the descriptive level.

    01:17 So what is actually being done? How are people behaving? What are their actions? What do they believe? Those are the descriptive levels of ethics.

    01:27 There is the normative level of inquiry. So what ought to be done.

    01:31 What are the justifications for an action? Are there cultural norms that might speak to how to be normatively, ethically correct? And then lastly there is the analytic.

    01:42 So, this is what philosophers might think about.

    01:45 Not in terms of as an action good or bad, or right or wrong.

    01:48 But what are the actual terms, the concepts? What do they mean? What does it mean to be good or right? Now, I want to point out that we're generally a medicine thinking about descriptive and normative levels of inquiry.

    02:02 And there's something called the is-ought phenomenon.

    02:06 You might say that this is how things are being done in the world, but that does not necessarily imply that that's how it ought to be done.

    02:14 So there may be a different level of understanding of what it means to be normatively ethically permissible.

    02:21 There are various ways to think about actions of especially human actions, how we evaluate those.

    02:26 First level is going to be the motivation.

    02:29 So, the actor or the moral agent. What motivates them to act? You might think of, you know, clinicians being motivated out of compassion to help the patient who is suffering.

    02:42 You then might go to the level of the intentions.

    02:45 What is the intent of the action? What are you trying to achieve through the action? If it's a thief coming upon you and stabbing you, their intention is to cause harm, you know to injure you so they can take your money.

    03:01 Whereas the surgeon who is taking their scalpel and doing an incision in the abdomen for patient with appendicitis, their intention is a healing act to try to take care of the appendicitis.

    03:14 Next level of inquiry for evaluating actions is going to be the character of the agent.

    03:19 Is this is a good person? You know, are there traits or character traits that we think about for that moral agent when we assess their actions in the world.

    03:31 Next, we might think about "Are there rules? Are there cultural norms by which we should perform actions? Is it following the rules when we're performing these actions?" The next level of inquiry might be the action itself.

    03:48 Are there core principles that everyone should pay attention to? And we'll get to those in future lectures about respect or justice.

    03:58 Are those sort of core element features that we then have to apply to specific actions? Or are there values that are important to people in how they perform their actions? And then lastly, we might think about the consequence of the action.

    04:13 What's the end result? Is it a good result or a bad result? A term called consequentialist and that we'll get into in future lectures.

    04:21 All of those ways are going to be ways to think about actions.

    04:24 And they're all important when we're trying to assess, again, for the clinician in how they're performing these actions.

    04:33 So now, let's apply those general principle about what ethics is to medical ethics.

    04:39 So this is an interdisciplinary field, which is studying morality in the medical context.

    04:45 And it's going to be primarily concerned with what should be done with patient care? How do we take care of patients? And are we upholding certain ethical principles in doing that? At its core feature, medical ethics is practical.

    05:00 At the end of the day, you have to make a decision, you have to perform an action to help that patient.

    05:06 So you're going to take those core ethical principles, apply those to the delivery of care by the clinician.

    05:13 That is what medical ethics is all about.

    05:16 It maybe that there's a critical evaluation of the assumptions or the arguments for which you're basing your medical decisions or your actions.

    05:25 So, there's also going to be, you know, an opportunity to step back and say "Was that a good action or right action in helping this patient?" And then lastly, there may be situations that create conflict or are very challenging in the delivery of care to patients.

    05:43 And so you need a systematic approach in how to recognize those situations, but also how to address them because again it's going to be practical.

    05:51 At the end of the day, you're going to have to do something for that patient.

    05:58 The way I think about ethics, especially medical ethics, is medicine has an internal morality.

    06:05 It starts with the idea that a patient who comes to us seeking help is ill.

    06:11 They're vulnerable. They have an existential crisis.

    06:15 You know, their health is affected.

    06:18 They don't know what's going to happen in the future to them.

    06:21 That vulnerability, that factive illness cause upon them to then seek care from someone they can trust.

    06:30 When a clinician says, you know, for each individual patient, "How can I help you?" Or at the beginning of our profession, it may be throughout our professional careers, we profess, we say "You know, I'm here to help other people." So I'm applying this to the physician, but this also applies to nurses that have their code of ethics.

    06:53 This idea of profession that I'm here to help you is the second step in this internal morality of medicine.

    07:01 And then lastly, you know, when you enter into this relationship, the vulnerable patient where the person who is saying they are here to help you, that healing act is going to be accomplished for me as a physician in taking care of a patient, for a nurse same way taking care of a patient, that relationship creates this internal morality that then is going to serve the patient's interest.

    07:29 For medicine, specifically for physicians, I think about it as a Greek term called tekne iatrike.

    07:37 So, tekne meaning technical. So this is a technical discipline.

    07:42 You know, we have the skills, knowledge that we have developed thru medical school, thru our training that we get this confidence to practice the science and the art of medicine.

    07:57 Iatreke, you may be familiar with the term iatrogenic.

    08:01 So that involving, you know, the study of medicine or the practice of physicians with diagnosing and treating patients.

    08:09 And then the important part is that medicine is neither solely an art or solely a science.

    08:15 It is a combination of both things.

    08:18 There is an inextricable link between both science and art.

    08:22 Think of it as a craftsman, a master craftsman building a house.

    08:28 Now, anybody can take a hammer or nail, and you know hammer that nail into a wall.

    08:34 But a craftsman, you know, creates a work of art.

    08:38 So they have both the technical discipline, they've learned their craft.

    08:44 But there's also an art to it, that experience that then comes with building something.

    08:50 The same way in medicine. We take our skills, we take our knowledge, and then we apply it and over time with our experience with other patients how to take care of this patient in front of us.

    09:04 So, it's a moral enterprise combining both scientific reasoning with judgment.

    09:10 You need to have the judgment about how to take care of this particular patient in this clinical experience right now.

    09:18 And the ultimate goal is a right and good healing action for a particular patient.

    09:24 So we're going to think about ethics in a variety of different ways.

    09:27 We're going to have different approaches to ethics.

    09:29 First of all, virtue theory. Looking at the character of the moral agent, you know the clinician and the virtues that they should espouse in taking care of patients.

    09:39 We're going to think about principalism.

    09:42 So, applying those general principles now to the medical context.

    09:47 And there are going to be some core principles that we need to think about in that regard.

    09:51 Next, the ethic of care. So, this is thinking about relationships.

    09:55 I talked about the healing relationship.

    09:57 So now, we're going to think about "What are the contexts of a relationship that are important in determining how we should behave and how we should act towards the patient?" And then lastly, casuistry. So this is case-based reasoning where we're thinking about previous cases, how did you solve the dilemma that might have happened in that case and now applying it to this new case in front of us? Are there any general rules that we should follow in terms of that case-based reasoning?

    About the Lecture

    The lecture Introduction to Ethics by Mark Hughes, MD, MA is from the course Introduction to Clinical Ethics.

    Included Quiz Questions

    1. Descriptive level
    2. Unusual level
    3. Microscopic level
    4. Emotional level
    5. Reward level
    1. Recognizing the core principle or value leading to the action
    2. Judging the social standing of the person
    3. Learning where the person lives
    4. Gossiping about the person with your friends
    5. Ignoring the action
    1. An interdisciplinary field studying morality in the medical context
    2. A field studying morality in the social context
    3. An interdisciplinary field studying mathematics in the medical context
    4. An interdisciplinary field studying medicine in the psychological context
    5. An interdisciplinary field studying morality in the psychological context
    1. Clinician professing to help
    2. Patient strength
    3. Boundary-setting
    4. Goal-setting
    5. Diagnostic uncertainty

    Author of lecture Introduction to Ethics

     Mark Hughes, MD, MA

    Mark Hughes, MD, MA

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