• ethics

Clarifying the meaning of ethical concepts is fundamental for medical ethics. Many of the best papers in the Journal of Medical Ethics have advanced our understanding of the limits and implications of ethical concepts. This issue includes a number of papers that give us reason to reflect on the use, implications and grounding of some important ethical concepts.

The concepts we use are rarely neutral. For example, those arguing against assisted dying are more likely to use terms such as ‘euthanasia’ or perhaps even ‘killing’, while those arguing in favour of it might opt for ‘aid in dying’ or ‘facilitated aid in dying’. Of course, these are different concepts and do not mean the same thing, but the different associations and implications of concepts can weaken or strengthen a position.

Woollard analyses the way in which the terms used in public information and discussions about breastfeeding can be morally loaded and thereby cause guilt or detract from the effectiveness of public information.1 She argues that normative concepts such as ‘harm’ or ‘dangerous’ and slogans such as ‘breast is best’ can imply moral duties or criticism when it is unhelpful and inappropriate to do so. She does this by showing how concepts such as ‘harm’ and ‘risk’, which we do tend to use in descriptive ways when there is relevant evidence, are moral concepts that can be taken to imply a moral failing if a mother does not follow this evidence. Her suggestion is that we should opt for morally neutral terms such as ‘difference’ to avoid implying something normative about mothers who choose to use formula.

All healthcare professionals know that compassion is expected and an important aspect of good healthcare. We don’t need elaborate arguments for why this is important, just as we don’t for many of the other ways in which clinical practice can fall short of an acceptable standard. A more relevant question is how healthcare professionals end up not demonstrating compassion. So, Rydon-Grange offers an account of the ‘compassion killers’ that play a role in professional and ethical failures of this kind.2 Shift patterns and staffing levels are environmental factors that influence behaviour and the likelihood of compassion. This is a different kind of ethical argument from, for example, attempting to derive a position about the use of embryos on research from a philosophical investigation of their moral status, and it is important that medical ethics is attuned to the importance of context when arguing about what we should do to help prevent unethical behaviour.

Just as the need for compassion in health care is a given, the importance of informed consent doesn’t need to emphasised. However, the psychological preconditions that make informed consent possible and meaningful are important for medical ethics. Bolt, Vos and Schermer3 consider psychological evidence that undermines the ‘rational choice theory’ justification of informed consent and consider what a more intuitive approach to decision making implies for consent.

Both of these papers draw on evidence so as to clarify our understanding of critical ethical concepts. In doing so they develop an ethical argument about what should be done. The argument in these papers is therefore more empirical in its methodology and the key steps in the argument are evidential.

Medical ethics also draws on philosophical accounts of duty, responsibility and blame. Two papers in this issue argue in this fashion and tease out implications for whether and when healthcare professionals should be held to account for not acting on professional duties. Ries-Dennis argues that forward looking nature of the ‘Just Health’ and its emphasis on system errors, fails to acknowledge the importance of attributing blame.4 He draws on philosophical accounts of punishment to argue that there are cases in which not attributing blame implies that those who have been wronged are not accorded appropriate respect. The conceptual link between professional duties and blame is also explored by Eriksen.5 Medical ethics usually involves weighing competing moral considerations in order to arrive at the best ethical course of action. So when a clinician judges that patient self-determination is more important in a given situation than what they think is in a patient’s interests, they might appear to be failing to act on a duty to act in that patient’s best interests. Eriksen analyses the nature of moral duties to argue that in such cases, a clinician is not blameworthy.

These papers use different forms of argument so as to analyse and deepen our understanding of ethical issues. A different and equally important approach to medical ethics is to plan and evaluate procedures for making challenging ethical decisions. Caplan et al 6 describe the processes and principles of a ‘Compassionate Use Advisory Committee’ that was constituted to help make fairer allocation decisions about access to experimental pharmaceuticals outside of a clinical trial. Pharmaceutical companies make a small amount of promising, but still experimental medications available to patients for ‘compassionate’ reasons. Caplan and his colleagues created an ethical framework designed to create a fair process for deciding which oncology patients should be able to access these medications.

Allocating treatment under conditions of scarcity is perhaps the most prominent justice issue discussed within medical ethics and what is important about this paper is the way that its authors explain how choices were made about the principles and processes to be used. In situations where there is a clear, unmet medical need then allocating on the basis of a lottery or first come first served are defensible principles. Interestingly, Caplan and colleagues opted for prioritising on the basis of three principles. First, that the experimental treatment should present no known or unacceptable harms to that patient. Second, the strength of evidence of benefit for that patient. Thirdly, that the patient is fit and stable enough to tolerate the therapy. This approach to medical ethics is one that involves reporting on a process created for making clinical ethics decisions. It’s important that medical ethics engages in the critical ethical analysis of concepts, but it is also important that it describes processes to guide ethical decision making on the ground.