Top 5 ethical issues in medicine

A leading medical ethicist lists his top 5 ethical issues in medicine today and in the near future.

1. Medical errors

No one knows exactly how many people are killed each year by medical errors, but it is in the hundreds of thousands in the United States and tens of thousands in the United Kingdom. Along with heart disease and cancer, it is a leading cause of death. Many more people are injured non-fatally by errors and the cost of payouts for clinical negligence claims in England in 2017/2018 was £2.23 billion.

Reducing the human and financial cost of medical errors is an ethical priority. The recent Bawa-Garba case, in which a junior doctor contributed to the death by sepsis of a 6-year-old-boy, highlighted the need to address both individual and systemic issues to reduce errors.

Clinicians have an ethical obligation to be open about their medical errors but how do we encourage them to do so when the personal and professional consequences of honesty can be devastating? The reality is that some medical errors are never disclosed to patients, who are then deprived of compensation, and little is learnt from the mistakes.

2. End of life

The population is ageing and our ability to keep desperately sick people alive is ever-increasing. Should we help people who want to end their lives? If so, should it only be terminally ill patients or should it include those suffering from psychiatric disease, like Aurelia Brouwers, the 29-year-old Dutch woman who was so unhappy that she described her mental suffering as ‘unbearable’? She lawfully drank lethal poison in the Netherlands in January 2018. Parliament must urgently consider whether to create a law allowing clinicians to help patients die in certain circumstances.

3. Confidentiality

Doctors have an obligation to keep their patients’ secrets but when can this be breached? If a person tells their GP that they have been a victim of domestic abuse but refuses to tell the police, should the doctor do so? What about the bus driver with epilepsy who continues to drive but withholds the diagnosis from the Driver and Vehicle Licensing Agency (DVLA)? If a patient has a serious genetic disease which a relative may also have, such as Huntingdon’s disease (a fatal, incurable condition which is passed on to children 50% of the time), should doctors tell the relative even if the patient refuses permission? Confidentiality is one of the most common issues raised by doctors when they contact the British Medical Association’s Ethics Department.

4. Resource allocation

How much money should the NHS receive from the government? Dr Richard Smith, a former editor of the British Medical Journal, recently argued that the NHS should not receive any more funds because 90% of health results from ‘environment, genes and lifestyle’ and ‘healthcare rapaciously swallows up funds that would do much for health if invested in education, housing, poverty reduction, the environment, community development’.

Within the healthcare budget, how much should be given to each condition? Should acute conditions, such as brain haemorrhages, get more investment than long-term ones, such as diabetes?

5. Artificial Intelligence

Artificial Intelligence is infiltrating the field of medicine, with AI software already interpreting the scans of radiologists, making treatment plans, and assisting surgeons in the operating theatre. Over the next few years, the role of AI will continue to grow but ethical and legal issues are yet to be addressed. Who will be to blame, if anyone, if the AI proves malfunctions?

The developer, the manufacturer, the maintenance people, the hospital, the clinician? How can doctors obtain informed consent from patients if no one quite understands how the AI’s self-learning algorithm works because it is too complicated, or when the error rate is unknown? And what if the algorithm contains or develops biases, discriminating against certain types of patients: the young, the old, the rich, the poor, men or women?

Several of these ethical issues are likely to be relevant to us at some point in our lives, whichever side of the stethoscope we stand. It is in our collective interest, therefore, to reflect on them and find practical solutions.

Daniel Sokol, PhD, is a medical ethicist and barrister at 12 King’s Bench Walk. His book ‘Tough Choices: Stories from the Front Line of Medical Ethics’ is published in October 2018 and is available for pre-order.