If you chance to browse through a textbook of medical ethics, you will sooner or later come across the four principles of Beauchamp and Childress (Beauchamp TL, Childress JF, Principles of Biomedical Ethics, 7th ed. Oxford: Oxford University Press; 2012).
- Respect for patient autonomy
- Beneficence
- Non-maleficence
- Justice
These principles are said to underpin our entire approach to patient care, and to remind us at the deepest level of not only what we do, but why to do it. One could write a textbook on each of these four elements alone, but here are just a few notes.
- Autonomy captures the idea that patients are entitled to be fully informed as to the nature of their condition, and the therapeutic options available, in order to give consent, or not, to a proposed course of action. It may be surprising that it is often the patient who is first to surrender this right, with a shrug. “You’re the doctor. You know best.” Patients may think better of medical paternalism than do doctors. And then, some patients are more autonomous than others. How autonomous is a child, or a patient with dementia, or with a psychotic illness?
- Beneficence requires that a proposed treatment be to the patient’s advantage. That seems self-evident, but what if the patient exercises his autonomy to request a treatment that the doctor considers futile, or even harmful?
- Primum non nocere. First do no harm. Non-maleficence might be taken as a synonym for beneficence, therefore redundant. But then, there is no therapy in the world that is not attendant with unwanted effects. Every proposed therapy requires a risk-benefit analysis. There is a saying in medicine: show me a drug that has no side effects, and I’ll show you a drug that doesn’t work.
- Justice reminds us that every individual patient is part of a community. If the health budget is finite, then spending the entire budget by prescribing an exorbitantly expensive drug on an individual, is going to be unjust to the rest of the community. Hence, bodies such as the National Institute for Clinical Excellence in England (NICE) must make decisions as to whether certain drugs can be prescribed on the NHS. “We have had to make some hard choices.”
Whenever I come across Beauchamp and Childress’s Four Pillars, I always think of a scene from the film Dead Poets Society, in which the English teacher John Keating (Robin Williams) has a pupil read aloud in class the introduction to a textbook of poetry, in which the anthologist provides the reader with a systematic approach to the estimation of a poem’s intrinsic worth. Two critical criteria – I forget what they were – are pinpointed on a graph’s x and y axes in order to produce a curve, or perhaps an area under the curve, that will represent a quantification of poetic value. Mr Keating draws the graph on the blackboard, and the pupils dutifully copy it down. But then they are somewhat taken aback by Mr Keating’s next comment.
“Excrement.”
I have to admit I tend to respond to Beauchamp and Childress with Mr Keating’s reaction. The four principles represent medical ethics in retrospect. You can imagine a hapless medical practitioner falling short of B & C’s standards, and finding himself up in front of a medical disciplinary committee, a group of august dons who take several days, or even weeks, to mull over a decision that the practitioner might have had to make in ten minutes. By and large, people who work in front line medicine don’t utilise an ethical calculus. Rather, they do their best, quite simply, to give tender loving care.
Mr Keating was teaching in a posh New England boarding school for boys, cramming the next generation of Ivy League scholars, in 1959. I wonder if he was aware of an event that took place across the Pond on 7th May, 1959. C. P. Snow gave the Rede Lecture in the Senate House in Cambridge, entitled The Two Cultures. I have an idea that Keating might have applied the excrement word to Snow’s thesis, just as F. R. Leavis did in his Cambridge Richmond Lecture in 1962. Snow thought that society was fractured, and therefore harmed, by a schism between the arts and the sciences, or more exactly between artists and scientists. The fact that Leavis’ reaction to this was viscerally antagonistic reminds us of a polemic that has dominated English letters really since the industrial revolution. Leavis was antagonistic towards the theories of utilitarianism, and it is no surprise that the only Dickens novel he admired was Hard Times, Dickens’ own reaction to the utilitarian calculus of “the greatest good for the greatest number”, and thus, the quantification of human souls. Dickens wanted to help the poor individually, but he didn’t want to create a welfare state. Perhaps George Orwell turned out to be more of a utilitarian champion when he realised that liberalism, romanticism, and sentiment can only take you so far. Who was it said, campaign in poetry, govern in prose?
I thought of all this, of Beauchamp and Childress, Mr Keating, Dickens, Orwell, Snow and Leavis, when I heard Sarah Montague conduct an interview last week with some health care gurus on BBC Radio 4’s The World at One. Digitalisation is apparently the coming thing. (Didn’t England’s erstwhile Health Secretary Matt Hancock tell us as much?) The NHS lags far behind. Everybody needs to be on line. The benefits are immeasurable. All that data will be available to all these health care professionals at the click of a mouse (except the data I never recorded, because the patient told me something in deepest confidence). When I was in practice, I was never so glad as when the computers crashed. The third eye in the room went blank and I could turn my undivided attention to the living individual in front of me.
But now, apparently, if you are a Luddite, perhaps because you are elderly or decrepit or demented or just plain bloody-minded, then frankly you are going to get a poorer service. It’s regrettable, but there it is.
I wonder what Messrs Beauchamp and Childress would have made of that.
jamescalumcampbell 