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Ethics, I have been told, is a side show to the main event - the science and the practice of medicine.

The argument goes that medical science is based on rational theory and experimental proof. It poses questions but has no “right” answers. But the art of medicine is all about doing the right thing for our patients and the study of ethics is primarily concerned with the nature of right and wrong. It is not true that ethics is all relative, there is a great deal of agreement about what is right (e.g. freedom, equality, privacy) and wrong (e.g. murder, theft, rape) and there are methods for resolving ethical conflict by the application of principles and reason. It is true that we do not always resolve conflict but then scientists do not always get it right the first time either.

A grey world
Geriatricians see things differently; we spend our time in the grey area of difficult decisions. Black and white decision making according to protocol and guideline is not for us because we understand that for every individual the application of evidence is different. Integral to our practice is the idea that we should consider the whole person as more than the sum of their pathologies. Ethical reasoning must be part of this decision making process. If we cannot explore the ethics of the problem how can we justify our decision?

Should we? Shouldn’t we?
Mr B is 70 years old, he has had a severe stroke, he has a dense right hemiplegia and he is aphasic. He is not imminently dying. If we put in a PEG (percutaneous endoscopic gastrostomy) feeding tube his life may be prolonged, if we do not provide ANH (artificial hydration and nutrition) he will die. Therefore, the moral question is: should we attempt to prolong Mr B’s life?

We start by specifying the ethical principles relevant to our decision. A number of different approaches may be applied; the four principles of Beachamp and Childress provide one such structure.

Autonomy – the patient has a right to decide for himself what treatment to accept or decline. However this patient is unable to communicate verbally. So we need help to gauge his understanding and interpret his non verbal communication. His family may be able to give us information on previously expressed wishes and values.

Beneficence – we start with the prima facie premise that human life is worth preserving, unless doing so would involve unbearable suffering to the individual. Generally the individual should decide but if they are unable to do so we must avoid making judgements on social utility or from our own perspective. Family members and friends also make an important contribution here.

Nonmaleficence - All medical care has side effects or burdens which must be taken into account when deciding if the treatment is worthwhile. There is a risk of complications with PEG placement. After the procedure the PEG may cause physical or psychological discomfort.

Justice – medical professionals should act within the law, respect human rights and take account of distributive justice. A treatment which is very expensive and only prolongs life for a short time may not be affordable. A publicly funded healthcare system has to ration healthcare resources and doctors have a professional duty to consider the wider implications of their decisions.
Conclusion - The procedure has relatively few complications and is not prohibitively expensive therefore the decision depends on whether prolonging life is of benefit to the patient. This will depend on the individual circumstances of the case.

Consistency and balance
What is important is that ethical decisions are made in a consistent way – using ethical principles justified, specified and balanced in the light of the individual facts of the case. This is not a care pathway or protocol; it is a method of ethical reasoning to ensure that decisions are reached in a logical and consistent manner.

I am excited to be taking over as Chair of the Medical Ethics SIG from Dr Martin Vernon who did an excellent job and will be a hard act to follow.

Highlights of the past 3 years include:

• A debate on physician assisted suicide at the BGS in Harrogate October 2006.
• A conference on ‘Ethical issues in the management of older people’ in Nottingham June 2007 organised by SIG secretary Professor Tahir Masud.
• A joint conference with the Royal College of Physicians in London September 2008 organised by Dr Martin Vernon.
• Publication of the RCP/ BGS guideline on Advance Care Planning 2009
• A debate on restraint at the BGS spring meeting in Bournemouth April 2009.

The SIG has a role in several areas:
1. Theory: To contribute to theory and debate in medical ethics e.g. the role of ethics in medical training, the application of normative theory to medical dilemmas.
2. Policy: To inform BGS policy on matters which have an ethical dimension e.g. consultation on privately funded drugs and NHS care.
3. Practice: To engage all geriatricians in the relevance of applied ethics to their clinical practice e.g. recent debate on restraint and workshop on the Mental Capacity Act 2005.

I hope over the coming two years to expand membership and set up a regular discussion forum for the SIG. If you are interested in joining the SIG (no fee) then please make contact through the editor.

Premila Fade
Chair, BGS Medical Ethics SIG
Consultant Physician
Pool Hospital NHS Foundation Trust

BGS Newsletter, March 2009
Issue 21 ISSN 1748-6343 21