Core Principles of Medical Ethics and Informed Consent

Ethics in Medicine, Lecture 1. This lecture covers the foundational ethical framework used in medical practice and the legal and ethical principles governing informed consent and decision-making capacity.

THE FOUR PRINCIPLES (PRINCIPLISM)

The most widely used framework in biomedical ethics was developed by Beauchamp and Childress in "Principles of Biomedical Ethics" (1979, now 8th edition). The four principles are:

1. Autonomy: respect for the individual's right to make decisions about their own body and healthcare, free from coercion, based on adequate information and intact decision-making capacity. Autonomy is the dominant principle in contemporary Western medical ethics but is not absolute — it is constrained by harm to others and, in some frameworks, by the rights of the foetus.

1. Beneficence: the obligation to act in the patient's best interest; to do good. This requires clinical competence, good clinical judgment, and attention to the patient's values as well as their medical needs.

1. Non-maleficence: "first, do no harm" (primum non nocere). This does not mean refusing all interventions with risks, but rather that harms must be weighed against benefits. The principle of double effect: an action that causes harm may be ethically permissible if (a) the action itself is not inherently wrong, (b) the agent intends the benefit not the harm, (c) the harm is not the means to the good, and (d) the good outweighs the harm. Applied in palliative care: opioids given for pain relief that may hasten death.

1. Justice: fairness in the distribution of healthcare resources and burdens; treating like cases alike; procedural justice (fair processes); distributive justice (fair allocation). In practice: allocation of scarce resources (ICU beds, transplant organs, expensive medications), health equity, and avoiding discrimination.

These principles do not form a hierarchy — their relative weight depends on the clinical context. Tensions are common: a patient with decision-making capacity refusing life-saving treatment (autonomy vs beneficence), or prioritising an individual's treatment vs a population health intervention (autonomy vs justice).

INFORMED CONSENT

Valid consent requires three elements: (1) Disclosure — the patient must receive adequate information about the proposed treatment, its purpose, material risks and benefits, alternatives (including doing nothing), and likely outcome without treatment. The "reasonable patient" standard (adopted in NZ following the Montgomery ruling UK 2015 and supported by NZ case law): disclose information that a reasonable patient in their position would want to know, or that this particular patient would want to know. (2) Competence/Capacity — the patient must have decision-making capacity (see below). (3) Voluntariness — the decision must be made freely, without coercion or undue influence.

DECISION-MAKING CAPACITY

Capacity is decision-specific and time-specific — it should be assessed for each decision at the time it needs to be made. The four components of capacity (MacArthur criteria): (1) Understanding — the patient can understand and process information about the decision; (2) Appreciation — the patient can appreciate how the information applies to their own situation; (3) Reasoning — the patient can reason about options and their consequences; (4) Communication — the patient can express their decision consistently.

Adults are presumed to have capacity until proven otherwise. Conditions that may impair capacity: dementia, acute delirium, severe mental illness, intellectual disability, substance intoxication. A psychiatric illness alone does not equal lack of capacity.

If a patient lacks capacity, decisions are made using the "best interests" standard (what is in the patient's overall best interests, considering their known values and previously expressed wishes). In NZ, the Protection of Personal and Property Rights Act 1988 (PPPR Act) governs the appointment of welfare guardians and enduring power of attorney.

ADVANCE DIRECTIVES

A competent adult may make an advance directive (living will) specifying treatment preferences for future circumstances when they may lack capacity (e.g., "do not resuscitate" [DNAR] orders, refusing specific treatments). Advance directives are legally binding in NZ if they meet requirements: made by a competent adult, specific to the decision, not withdrawn, and applicable to the circumstances.

THE SPIKES PROTOCOL FOR BREAKING BAD NEWS

SPIKES is a structured six-step framework for delivering bad news: Setting (private, quiet space, sit down, interpreter if needed), Perception (ask what the patient already knows/suspects), Invitation (ask how much information they want and in what form), Knowledge (deliver information in clear, plain language, in stages, checking understanding), Emotion (acknowledge and respond to emotional reactions with empathy), Summarise/Strategy (summarise what has been said, outline the plan, arrange follow-up). Breaking bad news poorly increases patient distress and erodes trust; good communication reduces anxiety and supports informed decision-making.