The four principles of medical ethics are the most important factors that can not only be used in a medical school interview to impress on any ethical question the interviewers may ask but are also extremely useful as a doctor to make ethical decisions about the treatment of patients.
Firstly, what are the four Principles (also known as ‘Pillars’) of medical ethics?
Justice
Justice is the principle that there should be fairness in all decisions that may be made in the clinical treatment of a patient. This means that all patients should be treated equally and have equal access to resources and treatments, no matter their circumstances or personal views.
Beneficence
The principle of beneficence states that a doctor should always act in the patient’s best interests. This goes further to ensure that all patients are treated equally and that they each attain the best possible outcome.
Non-Maleficence
Non-Maleficence ties in strongly with the principle of beneficence: it means to cause no harm to the patient. Ideally this is both physically and emotionally, although this is not always possible.
Autonomy
Autonomy means that a patient has the right to have the final say on all decisions made about their treatment, no matter whether this decision will have a positive or negative impact on them. It is important to note, however, that a patient can only refuse treatment: they cannot demand any treatment that the doctor has not yet suggested.
Justice
There are occasions where justice cannot be enforced, and this could be asked as a question to test your knowledge of the four principles. For example, is the NHS postcode lottery fair? This is a problem in which, depending on where you live, certain treatments may not be available to you, while they may be readily available elsewhere in the country. This raises the issue of justice in the NHS, as, based on this principle, surely all people should be offered the same treatment. Another area where issues can arise is when there is the case of an organ transplant. For example, if there are two people who both need a kidney, but there is only one kidney available. You would have to consider many external factors, such as who the kidney would benefit most, if there were children relying on the transplant recipient, as well as a multitude of other factors which may sway your decision. Ultimately, although justice is an ideal, it cannot always be implemented due to limitations of either resources or within the NHS.
Beneficence
The question of long-term vs short term benefit may be addressed in the interview. For example, heart surgery in the short term is definitely not the best thing for the patient. There is a high mortality rate, not only from human error, but also in the aftermath of the operation through sepsis, not to mention the incredible pain caused by the surgery. However, it is deemed as the best thing to do for the patient as, in the long run, this saves the patient’s life and may also increase their quality of life going forward. Although open for interpretation, beneficence is therefore characterised by doing the best thing for the patient in the long-term outcome, rather than focusing on the short term pain/ inconvenience.
Non-Maleficence
You could be given a scenario which tests your ability to identify where there are issues with this principle. For example, breaking bad news to a patient often has a negative effect on their mental outlook, as it can result in more serious conditions such as depression. However, it is still very important to break the bad news to them, as it is their right to know. The same issues with beneficence also apply here with physical harm to the patient.
Autonomy
Once again, problems may arise from different scenarios which interviewers love to test. For example, if a child is technically not of age to make their own decisions, what must be done? By law, they must pass the Gillick competence test before making any decisions, but what if they are too young to pass the test? In these cases autonomy would not be respected as the patient does not have capacity to make decisions. Other situations of confusion may arise when a patient is mentally unwell or in a coma. In these cases, the doctor must use the instructions given by the patient before they became unable to make decisions or use their own discretion to decide the best course of action for the patient. This is made more challenging, if the doctor’s views contradict that of the immediate relatives. Whilst the relatives views will likely be taken into consideration, it is ultimately the professional opinion of the medical team that will be implemented unless there is a valid advanced directive or LPA (Lasting Power of Attorney).
In all ethical questions posed in a medical school interview, it is open to the interpretation of the student being interviewed, and there is therefore no definitive right or wrong answer. The best way to score well on ethical questions is to use as many of the four principles of medical ethics as possible, and reason out loud to ensure that the interviewer clearly understands your thought process.
Any non-personal question can be related back to the four principles of medical ethics, not only ethical scenarios. These can be used anywhere, and they show that you are considering all arguments involved in a situation. This is exactly what interviewers are looking for: they want someone who can weigh up different arguments and points of view which may have influence, and then use these to come to a sensible outcome. Therefore, it is important to not only mention the principles of medical ethics but to implement them appropriately in order to help you stand out from other interviewees.
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