Medicine Interview Skills: Ethics Guide

What are medical ethics?

Medical ethics is an area that is based on the moral consequences of clinical decisions. The four pillars of medical ethics – Autonomy, Beneficence, Non-Maleficence and Justice are used in healthcare every day to determine the best course of treatment for a patient.

In an interview, the four pillars of medical ethics act as a framework for you to reason through an ethic scenario.

Here are the four pillars explained.

1. AUTONOMY

The patient has ultimate control over their medical treatment.

Autonomy states that the patient has the right to make their own decisions about their life and treatment, even if this means going against medical advice. There are exceptions to this, such as if a patient is detained under the Mental Capacity Act and deemed unable to make decisions themselves about their medical treatment.

When a patient is making a decision on their medical treatment, it is important that it has been explained to them, including the risks. The patient must be able to retain this information and explain it in their own words and consent must be voluntary.

Example:

A common example of this is Jehovah’s Witnesses refusing blood transfusions for religious reasons, even if it would be lifesaving, such as in an operation where the patients is expected to lose a lot of blood. As adult patients are assumed to be competent, the medical staff must respect this decision.

2. BENEFICENCE

Do good.

Beneficence is simplified to the phrase ‘do good’ but it is more complex than this. It is about maximising the benefits of medical care for a patient.

Doctors must promote the course of action that they believe is in the best interests of the patient.

Important considerations surrounding the principle of beneficence are whether the treatment will resolve the patient’s condition and whether the course of action is proportionate to the condition.

For example, if someone has broken their leg with no complications, amputation would solve the immediate issue, but it is completely disproportionate for the problem. Other things to be aware of are the patient’s circumstances and wishes.

Example:

A 90-year-old patient with lung cancer; the treatment would require surgery and chemotherapy. This treatment might prolong his life, however as a doctor you must consider the pillar of beneficence – what is in the best interest of the patient. Not treating the cancer and keeping the patient comfortable could be the most suitable course of action in this case. As surgery and chemotherapy may not be suitable options as the patient’s age will affect this.

3. NON-MALEFICENCE

Do no harm.

Non-maleficence is the famous do no harm principle.

This also extends to not allow harm to a patient through neglect. This pillar is all about minimising the harm that the treatment might do to a patient. It is important to weigh up all of the risks; those that come with an intervention and those that come with not intervening.

Non-maleficence and beneficence often come as a pair and seem like the same thing. However, there are subtle differences.

Non-maleficence is a constant consideration and is the principle that compels healthcare professionals to act. Non-maleficence acts as a threshold for treating a patient whereas beneficence involves weighing up the options to find the best one.

Example:

An unwell patient with a condition that currently has no treatment is demanding that you as a doctor prescribe an unproven and unlicensed medication saying that they are fed up and willing to try anything. You have a duty to that patient to not cause them harm, and an unproven medication may well cause them harm, therefore you should not prescribe what they are asking for. You may explore other avenues such as clinical trials.

4. Justice

What is the law?

Justice is about where the ethical and moral decision fits into the legal framework. Essentially, justice asks what the legal guidelines are and whether a course of action is compatible with the individual’s rights.

However, it also considers the wider impact on society. It is also about fairness and the distribution of benefits, costs, and risks.

Justice is especially relevant to the NHS which is committed to healthcare for all. Under this principle, it is important that no one is disadvantaged on access to healthcare.

As well as looking at the fairness of the action and the legality, it must be considered whether one group is being prioritised over another and if so, is there justification for this.

Example:

A patient being seen by their GP has tested HIV positive. They reveal that they have not told their partner and do not intend to. In this case, the GP has an obligation to breach patient confidentiality and inform the partner as a last resort in order for the situation to be just, informing the patient of their actions. They should first talk to the patient about the risks of not disclosing and encourage them to notify their partner.

The 4 pillars of medical ethics are the key to debating any ethics question well.

You may wish to talk about other issues that you can’t encompass whilst talking through these pillars, and if this is the case you should include these in your answer.

There are some other key concepts that are commonly important in ethical questions. This is not a complete list of other factors but these ‘3 Cs’ are very important.

1. Consent

Consent refers to the patient agreeing to their treatment.

Upon making this decision, the patient must have capacity, make a voluntary decision and be informed – i.e. given all the relevant information about what the treatment involves and the relevant risks.

2. Capacity

Capacity asks whether the patient able to make their own decision.

All adults (aged 16 and over) are presumed to have capacity unless shown otherwise. There are instances where adults may not have capacity, such as if they have dementia, severe learning disabilities or are intoxicated by alcohol.

Children can have Gillick competence – this is where a child under the age of 16 can consent to their own treatment if they can fully understand their treatment. Otherwise, someone with parental responsibility can consent for them i.e. a parent, legally appointed guardian and in some cases a local authority.

3. Confidentiality

Confidentiality means that no patient information may be disclosed without the patient’s consent.

Confidentiality is an ethical and legal duty, however there are circumstances where a healthcare professional may be required to break confidentiality such as disclosures that are required by law.

Why are medical ethics important and why are they tested?

Medical ethics are immediately important to you as they will be tested at your interview!

You must demonstrate that you have a firm grasp of the 4 pillars as well as other important concepts as discussed above.

However, medical ethics are much more important than this.

They are essential in the everyday practice of healthcare professionals and govern the decisions they make. Medical ethics represent not only a professional and often legal duty, but also a moral once.

Medical ethics are constantly in the news.

Whether it is debating the ethics and potential of genetic engineering or centred on specific cases such as the case of Charlie Gard in 2017, which resulted in a court battle between the family and Charlie’s doctors.

Medical ethics cases are debated in society as well as in healthcare every day. It is essential that you begin to understand the key principles and begin to apply them at what is potentially the start of your medical career.

Medical ethics are a great way for the interviewers to test your logical reasoning skills as well as your grasp of the key medical ethical concepts that will become increasingly important as you become a doctor.

They underpin all the decisions that doctors make on the patient’s treatment and it important that you are familiar with these difficult concepts that will one day govern your clinical practice.

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Common examples of ethics questions

Medical ethics is quite a large topic which should be considered when answering many interview questions.

Here are 5 ethics questions for you to have a go at and a guide on how to answer them, which you will hopefully be able to apply to similar types of questions.

Ethics Q1: Should euthanasia be allowed in the UK?

Euthanasia is the deliberate ending of someone’s life, most often to relieve suffering.

There are different types of euthanasia including active, passive, voluntary and involuntary. It is useful to know what each of these means and involves when answering a question that uses the general term of euthanasia.

Like any ethics question, there is no straightforward answer, so you need to start weighing up the issue using the 4 pillars – Autonomy, Beneficence, Non-Maleficence and Justice. You can do this in whatever order feels most logical to you.

It can be argued that Autonomy can be extended to euthanasia, as it is ultimately the patient choosing to end their life.

On one hand it can be benevolent, especially if the patient is suffering, however the Non-Maleficence principle directly contradicts this in this instance as helping a patient to die or not taking action to prevent this could be considered harm.

There are Justice implications here – it is currently illegal in the UK however in other countries varying degrees are legal. In Belgium and the Netherlands active euthanasia is legal but in Switzerland and Germany only assisted suicide and passive euthanasia are legal.

You can use these countries as examples to further your argument, as this could be a glimpse into the UK’s future and many patients travel to Europe for euthanasia.

Having covered the 4 pillars of medical ethics, you should come to a conclusion with a reason.

This does not have to be a simple yes or no but could come with caveats such as only passive euthanasia should be legal or only for patients who meet a strict set of criteria such as terminal cancer patients.

Ethics Q2: Is it ethical for doctors to go on strike?

This has made headlines in the news in the past and may happen again.

If this question is asked in relation to a specific strike, be sure to understand why the government believes the doctors are striking and why the doctors say they are striking.

There are many arguments against this, principally, that having fewer healthcare staff in hospitals will endanger patients. However, in the 2016 strike, it was ensured that adequate cover in emergency settings was in place.

It can be argued that workers have a right to strike and that for healthcare professionals it would be a last resort after trying everything else.

In 2016, junior doctors were on strike after talks over new contracts broke down. Talks had been ongoing and this strike was a last resort as a protest.

There were worries over patient safety with the proposed 7-day NHS and there were disputes over the hours and rates in the contract.

In the news, it was widely reported that the junior doctors were striking because of the money but it ran much deeper with concerns for patient safety, which they would have also been concerned for during the strike.

Until 2016, there had only been one strike in 40 years from doctors, showing that it was an extreme measure when no other options were left.

Team of Multi-ethnic medical staff

Ethics Q3: Do you think that the NHS should purchase very expensive drugs for patients with rare diseases?

The UK is unique in that it has the NHS which gives universal healthcare.

However, it is government-funded and does not have infinite money to fund every new expensive drug that may come onto the market.

You are likely to be asked a more specific question than this such as should patient X receive treatment Y on the NHS, which is not currently given to everyone.

Justice is the key principle here.

Ideally everyone would be given whatever treatment they needed, especially if it is lifesaving or majorly improves their quality of life.

However, the NHS does not have infinite money and if it is a choice between purchasing a very expensive drug for a few patients and providing routine surgeries for a larger group, this may be a difficult choice.

The obvious answer to this question is yes, but you need to reason through both sides.

Give reasons why they shouldn’t such as if they purchase these drugs for this select group of patients, will they do the same if a new cancer treatment comes along that is expensive and for a specific type of cancer? How will it impact other services – would it mean cutting back elsewhere?

Consider what is fairest for society and the patient population as a whole.

Ethics Q4: Organ donation is now opt-out in England. What are the ethical considerations for an opt-out system vs the opt-in one that was in place for years?

In May 2020, England moved to an opt-out system for organ donating following Wales doing so in 2015. Many people die whilst waiting for a transplant, over 400 a year in England.

Go through the 4 pillars to reason through this question.

Autonomy means that many people may not get to make their own decision if they did not opt-out and are unaware of the change to the system.

Before the opt-out system, less than 40% of adults were on the register but over 80% of adults said that they would consider organ donation.

This resulted in far fewer organs being donated than would be under the opt-out system. Families could previously refuse organ donation and still can under this new system, however the default is that the patient is an organ donor, rather than not being considered.

An opt-out system is more beneficent as it leads to more organ donation which saves more lives.

Non-Maleficence is less relevant here as the donor is already deceased so no harm can really be done to them. However, the issue of consent may cause problems for the family, especially if they have a differing view to that of their loved one.

Looking at the principle of Justice, an opt-out system is fairer for society.

Not only will it save more lives through more donations, but the treatment that patients require whilst waiting for a transplant is expensive and comes at a personal cost to them as their health worsens.

The money and time saved by the NHS can be used for other purposes.

Ethics Q5: You are a GP who has a consultation with a 14-year-old girl who tells you that she has recently become sexually active and is requesting the contraceptive pill. She asks that you do not tell her parents. What do you do in this situation?

There are many issues at play in this scenario.

In the UK, the age of consent is 16. The doctor has a duty to ensure the safety of the patient and follow any necessary child protection guidelines. If the GP believes that the safety or wellbeing of the patient is at risk, they must follow child protection protocol as this is in the best interest of the patient.

There may be worries that the girl is being taken advantage of or that sexual abuse may be occurring.

The Autonomy pillar says that the patient can make her own decision.

Confidentiality is important in this situation.  It must be respected so the parents should not be informed if the girl is deemed competent. It is important that Gillick competence is established so that the GP can, which she likely is in this situation.

If she is not deemed competence, this would overrule Autonomy. You may encourage her to make her parents aware that she is sexually active, however.

Beneficence means that the GP should act in the patient’s best interest. It is important that the GP is beneficent and considers the effects that being sexually active may have on the girl’s physical and mental health.

The GP should provide advice on sexual health and contraception including the risks of having unprotected sex in order to help the young person’s wellbeing.

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Top tips for ethics interview questions

Ethics questions are designed to be tricky and test your understanding and ability to reason through a problem. Here are my top tips for tackling ethics questions.

1

Take your time.

Take a pause before you answer and build a plan of how you are going to answer to avoid repetition and contradictory statements

2

Always consider the pillars.

Consider the 4 pillars of ethics as well as the three Cs if relevant.

3

Tie it all up.

Summarise your main points and come to a conclusion.

4

Explain your thoughts.

Finish with your final answer followed by a short explanation. Ethics questions are designed not to have a clear answer, but you do not want to seem indecisive. As a doctor, you will need to be able to make decisions on the evidence available to you. 

Ethics questions are difficult but with practise, you will improve your reasoning skills. It is important to highlight the 4 pillars of medical ethics and develop a structure for approaching medical ethics questions.

The more you practise, the better you will become at tackling unfamiliar ethics scenarios. Good luck!

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2020-06-26T15:23:47+00:00