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Making consistent ethical decisions

A moral framework is useful to ensure consistency ­ Dr David Molyneux outlines the thinking behind ethical decision-making

thics can be discussed on the basis of gut instinct. This may be the only way to discuss some issues, but the result can be fragmented and whole areas may be missed out. Furthermore, it's much harder to defend a particular action if all you have to rely on is a gut instinct about an issue. Your intuitions may lead to you to believe inconsistent things in different situations, but a moral framework can help ensure consistency.

Moral frameworks

There are many ethical frameworks in the literature, but the most widely accepted at present is an American framework called the 'four principles'.

This model was suggested by the American ethicists Beauchamp and Childress, and popularised in this country by the GP and moral philosopher, Ranaan Gillon. The claim is made that any ethical problem can be analysed by using these four principles, together with a consideration of whom these principles apply to (scope).

Critics of the four principles argue that they do not represent a coherent ethical theory, merely a mish-mash of ethical ideas. Nevertheless, it can be an incredibly useful tool in ethical analysis, even if we are merely using it as an


A raft of subsidiary principles can be derived from the four principles (see box right).

So far, so good. But what happens if the principles conflict? Take the example of a 14-year-old girl who comes to you and tells you she is being sexually abused by her father. Furthermore, she insists that you respect her confidentiality and not tell anyone. Here we see two ethical principles in collision. On one hand, the principle of respecting autonomy would tell you that you should respect her confidentiality. On the other hand, the principle of avoiding non-maleficence suggests you should try to prevent the harm done to the girl by the sexual abuse.

What do you do?

One way of progressing is to work from first principles and apply an underlying ethical theory to the situation. Unfortunately, in contrast to the situation in clinical sciences, there is no single agreed ethical theory, though there are two main ways of thinking about the rightness or wrongness of actions.


The first approach states that the only thing that matters ethically is the consequences of an action, and that the right thing to do is always to maximise any beneficial consequences. This theory is called consequentialism, and one variant of it (utilitarianism) states that the good consequence to maximise is the amount of happiness for the individuals involved. So a consequentialist GP would say something like this about the case of the 14-year-old girl. 'It is obviously very harmful for this girl to be abused in this way. Breaking her confidentiality is a bad consequence too, but in the long-term, the good from stopping the abuse will far outweigh this small loss of benefit. So clearly the right thing to do is to involve social services and thereby stop the abuse.'

This approach is attractive, but there are drawbacks. We may have wildly miscalculated the consequences of our actions. The girl may be lying, and the subsequent harm to the family may be incalculable. The girl may be telling the truth, but never recover from the upset of her father being taken off to jail.

The father may commit suicide. Even if you were prepared to live with these uncertainties, there is clearly more to morality than just consequences.


The second theory, deontology, states that the important thing ethically is not consequences, but our willingness to follow rules or honour duties. There are many rules, such as 'do not kill', 'keep your promises', 'do not commit adultery' and so on. Furthermore, under this approach, the things that matter are what we do, and not what other people do. The key thing is to follow the rule. So in this case, the argument might go something like this: 'The important thing for me is to keep the rule about confidentiality. Of course I'm sorry that this abuse is going on, and I'll encourage the girl to report it. But I myself am not doing the abuse, so I'm not to blame. My responsibility is to keep to the rules.'

Most of us alternate between deontology and consequentialism, depending on the seriousness of the possible consequences and the importance to us of the respective rules. But if you look at almost any controversial ethical issue, you will see that there is a conflict between these two approaches: for instance, issues such as euthanasia, cloning and surrogacy.

Ethical decision-making

The arguments above have been about deciding what is right. However, ethical decision-making is much more complex than this, as the rightness of an act has to be placed in a wider framework.

Here is a 10-step approach to ethical decision making:

 · Ask, is the question an ethical one?

 · List all the people in involved

 · Generate solutions to the problem: rule nothing out

 · Assess the advantages and disadvantages of each solution (using the four principles)

 · Make a decision (using consequentialist and deontological theory)

 · Discuss your decision with colleagues

 · Check the precedents: GMC, legal, etc

 · Make a final decision

 · Impart the information to the patient in an ethical way

 · Record everything.

The 'four principles'

Beneficence ('do good')  · Cure

 · Palliation

 · Comfort

 · Empathy

 · Compassion

 · Treating patients with dignity


('do no harm')

 · Non-harm

 · Non-iatrogenesis

Justice ('act fairly')  · Fairness

 · Treat equals equally

 · Treat non-equals unequally in proportion to the degree of inequality

 · Ethical rationing

Autonomy ('allow people to determine their own futures')  · Truth-telling

 · Confidentiality

 · Informed consent

 · Decision sharing

 · Preference maximisation


Scope ('to whom do we owe these duties?')


ethics for the MRCGP

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