Autonomy, Justice, Beneficence, Non-Maleficence
In today’s Western societies, it is assumed that all medical strategies, treatment and treatment plans are guided by the Four Pillars of Medical Ethics developed over centuries of ever-changing medical practice since Hippocrates of Ur, often considered the Father of Modern Medicine.
As a practitioner outside the purview of Western Medical governing bodies (AHPRA, MBA and others), am I or should I be guided by the same Four Pillars or something similar?
In my opinion, yes, all medical modalities should always be guided by these Four Pillars and judged against them.
What is Medicine? Some years ago, a comedian on stage, who obviously had a very dim view of all medical modalities except Western allopathic medicine (WAM), asked the question “What do we call medicine that works?” His answer, “Medicine”. His subsequent comments made it clear he thought that only WAM worked and, therefore, could legitimately be called medicine, yet failed to read, review or even acknowledge any of the plethora of research showing that many Complementary/Alternative Medical (CAM) modalities also work to restore health.
We know, from excellent research, trials and meta-analyses, population studies, traditional knowledge dating back thousands of years, and very persuasive anecdotal evidence, that many CAM modalities do work and are truly medicine.
Every medical modality is guided by ethics and, if examined closely, all could be summarised by the Four Pillars: Autonomy, Justice, Beneficence and Non-Maleficence. However, in recent years, we have seen WAM, in particular, and some branches of CAM, ethically challenged by paternalistic governing bodies making politically/power-driven decisions and rules that limit the ability of practitioners to provide excellent, ethical care to all patients.
The first pillar to be challenged is Autonomy. Ideally, patients and practitioners form a partnership to create a plan of activity to restore health for the patient. When decisions are needed regarding forms of treatment that the practitioner deems necessary, but that may have equivocal results or safety, the patient is, ideally, fully informed of all benefits and possible consequences, then allowed to make a personal decision without pressure, coercion, manipulation or compromised information.
Unfortunately, we see, too often, treatment decisions being made with little or no involvement from the patient, or with very limited information provided for the patient.
Conversations in my personal experience and reported in clinic include, “You must take this drug or you could die” (with no discussion of adverse effects or possible alternatives); “We will operate next week and remove ******* , then rehab”, (with no discussion of probable post-surgical difficulties, long-term deficits or possible alternatives); “Do what I tell you and nothing else – it is your only hope” (when this statement is ludicrously wrong and damaging).
Other situations I have seen in clinic include prescription of useful medication intended for short-term use (4-6 weeks) but continued for years without review while the patient is given no access to information about the medication. If adverse effects develop (almost invariably), further medication is provided without discussion.
Maintaining patient ignorance can be comfortable as it avoids awkward questions and saves time in consults. However, it completely destroys patient autonomy by removing their ability to make informed decisions about their own health care.
There is no doubt that some patients want to remain uninformed and be told what to do without question. That is their right. However, many want to be involved in decisions about their health and become distressed when they are prevented from gaining the knowledge required to make smart decisions.
My personal experience over 60 years has reflected this. Before I became aware of my rights and responsibilities as a patient, I was prescribed long-term antibiotics (daily for 6 years) with no explanation of possible adverse outcomes and, over those years following, have developed intractable tinnitus, lost all my teeth because of crumbling enamel, had numerous abscesses and persistent gut challenges that require constant attention. None of these possibilities were mentioned to my parents or, later, to me. I had to make my own discoveries.
From my twenties, I gained access to more information, so was able to ask questions and make more informed decisions about my health (not always right decision, but informed).
My older son became critically ill in 1980 and, at that stage, I had access to much more information and relationships with non-conforming doctors and scientists. My son’s doctors were most displeased when I asked questions about treatment, adopted complementary therapies to support his progress. I was criticized, abused and accused of “child abuse” because of my informed decisions, but I was able to retain autonomy on behalf of my son.
As practitioners, we have a responsibility to provide full and frank information to our patients, even when that information is unpleasant, and empower our patients to take as much responsibility for their health as they desire.
Justice implies that all forms of medicine that may benefit the patient will be available to them no matter their socio-economic status, race, religion, appearance or ability/disability.
There is no doubt that, in general, wealthy white patients have better access to a wider range of beneficial healthcare strategies than those from non-white backgrounds or lower socioeconomic groups. Some governments have tried to redress this inequity with a variety of national health schemes but, even in these countries, the wealthy have greater opportunities for wellness than the poor.
Marginal groups such as Australia’s First Nation people, Native American Indian populations and South Africa’s original inhabitants are often in a parlous state of neglect with only charities offering limited care.
I have also noticed a trend among mainstream doctors to give preference to patients with readily diagnosed conditions that require standardized treatments (usually drugs or surgery) and are hesitant to accept patients with complex disorders that are difficult to categorise into accepted “diseases”, require significant research, comprehensive treatments and/or collaboration with practitioners outside the limited parameters of western medical practice. This attitude is often enforced by regulatory bodies demanding that doctors comply with restrictive rules on what may or may not be treated and how.
But this is not only seen in WAM practices. Many CAM practitioners are unwilling to move outside their comfortable niches to help those with chronic disorders that do not fit text book descriptions. Chronic Borreliosis (“Lyme disease”) and common co-morbidities is a particular area where both WAM and CAM practitioners have largely refused to accept it exists and/or undertake the extensive study required to understand the process of these infections and strategies to eliminate them.
Add to these circumstances the challenge that most people with complex illness have spent much of their money chasing diagnoses and help, so cannot afford integrative doctors or CAM practitioners who are not subsidised by any government funding. Therefore, many seriously ill people are denied effective treatment and exist in miserable debilitation.
Medicine, in the western world, is not just.
Acting with beneficence means that the practitioner always puts the patient’s best interests ahead of their own, no matter what the outcome for the practitioner or practice may be.
In the modern environment of proprietary treatments, many practitioners in all modalities are tempted to provide treatments based on loyalties to product suppliers, dictatorial pronouncements by regulatory bodies, extra benefits (e.g. profits, bonuses, gifts) from manufacturers, or adherence to dogma that is outdated or inappropriate to the patient’s unique circumstances. In some circumstances, the practitioner may be unwilling to refer the patient on for fear of losing income.
There are other circumstances in which the best treatment for the patient is no treatment and, in these times, the practitioner’s responsibility is to spend whatever time is necessary to explain that no treatment is the best treatment and why.
Beneficence is closely linked to Autonomy in that, if we have clearly explained treatment options and allowed the patient to make a fully informed choice, the best interests of the patent may well be served by supporting their decision even if we disagree with it.
I have experienced that kind if beneficence in my past (yes, there are wonderful healthcare practitioners available) when I refused long-term chemotherapy and was supported by my oncologist who, no doubt, did not agree with that decision. As it turned out, no treatment was my best option and has proven to be successful.
This is often translated as meaning “First, do no harm”, a statement attributed to Hippocrates but more likely attributable, in this version, to a 17th century physician, Thomas Sydenham.
The pillar of non-malfeasance obligates us to search for treatment options that will be of benefit to the patient without causing damage, intended or unintended. Where harm is likely to be incurred (e.g. chemotherapy for cancer), the patient should be fully informed of all aspects of the offered treatment (Autonomy) and given time and support to make their decision.
All too often, we hear of patients being rushed into a life-changing decision that leaves them with adverse effects (“harm”) ranging from uncomfortable to debilitating. Therapeutic options that create adverse effects MUST be fully explained and alternatives offered where possible, even if not as immediately effective as the “harmful” option.
There is a similar lack of information around the use of statin drugs to lower serum cholesterol. I have seen hundreds of patients prescribed these drugs for 5-20 years without a break, with no explanation or recognition of common adverse effects like muscle and joint pain, confusion or brain fog, digestive and bowel distress, nasopharyngitis, UTI and headache. The more serious adverse effects are even better hidden and rarely spoken about except in CAM settings.
A report on a major study of a statin drug noted that “Throughout the study, all-cause mortality was numerically higher in the (drug) arm than the placebo arm.” Other large, well-designed studies of the use of statins and the resultant lowering of serum LDL have noted increased risks of Parkinson’s disease, dementia, and a variety of cancers.
Given that there are many proven strategies to maintain healthy serum cholesterol levels that have no adverse effects, and that there is growing awareness that serum cholesterol is an indicator rather than a cause of CVA risk, the persistent dogma of prescribing long-term statins to lower serum cholesterol readings with few, if any, concomitant strategies seems to meet the criteria of causing harm over benefiting the patient.
We could add many similar practices such as long-term antidepressants without review, anticonvulsants prescribed for minor sleep disturbances, long-term hypotensive drugs without review or recognition of adverse effects, and prescription of additional medication to cope with the adverse effects of doubtfully effective medications that may have been prescribed to reduce the adverse effects caused by an even earlier prescription.
In CAM practices, we have examples of over-enthusiastic detox regimens with no regard for patient sensitivity or fragility, and reluctance to refer patients on when the level of unwellness goes beyond the level of competence displayed by the practitioner.
Non-malfeasance must be at the forefront of every practitioner’s mind and we need to monitor our intentions and advice to focus on benefit for the patient.
FIFTH PILLAR - LOVE
In my opinion, there is a Fifth Pillar that guides and supersedes all the other four pillars.
“The measure of love that he shows to his patient counts above all” has been attributed to Hippocrates. More often, we see the Hippocratic quote, ““Wherever the art of Medicine is loved, there is also a love of Humanity. ”
Nearly twenty years ago, I wrote the following, based on Hippocratic values:
“If we engage our patients with love, approach them with humility, speak to them with simplicity and treat them as we would treat those we hold dearest, then we can do no harm and many will find their way to a better life with our help.”
With this as the base value for our practice, no matter what our modality, the Four Pillars of Medical Ethics become our instinctive way of life and practice with or without supervision and regulation.
John Coleman, July 2022