THE MEDICAL ETHICIST

How can we be just and fair when there’s not enough to go around? How do we agree on what’s fair? While every doctor wants to do their best for each patient, the current reality in the UK is that medicine is fraught with dilemmas and competing claims.

Prof Gillon, emeritus professor of medical ethics at Imperial College London and retired GP, believes that today’s pressures demand a more deliberate, committed focus on fairness. But he’s not so naïve as to believe that’s easy.

‘I believe that most of us agree that we ought to try to be fair, but we don’t necessarily agree on what we mean by that.’

Prof Gillon suggests that a first step might be to adopt ‘fairness’ as both a personal and an organisational value or principle. He’d like to see ‘Be fair’ enshrined as a BMA behaviour principle, for example, alongside ‘Be professional, accountable, kind, representative and respectful’. And he’d like doctors to commit to at least trying to be fair.

On behalf of the BMA, he was part of the drafting group responsible for adding ‘fairness’ to the WMA’s International Code of Medical Ethics, relating it to the rights of both patients and health professionals. This was one of the aims of his BMA presidential project on fairness in 2019-2020.

Along with ‘beneficence, non-maleficence and respect for autonomy’, fairness is one of four ‘prima facie’ principles of medical ethics identified by Beauchamp and Childress, whose approach Prof Gillon has long advocated. All four are now reflected in the WMA’s International Code.

Prof Gillon insists that ‘high-level’ principles such as these are practical tools, not abstract aspirations. They provide a framework for decision-making, a point of reference against which options can be weighed. But they need to be thought about, specified, contextualised, ‘translated’ into practical action.

‘With a crash call, you do what you know you have to do because it’s been worked out from first principles and agreed and practised in advance. Likewise, we should think about the ethical problems we encounter in medicine and try to agree in advance on how to deal with them, using those four principles to help us.’

A case for inequality

Like Prof Banfield, Prof Gillon wants to see greater equality in the workplace – but he adds an important qualification.

Fairness is just one of four principles, and these may conflict. And there are many different substantive theories of fairness or justice, which may also conflict, as legal battles over the withdrawal of life support painfully prove.

In this moral minefield, the different substantive theories of justice do at least agree on Aristotle’s ‘formal principle’ of justice or fairness, which says: ‘Equals should be treated equally and unequals should be treated unequally in proportion to the relevant inequalities.’

For example, the NHS doesn’t withhold treatment from patients who have knowingly exposed themselves to risk, whether skiers or drug users. But it tends to give precedence to people in the greatest medical need (where greater need is a ‘relevant inequality’).

‘At least part of medical care and medical ethics is to say: those people need to be treated differently from others – “unequally” – because they need it more. Treating people equally is crucial, but so is treating people unequally!

‘So, let’s start with Aristotle’s formal principle and work together on the morally difficult task of deciding when it is fair to treat people equally and when it is not fair to do so.’

He stresses, as Aristotle did, that medical ethics is not an exact science. ‘Medicine’s full of hard choices but committing ourselves to trying to be fair, whatever we mean by that, is an important starting point.’

A longer version of this piece is available at bma.org.uk