NEW Added to close a syllabus gap — "principles of ethical decision-making" is a listed item under Intensive Care.
Ethics & decision-making
The four principles, consent and capacity, end-of-life decisions in intensive care, and organ donation.
The four principles
Principle
Meaning
Autonomy
Respect for the patient's right to make their own informed decision — including the right to refuse treatment, even where refusal leads to death
Beneficence
Acting in the patient's best interest
Non-maleficence
"First do no harm" — weighing burden against benefit
Justice
Fairness in the distribution of finite resources, and equal treatment of equal need
These are prima facie principles — none automatically outranks the others; ethical reasoning is the work of balancing them in a specific case.
Consent & capacity
Valid consent requires three things
The patient must have capacity, be adequately informed, and give consent voluntarily without coercion.
Capacity — the four-part test
To have capacity a person must be able to: understand the information, retain it, weigh it in the balance, and communicate the decision.
Capacity is presumed until shown otherwise; it is decision-specific and time-specific; and an unwise decision is not evidence of incapacity.
If capacity is lacking, act in the patient's best interests, taking account of previously expressed wishes, an advance decision, a lasting power of attorney, and the views of those close to them.
Montgomery shifted the standard of information disclosure from what a reasonable doctor would say to what this particular patient would consider material — including reasonable alternatives.
Special situations
Emergency: treat without consent under the doctrine of necessity, limited to what is immediately required.
Children: a competent child may consent (Gillick competence); refusal by a competent child can in some jurisdictions be overridden. Know your local law.
Jehovah's Witnesses: a competent adult's refusal of blood must be respected, even if fatal. Discuss acceptable alternatives in advance — cell salvage, tranexamic acid, erythropoietin — and document precisely which products are refused.
End-of-life decisions in ICU
Withholding and withdrawing treatment are ethically and legally equivalent — a treatment that is not working may be stopped just as it might not have been started.
Futility: treatment that cannot achieve its intended physiological goal, or cannot deliver a benefit the patient would value. There is no obligation to provide it.
Doctrine of double effect: giving a drug intending to relieve suffering is permissible even if it may foreseeably shorten life — the intention is what distinguishes it from euthanasia.
DNACPR decisions are clinical decisions about one intervention only. They must be discussed with the patient or their representatives, and do not imply withdrawal of other treatment.
Decisions should be consultant-led, multidisciplinary, documented, and revisited. Seek a second opinion or clinical ethics advice where there is disagreement.
Organ donation
DBD — donation after brainstem death. Requires formal brainstem death testing: known irreversible cause, exclusion of hypothermia (>34 °C), drugs, and metabolic or endocrine disturbance. Two doctors test on two occasions; the apnoea test completes it.
DCD — donation after circulatory death, following planned withdrawal of treatment.
The dead donor rule: organ retrieval must not be the cause of death.
Separate the teams: those making the decision to withdraw must be independent of the transplant team.
Many jurisdictions now operate deemed (opt-out) consent — but the family is still always consulted. Know your local framework.
Legal detail varies by country. The principles are portable; the statute is not — check the framework where you practise and where you sit the exam.