vulnerable members of society at risk of developing some diseases that were previously eradicated in the UK, e.g. measles (Public Health England, 2019), with the associated implications to the individuals, wider society and to the health service. The utilitarian perspective would be that all eligible children should be immunised irrespective of the views/wishes of their parents. Utilitarianism would not be concerned with the autonomy of the individual (the right to not give consent to the vaccine) as this is arguably in conflict with the greater good.
Clinical considerations: Consent to treatment – children
Sixteen to seventeen‐year‐olds with capacity: According to Section 8(1) of the Family Law Reform Act (1969), consent can be sought from the child for medical and dental treatment. However, those with parental responsibility may still consent on the child's behalf.
Sixteen to seventeen‐year‐olds lacking capacity: Anyone with parental responsibility can consent on behalf of a child who lacks capacity. In situations where those with parental responsibility do not consent to treatment, but where treatment is felt to be in the best interests of the child, a court order may be obtained. In an emergency situation, treatment may still be provided without parental consent where it is deemed a necessity (Glass v UK, 2004).
Under sixteen years of age: An assessment of the child relating to ‘Gillick’ competence (Gillick v West Norfolk and Wisbech Area Health Authority, 1985) would determine whether the child has sufficient maturity and understanding of what is involved to enable them to make a decision to consent to treatment or not.
Deontological ethics, or deontology, is an approach to ethics that determines goodness or rightness from examining acts rather than the consequences of the act as in utilitarianism. Deontologists look at rules and duties. For example, the act may be considered the right thing to do even if it produces a bad consequence, if it follows the rule that ‘one should do unto others as they would have done unto them’. According to deontology, we have a duty to act in a way that does those things that are inherently good as acts. In this approach, the duty of care to the individual takes priority over any other considerations. Going back to our example of immunisations, children are, in reality, not forced to have immunisations where parents have opted out. Health professionals have a duty to ensure that any care given is consented to (within the parameters of the MCA 2005 as outlined above). Without this consent we cannot inject a live vaccine into a child no matter what the potential implications might be for wider society. So the act itself is good (abiding by rules of consent), but the consequence may be a negative one (the child contracting measles and passing this on to others). For deontologists, the ends or consequences of our actions are not important, nor are our intentions. Duty is the key consideration. However, it is not always clear what one's duty is. While we may agree that our duty is to ‘do no harm’, there will be instances where health professionals will have to override this with their duty of care.
Virtue ethics focuses on how we ought to behave, and how we should think about relationships, rather than providing rules or formulas for ethical decision‐making. It considers the virtues a ‘good’ person would have: honesty, compassion, generosity and courage, for example (Velasquez et al., 2009). With the common good in mind, these virtues will be applied to actions and decisions. A group of virtues can be accredited to particular roles or professions, and it could be argued that nurses are attracted to the profession because they already function according to these virtues.
This leads us to nurse ethics. The focus of nursing ethics is on developing a caring relationship and seeking a collaborative relationship with the person. Recently, care, compassion, courage, communication, commitment and competence (the 6 Cs Department of Health, 2012) have been highlighted as the required virtues of nurses. Common themes of nursing ethics emphasise respect for the autonomy of the individual and maintaining the dignity of the client by promoting choice and control over their environment.
What is deemed to be right is not therefore bound by absolute rules or duty, or purely the greatest good, but also considers the virtues that individuals and society value. The ethical views held by society affect healthcare laws and how they are implemented. As society's moral values alter, legislation follows. An example of this was in 1967 when UK society's beliefs changed regarding abortions. It became largely accepted that in some cases they were necessary for saving women's lives as well as reducing the potential for suffering (psychologically as well as physically) of the woman and her pre‐existing family, and so the Act was introduced (Abortion Act, 1967).
Regulatory bodies
In order to practice, healthcare professionals are aligned to a regulatory body such as the Nursing and Midwifery Council (NMC) or the Health and Care Professions Council (HCPC). The purpose of a regulatory body is primarily to protect the public, and as such they are established and based upon a legal mandate. Their function is regulatory and to impose requirements, restrictions and conditions – as well as offering a means of support and guidance to professionals. They also set standards in relation to practice activities, securing compliance and enforcement of their practitioners. Regulatory bodies have traditionally provided their practitioners with ethical guidance in the form of a ‘code’ or an ‘oath’, such as the NMC Code of Conduct (2008) or the Hippocratic Oath for doctors. A word of caution though; codes such as the NMC Code of Conduct (2008) could be viewed as merely being concerned with specifying rules of responsibility and conduct rather than focusing specifically on ethics.
Within healthcare, regulatory bodies have a duty to protect, promote and maintain the health and safety of the public. They do this by ensuring proper standards are in place in order to practice. Such standards define the overarching goals and the expected role and duties of their practitioners through listing the obligations associated with their individual responsibilities and skill set. The overarching goals are aspirational and represent an optimal position ethically, thus encouraging the individual to strive towards the optimal position. Healthcare professionals, like the public and their patients, possess their own values and beliefs which in turn influence their practice.
Imagine yourself working in a very busy gynaecological outpatients and you are required to administer mifepristone (medically induced abortion) to a young intravenous drug user (IVDU), currently sofa surfing among friends. Your service user is advised to return in between 24 and 48 hours for the second medication – misoprostol, to complete the treatment. She does not return. You notice certain client groups tend not to return to the clinic and you begin to think about why this is the case, using the principles of ethical professional practice, beneficence (do good) and non‐maleficence (do no harm).
Within this scenario, there is a possibility the service user's care has been affected by the healthcare professionals implicit bias (IB) towards certain social groups. Several authors have emphasised that a well‐meaning, egalitarian (fair) minded individual can have implicit biases which demonstrate the imbalance between their unconscious ways of thinking and how they explicitly perceive themselves treating people (Fitzgerald and Hurst, 2018; Lang et al., 2016). The elements of IB are one's perceived stereotypes (a mental picture of what one thinks, knows and expects) and prejudices (feelings) associated with certain categories of people, learnt through a shared culture, which over time slips into one's unconsciousness, which means it is hidden (Lang et al., 2016). As Stone and Moskowitz (2011) explained, this means the healthcare professionals are unaware of their biases, which impacts on the quality of care delivered, seen in how they may judge and behave towards particular groups (Kelly and Roedderts, 2008). Merino et al. (2018) highlighted over 60% of healthcare professionals harbour variants of IB towards marginalised/vulnerable groups. Examples of vulnerable or marginalised groupings can be based on: gender, age weight, homelessness, ethnicity, immigration status, socio‐economic status, educational achievement, mental ill‐health, sexual orientation, IVDUs, disabilities and social circumstances – or anyone rendered vulnerable in certain situations (Fitzgerald and Hurst, 2018).
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