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Dr Chin Jing Jih Chairman, SMA Ethics Committee Deputy Director, SMA Centre for Medical Ethics & Professionalism
ETHICS
= a systematic reflection on and analysis of morality A generic term for various ways of understanding and examining the moral life.
Developed from the view that ethical problems from medicine can be resolved by applying principles of moral philosophy.
For those situations in which we already know what is right and what is wrong it should help us explain why the one choice is right and the other wrong For those situations in which it is not obvious what is right and what is wrong it should guide us to discover what is the right thing to do
Doctor-patient relationship
Policies in
health care institutions
GOALS OF MEDICINE
The goal of medicine: Setting new priorities.
Prevention of disease and injury Promotion and maintenance of health Relief of pain and suffering Care and cure of those with malady Avoidance of premature death Pursuit of a peaceful death
LAW Seeks to educate and to regulate by announcing a minimal standard of conduct. Looks mainly at due Process
Establishes negative sanctions for ignoring the standard, which has the power of official coercion
ETHICS Extends beyond the law to prescribe desirable conduct and articulate ideas and virtues to which we should aspire Ethical sanctions- generally non-coercive, and include the praise or blame of colleagues or others. Power resides primarily in the strength of reasoning, unaccompanied by state endorsement
Because respecting law is an important moral duty, the legal cases have ethical relevance. However, what is legally permitted may not be ethically justifiable in a particular case
consequences ==> right or wrong right action = one which causes maximum beneficial results e.g. utilitarianism
4-Principle Approach: NONMALEFICENCE = the obligation to avoid the causation of harm requires merely the omission of harm-causing activities
4-Principle Approach: BENEFICENCE = the obligation to provide benefits and to balance benefits against risks requires positive steps to help others
4-Principle Approach:
JUSTICE
= obligations of fairness in the distribution of benefits and risks
4-principle Approach
(Beauchamp, Childress)
The principles are prima facie, i.e. always binding unless they conflict with obligations expressed in another moral principle Balancing of the demands of the conflicting obligations which principle overrides in case of conflict depends on the particular context, which is likely to have unique features
4-principle Approach
(Beauchamp, Childress)
The exercise of judgement in circumstances of uncertainty is inevitable. A justifiable infringement of a moral principle or rule must:
be necessary in the circumstances in the sense that there are no morally preferable alternative actions that could be substituted be the least infringement possible
4-BOX APPROACH
CASE HISTORY [casuistic approach]
recommendations
MEDICAL INDICATIONS
1. What is patients medical problem ? diagnosis?
prognosis? 2. Is problem acute? chronic? critical? emergent? reversible? 3. What are goals of treatment? 4. What are probabilities of success? 5. What are plans in case of therapeutic failure? In sum, how can this patient be benefited by medical and nursing care, and how can harm be avoided?
PATIENT PREFERENCE
1. What has the patient expressed about preferences for treatment? 2. Has patient been informed of benefits and risks, understood, and given consent? 3. Is patient mentally capable and legally competent? What is evidence of incapacity? 4. Has patient expressed prior preferences, e.g., Advance Directives? 5. If incapacitated, who is appropriate surrogate? Is surrogate using appropriate standards? 6. Is patient unwilling or unable to co-operate with medical treatment? If so, why?
In sum, is patients right to choose being respected to extent possible in ethics and law ?
QUALITY OF LIFE
1. What are the prospects, with or without treatment, for a
CONTEXTUAL FEATURES
1. Are there family issues that might influence treatment decisions? 2. Are there provider (physicians and nurses) issues that might influence treatment decisions? 3. Are there financial and economic factors? 4. Are there religious, cultural factors? 5. Is there any justification to breach confidentiality? 6. Are there problems of allocation of resources? 7. What are legal implications of treatment decisions? 8. Is clinical research or teaching involved? 9. Any provider or institutional conflict of interest?
4-BOX APPROACH
A device for teaching and discussion User (health care providers + families) friendly vocabulary A practical review method to move a discussion of an ethical problem toward a resolution Begins with the factual features of a case. Principles and rules are referred to as they arise in the discussion of each box/topic. Moral rules and principles are best appreciated in the specific context of the actual circumstances of a case.
No escape from the exercise of judgement in circumstances of uncertainty BUT not just any judgement will be acceptable. No system of guidelines could reasonably anticipate the full range of conflicts to provide mechanical solutions or definitive procedures for decision-making about moral problems in medicine. Experience and sound judgement are indispensable allies
Treatment : effective + humane & dignified Medical goals from the perspectives of doctors, are NOT necessary the only and most important goals of patients Judgements and decisions are frequently - value laden - role-dependent - influenced by self- and other interests
Patients and/or families demand for everything be done regardless of medical futility Patients refusal of treatment / placement Familys insistent of withholding diagnosis Use of tube feeding in demented patients Issues related to informed consent Confidentiality issues Justice / Distribution issues
Inappropriate medical indications Treatment options inadequately explored Communication problems Breakdown in therapeutic relationships due to bad outcomes Discharge problems Legal problems Assessment of decisional capacity of a patient Obtaining informed consent
Above all, do no harm. Risk of harm always exists risk-benefit ratio Proven or established treatments Implied and verbal consent applies except for high risk treatment Experimental treatment clinical equipoise Full informed consent process and document except for minimal risk research
The Belmont Report : Ethical Principles and Guidelines for the Protection of Human Subjects of Research [The National Commission for the Protection of Human Subjects
of Biomedical and Behavioral Research (April 18, 1979)] Nuremberg War Trials; Tuskegee Experiment
1. Respect for persons infromed consent 2. Benficence assessment of benefits and risks 3. Justice patient selection
The practice of medicine in a thoughtful, ethical, compassionate and effective manner helps to make doctoring a satisfying, sustainable and enjoyable part of our lives.