Medical ethics

What does professionalism

means to you?
Take a few minutes and write down your
thoughts as a definition or description.
Definition
It is not easy to define a profession, but it is
likely to have all or Some of the following
characteristics:

It is a vocation or calling and implies service
to others
It has a distinctive knowledge base which is
kept up to date
It determines its own standards and sets its
own examinations
It has a special relationship with those whom
it serves patients.
It has particular ethical principles
Professionalism is a term which embodies
numerous qualities of physicians as public
servants.

It has been described by The American
Board of Internal Medicine as :

Constituting those attitudes and behaviors
that serve to maintain patient interest
above physician Self-interest

The concept of professionalism
includes the following values as:

Honesty
Altruism
Service
Commitment
Communication


Commitment to
excellence
accountability
Life-long learning
Main Characteristics of
Professional Conduct
(by the American Board of Internal Medicine)

Altruism is the essence of
professionalism. The best interest of the
patients, not self-interest, is the rule.

Accountability is required at many levels:
individual patients, society and the
profession


Excellence entails a conscientious effort
to exceed normal expectations and make
a commitment to life-long learning


Duty is the free acceptance of a
commitment to service.

Honour and integrity are the consistent
regard for the highest standards of
behaviour and refusal to violate ones
personal and professional codes.

Respect for others, like patients and their
families, other physician and professional
colleagues such as nurses, medical
students, residents, subspecialty fellows
It will become increasingly difficult for
professions to sustain the policy that
qualification is for life. Most professionals
need to make a commitment to lifelong
learning. Professor Eraut.
What is Ethics?
The formal study of:
What is right and wrong.

The study of the bases or principles
for deciding right and wrong.

The analyses of the processes by
which we decide what is right and
wrong.
Medical ethics
Is based on philosophical ethics
It isnt any special ethics but rather ethics
of special cases.
Medical ethics does not concern only
doctors but also patients and society.
The central question of medical ethics is
the doctor-patient relationship.
Medical Ethics
a field of applied ethics, the study of moral values
and judgments as they apply to medicine. As a
scholarly discipline, medical ethics encompasses its
practical application in clinical settings as well as
work on its history, philosophy, theology, sociology,
and anthropology.


Based on definition of Medical Ethics http://en.wikipedia.org/wiki/Medical_ethics



Patients are entitled to good standards of
practice and care from their doctors.Essential
elements of this are professional competence,
good relationships with patients and colleagues
and observance of professional ethical
obligations.

From Good Medical Practice, GMC.
Nowadays, conflicts of interests between the
government and medical institutions,
between medical institutions and medical
personnel, between physicians and patients
are getting more and more serious and
complex.
Why Ethics Become Important?

High technologies not only brought us hopes
of cure but have also created a heavy
economic burden.
The ethical dilemmas of high technology
medicine-brain death, organ transplantation,
and concerns about quality of life-have
become increasingly prominent.
A new and more specific code of ethics must
be developed to meet the demands of social
development and medical service.
This new code integrates the traditional
medical ethics with modern principles and
values.
Importance of Medical Ethics
1. Increasing profile\Recent press headlines:

Dr Cox (euthanasia)
Destroying frozen embryos
Refusal to fund marrow transplants\new
drugs
Importance of Ethical Issues (contd.)
2)Increase in technology

3)Better informed society

4)Doctors in Management

5)Public scrutiny
Principles
1. Beneficence
2. Non-Maleficence
3. Autonomy
4. Truth telling
5. Confidentiality
6. Preservation of Life
7. Justice

Beneficence and Non-Maleficence
Questions:

1)Is the patient your only concern?
(possible conflict with utility)
2)Do we always know what is good for the
patient?
(patients view may differ from ours)
Beneficence
Literally being charitable or doing good
Performing care so as to maximise patient
wellbeing
Exercising clinical judgement
Going beyond the minimum standards required
3 constraints on Beneficence
1. Need to respect autonomy-patient and
doctor may differ re. Management

2. Need to ensure health is not bought at too
high a price

3. Need to consider rights of others
Non-malificence
Doing no harm
Avoidance of putting a person
at risk of avoidable harm
A 1
st
step towards beneficence
Defined under the Hippocratic
oath
Autonomy
Paramount
Being self-governing
Able to exercise free will in making a personal
decision
A right to withhold consent
Applicable to anyone who has capacity
Autonomy
1. Capacity to think, decide, take action
2. Mental incompetence= no autonomy
3. Autonomy v-Paternalism
When patient not autonomous no clash.
When patient autonomous-questionable
procedure






Truth telling (cont)
If you override it you endanger
doctor/patient relationship(based on
trust)

You offend against the principle of
autonomy(Dr.C Mooreland)

At times there are good reasons for
overriding the truth telling principle
The case for deception is
founded on three fallacies
1. Hippocratic obligations
2. Not in a position to know the truth
3. Patients do not want the truth if the
news is bad
Confidentiality
Act against this principle and you destroy
patients trust
Clash when keeping confidentiality would
harm others eg child abuse

Should patients have access to their notes?
Exceptions to Medical Confidentiality
Pt gives written and valid consent
To other participating professionals
Where undesirable to seek patients consent info can
be given to a close relative
Statutory requirements
Ordered by Court
Public interest
Approved Research
Preservation of Life
At what stage does human life begin?-coil, pill
Can we assess another persons quality of life?-
Jehovah's Witness
Euthanasia
Active: an active intervention to end life
Passive:deliberately withholding treatment that
might help a patient live longer
Voluntary :euthanasia is performed following a
request from a patient
Doctor assisted suicide: a doctor prescribes a lethal
drug which is self administered by the patient
Non-voluntary :ending the life of a patient who is
not capable of giving permission
Involuntary:ending life against a patients will
Other Moral doctrines
Acts and Omissions Doctrine-held by those
who believe that passive euthanasia is not
killing(killing is an act,and an omission is not
an act)
Doctrine of Double effect-makes a distinction
between what I intend and what I merely
foresee
Living Wills
Patient unconscious\severely mentally
disabled , and two docs agree it unlikely he
will be able to communicate treatment
decision
Refuse treatment if prolongs life with no
further benefit to patient
Justice
How to allocate scarce healthcare resources?
1. Medical need
2. Medical Benefits
3. Social worth-discriminates against underprivileged
4. Merits/contribution to society-very contentious
5. Desert
6. Market Forces
7. A lottery



Justice
No single definition
Usually distributive justice
when applied to medical ethics
Fairness
Equity
Method of righting wrongs
Other factors
Patient expectations
Family expectations
Genuine uncertainty
Wishes of patient
Wishes of family
Cultural values
Religious values

Preferences of
professionals
Power balance within
the healthcare team
Trust policies
Financial issues
Legal issues

The nature of morality
Moral acts are acts done to benefit others,
they are altruistic and are not motivated by
self-interest.
Morality makes reference to
right/wrong/permissible behavior with
regard to basic values.
The moral duties of the doctor
The duty to help, cure
The duty to promote and protect the
patients health
The duty to confidentiality
The duty to protect the patients life
The duty to respect the patients autonomy
The duty to protect privacy
The duty to respect the patients dignity
The moral rights of the patient
The right to high quality medical service
The right to autonomous choice
The right to decide
The right to be informed
The right to privacy
The right to health education
The right to dignity
The standards used to determine
the incompetence
Inability to express or communicate a preference
or choice.
Inability to understand ones situation and its
consequences.
Inability to understand relevant information.
Inability to give a (rational) reason.
Inability to give risk/benefit related reasons.
Inability to reach a reasonable decision.
Is it ethically permissible to accept gifts
from pharmaceutical representatives?
Ethical Scenario
Gifts to Physicians
from Industry
Any gift accepted by a physician should
primarily entail a benefit to patients and
should not be of substantial value.
Individual gifts of minimal value are
permissible as long as they relate to the
physicians work.
Ethical Scenario
A medical error has occurred in the course
of caring for a patient. Should the treating
physician disclose this information to the
patient?
Patient Information
When a patient suffers significant medical
complications that may have resulted from
a physicians error, the physician is
ethically required to inform the patient of
all the facts necessary to ensure
understanding of what has occurred.
Ethical Scenario
Should medical trainees perform
procedures such as endotracheal
intubation on the newly deceased patient?
Performing Procedures on the
Newly Deceased Patient
In the absence of previously expressed
preferences, physicians should request
permission from the family before
performing procedures.
Without such permission, physicians
should not perform procedures for training
purposes on the newly deceased patient.
Ethical Scenario
A resident has concerns that an attending
physicians order is reflective of poor
clinical judgment. How should this
situation be handled?
Disputes Between Medical
Supervisors and Trainees
Trainees should refuse to participate in
patient care ordered by their supervisors in
those rare cases in which they believe the
orders reflect serious errors in clinical or
ethical judgment, or physician impairment,
that could result in a threat of imminent
harm to the patient or to others.
Disputes Between Medical
Supervisors and Trainees (contd)
Trainees may withdraw from the care
ordered by the supervisor, provided
withdrawal does not itself threaten the
patients immediate welfare. The trainee
should communicate his or her concerns
to the physician issuing the orders and, if
necessary, to the appropriate persons for
mediating such disputes.
Disputes Between Medical Supervisors
and Trainees (contd)
Third-party mediators of such disputes may
include the chief of staff of the involved
service, the chief resident, a designated
member of the institutional grievance
committee, or, in large institutions, an
institutional ombudsperson largely outside
of the hospital staff hierarchy.
You are a doctor in a hospice
Ken 45-year-old has always lived with mum
Barbara. He is dying of mouth cancer. He
wants to eat but when he does he chokes. The
nurse asks you to sedate Ken as Barbara cant
bear to see him choking.

Will you give him sedation?
What will you say to the nurse and Barbara?
Dilemmas and topical issues
Mental capacity act
Replaced best practice
and common law
Adults who may be
unable to make a
decision
Decision specific
Time specific
Assessment
Presumption of capacity
Support to make
decisions
Unwise decisions
Best interests
Least restrictive option
Advance decision to refuse treatment
Validity
Has to be made when competent
Applicability
Have anticipated the situation
And the implications of the decision
If relating to withdrawing or withholding life
sustaining treatment
In writing, signed, witnessed
Express even if life is at risk


You are a young doctor in A&E
Mary 80-year-old lady admitted to hospital this
morning with a stroke. She has collapsed and
her heart has stopped. The nurse tells you Mary
told a student nurse she didnt want CPR if she
collapsed.

Will you resuscitate her?
Euthanasia/PAS/slow euthanasia
Euthanasia
Active an intentional act
Passive due to an omission
Voluntary
Involuntary - ?killing
PAS Carried out by patient with help of
another
Slow euthanasia sometimes used for
terminal sedation
Joan
94-year-old with advanced lung cancer. All
treatment has failed. She is admitted to the
hospice as her family cant manage to look
after her at home. She isnt able to wake up or
speak but she is very distressed and agitated.
You feel she is dying and start her on sedatives
to settle her agitation. She dies the next day
peacefully.
What happened next
Joans daughters say She was fine before she
came in. The sedative you gave killed her. Why
didnt you give her a drip when she couldnt
drink?
Did you kill her
Morally?
Legally?
Should you have given her a drip?
Doctrine of double effect
Thomas Aquinas and Dr Adams
An action having good and bad consequences is
defensible if:
The nature of the act is good
The intention is for the good effect
The good effect outweighs the bad and the situation is
grave enough to risk yielding to the bad effect
The good effect does not depend on the bad effect
Dr Adams
British GP and suspected serial killer. Edith Alice
Morrell was paralysed by a stroke. She was
given a cocktail of morphine, diamorphine
(heroin) and barbiturates to treat cerebral
irritation and help her sleep. He arranged her
cremation on the day of her death, stating on
the form her had no pecuniary interest. He
received a Rolls Royce, silver cutlery and a
lamp.
Question




The doctrine of double effect became well
known through this case.

Does it apply?
Withholding and withdrawing treatment
Are they any different
In theory?
In practice?
Are nutrition and hydration basic care or a
medical treatment
When given by mouth?
When given through tubes?
You are a doctor in a hospice
Jane 36-year-old lady with breast cancer. Has a
supportive husband, no children. Her GP send
her to the hospice to die. Jane has been told
by her GP that the hospice will give her
intravenous antibiotics and blood transfusions
to make her better. You feel that she is dying
and no treatment will help. These treatments
arent possible in the hospice.
Dilemmas
What do you tell Jane?
What do you tell her husband?
What treatment do you give
Send to hospital for aggressive treatment but poor
end-of-life care?
Give oral treatment that you know wont work?
Give no treatment, just supportive care?
Allocation of scarce resources
Resources available are not infinite
Drug companies exist to make a profit
The development of new treatments is
motivated by profit
How do we decide which treatments should
be funded?

You are the chief exec of the local PCT
You have overspent on last years drug budget
by several million. You have been asked to
fund several programmes but can only afford
to support one of them.

Which of the following programmes would
you support?
What factors would influence your decision?

Your options
1. Herceptin for early breast cancer
2. A drug for those at risk of stroke that costs
10 per week and decreases risk of stroke by
60%
3. A programme that would provide care for
terminally ill people to die at home
4. Increased staff parking at the local hospital



Endings
Ethical decisions are an everyday occurrence
Situations often complex
Consider all the factors
Consider each decision individually
Does autonomy really trump all other
considerations?
Contaception and Minors

1. Jane aged 15 yrs requests the OCP
2. Her mum phones you the next day
3. Several weeks later she tells you her
boyfriend slapped her across the face
4. Her boyfriend is her history teacher
Lord Frasers reccomendations
The doctor should assess whether the patient
understands his\her advice
The doctor should encourage parental involvment
The doctor should take into account whether the
patient is liekly to have sexual intercourse without
contraceptive treatment
The doctor should assess whether the patients
physical\mental healthare likely to suffer if she
does not receive advice\treatment
The doctor must consider whether the patients
best interestsrequire him\her to provide
contraceptive advice\treatment without parental
consent