ETHICS IN FAMILY MEDICINE

 
PRESENTED BY

 
DR. AGBARAKWE CHUKWUDI
MBBS (ILORIN), FMCFM
CONSULTANT FAMILY PHYSICIAN
 
 
BRIATHWIATE MEMORIAL SPECIALIST HOSPITAL
PORT HARCOURT
 
 
 OUTLINE

 Declaration
 Introduction
 Medical Ethics
 Informed Consent
 Perspective of Ethics in Family Medicine
 Ethical Conflicts
 Ethical Skills
 Conclusion
 DECLARATION BY A PROSPECTIVE MEDICAL OR
DENTAL PRACTITIONER (I)

 
 I, Doctor….., do sincerely and solemnly declare that as a
registered medical/dental practitioner of Nigeria;

 I shall exercise the several parts of my profession to the

best of my knowledge and ability for the good, safety and
welfare of the persons committing themselves to my care
and attention and that;

 
 
DECLARATION BY A PROSPECTIVE MEDICAL OR DENTAL
PRACTITIONER (II)

 I will faithfully obey the rules and regulations of the Medical

and Dental Council of Nigeria and all other laws that are
made for the control of the medical and dental profession in
Nigeria.

 Furthermore, I hereby subscribe to the PHYSICIAN’S OATH

as follows: I solemnly pledge to consecrate my life to the
service of humanity.

 I will give to my teachers the respect and gratitude which are

their due.
DECLARATION BY A PROSPECTIVE MEDICAL OR DENTAL
PRACTITIONER (III)

 I will practice my profession with conscience and dignity; the

health of my patient will be my first consideration.

 I will respect the secrets which are confided in me, even after
the patient has died.

 I will maintain by all means in my power the honor and the

noble tradition of the medical (dental) profession; my
colleagues will be my brothers and sisters.
 DECLARATION BY A PROSPECTIVE MEDICAL OR
DENTAL PRACTITIONER (IV)

 I will not permit considerations of religion, nationality,

race, party politics or social standing to intervene
between my duty and my patient.

 I will maintain the utmost respect for human life from the
time of conception; even under threat, I will not use my
medical knowledge contrary to the laws of humanity.
DECLARATION BY A PROSPECTIVE MEDICAL OR DENTAL
PRACTITIONER (V)

 I make these promises solemnly, freely and upon my honor.

 The Declaration of Geneva adopted by the General

Assembly of the World Medical Association at Geneva,
Switzerland, September 1948 and amended by 22nd World
Medical Assembly at Sydney, Australia in August, 1968.
 
 INTRODUCTION

History

 The first widely accepted medical ethics system was the

Hippocratic Corpus.

 It began in the 14th century BC.

 From then until Thomas Percival’s “Medical Ethics” in 1803.

 The Medical Assembly at Helsinki in 1964.

 The Oslo and Tokyo Declarations of 1970 and 1975

respectively.
Definition

 The word ‘ethics’ is derived from the Greek word “Ethos”,

that means custom and habits.

 It is the medical oath and codes that prescribes a

Physician’s character, his motives and duties.

 It is the moral relationship between the doctor and his

patients, colleagues and society.
Ethics and Religion

 There is a link between ethics and religion.

 Ethics has a reference to a universal code of doing good.

Religion could do something which goes against a
universal norm, by virtue of a doctor’s personal belief
(Abraham and his son Isaac).

 Production of a code of ethics has personal values as its

driver.
Medical Practice Yesterday

 Medical practice is a moral enterprise. It involves

determining what is right for the patient.

 In generations past, this concept was accepted by patients

and their physicians.

 There was then, a mutual trust and cordial relationship

between patients and their physicians.
Medical Practice Today and Tomorrow (I)

 As society evolved with more sophisticated technology,

medical practice was also affected.

 There is now increased governmental regulations, the

entry of third party players and increased litigations; these
have changed the face of medical practice.

 Increased emphasis on patient centered care is gradually

shifting power from the physician to the patient.

 
Medical Practice Today and Tomorrow (II)

 The third party players are also part of the nightmare that
has befallen the medical practice in Nigeria.

 Family physicians as frontline doctors, must be able to adapt

to the increasing complexity of medical care options, patients’
expectations and professional accountability.

 This is in the context of diverse cultures and dwindling

economy.
 MEDICAL ETHICS

 Ethics in medicine, is divided into three broad areas;

 Clinical Ethics

 Public Health Ethics

 Research Ethics
Clinical Ethics

This deals with the relationship between the clinician and

individual patient.

Principal Components of Clinical Ethics

 Autonomy
 Beneficence
 Non Maleficence
 Justice
 
Autonomy

 It is the patient that chooses to seek advice and therapy; he

also has the right to refuse the therapy.

 It has been argued that, there is a limit to this right, hence the
concept of paternalism.

 Paternalism is when the right of a patient not to take

medications, is breached by the attending physician,
particularly for life saving interventions.
 
 
Beneficence

 This is doing good to the patient always, acting in his best

interest, at all times.

 What is good for the patient or best for the society may
become controversial.

Non Maleficence

 It is to do no harm to the patient, i.e. balancing the risks

with the benefits.

 The patient decides what it is good for him.

Justice (I)

 This is doing well in the greatest good for the greatest

number of people.

 Those who need the intervention (therapy) have the right to

have it.

 Therapy is to be given to those, who need it.

Justice (II)

 Ethical consideration looks at the:

a) Intention

b) Actions

c) Context of the action

d) Consequences of the actions of the medical interventions

Types of Clinical Ethics

 Virtue Ethics

 Deontological Ethics

 Teleological Ethics

 Situational Ethics

 Virtue Ethics: Considers the character and actions of the

physician.
 Deontological Ethics:

a. Considers if the proposed action is right or wrong, regardless

of its consequences.

b. Is it ever right or always wrong to kill?

c. An action is right if it is in keeping with established rules and

principles.

 
Teleological Ethics:

a. Considers the consequences of the proposed action.

b. The ethical problem is weighed by what a virtuous person

will do.

Situational Ethics:

c. Considers the context (situation) in which a course of action

was chosen.
Public Health Ethics

 This deals with the health issues of a group of people. e.g. a

community.

 It is the education of the public, so as to be able to choose

the desired health behavior.

 Coercion at the expense of autonomy may be used e.g.

Restriction of the movement of people, when there is an
outbreak of a particular disease.
Research Ethics

 This deals with issues related to clinical research.

 Import consideration in research ethics are informed

consent, no coercion on recruitment.

 A mechanism of compensating subjects in case of harm.

This will not rely on their ability to prove negligence.
 INFORMED CONSENT (I)

 The patient must be armed with all information about his

case.

 These include, the risk, benefits, uncertainties and options of

every course of action.

 It is the patient who decides what is in his best interest.

 In emergency situations, consent may be presumed.

 INFORMED CONSENT (II)

 This presumption must not be against the previous settled

will of the patient e.g. the Jehovah’s Witnesses and blood
transfusion.

 Informed consent is valid, only if the patient has the

capability to understand.

 When the patient refuses consent to therapy, that fact

should be noted at that time.
 INFORMED CONSENT (III)

Age of Consent

 The current age of consent is 18 years.

 If the patient is below 18 years, the parents or guardians

must be made to consent for the minor.

 
 PERSPECTIVE OF ETHICS IN FAMILY MEDICINE

The Family Medicine Perspective

 Does the perspective have a twist?

 Has it become more different?

 Does it bring into play more ethical consideration?

 Does it require different skill?

Scope of Family Medicine

 Family Medicine practice offers comprehensive, continuous

care in the context of the family. It incorporates bio
psychosocial, spiritual approach to health care.

 
The Family Physician

 Is a frontline doctor.

 Attends to patients irrespective of age or gender.

 Attends to patients in respect of any organ and all the

organs.

 He offers continuous, comprehensive and co-ordinated care

till the end of life and beyond.
Background of the Family Physician
(A Risk in Ethical Conflicts)

 The family physician makes the first diagnostic evaluation,

amidst close differential diagnoses. He also initiates
treatment, based on his diagnosis.

 He sees patients till the end of life, these include; persistent

vegetative state, end of life care, life support, medical futility,
euthanasia, advanced directives and living will.

 He offers continuous and co-ordinated care to patients and

their families.
Ethical Peculiarities in Family Medicine (I)

 The family physician initiates treatment, and is the one likely

to make mistakes in both diagnosis and management.

 He sees the greatest number of patients with diversity of

epidemiological characteristics. This further complicates his
care.

 His decisions in caring for his patients in his diverse settings

(ambulatory and institutionalized patients), involve peculiar
ethical issues which he must recognize.

 He sees patients irrespective of gender and disease, this

implies diverse culture, social status, religion, education,
individual experiences and family values.
Ethical Peculiarities in Family Medicine (II)

 The frontline doctor must be able to navigate this diversity

of ethical issues wherever applicable.

 He is also saddled with possibilities of improper release

from work, under and over treatment, and must not slip
into compromise.

 His long term care of the patient, may lead to intimacy that
could result in sexual contact with patients and\or their
relations.

 Management of patient for the end of life presents a

peculiar challenge with undaunting ethical conflicts.
Ethical Conflicts in Family Medicine (I)

 In dealing with the minor, the family physician must act as a

bridge between the under-aged and their parents when they
are in conflict.

 He must act in a way to be trusted by the parents and their

ward while acting in the best interest of the minor.

 The Jehovah witness patient who refuses blood transfusion

must be persuaded to do so, and the case should be
properly documented and colleagues involved when need
be.
Ethical Conflicts in Family Medicine (II)

 In emergency, consent is presumed, but it must not be

against the previous settled wishes of the patient.

 When resources are limited e.g. O2 and the young and old
patients both need the same, it should be given to the young
in preference.

 He must balance the wishes of the dying, with those of his

living relatives along ethical lines. A patient thought to be
dying could surprisingly recover.
Ethical Conflicts in Family Medicine (III)

 Emergency baptism by the Catholic Priest for an infant that

is showing sign of life, though not viable, should be allowed.

 Euthanasia is not legalized in Nigeria as in Netherland and

Bulgaria.
Ethical Skills for the Family Physician (I)

 The family physician must therefore acquire these skills

while on training;

1. The identification of the ethical aspects of every particular

case.

2. Must exhibit appropriate behavior and conduct regarding

issues of consent and confidentiality;

a. Obtaining a valid Informed Consent or a valid Refusal of

Treatment.

b. Act appropriately if a patient is only partially competent or is

incompetent to consent to or refuse treatment.
Ethical Skills for the Family Physician (II)

c. Decide when it is ethically justified to withhold information

from a patient.

d. Decide when it is appropriate to breach confidentiality.

3. Present differing priorities to the patient and his group

(family, legal guardian) when dealing with conflicting ethical
issues.
Ethical Skills for the Family Physician (III)

4. Care for patients with a poor prognosis including patients

who are terminally ill with the sense of being in-charge.

a. Obtain informed decision from patients and families about

code status and advance directives.

b. Incorporate a team approach in dealing with ethical and

moral issues to provide understanding, acceptance and
provide a support system for the patient.

c. Moderate a family conference to discuss ethical dilemmas,

regarding a partially competent or incompetent patient.
Ethical Skills for the Family Physician (IV)

5. Discuss with patients on how managed care incentives or

restrictions may influence the determination of a preferred
planned care.

6. Apply ethical principles to professionalism and practice

management;

a. Act appropriately when aware of unethical conduct by a

colleague.
b. Self monitor his own professional behavior and ethical
capabilities.

7. Demonstrate appropriate consultation and\or participation

in an institutional Ethics committee.
 
 CONCLUSION (I)

 Family practice of all the specialties is characterized by

inherent uncertainties, conflicting responsibilities and
pervasive moral dilemma.

 Emphasis on patient centered care, the development of

sophisticated medical evaluative equipment, availability of
medical information on the internet, influence of health
system factor on care delivery and alternative therapies
have further compounded this fact.
 CONCLUSION (II)

 The front line doctor must recognize ethical dilemmas in all

his clinical decision making.

 He must therefore apply ethical frame work in his practice,

so as not to infringe on the law of the state, and the
current medical standard.
 THANK YOU FOR
LISTENING

ANY QUESTIONS?
 
 
 
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