First

primum non nocere,

“ above all, do no harm ”
 Medical ethics
 Learning Objectives
– To define the Medical Ethics .
– To understand the theories of Ethics
– To apply the ethical principle
– To know how to deal with ethical dilemma
– To understand the concept of informed consent
– To recognize the best way for making desion
Ethics?
 The difference between Ethics and Moral
 The word “Morals” and “Ethics” originally meant
much same thing:
 Ethics came from “Greek” while Morals came
from “Latin” Both words refer to the general area
of right and wrongs in the theory and practice of
human behavior.
 Morals refer to standards of behavior actually
held or followed by individuals and groups while
 Ethics refer to the science or study of morals
and its activity in the academic context .
 What is Ethics?
 A system of moral principles or standards governing
conduct.
 a system of principles by which human actions and
proposals may be judged good or bad, right or wrong;
 A set of rules or a standard governing the conduct of
a particular class of human action or profession;
 Any set of moral principles or values recognized by
a particular religion, belief or philosophy;
 The principles of right conduct of an individual.
(UNESCO/IUBS/Eubios Living Bioethics Dictionary
version 1.4)
What makes an action moral or not ??

– The act itself “ What ”

– The motive “ Why ”
– The circumstances: when, where, how,
to whom and how often.
 Ethical Terms
 Morals: standards of right and wrong
learned by socialization and based on
religious believes
 Statement of etiquette: describe expected
professional behaviors established in ethical
codes.
 Ethical Terms
 Values: concepts or ideals that give meaning to life and
provide frame work for decisions and action
 Laws: rules of social conduct designed to prevent the
actions of infringing on the right of others.
 Rights: entitlements that one deserves according to just
claims, legal guarantee, or moral lower principles.
 Categories of rights:
1. Option rights: freedom of choice (cloths)
2. Welfare rights: legal rights (speech)
3. Ethical rights: moral rights (health care)
 Ethical Terms
 Ethical dilemma: situation requires a choice
between two equally unfavorable alternatives.
 Accountability: answerability or responsibility:
1. Personal: to one self and patient.
2. Public: to employer and society.
Ethical Terms
 Attitude
 manner , way,
position and feeling
toward a person
 hypothetical
construct of like or
dislike (expression of
favor or disfavor)
toward a person,
place, thing, idea or
event
Ethical Terms

 behaviour :
isthe range of actions
and mannerisms made by
organisms, systems, or
artificial entities in
conjunction with their
environment
 Ethical Terms
 Believes: building blocks or attitude , the
strength of attitude depend on how strongly
believes are held to the extent to which they
are consistent to each other.
 Attitude are changeable and easy to
change
 Values are difficult to change
What’s right = what a culture
believes is right ??
Where does the ethics comes from.?
 Tradition :
– That's the way its always been
 Religion/Authority :
– That’s the way I was thought to do it
 Reasons
– That’s the way reality determine to believe
 Taxonomy of Ethics
Main Western Other Abrahamic Oriental
philosophies Philosophies philosophies
Philosophies
Utilitarianism African, Asian, etc. Islamic Buddhist

Deontology Human Rights Jewish Confucius

Feminist ethics Catholic Indian

Casuistry
Christian
Virtue ethics Ethics Protestant Persian

Principlism Jehovah Witnesses

 What is Bioethics?
 It is derived from Greek bio- life and ethicos moral.
 The science/art that aims at identification, analysis,
and resolution of the ethical issues in almost any field
that is related to human life and health.
 deciding what we should do (what
decisions are morally right or acceptable);
 explaining why we should do it (how do we justify
our decision in moral terms); and
 describing how we should do it (the method or
manner of our response when we act on our
decision).
 Medical ethics
 Medical ethics
– is a system of moral principles that apply
values and judgments to the practice
of medicine .
– It is the branch of bioethics that is related to
the identification, analysis, and resolution of
moral problems that arise in the healthcare of
individual patients.
 Clinical Ethics

Research
Bioethics ethics

Resource
Allocation
ethics
Business ethics
Public Health
Environmental ethics
ethics
Ethics Nursing
Social ethics ethics

Organizational other
ethics

IT ethics

Other
 Comparing Law and Ethics
 Law, ethics, and bioethics are different but
related concepts.
 Laws are mandatory to which all citizens must
adhere or risk civil or criminal liability.
– some actions that are illegal may not be unethical 
(kill)
– some actions that are unethical may not be illegal 
(secret)
– laws can be unethical or immoral ( colonialism)
 Reasons to discuss ethics
 We face ethical dilemmas everyday
 Ethical issues are often harder to deal with
than clinical.
 There are often no black or whites, but
greys
 It has been recognised as an area important
in medical education.
 If dealt with poorly can lead us into sticky
situations
Why is Ethics an Increasing Issue for
Health Care?
 an increasingly technological society with
complicated issues that never had to be
considered before.
 the changing fabric of society, particularly in
terms of family structure.
 health-care has become a consumer-driven
system based on clients becoming more
knowledgeable.
 What is an “ Ethical Issue ” or a “Moral
Problem”?
There is an ethical issue when:
– we encounter conflicting values, beliefs, goals,
or responsibilities
– we are concerned that persons or their rights are
not
being respected
– we are concerned about fairness and justice
– we are unsure what we should do or why
we should do
it, morally speaking
 Doctors Mission
 Doctor's primary goals are :
– To treat and cure where possible
– To bring relief in suffering
– To help the patient cope with illness,
disability and death
 The duties of a doctor GMC
– make the care of your patient your first concern .
– treat every patient politely and considerately .
– respect patients' dignity and privacy .
– listen to patients and respect their views .
– give patients information in a way they can
understand .
– respect the rights of patients to be fully involved in
decisions about their care .
– keep your professional knowledge and skills up to
date .
– recognise the limits of your professional
competence.
The duties of a doctor GMC
– be honest and trustworthy .
– respect and protect confidential information .
– make sure that your personal beliefs do not
prejudice your patients' care .
– act quickly to protect patients from risk if you have
good reason to believe that you or a colleague
may not be fit to practise .
– avoid abusing your position as a doctor; and
– work with colleagues in the ways that best serve
patients' interests .
GMC
Scope of ethics in Medical Practice
1. Historical background
• Hippocratic oath
• Geneva (1947)
• Sydney (1968)
• Tokyo (1975)
• Lisbon (1981)
• AMA Revised principle (2001)
2. Multidisciplinary nature
 Ethical
Theories
 Teleology / Consequentialism
 Deontology
 Situational Theory
 Caring-Based Theory - focuses on emotions,
feelings, and attitudes.
 Ethical Theories
 Consequentialism: Also called Teleological,
Greek word, Telos, meaning end or
consequence.
 Actions are determined and justified by the
consequence of the act.
Consequentialists consider all the
consequences of what they are about to
do prior to deciding a right action. This
also answers the question: What should I
do and why should I do it?
 Ethical Theories
 Deontology /Nonconsequentialism:
Derived from the Greek word, Deon, meaning
duty.
Considers that some acts are right or wrong
independent of their consequences. Looks to
one’s obligation to determine what is ethical
and answers the question:
What should I do and why should I do it?
 Ethical Theories
 Situational Theory
– holds that there are no set rules
or norms. Each situation must be
considered individually
 Ethical Theories
 Caring-Based Theory - focuses on
emotions, feelings, and attitudes.
What Are Ethical Principles, and
How Do They Help With Decision
Making?
 Ethical principles
{ Codes that direct or govern actions}.

Conflict is inevitable, Ethical principles

provide the framework/ tools which may
facilitate individuals and society to resolve
conflict in a fair, just and moral manner.
Ethical principle
1. Autonomy
2. Paternalism
3. Beneficence
4. Nonmaleficence
5. Utility
6. Justice
7. Truth telling (veracity)
8. Fidelity
9. Confidentiality
 Autonomy
 Autonomy can be defined as
the ability of the person to
make his or her own
decisions.
 The right to participate in
and decide on a course of
action without undue
influence.
 Paternalism
- One individual assumes the right
to make decisions for another.
- Justifiable if patient at risk of
significant preventable harm,
paternalistic action will prevent
harm, benefits outweigh risks
and the least autonomy-
restrictive course of action is
used
 Autonomy vs. Paternalism
The Central Conflict in Medical Ethics
 Autnomy  Paternalism
– Agents have the right – It is sometimes legitimate
to be self-determining, to restrict agent
individuals have a right autonomy, for their own
to conduct their lives good.
as the see fit. – Soft paternalism- agent
– Autonomy is typically is incompetent in
taken to be core some relevant way.
component of a good – Hard paternalism-agent
practice has less than ideal value.
Beneficence (Doing Good)
 The principle and obligation
of doing good and
avoiding harm.
 A practitioner should act in
the best interest of the
patient
 Nonmaleficence
Many consider that should be the main
or primary consideration Much harm has
been done to patients as a result, as in
the saying, "The treatment was a
success, but the patient died."
It is not only more important to do no
harm than to do good; it is also
important to know how likely it is that
your treatment will harm a patient
 "above all, do no harm"
 Justice
- The principle that deals with fairness,
equity and equality and provides for an
individual to claim that to which they are
entitled.
- and the decision of who gets
what treatment
– Comparative Justice: Making a decision based
on criteria and outcomes. ie: How to
determine who qualifies for one available
kidney. 55 year old male with three children
versus a 13 old girl.
– Noncomparative Justice: ie: a method of
distributing needed kidneys using a
lottery system.
Veracity

 The duty to tell the truth.

 Truth-telling, honesty.
 Fidelity
 Strict observance of promises
or duties.
 The need to keep promises
 This principle, as well as other
principles, should be honored
by both provider and client.
 Confidentiality

Keeping privileged
information private.
 Utility
The good of the many
outweighs the
wants/needs of the
individual.
 Informed consent
 Definition: A patient’s willing acceptance of a medical
intervention after adequate disclosure from their MD of
the nature of the intervention, risks, benefits and
alternative treatment options .
 What constitutes informed consent?

 Disclosure: information to allow reasonable person to make

a decision
 Understanding: comprehension of the information given

 Voluntary: no coercion or incentive to accept or deny a

treatment
 Agreement: verbal or written (preferred) to discussed

intervention
 Many are screening patients for HIV without informed
consent ?
 Ethical Dilemma
 Situations necessitating a
choice between two
equal (usually
undesirable) alternatives.
 A conflict between two or
more ethical principles.
 In an ethical dilemma, there is
no “correct” decision.
 Major Types of Ethical Dilemma
 Euthanasia.

 Refusal of Treatment.

 Scarcity of Resources.
 Euthanasia
 Intentional action or lack of action that
causes the merciful death of
someone suffering from a terminal
illness or incurable condition.
 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
 Refusal of Treatment
 Based on the principle of autonomy.
 A patient’s rights to refuse treatment
and to die often challenge the values of
most health care providers.
 Scarcity of Resources
 The allocation of scarce resources
(e.g. organs, specialists) is emerging
as a major medical dilemma.
To make appropriate ethical
decisions:
The doctor must
use a professional
approach that
eliminates trial and
error and focuses
on proven decision-
making models or
problem-solving
processes.
Ethical Decision Making
ASSESSMENT
Determination of claims and parties

ANALYSIS & DIAGNOSIS

Identification of problem: Statement of ethical dilemma

PLANNING
Consideration of priorities of claims
Consideration of consequences of alternatives

IMPLEMENTATION
Carrying out selected moral actions

EVALUATION
Evaluation of outcome of moral actions
"Were the actions ethical?" "What were the consequences?"
 Decision Making Model:
(ADPIE)
Diagnose
Assessment Planning
On-going Evaluation
On-going Implementation
Implementation
On-going Planning
Evaluate
On-going Diagnosis
On-going Assessment
 Ethics Committees
 Decision making in health care often
involves more than just medical facts of the
case
 Ethical principles and values will be the
determining factor in which course of action
to take.
 Many health care facilities have established
Ethics committees.
 Respect for persons
The patient and the person treating the patient
have the right to be treated with dignity.
 CONCLUSION
 “If a structured approach to problem solving
is used, data gathering is adequate, and
multiple alternatives are analyzed, even
with a poor outcome, the manager should
accept that the best possible decision was
made at that time with the information and
resources available.”