Introduction to Medical Ethics

Lecture 1 Medical Ethics: Theories and Principles

Programme aims

Definition of Medical Ethics Scope of Ethics in Medical Practice Theories and principles Duties of a Doctor

Objectives

Within small groups and by using case based material you will be able to: 1)Recognise ethical issues 2)Recognise ethical conflicts 3)Practice verbal reasoning skills 4)Be aware of own and others moral values

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.

Importance of Medical Ethics

1. Increasing profile\Recent press headlines: Dr Cox (euthanasia) Alder hay Enquiry Jodie and Mary 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

Scope of ethics in Medical Practice

1.

Historical background
Hippocratic oath Geneva(1947) Sydney(1968) Tokyo(1975) Lisbon(1981)

2.

Multidisciplinary nature

Four Misconceptions
1.

2.
3. 4.

Clear distinction :clinical and ethical analysis Clear distinction: profess. and everyday ethics Enshrined in lead Medical ethics=matter of opinion

Doctor X is considering whether or not to break a confidence. Patient has presented with an STD which he wishes to have treated confidentially.His wife is also your patient.What do you do?

DEONTOLOGICAL THEORIES
-

Some principles are intrinsically right regardless of resulting consequences.

CONSEQUENTIALIST THEORIES Consequence alone determines right and wrong. - greatest happiness of the greatest number.

Principles
1. 2. 3.

4.
5. 6. 7.

Beneficence Non-Maleficence Autonomy Truth telling Confidentiality Preservation of Life Justice

Beneficence and NonMaleficence

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)

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 Need to consider rights of others

3.

Autonomy
1. 2. 3.

Capacity to think, decide, take action Mental incompetence= no autonomy Autonomy v-Paternalism When patient not autonomous no clash. When patient autonomousquestionable procedure

Truth Telling In much wisdom is much grief:and he that increaseth knowledge increaseth sorrows (Ecclesiastics 1,18)

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.

2.

3.

Hippocratic obligations Not in a position to know the truth 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?

Against

Layman unable to cope with data Opinions not facts cause anxiety Third party information Defensive medicine

For

Data belongs to patient Accuracy improved by sharing

Access to Records

Data Protection Act (1998) What records are covered? Does it matter when the record was made? Who can apply? Are their exemptions? Must copies be given if requested? Access to records of deceased patients?

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

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

1. 2.

3.

4.

5. 6. 7.

How to allocate scarce healthcare resources? Medical need Medical Benefits Social worth-discriminates against underprivileged Merits/contribution to society-very contentious Desert Market Forces A lottery

Contaception and Minors

1. 2. 3.

4.

Jane aged 15 yrs requests the OCP Her mum phones you the next day Several weeks later she tells you her boyfriend slapped her across the face 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

4th Year- Case history

A 25 yr old lady comes to the treatment room requesting syringes.She is a lesbian and wishes to inseminate herself. 1) What else would you like to know 2)What are the ethical issues 3)What would you do

Duties of a Doctor Please apply ethical principles to the above list as described in Good Medical Practice

Truth Telling Video clip

1.

2.

3.

How much information should be given to patients preoperatively? When/how should we relay information to a postoperative patient? What lessons can be learned from this tape?