Introduction to Medical Ethics

Lecture 1Medical 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. Clear distinction :clinical and ethical analysis2. Clear distinction: profess. and everyday ethics3. Enshrined in lead4. 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 THEORIESConsequence alone determines right

and wrong.- greatest happiness of the greatest

number.

Principles

1. Beneficence2. Non-Maleficence3. Autonomy4. Truth telling5. Confidentiality6. Preservation of Life7. 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?

(patient’s 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

3. Need to consider rights of others

Autonomy

1. Capacity to think, decide, take action

2. Mental incompetence= no autonomy3. Autonomy –v-Paternalism When patient not autonomous –no

clash. When patient autonomous-questionable 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. Hippocratic obligations2. Not in a position to know

the truth3. Patients do not want the

truth if the news is bad

Confidentiality

Act against this principle and you destroy patient’s 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 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 need2. Medical Benefits3. Social worth-discriminates against

underprivileged4. Merits/contribution to society-very

contentious5. Desert6. Market Forces7. A lottery

Contaception and Minors

1. Jane aged 15 yrs requests the OCP2. Her mum phones you the next day3. Several weeks later she tells you her

boyfriend slapped her across the face

4. Her boyfriend is her history teacher

Lord Fraser’s 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 patient’s physical\mental healthare likely to suffer if she does not receive advice\treatment

The doctor must consider whether the patient’s best interestsrequire him\her to provide contraceptive advice\treatment without parental consent

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. How much information should be given to patients preoperatively?

2. When/how should we relay information to a postoperative patient?

3. What lessons can be learned from this tape?