Medical Ethics

1. Medical Ethics Daniel Chase, MD

2. Overview • What is medical ethics? • What are the generally accepted principles of medical ethics? • How have medical ethics developed to the form we know today? • What are codes of medical ethics, and which ones do we follow?

3. Defining our Terms • Morality - our belief about right and wrong (usually subjective and unexamined). • Ethics - (a) the study of principles for choosing right action when doing right may also involve doing harm or wrong; (b) the use of ethical theory to choose the best course of action; (c ) the study of what is good and bad in human character and conduct.

4. Up-Bringing Religion Peer Pressures Experience Local Rules The Media Self Interest Values Laws Loyalty Public Opinion Sense of Responsibility Attitudes, for example, Toward Science Morality is our personal, subjective sense of right & wrong. Its sources include:

5. Ethical theories somewhatdiscourage such sliding around. They force us to moresystematically define the assumptions that underlie our decisions about of what is the right action to take in a given situation.

6. Where Does Ethics Come From? • Tradition “That’s the way it’s always been.” • Authority • “That’s the way I • was taught to do it.” • Reason • “That’s the way • reality determines • we ought to behave.”

7. Definition and Scope of Medical Ethics - System of values common to the medical profession. - Systematic application of values concerning the practice of medicine. - Standards of behaviour by which the physician may evaluate his/her relationships with patients, colleagues and society. - Scope of medical ethics includes: development of ethical codes and guidelines promotion of ethical practice prevention of ethical breaches recognition of ethical dilemmas resolution of ethical conflicts

8. Components of Medical Ethics • The Physician -- Patient Relationship • The Physician -- Physician Relationship • The relationship of the Physician to the System of Healthcare • The Relationship of the Physician to Society

9. What are the Medical Ethical Principles? • What are the Medical Ethical Principles? • Beneficence? • Non-Maleficence? • How about . . .

10. Current Operative Principles of Medical Ethics • The Principle of Make-more-money-ence • The overriding principle of all physician behavior, this above all dictates patient care decisions.

11. Current Operative Principles of Medical Ethics • The principle of Don’t-get-sued-ience • Second only to make-more-money-ence, this most important principle is behind many unnecessary tests and consults.

12. Current Operative Principles of Medical Ethics • The Principle of Turficence • Learned early in med school or residency, this principle requires the physician to always ask the question, “could I turf this patient to someone else?”

13. Current Operative Principles of Medical Ethics • The Principle of Distributive Justice • Distribute the blame of your failure to as many other people as possible, including the patient.

14. Current Operative Principles of Medical Ethics • The Principle of Malevolence • The more of a jerk you are to the staff, the farther you’ll go. • Screaming and yelling is a perfectly acceptable practice and has a long, proud tradition in medicine.

15. Current Operative Principles of Medical Ethics • OK, time to be serious so I don’t get fired.

16. THE PRINCIPLES IN MEDICAL ETHICS • The Principle of Non-Maleficence • The Principle of Beneficence • The Principle of Autonomy • The Principle of Veracity • The Principle of Confidentiality(or Fidelity) • The Principle of Social Responsibility and Justice

17. The Principle of Non-Maleficence • first do no harm – “Primum non nocere” • sanctity of life • calculated risk or risk benefit

18. Impaired Physician • Physicians have the obligation to report impaired behavior in colleagues

19. Beneficience • Obligation to preserve life, restore health, relieve suffering and maintain function • To do “good” • Nonabandonment – obligation to provide ongoing care • Conflict of interest – must not engage in activities that are not in patients best interest

20. Autonomy • Right to self-determination • Requires decision making capacity • Lack should be proven not assumed • Competence – legal determination • Liberty – freedom to influence course of life/treatment

21. The Principle of Veracity • Truth telling • Obligation to full and honest disclosure

22. The Principle of Confidentiality • Based on loyalty and trust • Maintain the confidentiality of all personal, medical and treatment information • Information to be revealed with consent and for the benefit of the patient • Except when ethically and legally required • Disclosure should not be beyond what is required

23. The Principle of Justice and Social Responsibility • Actions are consistent, accountable and transparent • not to discriminate on age, sex, religion, race, position or rank • Allocation of medical resources must be fair and according to need • Physicians should not make decisions regarding individuals based upon societal needs

24. What is an Ethical Dilemma? • A conflict between moral imperatives, i.e., “what is the right thing to do?” • What is “medically” right vs. patient preference • Jehovah’s Witnesses and transfusions • What is preferred by patient vs. proxy decision maker • Rights of minor vs. legal guardians • What is best for patient vs. what is best for society • Commitment laws, notification of sexual partners of patients with HIV

25. Principles Ethical codes Clinical judgement Reasoned analysis Ethical committees Ethical tests Declarations Oaths & Pledges Common Sense Debate Ethical Consults The Law Resolution of Ethical Dilemmas

26. Key Moments in History of Medical Ethics • The Hippocratic texts display a sustained appreciation for the limits of medicine and the need to prevent unnecessary iatrogenic harm to the sick • The Art • “... I will define what I conceive medicine to be. In general terms it is to do away with the sufferings of the sick, to lessen the violence of their diseases, and the refuse to treat those who are overmastered by their diseases, realizing that in such cases medicine is powerless.”

27. Key Moments in History of Medical Ethics • Central themes of the Hippocratic texts • Hippocratic physicians were in a crowded, harsh, and unforgiving medical market place • Physicians and other practitioners with high mortality rates faced failure and poverty • Reputation for being a good physician, whose patients die only from their incurable diseases and injuries, becomes paramount • Leaving off the care of the dying becomes a matter of urgent self-interest and good reputation • My patients die from their incurable diseases and injuries, not anything that I do • Prognosis emerges in the Hippocratic text as the central clinical skill of the physician

28. Key Moments in History of Medical Ethics • Scottish physician-ethicist, John Gregory (1724-1773), wrote the first modern work on professional medical ethics in the English language • Used philosophy of medicine and philosophical ethics to reform medicine into a profession • Gregory changed the ethical standard of care for dying patients

29. Key Moments in History of Medical Ethics • John Gregory, Lectures on the Duties and Qualifications of a Physician (1772) • “Medicine, or the art of preserving health, of prolonging life, of curing diseases, and of making death easy.”

30. Key Moments in History of Medical Ethics • Thomas Percival (1740-1804) was an English physician best known for crafting perhaps the first modern code of medical ethics. He drew up a pamphlet with the code in 1794 and wrote an expanded version in 1803, in which he reportedly coined the expression "medical ethics” • Percival's Medical Ethics served as a key source for American Medical Association (AMA) code, adopted in 1847.

31. Nuremberg Trials See anyone we know?

32. Key Moments in History of Medical Ethics • The International Military Tribunal of 1946, convened by the U.S., British, French and Soviets, which convicted the major Nazi leaders who survived World War II AND • Twelve cases tried by U.S. military tribunals at Nuremberg from1946-9 of groups of doctors, lawyers, industrialists, Einsatzgruppen and more.

33. Key Moments in History of Medical Ethics • Nuremberg Code of Ethics: • Informed Consent mandatory and exercised freely • Experiments must avoid physical and mental suffering • Experiments must be avoided if death or disabling injury a possibility • Information from Nazi experiments is taboo

34. Medical Codes • Professional ethics of codes • Developed through a process of collaboration, consensus, and finally codification • Notion of professional self-regulation

35. AMA’s Code of Medical Ethics 1847 Edition 2001 Edition

36. AMA’s Code of Medical Ethics • The Code first drafted by Drs. Bell and Hays was based on Percival’s conceptions of professional ethics • A “living” compendium of ethical guidelines for physicians that is continually revised and updated by the Council on Ethical and Judicial Affairs • The Code is freely accessible at: www.ama-assn.org/ceja

37. Awareness of the Code • Routinely cited in legal cases and frequently referenced by judges, lawyers, legal scholars, and state licensing boards • Ironically, physicians are generally unaware of the ethical guidance embodied in the Code • Illustrative example: - Capital punishment

38. Capital Punishment Disallowedactions include: • Starting intravenous lines for lethal injection drug • Determining death during execution • Administering the lethal drug • Supervising personnel who give the lethal drug

39. Capital Punishment Disallowedactions include: • Ordering lethal drugs for the prison pharmacy • Maintaining or inspecting lethal injection devices • Monitoring vital signs during execution • Selecting injection sites for lethal drugs

40. Physician Attitudes about Capital Punishment • 80% indicated that at least 1 of the disallowed actions was acceptable • 53% indicated that 5 or more were acceptable • 34% approved all 8 disallowed actions

41. Northside’s Code of Ethics • Do you know what it is?

42. House Staff Manual • “Resident Physicians are governed by and are expected to abide by the policies and procedures which have been approved by the Graduate Medical Education Committee. In addition, it is expected that residents will follow all established practices, policies, and procedures of the hospital which may be determined by the professional staff, board of trustees, and the administration of the hospital.”

43. Professional Conduct • “All resident physicians shall maintain satisfactory performance in relation to the educational program, patient care, professional ethics, morals, personal integrity and demeanor.”

44. Personal Demeanor • No smoking in facilities • No drugs or alcohol at work • No sexual harassment

45. Miscellaneous • Wear lab coats and ID badges, business attire, including pantyhose. • Attend the educational program • Complete Medical Records

46. Doctor-Patient Relationship • “The conduct of the resident physician will always be directed toward the best interest of the patient.” • Don’t criticize patient’s management in front of them. • “The resident should render all possible aid and comfort to the patient. . . Courtesy and consideration for others, especially patients and the patient’s family are essential.”

47. Relations with Attending Physicians • Notify attending physician of changes in patient status or death.

48. Summary • Medical Ethics is the systematic application of principles of behavior to the practice of medicine • Commonly agreed on principles include: Non-Maleficence, Beneficence, Autonomy, Veracity, Confidentiality, and Justice.

49. Summary • Starting in the 18th and 19th centuries, medical ethics has become a recognized discipline. Based on earlier traditions and principles more recently articulated, it seeks to provide a useful framework for understanding and resolving ethical conflicts.

50. Summary • Ethical codes have been published by various medical organizations, and provide a guideline for behavior for physicians.