Medical Ethics

1. Medical Ethics Najia Sultan Year 4 MBBS

2. 3 Rules Understanding = Lots ; Learning = Little Easy to pass… Easy to fail There is always a right answer.

3. = LEARN THIS !

6. Autonomy (self rule) = Deciding the direction in which one’s life should go CHOICE ! We know ourselves best What is right for someone else may NOT be right for the patient ... Or you For all decisions if to be respected ! It is okay to make bad decisions ...

7. What if I make bad health related choices? Start smoking ??

8. Choice and Free Will Free Will ? Meaningful Choices ? Moral Responsibility Even if we make some (very) bad decisions, being free to make one’s own choices (and one’s own mistakes) is important to flourishing as a person Even if we make some (very) bad decisions, being free to make one’s own choices (and one’s own mistakes) is important to flourishing as a person

9. Who is autonomous ? Understand + Form Values + Make Decisions

10. Respecting autonomy Respecting autonomy means enabling patients to make autonomous choices: Reasonable choices Adequate information Clear explanation Time to consider options Not unduly pressurising Being non-judgemental

11. Harm to others

12. Paternalism v autonomy Overriding patient’s autonomy Because of Healthcare professional’s view of the patient’s best interests (Generally bad idea…)

13. Is withholding Information the same as lying? Withholding info restricts autonomy less Patients may actively ‘collude’ in the withholding of information Impossible to tell patients everything Less likely to cause mistrust Not telling a patient they have cancer Not telling a patient about the risks of a procedure Is withholding information morally distinct from lying? Not telling a patient they have cancer Not telling a patient about the risks of a procedure Is withholding information morally distinct from lying?

14. Is paternalism ever justified?

15. Paternalism ever justified Doctors best placed to make decisions about best medical interests BUT best medical interests ? best overall interests !! Even spouses/close family members are often mistaken about each other’s values and priorities (So remember… generally a bad idea …)

16. Children and Confidentiality

17. Children- Who decides? The child (How old…)? Parent(s)? Health care professional?

18. Autonomous children Teenagers and older children may have the understanding and value system to make autonomous decisions. Values, aspirations, priorities and beliefs change as child grows ? So we should override them ? Adults make bad decisions all the time. Respecting autonomous choices crucial to development ? But if the choice will result in death or serious harm then the basic and developmental interests take precedence Basic interest = physical + emotion + health Development = education, socialisation Autonomy= respecting it Basic interest = physical + emotion + health Development = education, socialisation Autonomy= respecting it

19. Children who lack autonomy

20. Babies, infants and younger children Who decides: DOCTORS + PARENTS ?

21. Parental Autonomy Do parents have a right to decide what should be done to their child ? Have best interest ? Too emotionally involved ? Personal beliefs – likely to share ? Cannot martyr children to their belief system ! OR Do parents have a responsibility to do what is best for their child?

22. When parents and doctors disagree Parents and doctors share welfare concerns BUT differing values ? Differing assessments Good communication ? Agreement

23. Non-therapeutic medical interventions in children ? Tissue/organ donation Medical research Tissue/organ donation Medical research

24. Confidentiality

26. Confidentiality and Autonomy Confidentiality = Expression of autonomy Permissible to override autonomy when there is serious and real harm to others Infants and young children / Adults with mental incapacity/ Dead patients ??

27. Confidentiality and Duty There is a moral duty not to break promises The duty is owed to ALL your patients- (Patients NOT general public !) Therefore it is wrong to breach confidentiality unless we are given permission to disclose EXCEPT Crime/ Abuse !! Why?

28. Serious crime – the duty argument refined The 2 parties to the promise of confidentiality are the doctor and patient The doctor is a public servant The patient is a public citizen The patient has a moral duty not to commit serious crime If the patient commits a serious crime has he breached the terms of the promise?

29. Patients who lack capacity – the duty argument refined With children and adults lacking capacity the doctor has an overriding duty to act in their best interests (disclosing personal information to those involved in care)

31. Mental incapacity, justice and the Mental Capacity Act

32. Human life is valuable ! What feature(s) makes human life valuable: Autonomy / Ability to form relationships/ Emotional capacity /Self-consciousness? We have right to healthcare … Basic human right If everyone is equal, how do we decide between people? Consequences What about those with mental disability ? Justice = Equal treatment of equals Equal treatment = Equal Rights Rights = Moral entitlements eg. Healthcare

33. Mental disability and autonomy Mental disability ? No autonomy

34. Best interests and mental disability Wishes of the individual Physical well being Prognosis Physical and psychological impact of treatment Impact of treatment on quality of life

35. The Mental Capacity Act 2005

36. The Mental Capacity Act: Key Principles Capacity = Understand + Retain + Use + Communicate decision All adults are presumed competent unless shown to lack competence Mental competence is task specific No one can give consent on behalf of a competent adult An individual who lacks mental competence CANNOT give consent NOT COMPETANT : Treatment was necessary It was in the patient’s best interests Expert assessment of capacity will only be required for a serious decision and when there is doubt or disputeExpert assessment of capacity will only be required for a serious decision and when there is doubt or dispute

37. Decisions/Actions must be in the person’s best interests Decisions made on behalf of a person lacking capacity must be in the person’s best interests, WHOEVER is making the decision: Carers/ Health care professional/ Court/ Donee of LPA Consider: Will regain capacity? Persons beliefs and values? Close family and carers have a legal right to be consulted except in an emergency Life sustaining treatments may be lawfully discontinued if their continuation is not in the person’s best interests Court declaration if in doubt !

38. Medical treatments that should continue to go before the court Withholding or withdrawal of artificial nutrition from patients with persistent vegetative states Organ donation or bone marrow transplants Sterilisation for non therapeutic purposes, e.g. contraception Some termination of pregnancy Major decisions where there is doubt or dispute about best interests

39. Independent Mental Capacity Advocates (IMCA) Under the MCA there is a statutory duty to appoint an IMCA, if a person lacking capacity has no one to support them and there are Decisions relating to serious medical treatment, unless it is an urgent situation Proposals to move a person into long term care in a hospital or care home

40. Lasting Power of Attorney All competent adults can create an LPA Strict Rules ! ONLY created when the adult has capacity Registered with the Court of Protection Can only make decisions when the donor has lost capacity Extent of decision making must be specified in the LPA eg. Financial/ health / Refusal of life sustaining treatment Decisions must be in the person’s best interests Or Court ….

41. Advanced Decisions A competent person has the right to decline to undergo treatment, even if the result of his doing so is that he will die. Precedence over a LPA unless the LPA was made later. Best interests does not apply ONLY exception is treatment under the Mental Health Act ie cannot make and advance decision to refuse treatment under the Mental Health Act Apply only to refusals of treatment Must be: Informed/ Competent / Voluntary Can be a witnessed oral statement

42. Not covered by the Mental Capacity Act An advance decision cannot refuse: Basic nursing care Hydration and nutrition that is given orally (artificial hydration and nutrition are considered medical treatment)

43. Advanced Decisions must be valid and applicable An advance decision may be inapplicable if: There has been a significant change in circumstances not addressed in the advance decision eg pregnancy There has been a significant change in the prognosis/ treatment of a condition since the advance decision was made

44. Advanced decisions to refuse life sustaining treatment Must be in writing and signed Must be witnessed and signed by the witness Must specifically state that decision is to be respected even if life is at risk Must indicate that the maker has taken into account circumstances that have changed from when the decision was first drafted It is the doctor’s decision as to whether a treatment is considered life sustaining.

45. Advanced Decisions A doctor would be liable if he provided treatment in the face of a valid and applicable advance decision If there are reasonable doubts over validity/applicability can treat in an emergency In a non-urgent situation can apply to the Court of Protection for a declaration regarding validity/applicability

46. Advanced Decisions –changing your mind The withdrawal may be oral Can be withdrawn at any time as long as maker is competent Once the maker loses competence it cannot be withdrawn

47. Legal Peeps Court of Protection = Specific hard decisions Independent Mental Capacity Advocates = Nobody to make choice Lasting Power of Attorney = Forward planning a person in case capacity lost … Advanced Decisions = Forward planning a decision ? Anything go wrong …. Court !

49. Start of Life Decisions, Disability and justice

50. Abortion is a criminal offence unless: A) the pregnancy is less than 24 weeks and that the risks to the physical and mental health of the woman or any children in her family are greater if the pregnancy were continued OR

51. At any stage of pregnancy: B) It is necessary to prevent grave and permanent injury to the mother OR C) Continuing pregnancy would involve a greater risk to the life of the pregnant woman than termination OR D) Substantial risk of serious physical or mental handicap

52. An abortion can be performed at ANY stage on the grounds of serious disability So bad that ‘better off dead’ ? Eg. 20% serious handicap abortions = DS Are you saying… It is different from terminating on the grounds of sex or hair colour? Lives of those with disability are less valuable? Reinforce prejudice against those with disability?

53. Society fails to adequately support those with disability Parents of disabled children are often more worried about the social stigma than the physical limitations

54. All comes down to the lawyers … Law makers must consider Fairness Individual rights Public consensus ? Discrimination? Policy implications

55. The Exam ?

56. Exam Format

57. EMQs: Legal issues

58. Remember

59. And….

60. Exam Format

61. Read the material well – they’re giving you the questions in disguise! If 2 papers are on: Ethical arguments for / for not eating Nando’s every day…. It will probably come up. You don’t learn the papers – extract the arguments and learn those. 20 pages in ADVANCE !! You shouldn’t be reading in the exam … Timing = Everything ? You will definitely not get the marks if you do not attempt the question… (Empty = E) Plan your essays ! Intro ? Body ? Conclusion Fertleman’s Lecture is really good for this …

62. Example : modified essay question 2. In the UK bone marrow donation is voluntary and payment of bone marrow donors is illegal. Discuss: The ethical arguments for and against paying competent adults to be bone marrow donors. Explain, on the basis of your arguments, whether paying competent adults to be bone marrow donors, is ethically acceptable. (8 marks total )

63. To gain full marks students need to present 1-2 well constructed arguments for and against payment of donors, drawing on the available empirical data. Students need justify their position for or against payment through clear reasoning and critical reflection of the counter arguments. Full marks should not be awarded to students who present only empirical arguments. Potential arguments include:

64. You are told…

65. The Modified Essay Question

66. The Modified Essay Question: preparation

67. Neo is a 37-year-old teacher. His mother died 12 years earlier, aged 62 from Huntington’s Disease. His father was killed in an accident at work when Neo was just 2 years old. Neo’s GP, Dr Smith, has discussed with him the option of genetic testing for Huntington’s but Neo has declined saying that he believes that we should be grateful for the life we are given. Neo recently got married to Niobe, a 41-year-old electrician. Niobe is keen to start a family as soon as possible. Neo has never told Niobe about his mother’s condition. Niobe is under another GP in the same Practice as Dr Smith. Soon after the wedding she makes an appointment to have her intra-uterine contraceptive device removed. Her GP is unwell and she is seen by Dr Smith. He notices that her surname has changed and soon ascertains that Niobe is married to Neo.  Seven months later Niobe is pregnant. Neo and Niobe are delighted. When Niobe finds out she is pregnant Neo contacts Dr Smith and tells him that Niobe must not know about his mother’s Huntington’s Disease. He believes that termination on the grounds of Huntington’s Disease is totally unacceptable. Dr Smith is unable to persuade Neo to change his mind and reluctantly agrees to Neo’s request.  The pregnancy proceeds without complications and Niobe gives birth to Trinity, a healthy baby girl. Fifteen years later Neo has had a few unexpected falls and Niobe comments that he seems to be getting clumsy. She suggests that he sees Dr Smith but Neo says there is nothing wrong with him. He begins suffering from episodes of depression and sudden mood swings. During one outburst he throws a glass at Niobe. Niobe and Trinity find his mood swings very upsetting. Neo goes to see a neurologist who thinks that it is quite likely that his symptoms are due to Huntington’s Disease. After a long discussion with Dr Smith, Neo agrees to tell Niobe that he may have Huntington’s Disease but he continues to refuse genetic testing. Niobe is distraught. A few weeks later she angrily confronts Dr Smith. She believes Dr Smith should have told her about Neo’s family history of Huntington’s Disease. She says that she would never have brought a child into the world if she had known about the possibility of Huntington’s Disease. She tells Dr Smith that Trinity told her that she thought there was something wrong with her father. Trinity had asked Niobe whether she was hiding something from her. Niobe tells Dr Smith that she does not know what to tell her daughter. A few days ago Niobe found Trinity searching the internet for information on movement and mood problems. 

68. Neo is a 37-year-old teacher. His mother died 12 years earlier, aged 62 from Huntington’s Disease. His father was killed in an accident at work when Neo was just 2 years old. Neo’s GP, Dr Smith, has discussed with him the option of genetic testing for Huntington’s but Neo has declined saying that he believes that we should be grateful for the life we are given. Neo recently got married to Niobe, a 41-year-old electrician. Niobe is keen to start a family as soon as possible. Neo has never told Niobe about his mother’s condition. Niobe is under another GP in the same Practice as Dr Smith. Soon after the wedding she makes an appointment to have her intra-uterine contraceptive device removed. Her GP is unwell and she is seen by Dr Smith. He notices that her surname has changed and soon ascertains that Niobe is married to Neo.  Seven months later Niobe is pregnant. Neo and Niobe are delighted. When Niobe finds out she is pregnant Neo contacts Dr Smith and tells him that Niobe must not know about his mother’s Huntington’s Disease. He believes that termination on the grounds of Huntington’s Disease is totally unacceptable. Dr Smith is unable to persuade Neo to change his mind and reluctantly agrees to Neo’s request.  The pregnancy proceeds without complications and Niobe gives birth to Trinity, a healthy baby girl. Fifteen years later Neo has had a few unexpected falls and Niobe comments that he seems to be getting clumsy. She suggests that he sees Dr Smith but Neo says there is nothing wrong with him. He begins suffering from episodes of depression and sudden mood swings. During one outburst he throws a glass at Niobe. Niobe and Trinity find his mood swings very upsetting. Neo goes to see a neurologist who thinks that it is quite likely that his symptoms are due to Huntington’s Disease. After a long discussion with Dr Smith, Neo agrees to tell Niobe that he may have Huntington’s Disease but he continues to refuse genetic testing. Niobe is distraught. A few weeks later she angrily confronts Dr Smith. She believes Dr Smith should have told her about Neo’s family history of Huntington’s Disease. She says that she would never have brought a child into the world if she had known about the possibility of Huntington’s Disease. She tells Dr Smith that Trinity told her that she thought there was something wrong with her father. Trinity had asked Niobe whether she was hiding something from her. Niobe tells Dr Smith that she does not know what to tell her daughter. A few days ago Niobe found Trinity searching the internet for information on movement and mood problems. 

69. To finish …3 Rules (Again) Understanding = Lots ; Learning = Little Easy to pass… Easy to fail There is always a right answer.

70. The End Buy MM Membership ! Contact ns806@ic.ac.uk if you need any help ?