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Medical Ethics. VTS 24/09/08. Curriculum statement 3.3 Curriculum statement 3.4. Timothy McVeigh Timothy McVeigh.doc. Should doctors have to swear an oath when they qualify? The Hippocratic Oath.doc Modern Hippocratic Oath.doc AMA Oath.doc. What is meant by Ethics?

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medical ethics

Medical Ethics

VTS 24/09/08

slide2

Curriculum statement 3.3

Curriculum statement 3.4

slide3

Timothy McVeigh

Timothy McVeigh.doc

slide4

Should doctors have to swear an oath when they qualify?

The Hippocratic Oath.doc

Modern Hippocratic Oath.doc

AMA Oath.doc

slide5

What is meant by Ethics?

What is meant by morality?

slide6

What is meant by Ethics?

  • Ethics – the philosophical study of morality
  • Morality – a system applying to all rational persons, governing behaviour that affects others, having the lessening of harm as its goal
slide7

Example from practice - 1

  • Microalbuminuria testing in diabetes
slide8

Example from practice - 1

  • Microalbuminuria testing in diabetes
    • Does this test benefit some patients?
    • If so, who?
    • Is it about QOF points?
    • Could it cause injury?
    • Is such a process respectful of patients’ views?
    • It is expensive and if we use much resource doing this is there a knock-on effect on other services? Is this fair? Do others suffer if we use “too much” for a few patients?
slide10

Example from practice - 2

  • Immunisation
    • Is this process beneficial? If so, to whom?
    • Individual benefit vs. herd-immunity.
    • Do we know who is going to benefit?
    • What about if GPs get paid for immunisations?
    • Could it cause injury?
    • If some might suffer from it, is it still right to proceed with it on grounds of benefit for the majority?
slide11

Example from practice - 3

  • Patient empowerment
slide12

Example from practice - 3

  • Patient empowerment
    • Is choice about treatment options always a good thing?
    • Information-giving may be good for the doctor-patient relationship but is it a good basis for making treatment decisions? (DXT, chemo)
    • “What would you do, doc?”
    • There may be an illusion of choice where there is no real choice
    • What about Choose and Book? If it is based on historical referral patterns, is there really choice?
slide13

Example from practice – 4

  • Why don’t we just give patients prescriptions if they ask for something?
slide14

Example from practice – 4

  • Why don’t we just give patients prescriptions if they ask for something?
    • E.g. antibiotics, tranquillisers?
    • This might be beneficial and patient-centred
    • Is patient choice more important than avoiding iatrogenesis or medicalisation? Or less?
    • In any case, how likely is iatrogenesis with such simple, widely used treatments?
    • Is it fair - to other patients? To colleagues?
    • Does doctor/nurse-practitioner know best?
slide15

The First Principle

  • Do good
  • This is BENEFICENCE
  • Such aspects as cure / palliation / comfort / empathy / compassion / treating patients with dignity
  • Such concepts are well understood by medical and nursing staff
slide16

Example from practice - 5

  • Cholesterol monitoring in the elderly
slide17

Example from practice - 5

  • Cholesterol monitoring in the elderly
    • How old is elderly?
    • Is this process beneficent? If so, to whom?
    • What is the evidence for benefit?
    • Is it about QOF points?
    • Could it cause injury?
    • Is such a process respectful of patient views?
slide19

Example from practice - 6

  • Spirometry
    • Is this process beneficent?
    • Do we know who is going to benefit?
    • Is it about QOF points?
    • Could it cause injury?
    • It uses up a lot of time. Do others suffer if we use “too much” for a few patients?
slide20

Example from practice – 7

  • Termination of pregnancy
slide21

Example from practice – 7

  • Termination of pregnancy
      • What is the purpose in discussing different numbers of weeks of time where abortion is permissible?
      • Is there a moral difference between abortion at 20 weeks and at 24?
      • Whose rights need to be considered – just the mother’s? The unborn child’s?
      • How much guidance do the clauses of the Abortion Act(s) offer?
slide22

The Second Principle

  • Do no harm
  • This is NON-MALEFICENCE
  • Not injuring patients by what we do
  • Non-iatrogenesis
  • Well understood but sometimes happens inadvertently
slide23
The Hippocratic Oath does notcontain the words “First, do no harm”, (nor was it actually written by Hippocrates, according to many sources). It expresses a similar idea, but does not use these words.
  • Hippocrates probably did originate the phrase, but did so in his Epidemics, Bk. I, Sect. XI. One translation reads: "Declare the past, diagnose the present, foretell the future; practice these acts. As to diseases, make a habit of two things — to help, or at least to do no harm.“
  • The Greek "First, do no harm" becomes "Primum non nocere" in Latin. A translation of the original perhaps, but some sources attribute "Primum non nocere" to the Roman physician, Galen.
slide24

Example from practice – 8

  • Should the cost of prescriptions be an issue?
slide25

Example from practice – 8

  • Should the cost of prescriptions be an issue?
    • How much should the PCT/DoH tell us what to prescribe? E.g. lansoprazole vs. omeprazole
    • Is generic prescribing always right? What about when patients feel branded medication is “better”?
    • Should we prescribe Calpol, cough mixtures, etc?
    • What about “setting precedents”?
    • What about top-up payments for “expensive” drugs?
slide26

Example from practice – 9

  • Fertility treatment
slide27

Example from practice – 9

  • Fertility treatment
    • Is it right to choose the sex of a child produced by fertility treatment? Always? Ever? Never?
    • What about selective abortion?
    • Cloning – what about for stem cell research or for treatment of an afflicted child?
    • How many embryos can be “sacrificed” for the purposes of research? 9 to 1? 99 to 1? 999 to 1?
    • Should egg and sperm donors be anonymous?
    • Explanatory Notes to Human Tissue Act 2004.doc
slide28

Example from practice – 10

  • Ethical employment practice
slide29

Example from practice – 10

  • Ethical employment practice
    • Hiring and firing – are non-discriminatory policies and procedures in place?
    • Issues of confidentiality for staff
    • What should be put in a reference?
    • How much weight and value should be given to the views of non-clinical staff in running a practice?
    • How much should staff be paid? And doctors?
slide30

The Third Principle

  • Act fairly
  • This is (distributive) JUSTICE
  • Such aspects as treating equals equally / if people are non-equal they should be treated in proportion to their degree of inequality (? e.g. those in custody, relatives) / ethical rationing – should those who are deprived have more?
  • A more difficult principle
slide31

Example from practice – 11

  • Is it ever right to break confidentiality?
slide32

Example from practice – 11

  • Is it ever right to break confidentiality?
    • Who has a “right” to know your medical history?
    • At what point does “need to know” override “need for confidentiality”?
    • HIV in a partner? Open TB in a family member?
    • Suspected murder? Driving while fitting? Driving whilst under the influence of drugs? If someone has “gone missing”? Who might you speak to – police, family, concerned neighbours?
    • Court may give an order to release medical records in some circumstances
slide33

Example from practice – 12

  • Should doctors always tell patients their diagnosis?
slide34

Example from practice – 12

  • Should doctors always tell patients their diagnosis?
    • What about uncertainty in diagnosis? Is it right to make patients share this?
    • Is it ever right to suppress diagnoses – what about stigmatising diagnoses, e.g. MS, dementia, HIV, psychiatric diagnoses?
    • What if relatives ask doctors not to disclose diagnoses to patients?
slide36

Example from practice – 13

  • Euthanasia
      • What about withdrawing feeding tubes when someone is in a persistent vegetative state?
      • Who could make such a decision? Who should?
      • What role should relatives have in these matters?
      • What about Living Wills?
      • Do we all “have a responsibility” not to be a burden on society under certain circumstances?
slide37

Example from practice – 14

  • Should mentally disabled babies be prevented from growing/maturing?
slide38

Example from practice – 14

  • Should mentally disabled children be prevented from maturing?
    • Has no awareness
    • Life should be as comfortable as possible
    • No sexual development – no periods
    • Perhaps remain light enough to be treated like a baby
    • Quality of life issues
    • But….?
slide39

The Fourth Principle

  • Allow people to determine their own futures
  • This is AUTONOMY
  • Such aspects as honesty / telling the truth / informed consent / decision sharing / maximising the ability of patients to make choices
  • CONFIDENTIALITY comes under this principle
slide40

A further aspect

  • There is another aspect to this and that is SCOPE
  • To whom do we owe these duties?
  • Who are the interested parties?
  • Individuals or patients as a group? The Practice? The NHS? Society? Government?
slide42

Example from practice – 15

  • Ethical research
    • Blood tests without specific consent
    • Blinding patients / consent
    • Taking tissue
    • Keeping tissue
    • Human Tissue Act 2004
slide43

Example from practice – 16

  • Practice-based commissioning
slide44

Example from practice – 16

  • Practice-based commissioning
    • Whose interest does this serve?
    • Is allocation of funds based on historical referral patterns a fair way to do it? Should some practices/patients/areas of deprivation have more?
    • Who decides on the amount? Should one practice which “saves” support others who “overspend”?
    • What about the time used in such a process?
    • Whose responsibility is it if overspends occur? The practice’s? The patients’? The PCT’s? The NHS’s? The Government’s?
    • What if PBC destabilises or damages secondary care providers’ services?
slide45

Example from practice - 17

  • Do violent patients lose their right to confidentiality?
slide46

Example from practice - 17

  • Do violent patients lose their right to confidentiality?
    • They may have to go somewhere “special” – different – for treatment; they may be in custody
    • They may have injured one of your colleagues and you may want or be asked to report something to the police
    • GMC advice is that information may be shared without consent where the public interests outweigh the benefits of keeping the information confidential - but may need a court decision
slide47

Example from practice – 18

  • Having health provision
slide48

Example from practice – 18

  • Having health provision
    • “Great physicians and nurses, skilled, caring and unparalleled in their training, intervened in my life and probably saved it. I was lucky but other Americans are not. It is time to speak again and stand again for the ideal that in the richest nation ever on this planet, it is wrong for 41 million Americans, most of them in working families, to worry at night and wake up in the morning without the basic protection of health insurance.”  
    • Senator John Kerry
slide49

The “Four Principles” of medical

  • ethics are:
  • Do good
  • Do no harm
  • Act fairly
  • Allow people to determine their own futures
slide50

Moral framework

  • The model of the Four Principles was suggested by the American ethicists Beauchamp and Childress
  • Popularised in UK by Ranaan Gillon
  • A moral framework such as this can help to give consistency in decision making
  • It is claimed that “Any ethical problem can be solved by considering these four principles”
  • But…
slide51

Critique of this model

  • It is not a coherent ethical theory
  • Rather it is a mish-mash of ideas
  • What about when there is conflict?
  • How do these ideas fit with underlying ethical theories?
slide52

Ethical theory

  • The problem is that there is no single agreed underlying ethical theory
  • The task of Ethics is to try to arrive at some conclusions without reference to religious ideas or gut instinct
  • There are two main ways of thinking about the rightness or wrongness of an action – Consequentialism and Deontology
slide53

Consequentialism

  • This holds that the only thing that matters is the consequences of an action
  • Best known example of this type of idea is UTILITARIANISM which proposes that the morally correct course of action is that which results in the greatest good for the greatest number of those affected by the action
  • These ideas were developed and set down by the English philosophers Jeremy Bentham – “An Introduction to the Principles of Morals and Legislation” (1789) – and John Stuart Mill – “Utilitarianism” (1861)
slide54

Good things about Utilitarianism

  • “The central insight of Utilitarianism, that one ought to promote happiness and prevent unhappiness whenever possible, seems undeniable”
  • Provides support for democracy as the way to ensure that the interests of government coincide with the general interest
  • Socially beneficial e.g. in 19th century - anti-slavery movement, promotion of women’s rights and spread of suffrage
slide55

Bad things about Utilitarianism

  • Disregards the distribution of benefits and burdens on individuals
  • Can we correctly work out what the consequences of an action are?
  • How can the sum of the benefits of actions be calculated?
  • Difficult to compare alternatives
  • Is more to morality than simply consequences?
slide56

Bad things about Utilitarianism

  • Might sometimes justify killing – killing Hitler as a child could have saved millions of lives
  • Deciding how to use limited resources – water, food, oxygen – in critical conditions - choosing one Siamese twin to survive after separation surgery instead of neither
  • Triage and rejection of critically injured patients after terrorist atrocities
  • If there are problems with Utiltarianism under these conditions, is there a general problem?
slide57

Deontology

  • These sorts of ethical theories regard obligation as deriving from reason or as residing primarily in certain specific rules of conduct rather than in the maximisation of some good
  • Concepts like duty, moral obligation, moral commitment, what you should and should not do
slide58

Good things about Deontology

  • Usually some sort of coherent system
  • Might give a set of answers to a range of problems
  • Chimes with what individuals feel about things
  • Fits with ideas of rules, laws, commandments
slide59
3 ¶ Thou shalt have no other gods before me.4 ¶ Thou shalt not make unto thee any graven image, or any likeness of any thing that is in heaven above, or that is in the earth beneath, or that is in the water under the earth:5 thou shalt not bow down thyself to them, nor serve them for I the LORD thy God am a jealous God, visiting the iniquity of the fathers upon the children unto the third and fourth generation of them that hate me;6 and showing mercy unto thousands of them that love me, and keep my commandments. 7 ¶ Thou shalt not take the name of the LORD thy God in vain for the LORD will not hold him guiltless that taketh his name in vain.8 ¶ Remember the sabbath day, to keep it holy. 9 Six days shalt thou labor, and do all thy work:10 but the seventh day is the sabbath of the LORD thy God: in it thou shalt not do any work, thou, nor thy son, nor thy daughter, thy manservant, nor thy maidservant, nor thy cattle, nor thy stranger that is within thy gates:11 for in six days the LORD made heaven and earth, the sea, and all that in them is, and rested the seventh day: wherefore the LORD blessed the sabbath day, and hallowed it.

12 ¶ Honor thy father and thy mother that thy days may be long upon the land which the LORD thy God giveth thee.

13 ¶ Thou shalt not kill. 14 ¶ Thou shalt not commit adultery.

15 ¶ Thou shalt not steal. 16 ¶ Thou shalt not bear false witness against thy neighbor.

17 ¶ Thou shalt not covet thy neighbor's house, thou shalt not covet thy neighbor's wife, nor his manservant, nor his maidservant, nor his ox, nor his ass, nor any thing that is thy neighbor's.

slide60
Code of Hammurabi - laws from the sixth king of the Amorite Dynasty of Old Babylon c. 1760 BC – contains medical aspects

Code of Hammurabi.doc

  • “The essence of Buddhism is very simple: it is finding ways to transform oneself. It could be summed up as 'learning to do good; ceasing to do evil; purifying the heart' (as the Dhammapada says)”.
slide61

Bad things about Deontology

  • Deontology depends on a variety of ideas -
    • The fundamental principles of right and wrong are authoritative by virtue of being self-evident truths
    • There are axiomatic or intuitive ideas of rightness or wrongness
    • (Some consider that) moral principles are based on God-given laws for humanity
  • But..
    • Not all accept appeals on such “absolute” grounds
    • It is easy to say if something is “square” but is it similar when something is described as “right”?
slide62

Conclusions and implications

  • Things are not always as straightforward as they may seem
  • There are ethical aspects to many medical situations
  • If the problem is an ethical one, try to generate lots of options – rule nothing out
  • Assess the advantages and disadvantages of each solution using the four principles
  • Consider consequential and deontological theory
slide63

Conclusions and implications

  • There may be legal precedents
  • There are sources of help and advice – colleagues, GMC, medical defence companies, RCN
  • Impart decisions to patients in an ethical way
  • Record everything