Defining a Moral Problem

1. Defining a Moral Problem Samantha Mei-che Pang RN, PhD School of Nursing The Hong Kong Polytechnic University

2. Traditional and contemporary ethical values in biomedicine and healthcare

3. Hippocratic Oath (~400BC) • Nightingale Pledge (1893) • International Council of Nurses Code of Ethics (1953, last revision:2005) • Declaration on Bioethics and Human Rights (UNESCO 2005) • Declaration of Helsinki, World Medical Association (1964, last revised 2008) • The Patient Charter (Hospital Authority Hong Kong, 1994) • Code of Professional Conduct for the Guidance of Registered Medical Practitioners, Medical Council of Hong Kong (1957, last revised 2009)

4. Traditional Medical Ethical Values in the Hippocratic Oath • I will prescribe regimen for the good of my patients according to my ability and my judgment and never do harm to anyone. • To please no one will I prescribe a deadly drug, nor give advice which may cause his death. Do no harm and do good

5. Ethical values upheld in the Nightingale Pledge (1893) • I will abstain from whatever is deleterious and mischievous and will not take or knowingly administer any harmful drug. Do no harm

6. Nightingale Pledge • I will do all in my power to elevate the standard of my profession, and will hold in confidence all personal matters committed to my keeping, and all family affairs coming to my knowledge in the practice of my profession. Respect for person: privacy & confidentiality

7. Nightingale Pledge • With loyalty will I …devote myself to the welfare of those committed to my care. Do good

8. Universal Declaration on Bioethics & Human Rights UNESCO 2005 • To provide a universal framework of principles and procedures to guide States in the formulation of their legislation, policies or other instruments in the field of bioethics

9. Bioethical Principles (UNSECO 2005) • Human dignity and human rights • Autonomy and individual responsibility • Consent and persons without the capacity to consent • Respect for human vulnerability and personal integrity • Privacy and confidentiality • Non-discrimination and non-stigmatization • Respect for cultural diversity and pluralism • Benefit and harm • Solidarity and cooperation • Social responsibility and health • Sharing of benefits • Protecting future generations • Protection of the environment, the biosphere and biodiversity

10. Patients’ Charter, Hospital Authority Hong Kong 1994 • Right to medical treatment • Right to information • Right to choices • Right to privacy • Right to complaint • Responsibilities • Provide accurate and relevant information • Comply with prescribed treatment • Respect others’ rights and follow hospital rules • Keep appointment • Do not ask for fake certification • Do not waste medical resources

11. Ethical Values in Patient-Health Professional Relationship • Do good • Do no harm • Fidelity • Privacy Trust-based, covenantal Autonomy-based, contractual • Respect for autonomy • Informed consent • Patient rights

12. Ideal Scenario Doing no harm Social responsibility Doing good • Equity Respect for autonomy Virtuous character Holistic inclusion of patient family Professional competence Following institutional rules & regulations Communal work attitude Values & preferences

13. A 60 years old man has undergone a comprehensive health assessment and is found to have probable dementia. The family members request the attending doctor not to tell the patient. Survey A Survey B What is the problem? What is the ethical issue at stake?

14. Define the moral problem? • Withholding information from the patient • Right of family member to access the patient’s medical information without the patient’s consent • Respect for autonomy

15. Doing no harm Social responsibility Mental competence? The patient’s wish to know? Patient vulnerability? Doing good • Equity Respect for autonomy Virtuous character • Competing ethical viewpoints: • Holistic inclusion of the patient family and doing no harm to the patient • Respect for autonomy and doing good to the patient Holistic inclusion of patient family Professional competence Following institutional rules & regulations Communal work attitude

16. The patient is suffered from multiple stroke, advanced dementia and is totally dependent. The doctor has indicated Do-not-resuscitate (DNR) for the patient. The family requests to try everything to preserve the patient’s life. What is the problem? What is the ethical issue at stake?

17. Define the moral problem • Is the medical team obliged to provide medically futile treatment upon the patient’s family request? • Professional integrity • Goal of medical care: preserve life or prolong dying • The patient’s wish/advance directive

18. The patient is suffered from multiple stroke, advanced dementia and is totally dependent. The doctor has indicated Do-not-resuscitate (DNR) for the patient. The family requests to try everything to preserve the patient’s life. Is the patient terminally ill? What is medical futility? Has the patient indicated any prior wish? What does it mean by dignified care to the patient?

19. Ethical justification: The set of reasons for providing moral groundings to one’s course of action?