Medical EthicsMedical EthicsAntony VaughanAntony Vaughan General PractitionerGeneral Practitioner

2

Medical ethics principlesMedical ethics principles

BeneficenceBeneficence Non-maleficenceNon-maleficence AutonomyAutonomy JusticeJustice DignityDignity TruthfulnessTruthfulness

3

Ethics: the study of the moral Ethics: the study of the moral value of human behaviourvalue of human behaviour

MedicalMedical BusinessBusiness EnvironmentalEnvironmental LegalLegal PoliticalPolitical

FeminismFeminism Animal rightsAnimal rights BioethicsBioethics Gay rightsGay rights

4

PhilosophyPhilosophy

LogicLogicMetaphysicsMetaphysicsEthicsEthics

5

History of ethicsHistory of ethics

Early GreeksEarly Greeks SocratesSocrates PlatoPlato AristotleAristotle EpicurusEpicurus

Ancient IndiaAncient India HinduHindu

Early European 1100-Early European 1100-12001200 Thomas AquinasThomas Aquinas MamonidesMamonides

Modern philosophy 1700-Modern philosophy 1700- Thomas HobbesThomas Hobbes Immanuel KantImmanuel Kant Jeremy BenthamJeremy Bentham John Stuart MillJohn Stuart Mill David HumeDavid Hume

6

Approaches to ethicsApproaches to ethics

Result based ethicsResult based ethics Standard based ethicsStandard based ethics Ethical intuitionismEthical intuitionism Ethical egoismEthical egoism Virtue ethicsVirtue ethics EmotivismEmotivism

7

Study of ethicsStudy of ethics

Meta-ethicsMeta-ethics Normative ethicsNormative ethics Applied ethicsApplied ethics

8

Medical ethicsMedical ethics

MedicalMedical Health care ethicsHealth care ethics Clinical ethicsClinical ethics BioethicsBioethics

9

Ethical topicsEthical topics

Patient confidentialityPatient confidentiality Doctor paternalismDoctor paternalism Rights of patient to refuse treatmentRights of patient to refuse treatment Rights of patients who lack capacityRights of patients who lack capacity Organ removalOrgan removal Involuntary detentionInvoluntary detention Foetal testing, selection and abortionFoetal testing, selection and abortion

10

Medical oaths and codesMedical oaths and codes

Ideal doctorsIdeal doctors Welfare of patientsWelfare of patients Advancement of medical knowledgeAdvancement of medical knowledge Honour of professionHonour of profession Awareness of limits of powerAwareness of limits of power Strive to help but “above all do no harm’Strive to help but “above all do no harm’

11

Doctors criticised for:Doctors criticised for:

PaternalismPaternalism Acting without patient’s knowledge or Acting without patient’s knowledge or

consentconsent Assuming patients share idea of Assuming patients share idea of

benefits and treatment risksbenefits and treatment risks

12

Consequentialism (teology)Consequentialism (teology)

Actions should provide a good outcomeActions should provide a good outcome Greatest good for the greatest numberGreatest good for the greatest number StrengthsStrengths

Resolves conflicts between individuals & societyResolves conflicts between individuals & society Also used in political & business ethicsAlso used in political & business ethics

WeaknessesWeaknesses Difficult to predict outcomeDifficult to predict outcome Society’s needs may not be correct morallySociety’s needs may not be correct morally Individual needs & conscience can suffer from Individual needs & conscience can suffer from

utilitarian thinkingutilitarian thinking

13

Dying widowDying widow A 71-year-old widow is dying of end stage breast cancer with secondaries

in brain and bone. She can still converse well. Her husband died 8 years ago. Her two sisters died before her-one from breast cancer. Her one source of comfort has been her only child, a computer specialist, who took leave from his work 6 months ago to be with his mother during the final episode of her life.

As the patient slips in and out of consciousness and her pain control medications increase she asks for her son Mark, “Why isn’t he here? Is Mark alright?” Yesterday her doctor and nursing staff were informed that Mark had died in the family house, an apparent suicide. He had become despondent over his mother’s approaching death. According to a note he wanted to “be there” with his aunts and father before his mother arrived.

Should the health care providers tell the patient about her son’s death?Should the health care providers tell the patient about her son’s death?

14

DeontologyDeontology

Duties and obligationsDuties and obligations Assumes people naturally act morallyAssumes people naturally act morally Nothing can be imposed on anyone Nothing can be imposed on anyone

without their will or consentwithout their will or consent

15

Deontology 2Deontology 2

StrengthsStrengths Avoids rationalisation and delusions to justify Avoids rationalisation and delusions to justify

personal actionspersonal actions Corrects inauthentic reasons for being moralCorrects inauthentic reasons for being moral Above constraints overrule the common goodAbove constraints overrule the common good

WeaknessesWeaknesses Cannot resolve conflicts between moral Cannot resolve conflicts between moral

persons who disagreepersons who disagree No room for compromiseNo room for compromise

16

Dying widowDying widow A 71-year-old widow is dying of end stage breast cancer with secondaries

in brain and bone. She can still converse well. Her husband died 8 years ago. Her two sisters died before her-one from breast cancer. Her one source of comfort has been her only child, a computer specialist, who took leave from his work 6 months ago to be with his mother during the final episode of her life.

As the patient slips in and out of consciousness and her pain control medications increase she asks for her son Mark, “Why isn’t he here? Is Mark alright?” Yesterday her doctor and nursing staff were informed that Mark had died in the family house, an apparent suicide. He had become despondent over his mother’s approaching death. According to a note he wanted to “be there” with his aunts and father before his mother arrived.

Should the health care providers tell the patient about her son’s death?Should the health care providers tell the patient about her son’s death?

17

Virtue theoryVirtue theory Virtues (habits) formed by personality, parental Virtues (habits) formed by personality, parental

and social training, professional training and and social training, professional training and standardsstandards

All human beings have an inborn routine that All human beings have an inborn routine that tends to the good in moral action (needs tends to the good in moral action (needs moulding)moulding)

Examples of virtue; courage, love, friendship, Examples of virtue; courage, love, friendship, responsibility, faithfulness, truth tellingresponsibility, faithfulness, truth telling

Doctors also need compassion, humility and Doctors also need compassion, humility and integrity (respect for science)integrity (respect for science)

18

Virtue theory 2Virtue theory 2

StrengthsStrengths Health professionals’ character is crucial as they Health professionals’ character is crucial as they

interpret and apply the ethical theoryinterpret and apply the ethical theory Encompasses duty of professional (deontological) Encompasses duty of professional (deontological)

and goodness of actions (teological)and goodness of actions (teological) Do good and avoid evil (Thomas Aquinas)Do good and avoid evil (Thomas Aquinas)

WeaknessesWeaknesses Agreement of what is virtuous is often difficultAgreement of what is virtuous is often difficult Society need to agree what is right and goodSociety need to agree what is right and good

19

Dying widowDying widow A 71-year-old widow is dying of end stage breast cancer with secondaries

in brain and bone. She can still converse well. Her husband died 8 years ago. Her two sisters died before her-one from breast cancer. Her one source of comfort has been her only child, a computer specialist, who took leave from his work 6 months ago to be with his mother during the final episode of her life.

As the patient slips in and out of consciousness and her pain control medications increase she asks for her son Mark, “Why isn’t he here? Is Mark alright?” Yesterday her doctor and nursing staff were informed that Mark had died in the family house, an apparent suicide. He had become despondent over his mother’s approaching death. According to a note he wanted to “be there” with his aunts and father before his mother arrived.

Should the health care providers tell the patient about her son’s death?Should the health care providers tell the patient about her son’s death?

20

Branches of medical ethicsBranches of medical ethics

Public policy ethicsPublic policy ethics

Applied medical Applied medical ethicsethics

Clinical medical ethicsClinical medical ethics

Age based rationingAge based rationing Medical researchMedical research Treatment availabilityTreatment availability Professional codesProfessional codes AbortionAbortion EuthanasiaEuthanasia FertilityFertility Genetic manipulationGenetic manipulation Case analysisCase analysis Patient & family involvedPatient & family involved

21

Four principle approach Four principle approach (Beauchamp & Childress)(Beauchamp & Childress)

AutonomyAutonomy BeneficenceBeneficence Non-malificenceNon-malificence JusticeJustice

22

Four principle approach 2Four principle approach 2 StrengthsStrengths

Compatible with deontological and Compatible with deontological and consequentialist theories & some aspects of consequentialist theories & some aspects of virtue theoryvirtue theory

Objective, specific, works well in clinical Objective, specific, works well in clinical situationssituations

WeaknessesWeaknesses Conflict between autonomy and justice, & Conflict between autonomy and justice, &

beneficience and non-maleficencebeneficience and non-maleficence Need to weight one principle over anotherNeed to weight one principle over another

23

Alternative approachesAlternative approaches

Normative ethicsNormative ethics LibertarianismLibertarianism Beneficence in trustBeneficence in trust Communitarian ethicsCommunitarian ethics Narrative ethicsNarrative ethics Feminist ethicsFeminist ethics

24

AutonomyAutonomy

Informed consentInformed consent ConfidentialityConfidentiality Keeping promisesKeeping promises Lack of deceitLack of deceit EmpowermentEmpowerment

25

Beneficence & Beneficence & non-maleficencenon-maleficence

Any effort to help may result in Any effort to help may result in harmharm

Education and trainingEducation and training Risk, probability of benefit and Risk, probability of benefit and

harmharm

26

JusticeJustice

Fair adjudication between Fair adjudication between competing claimscompeting claims

Personal decision makingPersonal decision making Organisational, professional and Organisational, professional and

societal decisionssocietal decisions

27

ScopeScope

To whom or to what we owe moral To whom or to what we owe moral obligationsobligations

PatientsPatients ChildrenChildren Mentally ill or impairedMentally ill or impaired

Right to lifeRight to life Not to be unjustly killedNot to be unjustly killed Right to be kept aliveRight to be kept alive

28

Change of mind over Change of mind over advanced directiveadvanced directive

Mr Z made a written advance directive 5 years ago. Mr Z suffers from chronic obstructive pulmonary disease and the advance statement provides that if he is admitted in respiratory failure he will not be ventilated. The advance directive is placed in his notes. Mr Z is brought into A&E in respiratory failure and is acutely confused because of low oxygen levels in his blood. He states that he wants 'everything done' in order to save him. The doctor in charge of his care decides to ventilate him.

29

Refusal of Treatment by an Refusal of Treatment by an Incompetent patientIncompetent patient

Mrs Y is 56 years old. She has a learning disability and lives in a care home. She is admitted to hospital with an ovarian cyst. The cyst is blocking her ureter and if left untreated will result in renal failure. Mrs Y would need an operation to remove the cyst. Mrs Y has indicated quite clearly that she does not want a needle inserted for the anaesthetic for the operation to remove the cyst - she is uncomfortable in a hospital setting and is frightened of needles.

The clinician is concerned that if the cyst is not removed Mrs Y will develop renal failure and require dialysis which would involve the regular use of needles and be very difficult to carry out given her fear of needles and discomfort with hospitals. The anaesthetist is concerned that if Mrs Y does not comply with the procedure then she would need to be physically restrained. Mrs Y's niece visits her in the care home every other month. The niece is adamant that her aunt should receive treatment.

Should the surgeon perform the operation despite Mrs Y’s objections?

30

Prevention or Treatment?Prevention or Treatment? Decisions about setting priorities for treatments and services on a larger scale raise difficult

ethical issues for PCTs. A PCT may seek advice on the ethical issues arising from these ‘macro-level’ decisions from a priorities forum, or a PCT may develop their own ethics committee to inform these decisions.

Metroville PCT has a sum of recurring money that has been ring-fenced for use in the area of ischaemic heart disease. The PCT has two proposals for developing services in this area and must decide which proposal to fund.

Proposal 1 is from the local acute trust and is for an increase in angiography and angioplasty services. The proposal cites evidence from research studies to show that reducing waiting times for angioplasty will save lives and is a cost effective use of resources.

Proposal 2 is from the local diabetes group and is for a project that will focus on the small Asian community within the population. This community has a high prevalence of diabetes and ischaemic heart disease and traditionally has tended to use health care services only when they are acutely ill rather than attending for regular care of their chronic diseases. The proposal is to provide a specialist diabetes nurse and health advocate for this population and an educational programme for the whole community focusing on prevention of diabetic complications and promotion of life-style changes to reduce the incidence of new cases of diabetes. There is no research evidence for this intervention but there is some anecdotal evidence from other areas that this approach has some success.

The PCT must choose one of these proposals.

31

Confidentiality and HIVConfidentiality and HIV Bob has attended the genito-urinary clinic at his local Trust hospital.

Bob is seen by Dr Gomez who informs him that he is HIV positive. Dr Gomez counsels Bob to contact his sexual partners to inform them of his status. Bob starts a course of treatment.

For the last 18 months Bob has been in a relationship with Sue. They are expecting a baby in 2 months time. Before this relationship Bob had a series of sexual partners.

On a subsequent visit to the clinic it becomes clear to Dr Gomez that Bob has not told Sue of his HIV status. Dr Gomez is aware of the impending arrival of their baby and tells Bob that steps should be taken to assess whether Sue is HIV positive and whether the baby is at risk so that if necessary treatment may be started.

Bob adamantly refuses to tell Sue and says that if she is told without his consent then he will stop his course of treatment.

What should Dr Gomez do? Should he inform Sue, or Bob’s GP?

32

Parents refuse to withhold RxParents refuse to withhold Rx Baby C born 8 weeks prematurely and contracted

meningitis soon after birth. As a result she suffered severe brain damage and an inability to respond to stimuli. She was receiving artificial ventilation. The treating team thought that it was not in the baby's best interests to continue with artificial ventilation, without which she would die within an hour. With continuance of such treatment she would live for at most one year, probably experiencing pain and distress. For religious reasons her parents could not agree to withdrawal of treatment.

What issues should an ethics committee consider in reviewing such a case?

33

Competent patient refuses RxCompetent patient refuses Rx Mrs X is 35 and is in need of dialysis. She is refusing

treatment because she is scared of treatment which she believes is invasive. She has been counselled about the nature of the treatment - there are no alternatives that would be of practical benefit. She is competent to make treatment decisions. She understands that if she refuses dialysis she will die. She has a daughter of 15 years who lives at home. The clinician feels very strongly that she should receive dialysis but despite numerous attempts to persuade her she refuses.

Can the clinician treat her?

34

Who should have the bed?Who should have the bed? Barry is a 32 year old man with meningitis and is brought into the A&E

department of hospital A. He is unconscious with an extremely low blood pressure and evidence of renal failure. His condition is grave and without intensive care support he is almost certain to die. With intensive care support he may make a full recovery. Until this illness he has been fit and well. The Intensive Care Unit (ICU) in hospital A is full, with some patients critically ill and some in a relatively stable condition but for who optimum care would still require the facilities of an ICU. There is evidence that moving a patient from an ICU early increases their chances of complications and may increase mortality. There is an available bed in an ICU in hospital B, which is fifty miles away. The intensive care consultant on call must decide if Barry should be moved to hospital B or if a patient already in ICU should be transferred to allow Barry to be admitted. The clinical ethics committee is asked to review the case retrospectively and advise on how such cases should be approached in the future