Introduction toProfessionalism &Medical ethicsIHAB B ABDALRAHMAN, MBBS, MD, ABIM, SSBB.CONSULTANT OF ACUTE CARE MEDICINE,S...
Aims To highlight the concept of professionalism To introduce the concepts of Ethics &  Medical Ethics To discuss ethic...
Compartmentalization of life One man cannot do right in one department of life, whilst he is occupied in doing wrong in a...
Ihab B Abdalrahman (Tarawa)   12/31/2012   4
You make me cry             Ihab B Abdalrahman (Tarawa)   12/31/2012   5
Compartmentalization of life One man cannot do right in one department of life, whilst he is occupied in doing wrong in a...
Ihab B Abdalrahman (Tarawa)   12/31/2012   7
SYSTEMS GOVERNING                       HUMAN SOCIAL BEHAVIOUR   CUSTOM      ETIQUETTE         ETHICS                LAW  ...
What type of professional?       or a good doctor                             Ihab B Abdalrahman (Tarawa)   12/31/2012   9
Definition                  Profession  An occupation whose core element is work    “  based upon the mastery of a comple...
                                                                                    Ihab B Abdalrahman (Tarawa)   10/1/...
                                                                                                                       ...
Why is ProfessionalismImportant?“ Neither economic incentives, nor technology,  nor administrative control has proved an  ...
The Physician Has TwoRoles      Healer      Professional
P h y s ic ia n             H e a le r        P ro fe s s io n a lCaring and compassion                             Autono...
The Social Contract The social contract in health care is based on professionalism. It serves as the basis for the expec...
The Social ContractSociety                     ProfessionPatient    expectations     Physician            obligations     ...
The Social ContractThis Contract Has Always Been  Implicit (largely unwritten)  Evolving (being constantly              ...
The Social Contract   Society’s Expectations of               Medicine’s Expectations of Society   Medicine               ...
The ContractDepends On  mutual trust  reasonable demands on both   sides  communication
Professionalism                        CommunicationEthics         Behavior                    Ihab B Abdalrahman (Tarawa)...
   Components of Medical Professionalism identified to be suitable for trainees: Behavior:     Collaboration.     Prof...
 Ethics:   Beneficence (do good).   Nonmaleficence (do no harm) & malpractice [e.g.      serious professional misconduc...
   Components of Medical Professionalism identified to be suitable for trainees: Communication – including effective    ...
Professionalism               E               CommunicationEthics         Behavior                    Ihab B Abdalrahman (...
Medical Technician         Skills          &       Knowledge             Ihab B Abdalrahman (Tarawa)   12/31/2012   27
Ethical  principlesSkills & knowledge Moral Character      Ihab B Abdalrahman (Tarawa)   12/31/2012   28
EthicsSkills & knowledge Moral Character      Ihab B Abdalrahman (Tarawa)   12/31/2012   29
 What is Ethics?                    Ihab B Abdalrahman (Tarawa)   12/31/2012   30
 Ethics is the branch of study dealing with  What is the proper  course of action.                         Ihab B Abdalra...
 It is the study of right and wrong.                 Ihab B Abdalrahman (Tarawa)   12/31/2012   32
 It answers the question,"What do I do?"                      Ihab B Abdalrahman (Tarawa)   12/31/2012   33
The last of human freedoms Every thing can be taken from a man, but one  thing:  To choose one’s attitude in a   given se...
 It is your choice   Emotion based   Principle based                      Ihab B Abdalrahman (Tarawa)   12/31/2012   35
Why Ethics is important? Ethics is a requirement for human life. It is our means of deciding a course of action.        ...
Moment of thoughtIn many casesit might help to put yourselfin your patient shoes.Seek to understand, before to be understo...
 What is medical ethics?It is just, Doing the right thing.                            Ihab B Abdalrahman (Tarawa)   12/31...
But what is right? Beginning of life End of life Limited resources When patient demands unacceptable  measures   What...
Medical ethics Refers to those guidelines and behaviors that  we expect   a medical professional   with moral integrity...
Medical Ethics    Beneficence    Non-maleficence & malpractice   Justice?”                                             ...
Ihab B Abdalrahman (Tarawa)   12/31/2012   42
Ethical Principles  BENEFICENCE       &NON-MALEFICENCE
objectives Definition of beneficence Definition of Non-maleficence Interaction of these principles                     ...
The practice of medicine &ethics are inseparable        Practice           of        medicine                           Pr...
Every medical  decision  Involve anethical decision       Ihab B Abdalrahman (Tarawa)   12/31/2012
What weMedicine can do                 not be apparent                 be apparent and                      clear         ...
 Beneficence      Non-maleficence (Do Good)        (Do No Harm)                                 Ihab B Abdalrahman (...
Good Vs Bad What is good What is bad                 Ihab B Abdalrahman (Tarawa)   8/4/2011   49
The context of GoodGood               Bad Strong            Weak Fortune           Misfortune Beautiful         Sick...
Ihab B Abdalrahman (Tarawa)   8/4/2011   51
Ihab B Abdalrahman (Tarawa)   8/4/2011   52
Ihab B Abdalrahman (Tarawa)   8/4/2011   53
Ihab B Abdalrahman (Tarawa)   8/4/2011   54
Ihab B Abdalrahman (Tarawa)   8/4/2011   55
Beneficence Beneficence is action that is done for the  benefit of others.                       Ihab B Abdalrahman (Tara...
Beneficence Beneficent actions can be taken to;   help   prevent   remove harms   simply improve the situation of oth...
Beneficence To do good. To act on the best interest of your patient. To promote patient health and well being. Simply ...
Non-maleficence: Definition: Non-maleficence means to “do no  harm.” Physicians must refrain from   providing ineffecti...
Non-maleficence:the Capital As   Alcohol   Adultery.   Abortion   Association   Advertisement                    Ihab...
Do goodDo no harm• Capital As               Ihab B Abdalrahman (Tarawa)   8/4/2011   61
Do                                goodDo no harm• Carelessness• Malice• Vengeance• Dislike                 Ihab B Abdalrah...
Why do good & do no harm The goal of medicine is to promote the  welfare of patients. Physicians possess skills and know...
Beneficence Examples of beneficent actions:   Resuscitating a drowning victim,   providing vaccinations for the general...
Non-maleficence: Examples Stopping a medication that is shown to be  harmful, Refusing to provide ineffective treatment....
Sami & samir are brothers and engineers in petroleum companyThey came for routine medical check Sami 44 year             ...
We should weigh and balancepossible benefits againstpossible risks. Do good                    Do no harm We have an ob...
Challenges Many beneficial therapies also have serious  risks. The pertinent ethical issue is whether the  benefits outw...
Balancing Beneficence and Non-maleficence It plays a role in nearly every medical  decision:   Whether to order a partic...
Types of risk Physical Financial Social Moral Religious                Ihab B Abdalrahman (Tarawa)   8/4/2011   70
BenefitBenefit   Harm                                      Harm                 Ihab B Abdalrahman (Tarawa)   8/4/2011    71
Balancing Beneficence and Non-maleficence Physicians give patients the information  necessary to understand the   Scope ...
Balancing Beneficence and Non-maleficence       One of the most common ethical dilemmas       arises in the balancing of ...
Ihab B Abdalrahman (Tarawa)   8/4/2011   74
Ihab B Abdalrahman (Tarawa)   8/4/2011   75
Case study36 years male presented               36 years pregnant lady                                      presented   F...
Case study Dr. X did his internship in obstetrics 20 years    ago.   He did 15 CS.   After the 7 CS, the registrar felt...
 Last week he was called to manage 25 years    lady (G1P0) at 34 weeks, pneumonia and    DKA.   The lady went into prema...
 What about if the same situation happened in  a rural area What is the appropriate course?                      Ihab B ...
In dilemmas, we see thecontent within the context             Ihab B Abdalrahman (Tarawa)   8/4/2011   80
Autonomy           Ihab B Abdalrahman (Tarawa)   12/31/2012   81
Reflect Definition of autonomy Prerequisite to acknowledge autonomy –  conditions need to be satisfied Limitations of a...
 72 male DM for 30 years HTN 20 years Stage 4 CKD withCreatinine 4.6                     Ihab B Abdalrahman (Tarawa)  ...
Case study 36 years old male Work as an engineer in Gulf area Visiting Sudan for 2 weeks vacation Has no significant p...
Case study General examination revealed an ill patient  who is alert awake and oriented. His interaction with the staff ...
 The patient had some doubts regarding the  diagnosis. He requested a second opinion. What would be the most appropriat...
Case study Arrangement was made for a second opinion. Appendicitis was re confirmed. At this point he requested a CT   ...
 CT scanning has high diagnostic accuracy of  95-98%. CT scanning is highly accurate, time-efficient,  cost-effective wa...
 Opinion varies as to whether these modalities  should be performed in all patients with  suggested appendicitis or if ra...
Case study CT scan confirmed the diagnosis. Urgent appendectomy was recommended. At this point the patient declined sur...
Autonomy Autonomy is a key component in medical  professionalism. Professional medical care depends on   a well trained...
Autonomy Patient’s independence . A competent adult has the right to make  decisions. Patient must be capable of ration...
AutonomyCapacity is a prerequisite A competent patient has the right to   determine for himself                       Iha...
 Treating patients with respect requires  doctors to accept the medical decisions of  persons who are informed and acting...
It is grey & uncertain In most clinical settings:   different goals and approaches are possible,   outcomes are uncerta...
 Thus competent, informed patients may  refuse recommended interventions and  choose among reasonable alternatives       ...
Could make sense or       not Satisfy his values  Well informed Not manipulated   Sound mind                   •Capable   ...
 Autonomy should prime all the time It is important to recognize the boundaries of  sound decision. The decision could ...
Ihab B Abdalrahman (Tarawa)   12/31/2012   99
 Dr P K Bansal is an orthopaedic surgeon,  who practices near New Delhi.  He too performs amputations on beggars.  Dr Ban...
 Beggars comes to your office Autonomously He is competent Demanding amputation of his leg He is paying cash         ...
 Should we do it? Why                     Ihab B Abdalrahman (Tarawa)   12/31/2012   102
When patient askfor unacceptableintervention        Ihab B Abdalrahman (Tarawa)   12/31/2012   103
 Autonomy should not be seen as  synonymous with freedom. Freedom to choose treatment is not absolute,  rather, it is su...
 Mr Z recently diagnosed with HIV and PCP. He is confused His brother asked you not to tell the wife.                  ...
Public hazards       Ihab B Abdalrahman (Tarawa)   12/31/2012   106
case study 73 year female with metastatic adenocarcinoma  of the ovary She has deposits in the spine, brain and lung Sh...
case study Evaluation by a hematologist confirmed  malignancy induced chronic DIC. He stated that it will be extremely  ...
 She was tender all over her body. Respiratory distress was noted. She was debilitated, malnourished and  cachexic. Ed...
Is it futility?         Ihab B Abdalrahman (Tarawa)   12/31/2012   110
 Futility is defined as a judgment that further  medical treatment of a patient would have no  useful result.            ...
 Medical futility is not a new concept. It was  reflected in Hippocratic collections “Whenever the illness is too strong...
 It is fundamental to recognize that the power  of medicine is limited. It is well established that sometimes the  disea...
Examining patient’s autonomy Autonomy entitles a patient to choose from  among medically acceptable treatment  options (o...
Limitations on Autonomy Patient with limited capacity Emergency care Futility of care When patient ask for unacceptabl...
Privacy & Confidentiality             Ihab B Abdalrahman (Tarawa)   12/31/2012   116
ConfidentialityWalking the fine line 23 years old unmarried female admitted with   severe right lower abdominal pain. She...
 She was found to have ruptured ectopic  pregnancy in the right ovarian tube.   Right salpingo-opherectomy plus appendec...
 Next day the patient was informed about the  finding. She admitted that she missed her  cycle for 50 days and she was wo...
The unspoken Her mom who did not know the outcome  “she thought it was just appendicitis”“ felt that surgery was delayed ...
Privacy & Confidentiality They go hand in hand. The difference between privacy and  confidentiality can be confusing.   ...
Privacy & Confidentiality Privacy is the right of individuals to keep  information about themselves from being  disclosed...
Privacy & Confidentiality On the other hand, confidentiality is how we,  as health-workers, treat private information  on...
Privacy & Confidentiality Confidentiality can be breached in case of  public hazard                       Ihab B Abdalrah...
justice          Ihab B Abdalrahman (Tarawa)   12/31/2012
Ihab B Abdalrahman (Tarawa)   12/31/2012
 Being in a society this requires:   Peace   Harmony  Justice   Others                        Ihab B Abdalrahman (Tar...
"Justice is the first virtue of     social institutions,              Ihab B Abdalrahman (Tarawa)   12/31/2012
Justice is a basic need "Fairness is activating the same part of the  brain that responds to food in rats... This is con...
Justice Means giving others what is due to them; it is fair distribution of   benefits,   risks,   costs.            ...
Injustice,historical reflection Patient Vs Sick Poor               Ihab B Abdalrahman (Tarawa)   12/31/2012
He also claimed The life of a sick person can be shortened not  only by the acts, but also by the words or    Injustice m...
Justice in Medical practice In a medical setting, justice involves the  allocation of health-care resources in a fair  wa...
Aristotle definition,                          more than 2000 years ago      "equals    should be     treated             ...
Aristotle definition,                                    more than 2000 years ago "Individuals should be treated the same...
as justifying differentialtreatment, need, desert, contribution, and effort                  Ihab B Abdalrahman (Taraw...
? We are spending 2/3 of our budget in dialysis.                       Ihab B Abdalrahman (Tarawa)   12/31/2012
Justice Fairness with respect to the distribution of  medical resources. Who should receive scarce medical resource. Ho...
Thanks      Ihab B Abdalrahman (Tarawa)   12/31/2012   139
Ethics and Professionalism
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Ethics and Professionalism

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by Ihab Tarawa, MD, Consultant Physician, Soba University Hospital
Vice President of SAMA

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Ethics and Professionalism

  1. 1. Introduction toProfessionalism &Medical ethicsIHAB B ABDALRAHMAN, MBBS, MD, ABIM, SSBB.CONSULTANT OF ACUTE CARE MEDICINE,SOBA UNIVERSITY HOSPITAL.ASSISTANT PROFESSOR OF MEDICINE, U OF K
  2. 2. Aims To highlight the concept of professionalism To introduce the concepts of Ethics & Medical Ethics To discuss ethical principles  Beneficience, do good  Non Maleficience, do no harm  Autonomy,  Privacy & confidenciality  Self determination  Justice Ihab B Abdalrahman (Tarawa) 12/31/2012 2
  3. 3. Compartmentalization of life One man cannot do right in one department of life, whilst he is occupied in doing wrong in any other department Ihab B Abdalrahman (Tarawa) 12/31/2012 3
  4. 4. Ihab B Abdalrahman (Tarawa) 12/31/2012 4
  5. 5. You make me cry Ihab B Abdalrahman (Tarawa) 12/31/2012 5
  6. 6. Compartmentalization of life One man cannot do right in one department of life, whilst he is occupied in doing wrong in any other department Ihab B Abdalrahman (Tarawa) 12/31/2012 6
  7. 7. Ihab B Abdalrahman (Tarawa) 12/31/2012 7
  8. 8. SYSTEMS GOVERNING HUMAN SOCIAL BEHAVIOUR CUSTOM ETIQUETTE ETHICS LAW MORALITYMores Professional Professional State, Statutes Spirituality Etiquette Values LegislatureTradition Courtesy Competence Enforcement Religious Integrity Compulsion Good vs Evil Fairness Judiciary Right vs Wrong Goodwill Punishment Truth Justice Ihab B Abdalrahman (Tarawa) 12/31/2012 8
  9. 9. What type of professional? or a good doctor Ihab B Abdalrahman (Tarawa) 12/31/2012 9
  10. 10. Definition Profession An occupation whose core element is work “ based upon the mastery of a complex body of knowledge and skills. In which knowledge and practice of an art is used in the service of others. Its members are governed by codes of ethics they are committed to the promotion of the public good within their domain. Professions and their members are accountable to those served and to society.” • Derived from the Oxford English Dictionary
  11. 11.   Ihab B Abdalrahman (Tarawa) 10/1/2011 11
  12. 12.     Ihab B Abdalrahman (Tarawa) 10/1/2011 12
  13. 13. Why is ProfessionalismImportant?“ Neither economic incentives, nor technology, nor administrative control has proved an effective surrogate for the commitment to integrity evoked in the ideal of professionalism ” Sullivan, 1995
  14. 14. The Physician Has TwoRoles  Healer  Professional
  15. 15. P h y s ic ia n H e a le r P ro fe s s io n a lCaring and compassion Autonomy CompetenceInsight Commitment Self-regulationOpenness ConfidentialityRespect for the Responsibility Altruism to society healing function Integrity and Team workRespect patient dignity and honesty autonomy Morality and ethicsPresence Responsibility to the profession
  16. 16. The Social Contract The social contract in health care is based on professionalism. It serves as the basis for the expectations of medicine and society.
  17. 17. The Social ContractSociety ProfessionPatient expectations Physician obligations Professionalism
  18. 18. The Social ContractThis Contract Has Always Been  Implicit (largely unwritten)  Evolving (being constantly renegotiated)
  19. 19. The Social Contract Society’s Expectations of Medicine’s Expectations of Society Medicine  trust  autonomy to fulfill the role of the healer  self-regulation guaranteed competence  Health Care System altruistic service  value-laden morality, integrity, honesty  adequately funded  role in public policy accountability  rewards – non-financial transparency • respect source of objective advice • status promotion of the public good – financial Individual and Collective Responsibilities
  20. 20. The ContractDepends On  mutual trust  reasonable demands on both sides  communication
  21. 21. Professionalism CommunicationEthics Behavior Ihab B Abdalrahman (Tarawa) 12/31/2012 22
  22. 22.  Components of Medical Professionalism identified to be suitable for trainees: Behavior:  Collaboration.  Professional health care [e.g. Risk management, Management of conflicts, Exerting maximum effort, Appropriate relations within the health system].  Self regulation [Self health care, Continuous Professional Development, Compliance with regulation of Health authorities such as the Medical Council].  Health advocacy. Ihab B Abdalrahman (Tarawa) 12/31/2012 23
  23. 23.  Ethics:  Beneficence (do good).  Nonmaleficence (do no harm) & malpractice [e.g. serious professional misconducts highlighted in the Capital As: Abortion, Association, Advertisement, Alcohol, Adultery].  Justice.  Autonomy [with its three components: Self determination, Privacy, Confidentiality].  Probity [e.g. Integrity, Truth telling, Trust].  Sensibility in dealing with sensitive issues e.g. dying patient, futility & organ transplant.  Appropriate doctor-patient relationship Ihab B Abdalrahman (Tarawa) 12/31/2012 24
  24. 24.  Components of Medical Professionalism identified to be suitable for trainees: Communication – including effective and professional communication with:  Patients [e.g. History Taking, Consultation, Delivering Information, Discussing Results, etc ].  Relatives and Family,  Colleagues (e.g. Medicals, Para-medicals, Nurses, Admin & Supporting Staff, etc..).  Public – including communication with Health Authorities, Police, Courts, etc..  Other Methods, such as communicating In Writing & Electronically (e.g. Record keeping, Prescribing skills, Referrals and Transfer letters, etc. Ihab B Abdalrahman (Tarawa) 12/31/2012 25
  25. 25. Professionalism E CommunicationEthics Behavior Ihab B Abdalrahman (Tarawa) 12/31/2012 26
  26. 26. Medical Technician Skills & Knowledge Ihab B Abdalrahman (Tarawa) 12/31/2012 27
  27. 27. Ethical principlesSkills & knowledge Moral Character Ihab B Abdalrahman (Tarawa) 12/31/2012 28
  28. 28. EthicsSkills & knowledge Moral Character Ihab B Abdalrahman (Tarawa) 12/31/2012 29
  29. 29.  What is Ethics? Ihab B Abdalrahman (Tarawa) 12/31/2012 30
  30. 30.  Ethics is the branch of study dealing with What is the proper course of action. Ihab B Abdalrahman (Tarawa) 12/31/2012 31
  31. 31.  It is the study of right and wrong. Ihab B Abdalrahman (Tarawa) 12/31/2012 32
  32. 32.  It answers the question,"What do I do?" Ihab B Abdalrahman (Tarawa) 12/31/2012 33
  33. 33. The last of human freedoms Every thing can be taken from a man, but one thing: To choose one’s attitude in a given set of circumstances, to choose one’s way Viktor Frankl Ihab B Abdalrahman (Tarawa) 12/31/2012 34
  34. 34.  It is your choice  Emotion based  Principle based Ihab B Abdalrahman (Tarawa) 12/31/2012 35
  35. 35. Why Ethics is important? Ethics is a requirement for human life. It is our means of deciding a course of action. Ihab B Abdalrahman (Tarawa) 12/31/2012 36
  36. 36. Moment of thoughtIn many casesit might help to put yourselfin your patient shoes.Seek to understand, before to be understoodWhat do you want if you are a patient? Ihab B Abdalrahman (Tarawa) 12/31/2012 37
  37. 37.  What is medical ethics?It is just, Doing the right thing. Ihab B Abdalrahman (Tarawa) 12/31/2012 38
  38. 38. But what is right? Beginning of life End of life Limited resources When patient demands unacceptable measures  What is acceptable? Futility of care  How to define futility? Ihab B Abdalrahman (Tarawa) 12/31/2012 39
  39. 39. Medical ethics Refers to those guidelines and behaviors that we expect  a medical professional  with moral integrity  to exhibit. Ihab B Abdalrahman (Tarawa) 12/31/2012 40
  40. 40. Medical Ethics Beneficence Non-maleficence & malpractice Justice?” Principles Respect of autonomy  Privacy  Confidentiality  Right to self-determination Probity (honesty & integrity) Moral Values Sensitivity in dealing with the dying, futility & organ donation Situation Appropriate doctor-patient relationship 12/31/2012 Ihab B Abdalrahman (Tarawa) 41
  41. 41. Ihab B Abdalrahman (Tarawa) 12/31/2012 42
  42. 42. Ethical Principles BENEFICENCE &NON-MALEFICENCE
  43. 43. objectives Definition of beneficence Definition of Non-maleficence Interaction of these principles Ihab B Abdalrahman (Tarawa) 8/4/2011 44
  44. 44. The practice of medicine &ethics are inseparable Practice of medicine Practice of ethics Ihab B Abdalrahman (Tarawa) 12/31/2012
  45. 45. Every medical decision Involve anethical decision Ihab B Abdalrahman (Tarawa) 12/31/2012
  46. 46. What weMedicine can do not be apparent be apparent and clear be apparent and messy/ conflictingWhat we should Ethics do Ihab B Abdalrahman (Tarawa) 8/4/2011 47
  47. 47.  Beneficence  Non-maleficence (Do Good)  (Do No Harm)  Ihab B Abdalrahman (Tarawa) 8/4/2011 48
  48. 48. Good Vs Bad What is good What is bad Ihab B Abdalrahman (Tarawa) 8/4/2011 49
  49. 49. The context of GoodGood Bad Strong  Weak Fortune  Misfortune Beautiful  Sickly Advantageous  Unlucky Gender  Opposite Gender Ihab B Abdalrahman (Tarawa) 8/4/2011 50
  50. 50. Ihab B Abdalrahman (Tarawa) 8/4/2011 51
  51. 51. Ihab B Abdalrahman (Tarawa) 8/4/2011 52
  52. 52. Ihab B Abdalrahman (Tarawa) 8/4/2011 53
  53. 53. Ihab B Abdalrahman (Tarawa) 8/4/2011 54
  54. 54. Ihab B Abdalrahman (Tarawa) 8/4/2011 55
  55. 55. Beneficence Beneficence is action that is done for the benefit of others. Ihab B Abdalrahman (Tarawa) 8/4/2011 56
  56. 56. Beneficence Beneficent actions can be taken to;  help  prevent  remove harms  simply improve the situation of others. Ihab B Abdalrahman (Tarawa) 8/4/2011 57
  57. 57. Beneficence To do good. To act on the best interest of your patient. To promote patient health and well being. Simply helping your patient. Ihab B Abdalrahman (Tarawa) 8/4/2011 58
  58. 58. Non-maleficence: Definition: Non-maleficence means to “do no harm.” Physicians must refrain from  providing ineffective treatments  acting with malice toward patients. Ihab B Abdalrahman (Tarawa) 8/4/2011 59
  59. 59. Non-maleficence:the Capital As Alcohol Adultery. Abortion Association Advertisement Ihab B Abdalrahman (Tarawa) 8/4/2011 60
  60. 60. Do goodDo no harm• Capital As Ihab B Abdalrahman (Tarawa) 8/4/2011 61
  61. 61. Do goodDo no harm• Carelessness• Malice• Vengeance• Dislike Ihab B Abdalrahman (Tarawa) 8/4/2011 62
  62. 62. Why do good & do no harm The goal of medicine is to promote the welfare of patients. Physicians possess skills and knowledge that enable them to assist others. Ihab B Abdalrahman (Tarawa) 8/4/2011 63
  63. 63. Beneficence Examples of beneficent actions:  Resuscitating a drowning victim,  providing vaccinations for the general population,  encouraging a patient to  quit smoking  start an exercise program,  Treat HTN & DM. Ihab B Abdalrahman (Tarawa) 8/4/2011 64
  64. 64. Non-maleficence: Examples Stopping a medication that is shown to be harmful, Refusing to provide ineffective treatment. Ihab B Abdalrahman (Tarawa) 8/4/2011 65
  65. 65. Sami & samir are brothers and engineers in petroleum companyThey came for routine medical check Sami 44 year  Samir 48 year No medical problems  No medical problems Mother has DM & HTN  Mother has DM & HTN Father has HTN  Father has HTN BMI 28kg/m2  BMI 32 Kg/m2 BP 154/96 in several  BP 134/84 in several occasions occasions Ihab B Abdalrahman (Tarawa) 8/4/2011 66
  66. 66. We should weigh and balancepossible benefits againstpossible risks. Do good  Do no harm We have an obligation  We are expected to to help our patients refrain from causing harm. Ihab B Abdalrahman (Tarawa) 8/4/2011 67
  67. 67. Challenges Many beneficial therapies also have serious risks. The pertinent ethical issue is whether the benefits outweigh the burdens. Ihab B Abdalrahman (Tarawa) 8/4/2011 68
  68. 68. Balancing Beneficence and Non-maleficence It plays a role in nearly every medical decision:  Whether to order a particular test  Medication  Procedure  Operation  Treatment Ihab B Abdalrahman (Tarawa) 8/4/2011 69
  69. 69. Types of risk Physical Financial Social Moral Religious Ihab B Abdalrahman (Tarawa) 8/4/2011 70
  70. 70. BenefitBenefit Harm Harm Ihab B Abdalrahman (Tarawa) 8/4/2011 71
  71. 71. Balancing Beneficence and Non-maleficence Physicians give patients the information necessary to understand the  Scope  Nature  Potential risks and benefits. Ihab B Abdalrahman (Tarawa) 8/4/2011 72
  72. 72. Balancing Beneficence and Non-maleficence  One of the most common ethical dilemmas arises in the balancing of beneficence and non-maleficence.Bad Good Ihab B Abdalrahman (Tarawa) 8/4/2011 73
  73. 73. Ihab B Abdalrahman (Tarawa) 8/4/2011 74
  74. 74. Ihab B Abdalrahman (Tarawa) 8/4/2011 75
  75. 75. Case study36 years male presented 36 years pregnant lady presented  Fever 39.2,  Fever 39.2,  Cough,  Cough,  Production of green sputum  Production of green sputum  Rt sided Pleuritic chest pain  Rt sided Pleuritic chest pain  Shortness of breath.  Shortness of breath.  He has bronchial breathing  He has bronchial breathing  TWCC 14.000  TWCC 14.000 Ihab B Abdalrahman (Tarawa) 8/4/2011 76
  76. 76. Case study Dr. X did his internship in obstetrics 20 years ago. He did 15 CS. After the 7 CS, the registrar felt, Dr X was competent enough to supervise junior HS. Now he is an internist. No surgical training for the last 15 year. Ihab B Abdalrahman (Tarawa) 8/4/2011 77
  77. 77.  Last week he was called to manage 25 years lady (G1P0) at 34 weeks, pneumonia and DKA. The lady went into premature labor. She went into maternal distress. Is it justifiable for Dr to do a CS? What is the appropriate course? Ihab B Abdalrahman (Tarawa) 8/4/2011 78
  78. 78.  What about if the same situation happened in a rural area What is the appropriate course? Ihab B Abdalrahman (Tarawa) 8/4/2011 79
  79. 79. In dilemmas, we see thecontent within the context Ihab B Abdalrahman (Tarawa) 8/4/2011 80
  80. 80. Autonomy Ihab B Abdalrahman (Tarawa) 12/31/2012 81
  81. 81. Reflect Definition of autonomy Prerequisite to acknowledge autonomy – conditions need to be satisfied Limitations of autonomy Ihab B Abdalrahman (Tarawa) 12/31/2012 82
  82. 82.  72 male DM for 30 years HTN 20 years Stage 4 CKD withCreatinine 4.6 Ihab B Abdalrahman (Tarawa) 12/31/2012 83
  83. 83. Case study 36 years old male Work as an engineer in Gulf area Visiting Sudan for 2 weeks vacation Has no significant pass medical history. came to the ER with acute right lower quadrant pain. Ihab B Abdalrahman (Tarawa) 12/31/2012 84
  84. 84. Case study General examination revealed an ill patient who is alert awake and oriented. His interaction with the staff was appropriate. Abdominal exam suggested an appendicitis. Urinalysis was normal & TWCC 14,800 Ihab B Abdalrahman (Tarawa) 12/31/2012 85
  85. 85.  The patient had some doubts regarding the diagnosis. He requested a second opinion. What would be the most appropriate actions? Ihab B Abdalrahman (Tarawa) 12/31/2012 86
  86. 86. Case study Arrangement was made for a second opinion. Appendicitis was re confirmed. At this point he requested a CT Ihab B Abdalrahman (Tarawa) 12/31/2012 87
  87. 87.  CT scanning has high diagnostic accuracy of 95-98%. CT scanning is highly accurate, time-efficient, cost-effective way to evaluate adult patients with equivocal presentations for appendicitis. Ihab B Abdalrahman (Tarawa) 12/31/2012 88
  88. 88.  Opinion varies as to whether these modalities should be performed in all patients with suggested appendicitis or if radiology should be reserved for select patients with atypical or confusing clinical presentations. Ihab B Abdalrahman (Tarawa) 12/31/2012 89
  89. 89. Case study CT scan confirmed the diagnosis. Urgent appendectomy was recommended. At this point the patient declined surgery and requested to be treated with antibiotics. What was most appropriate action at thas point? Ihab B Abdalrahman (Tarawa) 12/31/2012 90
  90. 90. Autonomy Autonomy is a key component in medical professionalism. Professional medical care depends on  a well trained and competent physician,  who delivers his care with empathy,  to a willing patient. Ihab B Abdalrahman (Tarawa) 12/31/2012 91
  91. 91. Autonomy Patient’s independence . A competent adult has the right to make decisions. Patient must be capable of rational thought. Not manipulated. He can refuse intervention. Ihab B Abdalrahman (Tarawa) 12/31/2012 92
  92. 92. AutonomyCapacity is a prerequisite A competent patient has the right to determine for himself Ihab B Abdalrahman (Tarawa) 12/31/2012 93
  93. 93.  Treating patients with respect requires doctors to accept the medical decisions of persons who are informed and acting freely. Individuals place different values on health, medical care, and risk. Ihab B Abdalrahman (Tarawa) 12/31/2012 94
  94. 94. It is grey & uncertain In most clinical settings:  different goals and approaches are possible,  outcomes are uncertain,  an intervention may cause both benefits and harms. Ihab B Abdalrahman (Tarawa) 12/31/2012 95
  95. 95.  Thus competent, informed patients may refuse recommended interventions and choose among reasonable alternatives Ihab B Abdalrahman (Tarawa) 12/31/2012 96
  96. 96. Could make sense or not Satisfy his values Well informed Not manipulated Sound mind •Capable Ihab B Abdalrahman (Tarawa) 12/31/2012 97
  97. 97.  Autonomy should prime all the time It is important to recognize the boundaries of sound decision. The decision could be sound to the patient since it satisfies certain values. The same decision might not make sense to the physician. Ihab B Abdalrahman (Tarawa) 12/31/2012 98
  98. 98. Ihab B Abdalrahman (Tarawa) 12/31/2012 99
  99. 99.  Dr P K Bansal is an orthopaedic surgeon, who practices near New Delhi. He too performs amputations on beggars. Dr Bansal belongs to a network of doctors who amputate beggars for money. CNN-IBN Posted Saturday , July 29, 2006 at 19:24 Updated Saturday , July 29, 2006 at 20:57 Ihab B Abdalrahman (Tarawa) 12/31/2012 100
  100. 100.  Beggars comes to your office Autonomously He is competent Demanding amputation of his leg He is paying cash Ihab B Abdalrahman (Tarawa) 12/31/2012 101
  101. 101.  Should we do it? Why Ihab B Abdalrahman (Tarawa) 12/31/2012 102
  102. 102. When patient askfor unacceptableintervention Ihab B Abdalrahman (Tarawa) 12/31/2012 103
  103. 103.  Autonomy should not be seen as synonymous with freedom. Freedom to choose treatment is not absolute, rather, it is subject to constraints and thus only involves a substantial degree of freedom of choice. Ihab B Abdalrahman (Tarawa) 12/31/2012 104
  104. 104.  Mr Z recently diagnosed with HIV and PCP. He is confused His brother asked you not to tell the wife. Ihab B Abdalrahman (Tarawa) 12/31/2012 105
  105. 105. Public hazards Ihab B Abdalrahman (Tarawa) 12/31/2012 106
  106. 106. case study 73 year female with metastatic adenocarcinoma of the ovary She has deposits in the spine, brain and lung She received palliative radiotherapy. She was found to be coagulopathic, thrombocytopenic and anemic. Ihab B Abdalrahman (Tarawa) 12/31/2012 107
  107. 107. case study Evaluation by a hematologist confirmed malignancy induced chronic DIC. He stated that it will be extremely difficult to cure the DIC without curing her malignant disease first. Ihab B Abdalrahman (Tarawa) 12/31/2012 108
  108. 108.  She was tender all over her body. Respiratory distress was noted. She was debilitated, malnourished and cachexic. Edematous legs and ascites were noted. Her renal function was worsening with a creatinine of 4.3mg/dl, K 5.4mg/dl, Hb 8.2 gm/dl, platelets 23,000 and INR 3.2. Ihab B Abdalrahman (Tarawa) 12/31/2012 109
  109. 109. Is it futility? Ihab B Abdalrahman (Tarawa) 12/31/2012 110
  110. 110.  Futility is defined as a judgment that further medical treatment of a patient would have no useful result. Ihab B Abdalrahman (Tarawa) 12/31/2012 111
  111. 111.  Medical futility is not a new concept. It was reflected in Hippocratic collections “Whenever the illness is too strong for the available remedies, the physician surely must not expect that it can be overcome by medicine” . Ihab B Abdalrahman (Tarawa) 12/31/2012 112
  112. 112.  It is fundamental to recognize that the power of medicine is limited. It is well established that sometimes the disease process exceeds our medical capability . Ihab B Abdalrahman (Tarawa) 12/31/2012 113
  113. 113. Examining patient’s autonomy Autonomy entitles a patient to choose from among medically acceptable treatment options (or to reject all options). It does not entitle patients to receive whatever treatments they ask for . Ihab B Abdalrahman (Tarawa) 12/31/2012 114
  114. 114. Limitations on Autonomy Patient with limited capacity Emergency care Futility of care When patient ask for unacceptable intervention Public hazards Ihab B Abdalrahman (Tarawa) 12/31/2012 115
  115. 115. Privacy & Confidentiality Ihab B Abdalrahman (Tarawa) 12/31/2012 116
  116. 116. ConfidentialityWalking the fine line 23 years old unmarried female admitted with severe right lower abdominal pain. She reported 2 fainting episodes. As patient’s symptoms were worsening, she was taken for exploration surgery. Ihab B Abdalrahman (Tarawa) 12/31/2012 117
  117. 117.  She was found to have ruptured ectopic pregnancy in the right ovarian tube.  Right salpingo-opherectomy plus appendectomy were done. Ihab B Abdalrahman (Tarawa) 12/31/2012 118
  118. 118.  Next day the patient was informed about the finding. She admitted that she missed her cycle for 50 days and she was worried that she was pregnant. She asked you to keep her information confidential. Ihab B Abdalrahman (Tarawa) 12/31/2012 119
  119. 119. The unspoken Her mom who did not know the outcome “she thought it was just appendicitis”“ felt that surgery was delayed and her daughter life was risked”. She complained to the medical manager that the on call team was negligent. Ihab B Abdalrahman (Tarawa) 12/31/2012 120
  120. 120. Privacy & Confidentiality They go hand in hand. The difference between privacy and confidentiality can be confusing. Ihab B Abdalrahman (Tarawa) 12/31/2012 121
  121. 121. Privacy & Confidentiality Privacy is the right of individuals to keep information about themselves from being disclosed. Patients decide who, when, and where to share their health information. Ihab B Abdalrahman (Tarawa) 12/31/2012 122
  122. 122. Privacy & Confidentiality On the other hand, confidentiality is how we, as health-workers, treat private information once it has been disclosed to us or others. Ihab B Abdalrahman (Tarawa) 12/31/2012 123
  123. 123. Privacy & Confidentiality Confidentiality can be breached in case of public hazard Ihab B Abdalrahman (Tarawa) 12/31/2012 124
  124. 124. justice Ihab B Abdalrahman (Tarawa) 12/31/2012
  125. 125. Ihab B Abdalrahman (Tarawa) 12/31/2012
  126. 126.  Being in a society this requires:  Peace  Harmony Justice  Others Ihab B Abdalrahman (Tarawa) 12/31/2012
  127. 127. "Justice is the first virtue of social institutions, Ihab B Abdalrahman (Tarawa) 12/31/2012
  128. 128. Justice is a basic need "Fairness is activating the same part of the brain that responds to food in rats... This is consistent with the notion that being treated fairly satisfies a basic need". Ihab B Abdalrahman (Tarawa) 12/31/2012
  129. 129. Justice Means giving others what is due to them; it is fair distribution of  benefits,  risks,  costs. Ihab B Abdalrahman (Tarawa) 12/31/2012
  130. 130. Injustice,historical reflection Patient Vs Sick Poor Ihab B Abdalrahman (Tarawa) 12/31/2012
  131. 131. He also claimed The life of a sick person can be shortened not only by the acts, but also by the words or Injustice murders manner of a physician. the soul Ihab B Abdalrahman (Tarawa) 12/31/2012
  132. 132. Justice in Medical practice In a medical setting, justice involves the allocation of health-care resources in a fair way. Egalitarianism This may be an equal distribution Utilitarianism maximization of the total or average welfare across the whole society. Ihab B Abdalrahman (Tarawa) 12/31/2012
  133. 133. Aristotle definition, more than 2000 years ago "equals should be treated Ihab B Abdalrahman (Tarawa) 12/31/2012
  134. 134. Aristotle definition, more than 2000 years ago "Individuals should be treated the same, unless they differ in ways that are relevant to the situation in which they are involved." Ihab B Abdalrahman (Tarawa) 12/31/2012
  135. 135. as justifying differentialtreatment, need, desert, contribution, and effort Ihab B Abdalrahman (Tarawa) 12/31/2012
  136. 136. ? We are spending 2/3 of our budget in dialysis. Ihab B Abdalrahman (Tarawa) 12/31/2012
  137. 137. Justice Fairness with respect to the distribution of medical resources. Who should receive scarce medical resource. How should we distribute them What is the best outcome. Ihab B Abdalrahman (Tarawa) 12/31/2012 138
  138. 138. Thanks Ihab B Abdalrahman (Tarawa) 12/31/2012 139

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