Medical ethics notes

1. MEDICAL ETHICS
SIMKONDA Twambilire
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2. Outline
Definition
Types of ethics
Importance of medical ethics
Ethical Theories
Principles of ethics
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3. Definition
 Ethics derives from Greek “ethikos”
 the philosophical study of the moral value of human
conduct and the rules that govern it.
 Considers the ideal human behavior and ideal ways of being
 The practical manifestations of ethics relates to codes of
normative behaviour for society and an awareness of issues
within society that have moral importance.
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4. Cont
 Ethics have been particularly associated with specific
groups in society that are deemed to have societal
responsibility
 Professions are among such groups. Professions have a
prestigious, powerful and trusted place in society e.g.
Christian ethics, medical ethics or nursing ethics.
 Both the public and the law expect high standards of
conduct, especially where society allows self-regulation
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5. Cont
 The purpose of this code of ethics is to serve as a guide to
conduct Health Services programmes
 It contains standards of ethical behaviour for Health workers
in fulfilling their duties and responsibilities
 Ethics is a system of moral principles. They affect how
people make decisions and lead their lives.
 Ethics is concerned with what is good for individuals and
society and is also described as moral philosophy
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6. Policy part
 Health has long been and is increasingly a concern of all
people as citizens of the world
 As citizens of sovereign nations, as participants in the
endeavours of the field of social welfare/social
development, and as professionals engaged directly or
indirectly in various roles in the human services
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7. Cont
 In keeping with their holistic view of the person, health
workers view health a state of complete physical, mental
and emotional well-being (WHO, 1947)
 Illness is the converse of health
 includes suffering from sickness and disablement,
contagious diseases and diseases of deprivation that
involve the lack of food, of clean water, of pure air, of safe
shelter, of health services, and of social services
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8.  The policy as a guide for action is a means for identifying
and addressing issues of health and illness that affect:
 the individual, the family (and particularly the vulnerable
family), the neighborhood, the region, the country, and also
the world - defined both as the collectivity of all people and
as the fragile and endangered environment on which all life
ultimately depends
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9.  The importance of the issues associated with health implies
responsibility for Health worker to become familiar with its
extensive body of relevant knowledge, partly outlined as
follows:
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10.  The linkages between health policies and human rights
policies including those relating to the rights of the child,
the rights of oppressed minorities and of refugees fleeing
from oppression;
 The structures and programmes of international
governmental and non-governmental organizations, and of
multinational corporations, that have an impact on health
and illness;
 The psychosocial aspects of illness, disability and disease;
 The factors that promote positive health and well-being;
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11.  The range of social, economic, cultural and political factors
that cause or contribute to illness and disability;
 The range of positive and negative factors in the physical
environment that affect the quality of air, water and food;
 The range and nature of physical, mental and emotional
illnesses and disabilities throughout the world;
 The factors affecting the HIV/AIDS pandemic and the
mammoth measures needed to prevent its proliferation, to
ameliorate and treat its physical, emotional, and social
symptoms and to seek its cure
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12. Ethics vs Law
 Ethics is not law and yet they are complimentary.
 Ethics can be proposed but cannot be imposed.
 Law on other hand can be imposed.
 One could obey the law without necessarily acting ethically.
 Sometimes one needs to disobey the unjust law in order to
act ethically.
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13.  The best scenario is that an act can be both lawful and
ethical.
 The law is the bottom line and the ethics is top line of the
same entity of social control.
 They are both united and yet distinct. Ethical principle can
become law through promulgation.
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14. Example
1
Acting according to your
scope of practice
Legal
Ethical
2
Giving scheduled pain meds,
though not prescribed
Illegal
3
Medical abortion – Malawi
4
Safe abortion - Malawi
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15.  Both ethics and Law serve as guides to action
 Both have social sanctions and functions
 Laws are promulgated to maintain order in society and to
establish minimum standard for social conduct
 Ethics may make a demand on an individual, which may
conflict with or even violate the demands of the law
 Ethics is regarded as higher than the law and often serves as
a source of judgment of the law itself.
 As regards decision making, disregard for the law may result
in punishment whereas a disregard for ethical norms does
not carry same force
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16. Types of Ethics
 Normative ethics: nature of right or good, nature and
justification of ethical issues
 Meta ethics: standards, principles
 Applied ethics: actual application of ethical principles to
particular situation
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17. Applied athics
 Terms used in ethical judgement
o Obligatory: it is not only right to do it, but that it is wrong
not to do it (ethical obligation to perform the action)
o Impermissible: it is wrong to do it and right not to do it
o Permissible: or ethically “neutral,” because it is neither right
nor wrong to do
 Supererogatory: types of actions are seen as going “above
and beyond the call of duty (they are right to do, but it is
not wrong not to do them)
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18.  Professional ethics
 Medical ethics
 Bioethics
 Clinical ethics
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19. Professional ethics
 Professional ethics are standards of conduct that apply
to people who occupy a professional occupation or role.
 A person who enters a profession acquires ethical
obligations because society trusts them to provide valuable
goods and services that cannot be provided unless their
conduct conforms to certain standards.
 Professionals who fail to live up to their ethical obligations
betray this trust.
 Professional ethics studied by ethicists include medical
ethics.
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20. Bioethics
Bioethics could be defined as the study of ethical
issues and decision-making associated with the use of living
organisms
 Bioethics includes medical ethics. Bioethics is learning how
to balance different benefits, risks and duties.
 branch of applied ethics that studies the philosophical,
social, and legal issues arising in medicine and the life
sciences
 it is chiefly concerned with human life and well-being,
though it sometimes also treats ethical questions relating to
the nonhuman biological environment
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21. 10/20/2022
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22. Medical ethics
 Concerns issues related to practice of medicine
 Explores and promotes principles guiding conduct of health
care professionals
 Involves the consideration of others in deciding how to act
 It is applied ethics. It consists of the same moral principles
and rules that we would appeal to, and argue for, in
ordinary circumstances.
 is a system of moral principles that apply values and
judgments to the practice of medicine.
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23. Clinical ethics
 Clinical medical ethics is a practical and applied discipline
that aims to improve patient care and patient outcomes by
focusing on reaching a right and good decision in individual
cases
 It focuses on the doctor-patient relationship and takes
account of the ethical and legal issues that patients, doctors,
and hospitals must address to reach good decisions for
individual patients
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24. Content of Clinical Ethics
 Specific issues such as
1. truth-telling,
2. informed consent,
3. end of life care,
4. confidentiality
4. palliative care,
5. allocation of clinical resources,
6. the ethics of medical research.
7. The study of the doctor-patient relationship, including such
issues as: 1. honesty, 2. competence, integrity, 3. respect for
persons.
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25. Medical ethics
 Long history
Third Dynasty (Egypt) 2700 BCE
Code of Hammurabi (Babylon) 1750 BCE
Oath of the Hindu Physician (Vaidya’s Oath)
15th cy. BCE
Hippocratic oath (Hippocrates, ca 460-370
BCE)
The Oath of Asaph and Yohanan (ca 6th cy. CE)
Advice to a Physician (Persia) 10th cy. CE
Oath of Maimonides 12th cy. CE
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26. Ming Dynasty (China) 14th cy. CE
Seventeen Rules of Enjun (Japanese Buddhist
Physicians) 16th cy. CE)
Drawn from Codes of Medical and Human Experimentation
Ethics by Victoria Berdon and Jennifer Flavin viewable at
http://wisdomtools.com/poynter/codes.html
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27.  Percival's Code (England), 1803: basis for first AMA
Code of Medical Ethics.
 Beaumont's Code (United States), 1833: experimental
treatments,
voluntary, informed consent.
 American Medical Association (AMA) - Code of Medical
Ethics, 1847.
 Claude Bernard (France), 1865.
 Walter Reed (United States), 1898: introduces written
consent “contracts”. Allows healthy human subjects in
medical experiments.
 Berlin Code or Prussian Code (Germany), 1900: no medical
experiments when subject not competent to give informed
consent, in the absence of unambiguous consent, or when
information not properly explained to subject.
 Reich Circular (Germany), 1932: concerned with consent and
well-being of the subjects.
Drawn from “Codes of Medical and Human Experimentation Ethics” by Victoria
Berdon and Jennifer Flavin viewable at
http://wisdomtools.com/poynter/codes.html
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28. Modern issues and statements
 Nuremberg Code (1947)
Medical research
 Declaration of Geneva, W.M.A. (1948, 1968, 1984,
1994, 2005, 2006)
 World Medical Association International
Code of Medical Ethics
 AMA revision (1957)
 Declaration of Helsinki, application to
medical research (1964, rev. 1975, 1983, 1989, 1996, 2000)
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29. Belmont Report (1979)
AMA revision (2001)
Drawn from “Codes of Medical and Human Experimentation
Ethics” by Victoria Berdon and Jennifer Flavin viewable at
http://wisdomtools.com/poynter/codes.html
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30. IMPORTANCE OF ETHICS
 To help health professional identify moral and ethical issues,
 To know what is right and wrong about what should and
should not be done for and to client,
 To know and respect the issues of human rights, personal
and civic.
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31.  Conflicts of interests between the government and medical
institutions, between medical institutions and medical
personnel, between physicians and patients are getting
more and more serious and complex.
 High technologies not only brought us hopes of cure but
have also created a heavy economic burden.
 The ethical dilemmas of high technology medicine-brain
death, organ transplantation, and concerns about quality of
life-have become increasingly prominent.
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32.  A new and more specific code of ethics must be developed
to meet the demands of social development and medical
service.
 This new code integrates the traditional medical ethics with
modern principles and values
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33. As a practical ethics, medical
ethics focuses on
The process of deciding what is the most appropriate (right)
course of action in a particular situation:
 given these facts
 given my skills and abilities
 operating with finite knowledge
 in real time
 and then effecting that course of action
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34. Factors in ethical decision
making in health care
1. Ethical theories
2. Ethical principles
3. Ethical rules
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35. Ethical Theories
1. Consequentialist theories:
 primarily concerned with the ethical consequences of
particular actions
2. Non-consequentialist theories
 broadly concerned with the intentions of the person making
ethical decisions about particular actions
3. Agent-centered theories
 more concerned with the overall ethical status of individuals
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36. Consequentialist theories
 The Utilitarian Approach
o the best life is one that produces the least pain and distress
o actions could be described as good or bad depending upon
the amount and degree of pleasure and/or pain they would
produce
 The Egoistic Approach
o ethical egoism, or the ethics of self- interest: an individual
often uses utilitarian calculation to produce the greatest
amount of good for him or herself
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37.  The Common Good Approach
o our actions should contribute to ethical communal life
o the best society should be guided by the “general will” of
the people which would then produce what is best for the
people as a whole
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38. Non Consequentialist theories
 The Duty-Based Approach
o Sometimes called deontological ethics
o doing what is right is not about the consequences of our
actions but about having the proper intention in performing
the action
o Act only according to that maxim by which you can at the
same time will that it should become a universal law
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39.  The Rights Approach
o stipulates that the best ethical action is that which protects
the ethical rights of those who are affected by the action
o it emphasizes the belief that all humans have a right to
dignity
o many now argue that animals and other non-humans such
as robots also have rights
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40.  The Fairness or Justice Approach
o all free men should be treated alike, just as all slaves should
be treated alike (Law code of Hammurabi)
o John Rawls (1921-2002) argues along Kantian lines, that just
ethical principles are those that would be chosen by free
and rational people in an initial situation of equality
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41.  The Divine Command Approach
o sees what is right as the same as what God commands;
ethical standards are the creation of God’s will
o following God’s will is seen as the very definition what is
ethical
o because God is seen as omnipotent and possessed of free
will, God could change what is now considered ethical
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42. Agent centred theories
 The Virtue Approach
o argues that ethical actions should be consistent with ideal
human virtues
o Aristotle: ethics should be concerned with the whole of a
person’s life, not with the individual discrete actions a
person may perform in any given situation
o to act virtuously (in an appropriate manner)
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43.  The Feminist Approach
o virtue approach to ethics supplemented and sometimes
revised by thinkers in the feminist tradition, who often
emphasize the importance of the experiences of women
and other marginalized groups to ethical deliberation
o the most important contributions of this approach: the
principle of care as a legitimately primary ethical concern,
often in opposition to the cold and impersonal justice
approach
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44. Basic Ethical Principles
(General)
 Four ethical principles (brainstorm)
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45.  respect for patient autonomy.
 not inflicting harm on patients.
 a positive duty to contribute to the welfare of patients
 justice or fair treatment of patients.
o Being faithful (fidelity)
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46. Autonomy:
 Autonomy derives from Greek: autos=“self” and
nomos=“rule” “governance” or “law”
 This means that people, being individuals with individual
differences must have a freedom to choose their own ways
and means of being moral with the framework of the other
four principles.
 Respect for autonomy involves respecting another persons
rights and dignity such that a person reaches a maximum
level of fulfillment as a human being.
 In the context of health care this means that the relationship
between client is based on a respect for him or her as a
person and with individual rights
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47. Rights in relation to health care are
usually taken to include
 The right to information (tell the truth)
 The right to privacy and confidentiality
 The right to appropriate care and treatment
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48.  Empower one to make their own decisions or to participate
in decision making process
 That requires giving necessary information that is
understandable
 Freedom of coercion and manipulation
 Actualised in asking for informed consent and informed
consent requires disclosure, understanding, free choice and
competence
 Respect of confidentiality
 Respect of privacy
 Privacy and confidentiality deal with ownership, control and
access to personal information, to personal property or
body
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49.  At minimum, acknowledge a person’s right to hold views, to
make choices, and to take actions based on personal values
and beliefs
 Such respect involves respectful action, not merely
respectful attitude; noninterference in other’s personal
affairs
 Respect for autonomy has prima facie standing and can
sometimes be overridden by competing moral
considerations
 If choices endanger the public health, potentially harm
others or require a scarce resource for which no funds are
available
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50.  Special care to incompetence (seek legal declaration),
minority, intentional or nonintentional, inducement, gender,
race, religion
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51. Beneficence (doing good)
 beneficence means doing or promoting good as well as
preventing, removing and avoiding evil or harm e.g. Giving
clients clean needles, condoms and provide information
about emergency first aid to reduce the risks of HIV
infection or accident.
 Positive beneficence v Utility principles
 Positive beneficence requires agents to provide benefits;
utility requires that agents balance benefits and drawbacks
to produce the best overall results
 The goal of beneficence is to achieve favourable benefit-risk
ratios
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52. Rules of beneficence
 Protect and defend the rights of others (ought to do or
promote good)
 Prevent harm or evil from occurring to others
 Remove conditions that will cause harm to others (ought to
remove evil or harm)
 Help persons with disabilities
 Rescue persons in danger
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53. Non-maleficence (doing no
harm)
 Non-maleficence holds a central position in the tradition of
medical ethics and guards against avoidable harm to
subjects.
 Non-maleficence requires refraining from actions that cause
harm (ought not to inflict evil or harm)
 Rules of non-maleficence therefore take the form “Do not
do X” e.g.
- Do not kill
- Do not cause pain or suffering
- Do not incapacitate
- Do not cause offense
- Do not deprive others of good of life
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54.  Withholding vs Withdrawing treatment
 0rdinary vs Extraordinary treatment
 Killing vs Letting die
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55. Justice (fairness)
 This principle states that human being should treat other
human being fairly and justly in distribution goodness and
badness among them. In other words justice should include:
- Fair distribution of scarce resources
- Respect for individual and group rights
- Following morally acceptable laws
 Equal opportunity
 Fairness
 Treating equals equally and unequal unequally
 Equal share of benefits and burdens
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56. Types of Justice
 Procedural justice
 Social justice
 Distributive justice
 Criminal justice
 Retributive justice
 Mob justice
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57. Principles of distributive +
justice
 To each person an equal share
 To each person according to need
 To each person according to effort
 To each person according to contribution
 To each person according to merit
 To each person according to free-market exchange
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58. Ethical rules (Codes)
 manners developed by professional organizations
Structure of codes:
1. regulative
2. protective (for public opinion)
3. specific (regarding membership)
4. Obligated
 Professional codes as a framework for decision making
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59. The principle of truth telling:
honesty
 At the heart of any moral relationship is communication. A
necessary component of any meaningful communication is
telling the truth, being honest
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60. Ethical Issues in Medicine
 End of Life Issues
 There has never been a time in the history of
medicine when it was thought that we should do
everything possible to keep someone alive even if
that person wishes to die. However, the medical
tradition has forbidden the direct killing of patients
by, for example, giving a lethal injection or
deliberately increasing the dose of a painkiller with
the intention of killing them.
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61.  In the United States physician-assisted suicide is
only permitted in Washington and Oregon, but
even in these states physicians are not permitted
to directly administer lethal doses of drugs to
their patients. They can assist suicide by advising
patients about how to take their own lives
through self-administered lethal doses of
medication, prescribed by the physician for that
purpose.
 Medical ethics has traditionally attached great
importance to the distinction between killing and
letting die, but recent work in medical ethics has
frequently denied the moral significance of this
distinction
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62. Abortion
Abortion continues to be one of the most
divisive moral issues in American public
life, as it has been since the Supreme
Court's Roe v. Wade ruling of 1973.
In Malawi it is illegal
What about sex work?
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63. Truth-Telling in Medicine
There has been a dramatic - and relatively sudden - shift in
public opinion concerning the obligations of doctors to tell
the truth to their patients.
Within living memory it was common practice for doctors
to lie to their patients for paternalistic reasons - i.e. when
they believed that lying to their patients would be in their
patients' best interests - but far fewer people now regard
this as acceptable. This change of opinion is a
consequence of the increasing importance attached to
patient autonomy in medical ethics. The concept of
autonomy will play an important role in many of the
ethical issues discussed in this course.
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64. Medical Experimentation
 There are a number of issues surrounding medical
experimentation. The most controversial issue in recent
years has been embryonic stem-cell research. It is a
common misconception that such research is illegal.
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65. The Doctor Patient Relationship
 There are many reasons we go to see doctors other than
because we are sick.
 The doctor has become a "gatekeeper" figure (e.g. students
have to get a doctor's signature in order to attend Notre
Dame).
 We also go to doctors for non-therapeutic help of various
kinds (e.g. if we want help getting pregnant or not getting
pregnant)
 we often expect doctors to take an interest in our general
wellbeing and to provide advice
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66. Doctors perform multiple roles
Doctors are expected to perform multiple
roles. In addition to healing sickness, doctors
provide education about health issues,
and are meant to act in a way that shows
concern for the health of the general public
as well as the health of their individual
patients.
The fact that doctors are expected to perform
multiple roles can lead to ethical issues when
those roles conflict.
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67. Our understanding of the doctor-
patient relationship has changed
 Twentieth century the relationship of patients with
their doctor was understood to be largely passive.
 The general trend over the course of the twentieth
century has been toward an understanding of the
doctor-patient relationship in which the patient's
autonomy is emphasized to the point where the
patient takes the lead in decision making.
 There is no consensus on the proper nature of the
doctor-patient relationship however.
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68. The Profession of Medicine
 The practice of medicine has long been regarded as a
profession, like being a lawyer or a priest.
 Traditionally, the professions enjoyed a high level of
prestige in society.
 Professions are supposed to be self-regulating and
membership of a profession involves strong identification
with one's social role and often a notion of vocation
(people are called to their role).
 Charitable work is often held to be part of the life of a
profession (e.g. pro bono work for lawyers, working a free
clinic for doctors).
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69. Euthanasia and Physician Assisted
Suicide
 active and passive euthanasia
 killing and letting die
 a doctor can administer a lethal dose of a
drug to a patient with the intention of
ending the patient's life: active euthanasia
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70. Famous Cases 1: Karen Ann
Quinlan.
 In 1975 Karen Ann Quinlan, then 21, was taken home from a party
feeling faint. At home she suffered respiratory failure and fell into a
coma. After being hospitalized Quinlan was diagnosed as being in a
persistent vegetative state (PVS) and after several months her parents,
who were devout Catholics, decided that her case was hopeless and
asked that her respirator be removed. A complicated legal battle
ensued, but the Quinlans right to make this decision was eventually
upheld by the New Jersey Supreme Court. However, after the
respirator was withdrawn Karen Ann Quinlan continued to breathe on
her own and she lived another nine years before eventually
succumbing to pneumonia in 1985. The Quinlan case was the subject
of a great deal of media attention and has influenced subsequent
debates surrounding euthanasia and the right to refuse medical
treatment.
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71. Case 2: Nancy Cruzan
 In 1983 Nancy Cruzan, a young woman from Missouri, was
severely injured in a car crash. She was diagnosed as being in a
persistent vegetative state and her family petitioned to have
her feeding tube removed. Testimony that Cruzan had
previously told a former housemate that were she to be so
severely injured that she would be unable to live anything close
to a normal life she would not wish to be kept alive through
artificial feeding played an important role in the legal
controversies over her case, which eventually reached the
United States Supreme Court. The importance attached to
Cruzan's expressed wishes, combined with controversy over the
reliability of the evidence of those wishes were a major spur to
the practice of making living wills in which people express their
desires as to how they would be treated in such circumstances
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72. Case 3: Elizabeth Bouvia.
 In 1983 Elizabeth Bouvia, who was quadriplegic and
suffering from severe cerebral palsy, admitted herself to a
California public hospital. Bouvia expressed the desire to die
by starving herself while receiving care from the hospital.
The hospital refused and Bouvia sued them. She lost her
case, although an appeals court overturned the decision
three years later
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73. Case 4: Terri Schiavo.
 A more recent case, which received a tremendous amount of
media attention, concerned Teresa Marie "Terri" Schiavo. In 1990
Schiavo suffered cardiac arrest and fell into a coma. Several
months later she was diagnosed as being in a persistent
vegetative state. In 1998 Michael Schiavo, her husband,
petitioned to have Terri's feeding tube removed, against her
parents wishes. The legal battle that followed was immensely
complicated and lasted until 2005 when Terri's feeding tube was
removed and she died.
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74. Confidentiality in Medical
Practice
 Why Is Confidentiality Important?
 Confidentiality is part of the Hippocratic Oath.
 The practice of medicine requires that patients reveal
information to their doctors that can be deeply
embarrassing.
 Patients will be especially reluctant to reveal such
information if they are not confident that it will be
kept confidential.
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75.  Different types of argument can be offered in support of
confidentiality requirements.
 The consequentialist argument is simple; the beneficial
effects of having such requirements will outweigh the
disadvantages that they may sometimes produce.
 A deontological argument in favor of such requirements
would attempt to justify them by reference to the duties of
the doctor.
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76. Practical Obstacles to the
Practice of Confidentiality.
 In an influential article for the New England Journal of
Medicine, Mark Siegler argued that confidentiality has
become a decrepit concept.
 There are a number of factors which make it difficult if not
impossible to maintain traditional norms of confidentiality
in contemporary medical practice
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77.  One is that modern medical treatment often involves a large
number of medical professionals amongst whom
information relevant to the course of treatment must be
shared.
 Another is that information about patients is increasingly
stored on large electronic databases, the security of which is
impossible to guarantee absolutely
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78. Reasons for Compromising
Confidentiality
 The Patient's Interest.
 There are cases in which it may seem as if violating a patient's
confidentiality will be in the patient's best interest.
 One objection to this kind of justification for breaking
confidentiality will involve doubts about whether the physician
is the best judge of the patient's best interest. This worry is
exacerbated by the increasingly impersonal nature of modern
medical practice, which reduces the chances that the doctor will
know the patient well.
 Another objection is that even if a patient's interests will be
served by breaching their confidentiality, this is still a violation
of the patient's autonomy and unacceptably paternalistic.
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79. The Public Interest
 Sometimes there may be a conflict between the
requirements of confidentiality and the obligations of
medical professionals toward the general public.
 The bus driver was less than a year from retirement and
begged the doctor not to reveal his condition, because
he would lose his job and his pension. Shortly afterward
the bus driver had a heart attack while driving the bus,
killing the school children riding in it.
 If we accept the principle that medical professionals
should always act so as to bring about the best result for
the public as a whole, then it will be hard to deny that
there will be cases in which it is morally required to
breach confidentiality
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80. Institutional Obligations
 Difficulties concerning confidentiality can also occur when
physicians occupy a position within an organization such that
their obligations to the organization conflict with their medical
duties.
 A somewhat old example concerns physicians employed by
Asbestos mining companies to determine which miners were
showing early signs of Asbestosis.
 When a case was discovered the physicians were required to
inform the manager rather than the miners themselves.
 It is interesting to compare the professions of law and medicine
in this regard; the legal profession generally has much more
extensive restrictions designed to prevent conflict-of-interest
than does medicine.
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81. References
 Beauchamp, T. & Childress, J.: Principles of Biomedical
Ethics, 5th Edition [New York:Oxford University Press, 2001]
 Pera, S. & Tonder S.: Ethics in Healthcare 3rd Edition
[Lansdowne: Juta & Co. Ltd, 2011]
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