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Medical ethics.doc 5th year


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Medical ethics.doc 5th year

  1. 1. Medical EthicsProfessor Salma Fouad DowaraProfessor of General SurgeryVice Director of the Medical Education Development Center (MEDC)What does ethics mean? o “Ethics is a code of values which guide our choices and actions and determine the purpose and the course of our lives.” o Ethics is an important component of the international standards of medical education. It should be taught and assessed as an integrated course in the whole educational program. o Graduates should be able to behave ethically at all times towards patients and their relatives in a manner consistent with the ideals of the profession and to use ethical principles in clinical decision making and research. They should be able to properly collaborate with other health care professionals and society for health promotion service. o It is well based standards of right and wrong that prescribe what humans ought to do, usually in terms of rights, obligations, benefits to society, fairness…History of Medical Ethics: Hippocratic Oath (400 BC) was the first code. It has addressed two mainareas:1. The ethical attitude towards other physicians2. The clinical practice dealing with a doctors duty of care to his patients.The oath did not consider the patients right of choice in the managementof his medical problem.Hippocrates oath remained the main code of ethics in medical practice tillthe the Declaration of Human Rights code (1948) which recognized "theequal and inalienable rights of all members of the human family"The Declaration of Human Rights was followed by several internationalcodes of ethics in medical practice and medical research to protect thepatient rights.١
  2. 2. Why teach medical ethics? o Teaching clinical medical ethics is based on its contribution to the care of patients. o Ethics - common in all curricula o Part of Faculty mission and program ILOs o The skills of ethical analysis are part of the competence-set of young physician adding to his competencies in knowledge and technical skills. o Teaching clinical medical ethics is part of adoption of professionalism.Goals o Students should understand the ethical principles and values underpinning good medical practice. o They should think critically about ethics, reflecting their own believes and appreciating alternative approaches even if competing o Be able to argue and counter argue in order to contribute to informed discussion and debate o Know professional and legal obligations of doctors in their countryIntended learning outcomes o Know the theories and principles that govern ethical decision making in clinical practice and the major ethical dilemmas in medicine, particularly those that arise at the beginning and the end of life and from the rapid expansion of medical knowledge and technology. o Identify alternatives in difficult ethical choices, analyze considerations supporting different alternatives and formulate course of action that takes account of this ethical complexity, the conflicting and carry out a behave towards patients in a manner consistent with the ideals of the profession by consistently doing the following:(1)Treat the patient as a person, not a disease, and understand that thepatient is a person with beliefs, values, goals and concerns which must berespected.(2)Respect the patients dignity, privacy, information confidentiality andautonomy.(3) Deliver care in a way that will allow the patient to feel he/ she hasreceived medical care in a caring, compassionate and human manner.٢
  3. 3. (4)Maintain honesty and integrity in all interactions with patients,patients families, colleagues and others with whom physicians mustinteract in their professional lives. This includes reliability, availabilityand timeliness of task completion. (5)Maintain a professional image in manner, dress, speech andinterpersonal relationships that is consistent with the medical professionsaccepted contemporary standards in the community.(6)Responsible towards work and calmness in emergency situations.(7)Advocate the patients interests over ones own interests. (8) Provide care to patients who are unable to pay and advocate access tohealth care for members of underserved populations.(9)Recognize and effectively deal with unethical behavior of othermembers of the healthcare team.Approaches to ethicsThe "four principles" approachThe "four principles" approach to ethics is based on principles of ethics articulated by Beauchamp and Childress. These principles are: o Beneficence (the obligation to provide benefits); o Non-maleficence (the obligation to avoid harm); o Respect for autonomy (the obligation to respect the decision-making capacity of others) o Justice (the obligation of fairness).It is claimed that these four principles encompass most, if not all,ethical issues in healthcare and provide a common set of moralcommitments, moreover a common language for discussing ethicalissues.The main Ethical concerns in medical practice:A - Patient rights:Aِ utonomy versus paternalismInformed ConsentBeneficenceNon malficence٣
  4. 4. The right to refuse treatmentAdvanced Medical DirectiveB - Patient-doctor relationship:ConfidentialityTruth-telling versus withholding informationJustice and Resources allocationBoundaries violation and Social and sexual relationships Professionalism in Medicine (general) The physician should o Demonstrate good medical knowledge, clinical judgment, and clinical skills o Serve the interests of the patient above his or her self-interest o It inspires altruism, accountability, excellence, duty, service, honor, integrity, and respect for others and oneself. o In Patient-Physician Relationship o Professional codes o Ethical Conduct o Recognition of the moral and religious values of Patient and Physician o Duty/obligation to the Patient o Vulnerable patients o Patients Rights Four Basic Ethical Principles (Applicable to any culture or society) Respect to autonomy Non-maleficence Beneficence Justice٤
  5. 5. Autonomy o Allow competent patients to make their own health care decisions, based on their own values. o It is intertwined with the concept of Competence o The Patient’s ability to understand the possible consequences of his or her own decisions and the available alternatives. o Only competent patients are granted the right to make their own health care decisions. Non-Maleficence o The obligation not to do harm o Not causing harm without the likelihood of compensating good. o Weighing risks against benefits (Risk benefit ratio) Beneficence o The duty to ‘do good’ and to advance the welfare of others. o Competent patients should be allowed to decide for themselves how to balance harms and goods. Paternalism o Generally considered to be a duty of parents. o Usually practiced for incompetent patients. o Interfering with the liberty of another person for his or her own benefit. Truth-telling o Trust is essential because of unequal power and the serious consequences of medical decisions. o Omissions should not be made for the purpose of deception or of manipulating the patient’s response. o Confidentiality٥
  6. 6. o Patients need to trust their physicians not to disclose private information to others. o This facilitates full disclosure of information relevant for providing effective personal health care. o Exceptions: consent, required by law, high risk of serious physical harm e.g., child abuse. Informed Consent o Medical or Surgical Treatment o Medical Research o Teaching exercises involving students and residents. o A process rather than a signature on a form. o It involves shared information and developing choices as long as one is seeking medical assistance. o For every procedure, the patient should be offered an explanation of the problem and possible solutions, and then their consent asked. o A description of the recommended treatment or procedure o A description of the alternatives, including other treatments or procedures, together with the risks and benefits of these alternatives. o The likely results of no treatment o The probability of success, and what the physician means by success. o The major problems anticipated in recuperation and the time period during which the patient will not be able to resume his or her own activities. Professionalism in Interactions with Other Health Professionals o Understanding of the Professional roles of self and others (e.g., nurses, nurse practitioners, technologists, aides, clerks) o Team approach vs. hierarchical approach o Recognition of and appropriate response to sub optimal performance o Respecting Seniors’ experience٦
  7. 7. Resource Allocation o Choose interventions known to be beneficial on the basis of evidence of effectiveness. o Minimize the use of marginally beneficial tests or marginally beneficial interventions. o Seek the tests or treatments that will accomplish the diagnostic or therapeutic goal for the least cost. o Avoid manipulating the system to gain unfair advantage to your patients. o Inform patients of the impact of cost constraints on care, but do so in a sensitive way. o Blaming administrative or governmental systems during discussions with the patient at the point of treatment should be avoided; it undermines care by reducing confidence and increasing anxiety at a time when the patient is most vulnerable. o Seek resolution of unacceptable shortages at the level of hospital management (misallocation) or government (macro allocation). Futility What is "medical futility"? o "Medical futility" refers to interventions that are unlikely to produce any significant benefit for the patient. o What if the patient or family requests an intervention that the health care team considers futile? o In such situations, you have a duty as a physician to communicate openly with the patient or family members about interventions that are being withheld or withdrawn and to explain the rationale for such decisions. o It is important to approach such conversations with compassion for the patient and grieving family. For example, rather than saying to a patient or family, "there is nothing I can do for you," it is important to emphasize that "everything possible will be done to ensure the patients comfort and dignity." o The goal of medicine is to help the sick. You have no obligation to offer treatments that do not benefit your patients. Futile interventions are ill advised because they often increase a patients٧
  8. 8. pain and discomfort in the final days and weeks of life, and because they can expend finite medical resources. o Although the ethical requirement to respect patient 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. Instead, the obligations of physicians are limited to offering treatments that are consistent with professional standards of care.*********************************************************************٨