Introduction to Medical Ethics Lecture 1 Medical Ethics: Theories and Principles
Programme aims Definition of Medical Ethics Scope of Ethics in Medical Practice Theories and principles Duties of a Doctor
Objectives Within small groups and by using case based material you will be able to: 1)Recognise ethical issues 2)Recognise ethical conflicts 3)Practice verbal reasoning skills 4)Be aware of own and others moral values
“Patients are entitled to good standards ofpractice and care from their doctors.Essentialelements of this are professional competence,good relationships with patients and colleaguesand observance of professional ethicalobligations.”From Good Medical Practice, GMC.
Importance of MedicalEthics1. Increasing profileRecent press headlines: Dr Cox (euthanasia) Alder hay Enquiry Jodie and Mary Destroying frozen embryos Refusal to fund marrow transplantsnew drugs
Importance of EthicalIssues (contd.)2)Increase in technology3)Better informed society4)Doctors in Management5)Public scrutiny
Four Misconceptions1. Clear distinction :clinical and ethical analysis2. Clear distinction: profess. and everyday ethics3. Enshrined in lead4. Medical ethics=matter of opinionDoctor X is considering whether or not to break a confidence.Patient has presented with an STD which he wishes to have treated confidentially.His wife is also your patient.What do you do?
DEONTOLOGICAL THEORIES Some principles are intrinsically right- regardless of resulting consequences. CONSEQUENTIALIST THEORIESConsequence alone determines right and wrong. - greatest happiness of the greatest number.
Principles1. Beneficence2. Non-Maleficence3. Autonomy4. Truth telling5. Confidentiality6. Preservation of Life7. Justice
Beneficence and Non-MaleficenceQuestions:1)Is the patient your only concern? (possible conflict with utility)2)Do we always know what is good for the patient?(patient’s view may differ from ours)
3 constraints onBeneficence1. Need to respect autonomy-patient and doctor may differ re. Management2. Need to ensure health is not bought at too high a price3. Need to consider rights of others
Autonomy1. Capacity to think, decide, take action2. Mental incompetence= no autonomy3. Autonomy –v-Paternalism When patient not autonomous –no clash. When patient autonomous- questionable procedure
Truth Telling“In much wisdom is muchgrief:and he that increasethknowledge increasethsorrows”(Ecclesiastics 1,18)
Truth telling (cont)If you override it you endangerdoctor/patient relationship(based ontrust)You offend against the principle ofautonomy(Dr.C Mooreland)At times there are good reasons foroverriding the truth telling principle
The case for deceptionis founded on threefallacies 1. Hippocratic obligations 2. Not in a position to know the truth 3. Patients do not want the truth if the news is bad
Confidentiality Act against this principle and you destroy patient’s trust Clash –when keeping confidentiality would harm others eg child abuse Should patients have access to their notes?
Against Layman unable to cope with data Opinions not facts cause anxiety Third party information Defensive medicine
For Data belongs to patient Accuracy improved by sharing
Access to Records Data Protection Act (1998) What records are covered? Does it matter when the record was made? Who can apply? Are their exemptions? Must copies be given if requested? Access to records of deceased patients?
Exceptions to MedicalConfidentiality Pt gives written and valid consent To other participating professionals Where undesirable to seek patients consent info can be given to a close relative Statutory requirements Ordered by Court Public interest Approved Research
Preservation of Life At what stage does human life begin?- coil, pill Can we assess another persons quality of life?-Jehovahs Witness
Euthanasia Active: an active intervention to end life Passive:deliberately withholding treatment that might help a patient live longer Voluntary :euthanasia is performed following a request from a patient Doctor assisted suicide : a doctor prescribes a lethal drug which is self administered by the patient Non-voluntary :ending the life of a patient who is not capable of giving permission Involuntary:ending life against a patients will
Other Moral doctrines Acts and Omissions Doctrine -held by those who believe that passive euthanasia is not killing(killing is an act,and an omission is not an act) Doctrine of Double effect -makes a distinction between what I intend and what I merely foresee
Living Wills Patient unconsciousseverely mentally disabled , and two docs agree it unlikely he will be able to communicate treatment decision Refuse treatment if prolongs life with no further benefit to patient
Justice How to allocate scarce healthcare resources?1. Medical need2. Medical Benefits3. Social worth-discriminates against underprivileged4. Merits/contribution to society-very contentious5. Desert6. Market Forces7. A lottery
Contaception and Minors1. Jane aged 15 yrs requests the OCP2. Her mum phones you the next day3. Several weeks later she tells you her boyfriend slapped her across the face4. Her boyfriend is her history teacher
Lord Fraser’sreccomendations The doctor should assess whether the patient understands hisher advice The doctor should encourage parental involvment The doctor should take into account whether the patient is liekly to have sexual intercourse without contraceptive treatment The doctor should assess whether the patient’s physicalmental healthare likely to suffer if she does not receive advicetreatment The doctor must consider whether the patient’s best interestsrequire himher to provide contraceptive advicetreatment
4th Year- Case history A 25 yr old lady comes to the treatment room requesting syringes.She is a lesbian and wishes to inseminate herself. 1) What else would you like to know 2)What are the ethical issues 3)What would you do
Duties of a DoctorPlease apply ethical principlesto the above list as describedin “Good Medical Practice”
Truth Telling Video clip1. How much information should be given to patients preoperatively?2. When/how should we relay information to a postoperative patient?3. What lessons can be learned from this tape?