The Attitude, Ethics & Communication module introduced by the National Medical Commission is being followed in Medical Colleges. Here's a simple understanding of aspects on Bioethics & solution to Phase 2 MBBS modules

1. Case Studies On Patient Autonomy &
Decision Making
Dr. Lavanya SH
Department of Pharmacology
BGSGIMS
Attitude Ethics & Communication Module
AETCOM - Bioethics

2. Bioethics – Origin & Significance
 Bioethics is a philosophical
disciplineencompassing
social, legal, cultural,
epidemiological, and
ethicalissues arisingdue
to advance in healthcare
and life science research
Dates back to the Nuremberg
Doctor’s Trial – Nazi Regimen

3. What is Medical Ethics?
 Medical ethics – Moral
principles for
registered medical
practitioners in their
dealings with each
other, their patients
and state

4. Foundation of Medical Ethics
http://medinterestblog.blogspot.com/2015/10/4-principles-of-medical-ethics.html

5. Terminologies
https://clipboardhealth.com/how-the-4-principles-of-health-care-ethics-improve-patient-care

6. Patient Autonomy
Informed
Consent
Confidentiality
Truth
Telling
Fidelity
Autonomy As

7. Case study – AETCOM Booklet 2.5
 You evaluate Mrs. Lakshmi Srinivasan who is a 48
year old woman presenting with lymphadenopathy.
She had been complaining of mild fever and weight
loss for the past 4 -5 months. Examination of the
neck shows large rubbery lymph nodes that are
present also in the axilla and the groin. There is a
palpable spleen. She is accompanied by her caring
husband.
https://www.nmc.org.in/wp-
content/uploads/2020/01/AETCOM_book.pdf

8. Case study contd......
 Lakshmi undergoes a lymph node biopsy and the
pathologist calls you and tells you that she has a
lymphoma. That evening Mr. Srinivasan comes in first
into your office and leaves the report on your table. As
you read the description you realise that the final
diagnosis has been altered to Tuberculosis by whitening
out the pathologist’s report. When you look up he tells
you –“Sir, I googled lymphoma - it is almost like a
cancer. My wife can’t handle that diagnosis. She has
always been a worried frightened person. I want you to
tell my wife that she had TB. She is waiting outside,
doctor. I thought I will call her in after I had a chat about
this with you”.

9. Discussion Q1
 Does the patient have a right to know their
diagnosis?
 Yes, every patient has the rightto know their diagnosis
 Truthfuland open communicationbetween physician
and patient is essential for trust in the relationship and
for respect for autonomy
 Withholdingpertinentmedicalinformationfrom
patientsin the belief that disclosure is medically
contraindicated createsa conflict between the
physician’sobligationsto promote patient welfare and
to respect patient autonomy

10. Discussion Q2
 What should the patient be told about their
diagnosis, therapy and prognosis?
 Paternalismversus Autonomy
https://aneskey.com/the-ethics-of-withholding-and-withdrawing-mechanical-ventilation/

11. Moving from Paternalism to Shared Decision
Making
 Paternalism - The physician alone makes the decision
https://org/2019/11/21/shared-decision-making-protecting-patient-autonomy-and-informed-
consent/

12. Discussion Q3
 How much should be told to a patient about
their illness?
 The obligation to communicate truthfully does not
mean that the physician must communicate
information to the patient immediately or all at once.
 Information may be conveyed over time in keeping
with the patient’s preferences and ability to
comprehend the information.
 Physicians should always communicate
sensitively and respectfully with patients.

13. Discussion Q4
 Are there exceptions to full disclosure? Can family
members request withholding of information from
patient?
 Although the principle of respect for autonomyis the
most importantaspect, the principlesof beneficence
and non-maleficence have a place in evaluating
truth-telling and nondisclosure, as in this case study
 Timing of full, truthfuldisclosure can be influenced by:
 Age & emotional state of patient
Family’s desire for such disclosure

14. Practical aspects of Disclosure
Develop an understandingof the
family’s point of view
Understand the patient’s true
preferences for receiving information
Convey information over time
considering patient’s preferences &
comprehension
Offerfull disclosure when the patient is
able to decide whetherto receive the
information.

15. Case study 2
 You are taking care of 78-year-oldMrs. Mythili who was living all
alone in an apartment withonly a live-in caretaker, 3 streets
away from your clinic. She is a widow and her only son emigrated
to the US 32 years ago. He visits her once a year. One year ago,
she had a fall with a hip fracture that healed badly. She has
hypertensionwhichis reasonably controlledon medications. She
continuesto come to your clinic once a month.
 Four monthsago, she spent some time talking about her sister
who recentlydiedfollowing metastatic breast cancer. “My sister
suffereda lot, Doctor - they put a tube down her throat to
breathe.Even when her heart stoppedthey kept thumpingher
chest - it was awful. If I ever fall sick I don't want to go through
all this. Promise me, doctor, that you won’t do all of this to me. I
have lived all alone since my husband died but I have lived
independently- now I don't want to dependon a machine to live”

16. Case contd....
 One day you get a call from the Emergency Room of the
local hospital stating that Mrs. Mythili has been admitted
by the caretaker. She had developed fever and shortness of
breath. She was brought hypoxic to the emergency room
and they had intubated her. Chest X ray revealed a large
pneumonicpatch. Laboratory testing revealed
hyponatremia. When you visited her she is somewhat
drowsy, intubated and restrained. The nurse tells you that
she is sometimes lucid; at other times not even able to
recognise her son who was there since this morning. She
points out at the endotracheal tube and makes a pleading
gesture to remove it.
https://www.nmc.org.in/wp-content/uploads/2020/01/AETCOM_book.pdf

17.  Her son accosts you in the hallway. He tells you that he
got a call while he was traveling in Singapore and took
the first flight out to be with his mom. He was very
distressed at his mother’shealth and that he wants
“everything”possible done for her. You ask him if she
had ever indicated what she wanted to be done if she
were to require hospitalizationand intubation - he says
that he used to speak to her every month on the phone
and she was always cheerfuland enquiring abouther
grandchildrenbut did not talk about her health.

18. Ethical Concepts in this CASE
 Patient Autonomy
 Decision Making Capacity
 Surrogacy in Decision Making
 Autonomy vs Beneficience vs Non-maleficience

19. Supporting Mrs. Mythili’s decision which honors
her own beliefs and wishes recognizes the role of
….
Autonomy (Self- Determination)
The moral and legal right of a person with decisional
capacity to determine what will be done with their own
person.
This respects the right of each person to make decisions
regarding their own body and course of life.
However.................

20. Is she competent to make decisions?
 What determines decision making capacity &
competency?
“Testing” decision making capacity
 Ability to communicate
 Ability to understand treatment options
 Ability to grasp consequences of accepting
or declining therapy
 Ability to reason
In this case, the patient is incapacitated: Unable to understand the benefits,
risks, alternatives to treatment

21. Who can decide??
 Surrogate Decision Makers: Individual with authority to
consent to medical treatment for an incapacitated patient
 Who can be legal surrogate-decision-makers?
• Spouse
• Adult child with Power of Attorney or majority of adult
children
• Parents (In case of minors)
• In Parents Absence – (Grandparent, Adult sibling, Adult aunt/uncle
Educational institution with written authorization, Court with
jurisdiction
• Nearest living relative
• Patient’s clergy

22. What if the Surrogate decision maker opts for ‘Do
not Resuscitate’?
 The Conflicts: Autonomy vs Beneficience vs Non-
maleficience
Initiation of life-saving
measures may be indicated
(beneficence) if there is
uncertainty about the
outcomes of therapy and how
much benefit there will be for
the patient
Withdrawalof life-sustaining
therapies (non-maleficence)
may be appropriate whenthey
are no longer beneficialor
desirable for the patient and
produce negative outcomes

23. Rule of Thumb
Rightness or wrongness of an action depends on the merits
of the justification underlying the action, not the action
itself.
Every situation needs to be evaluated in its own context, so
that patients, families and caregivers can achieve comfort
and trust in the final decisions.