Ethical dilemmas are common in neurology practice. Good knowledge of laws and ethics is needed to properly counsel patients and families. The key ethical principles of beneficence, nonmaleficence, respect for autonomy, and justice must be considered. Informed consent is essential. Further debate is required to resolve complex issues like euthanasia, physician-assisted suicide, and resource allocation.

1. ETHICAL ISSUE IN
NEUROLOGICAL PRACTICE
Dr Ravi goyal
SR Neurology
GMC ,KOTA

2. INTRODUCTION
• Ethical and moral dilemmas are common in
• clinical practice, especially in neurology practice.
• Guidelines are few, and there are often conflicting opinions on
various issues.
• It is important to understand or discuss the ethical issues so as
• To satisfy patients or families
• To keep our conscience clear and
• To prevent medical law suits .

3. • Even a cursory knowledge of law and medicine can
render neurologists
• more capable in certain aspects of clinical care
• reduce the incidence of risky behaviors and enhance
professionalism.

4. ETHICS
• Ethics is the branch of philosophy that concerns itself with
the good and evil nature (morality) of actions and
• seeks to guide behavior in a way that increases good
actions in society.

5. SUBDISCIPLINES WITHIN ETHICS
Biomedical ethics (bioethics) :
deals with the ethical implications of biology in patient care,
research, and policy development.
Neuroethics :
• are the ethical, legal and social policy implications of
neurosciences, including clinical care and neuroscience research
(Illes and Bird, 2006).
Clinical ethics : a subset of bioethics
• as “the identification of morally correct actions and the
resolution of ethical dilemmas in medical decision-making
through the application of moral concepts and rules to medical
situations”(Bernat, 2008, p. 5).

6. • Jonsen et al. (2010, p. 2) define clinical ethics as a
structured approach to ethical questions in clinical
medicine .
• Most of the ethical issues that the neurologist will
encounter fall within the classification of clinical ethics,
although some issues will extend beyond traditional
medical situations .

7. • Ethical reasoning is usually grounded in one of two broad
approaches:
• utilitarianism and
• deontology.
• The utilitarian approach focuses on the consequences of
an act.
• The deontology, considers a person’s duty and focuses on
the intent and reasons behind an individual’s actions.

8. • In other approaches , For the neurologist,
• virtue-based ethics, with its emphasis on the moral
character of the physician, may be of particular interest.
• It focuses attention on the motivations behind and the
behaviour that make up a physician’s practice of
medicine.
• Activities that enhance the physician’s virtuous behavior
will result in greater good for the patient.

9. INTERPLAY BETWEEN ETHICS AND LAW
• Ethical statements are neither binding nor enforceable in
contrast, laws are both binding and enforceable.
• overlap between ethics and law is related to three factors:
• the purpose of each discipline,
• the character of medicine as a traditional profession,
• societal responses to past ethical abuses by physicians and
scientists.

10. ETHICAL PRINCIPLES
• The method of principlism applies four ethical principles
that have particular importance in clinical medicine –
• Nonmaleficence
• Beneficence
• Respect for autonomy
• Justice

11. NON MALEFICENCE
• It refers to the physician’s responsibility not to harm his or her
patient.
• It is a prominent ethical principle that underlies laws about
physicians’ involvement in voluntary active euthanasia and
physician-assisted suicide. (in end-of-life care )
• It is also a core principle with a extremely common aspect of
everyday neurologic practice - respect for patient privacy.

12. VOLUNTARY ACTIVE EUTHANASIA
• Voluntary active euthanasia is the administration, by the
physician, of a lethal agent (or the administration of a
therapeutic agent at a lethal dose), with the intent
• to cause a patient’s death for the purpose of relieving
intolerable, intractable, and incurable pain.

13. • Active voluntary (after consent from patients/relatives)
• euthanasia is legal only in Netherlands, Belgium,
Columbia and Luxembourg.
• It requires administration of an agent to hasten death.
• Passive euthanasia involves withdrawal/withholding of
• supportive treatments (such as antibiotics, adrenaline,
• ventilator, etc) and is legal in US.

14. • Reasons for the prohibition of voluntary active
• euthanasia in codes of professional behavior includes-
• The goals of medicine
• The possibility that the practice might be extended to
unwilling persons,
• The potential for coercion of members of vulnerable
populations
• The potential for reduced trust in the medical
profession

15. EUTHANASIA IN INDIA
• Active euthanasia by administering an injection is illegal in India
• Passive euthanasia is legal in India after a March 2011 judgement
by Supreme Court. (Aruna Shanbaug case)
• It is permitted by Supreme Court in two situations-
• 1. Brain dead patient, where the ventilator can be switched off.
• 2. Persistent vegetative state, where the feeds/water can be
tapered off, along with addition of pain-managing palliatives.

16. EUTHANASIA IN INDIA
• Guidelines as laid down by the Supreme Court:
1. The decision can be taken by parents, spouse, other
relatives, or friend. Can be taken even by the doctor. It should
be in the best interest of the patient.
2. Even if the decision to withdraw life supports has been
taken by close relatives, prior approval from High Court is
required to execute the decision.
3. Chief Justice of High Court would constitute a bench of at
least two judges, who would decide to grant approval or not.

17. PHYSICIAN-ASSISTED SUICIDE
• Physician assisted suicide is a physician’s active
assistance in implementing a patient’s suicide plan,
usually through
• prescribing drugs that will be used in the suicide and
possibly
• providing instruction on their use for that purpose.
• It is legal in Switzerland and the US states California,
Oregon, Washington, Montana and Vermont.

18. PRIVACY
• The obligation of physicians to respect patient privacy, including
the embedded obligation to maintain patient confidentiality, was
articulated in the Hippocratic Oath(Hippocrates, 2002).
• Arguments supporting respect of privacy include -
• The deontologic rationale
• ( as a result of their special relationship, with special knowledge
about patient not available to the general public)
• The utilitarian rationale
• ( patients will make full disclosures to their physicians, when
they are confident that the private aspects of their lives will
remain private) .

19. • The requirements that physicians respect privacy and
• maintain confidentiality are not legal (or ethical) absolutely
• Because there are legal rules that balance a physician’s duty
to protect patient privacy with society’s need to have
information for public health and safety.

20. BENEFICENCE
• It is the ethical duty of physicians to act in the patient’s
best interest.
• Beneficence may involve actions to prevent harm or
actions to accomplish good.
• These include advocating for a patient’s needs, caring
for a difficult patient, seeing a patient outside usual
office hours, and avoiding conflicts of interest.

21. • Two examples of beneficence in the law are-
• Physician expectation before unilaterally ending the
patient–doctor relationship.
• The management of conflicts of interest

22. ENDING A PATIENT–PHYSICIAN
RELATIONSHIP
• When there is a mutual decision on the part of the patient
and the physician to end a treatment relationship, no issue
occurs.
• A patient may unilaterally end the professsional
relationship with a physician at any time for any reason
and without permission or notice.
• Ethical statements note that the physician should
attempt to salvage the relationship even with a difficult
patient.

23. • A patient should be dismissed from a physician’s
practice only for good reasons and
• after adequate notice and identification of an alternative
care provider.
• Legally, if a physician does not properly release a patient
from his or her practice, the may be found liable for
patient abandonment.
• can lead to investigation and disciplinary action by the
medical board of the state in which the physician
practices.

24. CONFLICT OF INTEREST
• A conflict of interest occurs when a physician’s
professional judgment or actions toward a patient (the
physician’s primary interest) is unduly influenced by
circumstances that
• includes money (financial conflict of interest) Personal
relationships, stock ownership, gifts, meals, desire for
status, and feelings of obligation .

25. • However, conflicts are to be avoided whenever possible
and managed when they exist so that no wrong-doing
occurs.
• The goal in avoiding and managing conflicts of interest is
to avoid any actual wrong-doing or
• to avoid any public perception of wrong doing that
result in patient discomfort or lack of trust in a physician
or in the profession as a whole.

26. RESPECT FOR AUTONOMY
• Respect for autonomy requires a physician to foster and
respect an individual patient’s right of self
determination.
• Informed medical decision making ( informed consent ) is
a fundamental ethical doctrine grounded in the principle
of respect for autonomy.

27. INFORMED CONSENT
• The purpose of informed consent is to promote patient
autonomy through shared decision-making between the
patient and the physician.
• For that four requirements must be met –
• 1. the patient must be competent.
• 2. the patient must be given adequate information on which to
base a decision.
• 3. there must be no duress, the patient’s decision must be
made voluntarily.
• 4. the patient must agree to the propose intervention.

28. • Patient competence consists of two parts: legal
competence and clinical competence.
• Adult patients and emancipated minor is legally competent
for all medical decision-making.
• In clinical competence, the patient can understand
information, formulate a decision, and communicate that
decision.
• Neurologists are often involved in the care of patients for
whom a question of clinical competence exists.
• It may fluctuate across time, on the basis of disease
process, medication, and even time of day.

29. EXCEPTION
• In emergency situations (Comatose patients after
• severe head injury or massive brain stroke, or
• suicidal attempts) in which the patient cannot provide
consent and no surrogate decision-maker, treatment
should proceed.
• the patient’s waiver of consent .
• The physician’s therapeutic privilege to the treatment
without consent.

30. • When a patient is not competent to make medical
decisions, a surrogate decision-maker becomes
responsible
• for making such decisions on behalf of the patient.

31. JUSTICE
• The ethical principle of justice embodies several
concepts:
• fairness to persons within and across groups,
• similar treatment of similar situations, and
• the allocation of scarce resources across society in
equitable manner.

32. SUMMARY
• Ethical dilemmas are common in routine neurology
practice .
• Good knowledge of laws regarding these issues is
needed.
• Patient/family should be properly counseled.
• Informed consent is a must.
• Further debates among public and lawmakers
• are needed to further resolve the issues.

33. REFRENCES
• American Academy of Neurology (2005). AAN
• Qualifications and Guidelines for the Physician Expert
Witness.
• Bernat J (2008). Ethical Issues in Neurology. 3rd edn. AAN
Press, Lippincott Williams & Wilkins, Philadelphia.
• Handbook of Clinical Neurology, Vol. 118 (3rd series)
Ethical and Legal Issues in Neurology