1) The document discusses several key principles in medical ethics including autonomy, beneficence, non-maleficence, and justice as they relate to informed consent and treatment decisions. 2) It examines the concepts of medical negligence, duty of care, standards of care, damages, and proximate cause in medical malpractice cases. 3) It also addresses treatments for incompetent patients, the principles of patient autonomy and medical futility in end-of-life decisions around cardiopulmonary resuscitation.

1. KS Chew Emergency Medicine Department Universiti Sains Malaysia

2. Principle #1 Autonomy Does my action impinge on an individual’s personal autonomy? Do all relevant parties consent to my action? Do I acknowledge and respect that others may choose differently?

3. Principle #2 Beneficence Who benefits from my action and in what ways? Principle #3: Non-maleficene Which parties may be harmed by my action? What steps can I take to minimise this harm? Have I communicated risks involved in a truthful and open manner?

4. Principle #4: Justice Is my proposed action equitable? How can I make it more equitable? Substantial resources (supply costs and manpower) are often invested in this clinical setting, in which there is a low likelihood of benefit, while the care of other patients is delayed ( distributive justice ).

5. A proper informed consent must satisfy FOUR essential elements: ‘disclosure’ of information by the doctor (it is a medical duty of care to disclose) adequate ‘understanding’ of information by the patient patient’s ‘voluntariness’ during the consent process, and the patient has sufficient mental ‘competence’.

6. Under Bolam test , a doctor is not negligent if what he has done is accepted by a responsible body of medical opinion. Under the Bolitho case , the court must be satisfied that the exponents of a body of professional opinion have a logical basis and had directed their minds to the comparative risks and benefits in reaching a defensible conclusion. The opinion of the expert witnesses must be founded on logic and good sense.

7. The name of the operation Nature of the proposed treatment What the operation involves Other treatment options or alternatives Potential complications Risks of the operation

8. Risks of no treatment Special precautions required postoperatively Benefits of treatment Limitations of treatment Success rate of operation What happens on admission How patient will feel after treatment

9. Duty of Care A doctor on duty in ER automatically assumed the duty to treat ANY patient Standard of Medical Care Was there actually a negligence (to the jury’s satisfaction)? Damages Did the patient suffer actual damages? How extensive? Proximate cause Did the negligence cause the damages?

10. Incompetent patients include: Children Mentally disordered patients Patients who are temporarily unconscious, permanently unconscious through disease, trauma, injury, who has the capacity to consent but are unable to.

11. The common law - It is lawful to give treatment without consent in cases of urgency and necessity. Doctrine of necessity Bona fide/acting in good faith Lord Bridge - “treatment which is necessary to preserve life, health and well-being of the patient my lawfully be given without consent.”

12. Is governed by two important principles: A. The Principle of Patient Autonomy Advanced directives (DNAR) If patient preferences uncertain, emergency conditions should be treated until those preferences are known

13. B. The Principle of Futility Definition: If the purpose of a medical treatment cannot be achieved, the treatment is considered futile. The key determinants - duration remaining in cardiac arrest, length and quality of life expected

14. “ Physicians are NOT obliged to provide care when there is scientific and social consensus that the treatment is ineffective.” American Heart Association

15. “ Physicians are under no ethical obligation to render treatments that they judge have no realistic likelihood of medical benefit to the patient” American College of Emergency Physician, 1998

16. CPR maybe withheld even if requested by the patients “when efforts to resuscitate a patient are judged by the treating physician to be futile” AMA Council on Ethical and Judicial Affairs, 1991

17. “ Whereas patients have a right to refuse treatment, they do not have automatic right to demand treatment; they cannot insist that resuscitation must be attempted in any circumstances” European Resuscitation Council, Resuscitation Guidelines 2005

18. …“ futility is a professional judgment that takes precedence over patient autonomy and permits physicians to withhold or withdraw care deemed to be inappropriate without subjecting such a decision to patient approval.” Schneiderman LJ, Jecker NS, Jonsen AR. Medical futility: its meaning and ethical implications. Ann Intern Med. 1990 Jun 15;112(12):949-54.

19. “ It is wise for a doctor to seek a second opinion in making a momentous decision to withhold resuscitation for fear of the doctor’s own personal values, or the questions of available resources might influence his/her decision.” European Resuscitation Council, Resuscitation Guidelines 2005

20. Spouse Adult child Parent Any relative Person nominated as the person caring for the incapacitated patient Specialized care professionals Must act in best interest of patient

21. May be colored by the doctor’s conviction on issues of death, life, etc viewed through a socio-cultural and religious lens The concept of God The sanctity of human life The view of pain and suffering The afterlife, etc

22. “ Most doctors will err on the side of intervention in children for emotional reasons, even though the overall prognosis is often worse in children than in adults.” European Resuscitation Council

23. DNAR order means just that - in the event of cardiopulmonary arrest, CPR should not be attempted at all. Other treatment should be continued; e.g. pain relief, sedation on required basis in terminal illnesses.

24. Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity – WHO Definition, 1948

25. A 80-year old man with history of frequent exacerbation of COPD is diagnosed with acute pulmonary edema, currently complicated with respiratory failure Type 2. All other treatment modalities fail to prevent his deterioration. You know that his prognosis is not good but he needs mechanical ventilation to support his worsening respiratory effort. Would you have intubated him? If the relatives insist on you to actively resuscitate him but you do not, would you be liable to be sued?