The document discusses several topics relating to medical ethics including: 1. It defines ethics as a code of values that guide choices and actions. 2. It discusses the importance of teaching medical ethics as part of the medical education curriculum to help graduates behave ethically towards patients. 3. The history of medical ethics is reviewed from the Hippocratic Oath to modern declarations of human rights and international codes to protect patient rights.

1. Medical Ethics
Professor Salma Fouad Dowara
Professor of General Surgery
Vice 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 main
areas:
1. The ethical attitude towards other physicians
2. The clinical practice dealing with a doctor's duty of care to his
patients.
The oath did not consider the patient's right of choice in the management
of his medical problem.
Hippocrates oath remained the main code of ethics in medical practice till
the the Declaration of Human Rights code (1948) which recognized "the
equal and inalienable rights of all members of the human family"
The Declaration of Human Rights was followed by several international
codes of ethics in medical practice and medical research to protect the
patient rights.
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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
country
Intended 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 the
patient is a person with beliefs, values, goals and concerns which must be
respected.
(2)Respect the patient's dignity, privacy, information confidentiality and
autonomy.
(3) Deliver care in a way that will allow the patient to feel he/ she has
received medical care in a caring, compassionate and human manner.
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3. (4)Maintain honesty and integrity in all interactions with patients,
patient's families, colleagues and others with whom physicians must
interact in their professional lives. This includes reliability, availability
and timeliness of task completion.
(5)Maintain a professional image in manner, dress, speech and
interpersonal relationships that is consistent with the medical profession's
accepted contemporary standards in the community.
(6)Responsible towards work and calmness in emergency situations.
(7)Advocate the patient's interests over ones' own interests.
(8) Provide care to patients who are unable to pay and advocate access to
health care for members of underserved populations.
(9)Recognize and effectively deal with unethical behavior of other
members of the healthcare team.
Approaches to ethics
The "four principles" approach
The "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 moral
commitments, moreover a common language for discussing ethical
issues.
The main Ethical concerns in medical practice:
A - Patient rights:
A
ِ utonomy versus paternalism
Informed Consent
Beneficence
Non malficence
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4. The right to refuse treatment
Advanced Medical Directive
B - Patient-doctor relationship:
Confidentiality
Truth-telling versus withholding information
Justice and Resources allocation
Boundaries 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
Justice
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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 Confidentiality
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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’ experience
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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 patient's 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 patient's
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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.
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