PROBLEM CASES IN MEDICAL ETHICS

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PROBLEM CASES IN MEDICAL ETHICS

• Roshan A. KhurooWorcester VTSOctober 2005

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Confidentiality

• GMC Guidelines.
• Confidentiality is central to trust between
  doctors ant patients.
• Before providing information regarding patients
  you should
• Seek patients consent, whether or not you should
  judge that patients can be identified.
• Anonymise data where unidentified data will serve
  the purpose.
• Keep disclosures to the minimum necessary.

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Confidentiality And Medical Practice

• Examples of situations in which doctors must not
  breach confidentiality.
• Casual breaches e.g for amusement.
• To prevent minor crime
• To prevent minor harm to another individual.
• Doctors working in genitourinary clinics.
• Doctors should not write a report or fill in a
  form disclosing confidential information without
  the patients consent.

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Situations in which doctors have discretion to
breach confidentiality

• Sharing of information with other members of the
  health-care team in the interests of the patient.
• A patient who is not medically fit to drive
  continues to do so.
• A third party is at significant risk of harm.

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Examples of situations where doctors must breach
confidentiality.

• Notifiable diseases.
• Drug addiction. Misuse of Drugs Act( 1973)
• Termination of Pregnancy. Abortion Act (1967).
• Births And Deaths. Registration Act ( 1953).
• To police on request. Name and address only, no
  clinical details. Road traffic Act ( 1988).
• Under court orders.
• Identification of patients undergoing in vitro
  fertility treatment with donated gametes. Human
  fertilisation and embryology Act (1990)
• Identification of donors and recipients of
  transplanted organs. Human organ transplant Act
  (1989).

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Legal case of confidentiality

• W was a patient detained in a secure hospital for
  an indefinite period of time because he had
  killed five people and wounded two others. He was
  diagnosed with schizophrenia and found not guilty
  by reason of insanity. Then 10 years into his
  detention, he appealed to a mental health review
  tribunal for transfer to a less secure hospital.
  Ws solicitor asked Dr. Egdell, a consultant
  psychiatrist, for a report on Ws condition,
  hoping that the report would support Ws
  transfer. However, Dr. Egdell formed the opinion
  that W was suffering from paranoid psychosis and
  remained dangerous. His report strongly opposed
  Ws transfer. When Dr. Egdell discovered that Ws
  solicitors would not make his report available to
  Ws consultant or to the tribunal, he sent a copy
  to the medical director of the hospital with a
  suggestion that it be forwarded to the home
  secretary. When W realised what Dr. Egdell had
  done, he issued an injunction restraining the use
  of the report and seeking damages for breach of
  confidentiality. The case went to court of
  appeal.
• Was Dr. Egdell right or wrong?

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• To breach confidentiality the judgment found that
  Dr. Egdell was right to breach confidentiality,
  because the public interest was in favour of
  disclosure.

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Consent in English Law

• Competent Adults
• Patients may refuse any life-saving treatment
• Patients should be given information about the
  nature of procedure, common and rare serious
  side-effects, benefits and reasonable alternative.

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• Incompetent adult
• Doctors should act in the best interests of
  patients.
• Relatives and friends may be sources of
  information when judging best interests, but
  cannot give or withhold consent.

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Case report regarding consent

• Mrs D IS 77 YR OLD. She has been suffering
  moderate dementia for 7 years. She recently
  slipped and fell, fracturing the neck of her left
  femur.Both her GP and the surgeon believe that it
  is in her best interests to operate to repair the
  fracture. Her 45 year old son, who is her next
  off kin, refuses to give his consent-he says that
  he does not like hospitals and that his mother
  should stay at home in bed while the fracture
  mends itself.
• Questions
• What legal authority does the sons consent have?
• What should the doctors do?

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• Neither the son nor his refusal has any legal
  relevance
• The doctor should assess what is in the patients
  best interest's.

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Case history regarding incompetent adult

• Mr. C is a 70year old man with dementia and long
  standing COPD. He is cared for at home by his 72
  year old wife. He suffers frequent chest
  infections for which he receives antibiotics, and
  requires oxygen at home. His most recent chest
  infection has not responded well to antibiotic
  tablets and his general condition is
  deteriorating. He is not eating and is drinking
  little.. Admission to hospital in the past has
  caused him distress because he does not cope well
  with changing environment. However,his wife says
  that he should go to hospital and receive the
  maximum treatment.
• Imagine that you are Mr. Cs doctor. You think
  that his best interests would be served by him
  staying at home and being made comfortable,but
  his wife wants him in hospital. Were do you go
  from here?

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Options at the end of life

• Mr L has metastatic melanoma and respiratory
  failure.
• He has an intravenous syringe-driver with
  morphine for pain relief.
• He wants to die.
• What options do we have ?????

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• Do not place on a Ventilator, ( form of passive
  euthanasia )
• Place on a ventilator, and withdraw on
  deterioration

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English Law and the end of life

• Killing a patient for any reason is normally
  murder.
• Assisting suicide is criminal offence.
• A competent patient can refuse any, even life
  saving treatment.
• Treatment of incompetent patients should be in
  their best interests.

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Thank you for your patience