Medical ethics

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Medical ethics

• Dr D Grace MD. FFARCSI. Dip.ICM.
• Dept of Anaesthesia Critical Care Medicine
• Altnagelvin Area Hospital

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Aims

• Ethics, clinical practice research
• Principles
• Practicalities
• Case studies
• Challenging issues

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Context

• Medical advances
• Medical practice
• Societal changes
• Individual v communal rights
• Medico-legal framework

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Principles

• Health physical and mental well-being
• Ethics study of practical morality
• Autonomy
• Beneficence
• Non-maleficence
• Justice
• Utility

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Ethics

• System of moral behaviour
• Moral philosophy
• Theoretical study of practical morality
• Ordinary morality / value judgements in a
  professional context
• Codes of procedure

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Autonomy

• Self-determination v paternalism
• Allowing / withholding consent
• Advance statements
• Advocacy by proxy
• Do not resuscitate (DNR)
• Organ donation
• Preference v consumer autonomy
• Autonomy applies to the clinician too!

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Advance statements

• Advance directives / living will
• Chronic debilitating illness / critical care
• An expression of preferences
• Generic v disease specific
• Often broad non-specific in nature
• Limited legal standing
• Contemporaneous decision overrides

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Advantages / disadvantages

• Autonomy
• Facilitate communication
• A guide
• Shorten dying

• Limited uptake
• Limited impact
• Patient-clinician conflict
• Wording crucial
• Unanticipated circumstances

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DNR

• Cardio-respiratory arrest
• CPR success circumstance-dependent
• Presumed consent (for CPR)
• Communication absolutely essential
• Multidisciplinary
• Status / wishes recorded reviewed
• ? witnessed CPR

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Brain death / BSD

• Traditional cardio-respiratory death
• The body as an integrated whole has ceased to
  function
• Loss of whole brain function
• Physiology and diagnosis of BSD
• Implications - organ donation / retrieval

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Organ donation

• Demand rising, supply falling
• BSD patients
• Life-saving life-enhancing
• Requires consent / assent patient or N.O.K.
• Advance statement (registration)
• Relatives wishes
• ? presumed consent / opt out
• Cultural variance

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Non-beating heart donors?

• Limited BSD organ pool
• CVS-RS death
• Immediate organ retrieval preservation
  (controlled withdrawal / failed resuscitation)
• Life saving enhancing
• Elective ventilation its implications?
• Comparable retrieved organ efficacy?
• Misunderstanding of motives of care?

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Consumer autonomy

• Access
• Choice
• Competition
• Adequate information
• Redress
• Safe subject to regulation

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Beneficence / non-maleficence

• Do good / do no harm
• Sanctity- quality / duration
• Futility
• Changing practice
• Autonomy v paternalism
• Cost justice

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Futility withdrawal

• Institute / continue / escalate / limit /
  withhold/ withdraw
• Communication paramount
• Dignity, rights, comfort of patient
• Wishes (patient proxy)
• BMA / GMC guidelines standards

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Acts, omissions double effect

• Withholding / withdrawing v killing
• Outcome v intention
• Voluntary passive euthanasia
• Physician-assisted suicide / active euthanasia
  illegal
• Symptom palliation CVS-RS depression

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Justice

• Futility costly (economic and emotional)
• Finite healthcare resources
• Fair distribution
• Ration services / limit treatment options
• Clinicians - patient advocates rationers
• Govt judiciary as advocates rationers
• Pressure groups - advocates never rationers!
• Cultural variance / economic variance

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Utility

• Maximizing outcomes / preferences
• Tension between utility equality
• Resource concentration?
• Service choices
• Implies measurement / quality immeasurable?
• Demands research

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Research

• An imperative to enhance care
• Conflict public v personal interests?
• Quantifiable / identifiable risks?
• Declaration of Helsinki concern for the
  interests of the subject must prevail over the
  interest of science society
• Requires rigorous consenting (i) research (ii)
  not contrary to subjects interests (iii) outcome
  unpredictable (iv) freedom to withdraw
• Research ethics committees / MRC / Colleges

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Consent - principles

• Every adult has an inviolable right to determine
  what is done to his or her body Lord Donaldson
• To examine, treat, care
• Verbal, written, implied
• Voluntary
• Informed quality clarity of info -gt validity
• A process / not time-limited / reaffirmation
• Withdrawal of consent (without prejudice)
• Competency, refusal respect

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Consent - competence

• Adults (gt 16 yrs) assumed to be competent unless
  evidence to contrary
• Adults may be competent to make some decisions
  even if they are not competent to make others
• Mental disorder / impairment does not imply
  incompetence
• Understand, retain, choose freely
• lt 16 yrs demonstrated competence required i.e.
  sufficient understanding intelligence

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Consent and children

• May consent if gt16 yrs or if younger and fully
  understand (involve parents wherever possible)
• lt 16 yrs - someone with parental responsibility
  must give consent on the childs behalf, unless
  they cannot be reached in an emergency.
• If a competent child consents, a parent cannot
  override that consent.
• If a competent child refuses, legally a parent
  can give consent, but it is likely that such a
  serious step will be rare.

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Incompetence 1

• No-one can give consent on behalf of an adult who
  is not deemed competent. May treat if in their
  best interests.
• Best interests include patients wishes and
  beliefs when competent, current wishes, general
  well-being and spiritual and religious welfare
• Relatives/carers/friends may be able to give
  information on some of these but cannot give
  consent for the person
• If people no longer have capacity but have
  previously clearly indicated their refusal of
  such treatment in the circumstances in which they
  now find themselves, the refusal must be accepted

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Incompetence 2

• Mental health legislation provides the
  possibility of treatment for a persons mental
  disorder or its complications without their
  consent
• It does not give power to treat unrelated
  physical illness without consent

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Adequacy of information?

• Illness / nature / treatment / invgn / prognosis
• Purpose, nature, complexity, implications
• Risks quantification, uncertainties
• Alternatives
• Patient wishes / authority / unanticipated issues
  
• Harm v distress
• Reasonable patient v reasonable body of doctors

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Emergency Tx / unavailable consent

• Treatment which is immediately necessary
• Parental consent for child (lt 18 yrs unable to
  consent) or Tx as above
• Parental refusal life-saving provision

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Should all patients be treated?

• Natural claim
• Natural duty
• Professional duty
• Statutory right to care (consultation, advice,
  treatment)
• Received, respected, heard, advised, treated
  appropriately if available
• Responsibility for the treatment chosen rests
  with the clinician
• Courts authorize not order

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Self harm, cost treatment

• Medical indications
• Autonomy
• Best interests
• External factors relatives / resource
  allocation
• Public policy
• Informed debate

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Summary

• Principles
• Directives / DNRs / BSD organ donation
• Sanctity quality of life
• Futility
• Commission, omission double effect
• Utility, equality, justice, rationing
• Consent
• Research

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Glossary

• Philosophy study of realities general
  principles / system of theories on nature of
  things or on conduct
• Morals pertaining to right and wrong (conduct)
• Ethics system of moral behaviour / theoretical
  study of moral philosophy
• Autonomy the right of a fully informed
  individual to choose a course of action or
  inaction

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Glossary 2

• Beneficence the obligation to do good
• Non-maleficence the obligation to avoid doing
  harm
• Justice the right to receive what is deserved
• Equity fairness
• Utility pertaining to maximizing outcomes or
  preferences
• Futility treatment which cannot with reasonable
  probability cure, ameliorate or restore a quality
  of life which would be satisfactory to the patient