ETHICAL

1
ETHICAL LEGAL PRINCIPLES IN SURGICAL PRACTICE
2
4 TRADITIONAL PRINCIPLES

• Obligation of Beneficence-------- doing good
• Obligation of non-maleficence---Avoiding harm
• Obligation of respect autonomy--Respecting
  Consent , Confidentiality
• Obligation to aspire to justice---- Being fair to
  all stakeholders

3
DIFFERENT ETHICAL TRADITIONS

• DEONTOLOGICAL (DUTY BASED)
• UTILIATARIANS
• EXISTENTIAL / POSTMODERN
• DUTY BASED
• OUTCOME BASED
• CONTEXT BASED

4
BENEFICIENCE DOING GOOD

• DEMANDS COMPETENCE
• DOCTORS SHOULD NOT EXCEED THEIR PERSONAL
  COMPETENCE IF A MORE APPROPRIATE PRACTITIONER OR
  SERVISE IS AVAILABLE
• ACCREDITATION CONTINUING MEDICAL EDUCATION
• COMMUNICATION SKILLS ARE VITAL

5
NON-MALEFICENCE AVOIDING HARM

• Primum non nocere (First do no harm)
• Paternalism
• Consumerism

6
RESPECT FOR AUTONOMY

• Individuals should be treated as ends not as
  means
• Respect for dignity,integrity and authenticity of
  the patient
• Informed consent
• Capacity to consent exists if a patient can
• understand relevant information
• consider the implications of different options
• consider to communicate decisions
• Capacity to consent may not exist
• minors
• transient or irreversible cognitive impairment
• mental illness
• undue coercion

7
LAW RELATING TO CHILDREN

• COMPLEX
• DIFFERENCE BETWEEN ENGLISH SCOTTISH LAW
• IN SOME INSTANCES A COMPETENT CHILD MAY REFUSE
  TREATMENT,IN CONTRADICTION TO THE WISHES OF THE
  PARENTS.AN AUTONOMIC RIGHTS TO OVERULE THIS BY
  THE PARENTS MAY NO EXIST. LEGAL ADVICE IS
  RECOMMENDED.

8
SUMMARY

• Establish the various options available(including
  non-treatment)
• Seek evidence of previously expressed views (e.g.
  advance directives)
• Seek opinion of third parties to whom the patient
  may be known as to the patients previously
  expressed views
• Administer the level of treatment that least
  restricts the patients future choice
• If substantial doubts or conflicts exists, seek
  counsel from more experienced colleagues, from
  more experienced colleagues, from professional
  organizations, from legal sources
• If necessary, seek advice as to whether a court
  ruling is necessary.

9
JUSTICE

• DEMAND OUTSTRIPS SUPPLY
• PRINCIPLE OF JUSTICE OF ARISTOTLE (Nicomachean
  ethics)
• Equals should be
  treated equally, but where inequality exists
  then unequal treatment should occur to correct
  this imbalance.
• e.g. Terminal
  Cardiac failure had a more immediate and life
  threatening (unequal)need than those with ingrown
  toe nails.

10
SPECIFIC TOPICS

• EUTHANASIA
• ABORTION
• NEGLIGENCE

11
ETHICAL LEGAL PRINCIPLES IN SURGICAL PATIENTS

• Clinical Scenarios

12

• A 70 year old female patient develops cellulitis
  of her abdominal wound following total abdominal
  hysterectomy. In the space of a few hours the
  wound edges become necrotic, and the surrounding
  skin becomes red and inflammed with a rapidly
  advancing edge. She needs to go to theatre for a
  wide excision of her wound. She is rather drowsy
  and a little confused.
• What is the condition described and what is the
  treatment?
• How would you obtain informed consent?
• Who would you ask to help you?
• The patients condition deteriorates and she
  becomes incapable of giving consent. What will
  you do next?
• How will you justify your actions?

13

• A 65 year old lady is referred to you by another
  doctor. A large ulcerated growth has been found
  on digital examination just above the anal
  margin. The patients daughters have been told
  that a cancer of the rectum is the likely
  diagnosis. Before you see the patient they
  approach you and state that they do not want
  their mother to be told the diagnosis.
• 1.How will you approach this and what will you
  tell them?
• 2 How will you approach the patient and what will
  you say to her?
• 3.The patient says she does not wish to know
  about her surgery but will leave the decision up
  to you. Will you give her any information and if
  so what will you tell her?
• 4.Who would you ask to help you?

14

• You are the house officer on duty, when at 11.00
  pm you are called by the Nursing Staff because Mr
  Jones is being unco-operative. Mr Jones is a
  heavy drinker who was admitted to the ward 48
  hours previously with severe pancreatitis.
• When you arrive you find that Mr Jones has pulled
  out his drip and has announced he is going home.
  He is only wearing pyjama trousers and has put
  all his possessions into a plastic bag and is at
  the door of the ward, about to leave.
• 1.Why do you think this situation has occurred?
• 2.What can you do about it?
• 3.What will you do if Mr Jones will not listen to
  reason?
• 4.Can you use force to restrain him?
• 5.How can you keep him in the ward? Who can help
  in this situation ?