Medical Ethics

1
Medical Ethics

• Antony Vaughan
• General Practitioner

2
Medical ethics principles

• Beneficence
• Non-maleficence
• Autonomy
• Justice
• Dignity
• Truthfulness

3
Ethics the study of the moral value of human
behaviour

• Medical
• Business
• Environmental
• Legal
• Political

• Feminism
• Animal rights
• Bioethics
• Gay rights

4
Philosophy

• Logic
• Metaphysics
• Ethics

5
History of ethics

• Early Greeks
• Socrates
• Plato
• Aristotle
• Epicurus
• Ancient India
• Hindu

• Early European 1100-1200
• Thomas Aquinas
• Mamonides
• Modern philosophy 1700-
• Thomas Hobbes
• Immanuel Kant
• Jeremy Bentham
• John Stuart Mill
• David Hume

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Approaches to ethics

• Result based ethics
• Standard based ethics
• Ethical intuitionism
• Ethical egoism
• Virtue ethics
• Emotivism

7
Study of ethics

• Meta-ethics
• Normative ethics
• Applied ethics

8
Medical ethics

• Medical
• Health care ethics
• Clinical ethics
• Bioethics

9
Ethical topics

• Patient confidentiality
• Doctor paternalism
• Rights of patient to refuse treatment
• Rights of patients who lack capacity
• Organ removal
• Involuntary detention
• Foetal testing, selection and abortion

10
Medical oaths and codes

• Ideal doctors
• Welfare of patients
• Advancement of medical knowledge
• Honour of profession
• Awareness of limits of power
• Strive to help but above all do no harm

11
Doctors criticised for

• Paternalism
• Acting without patients knowledge or consent
• Assuming patients share idea of benefits and
  treatment risks

12
Consequentialism (teology)

• Actions should provide a good outcome
• Greatest good for the greatest number
• Strengths
• Resolves conflicts between individuals society
• Also used in political business ethics
• Weaknesses
• Difficult to predict outcome
• Societys needs may not be correct morally
• Individual needs conscience can suffer from
  utilitarian thinking

13
Dying widow

• A 71-year-old widow is dying of end stage breast
  cancer with secondaries in brain and bone. She
  can still converse well. Her husband died 8 years
  ago. Her two sisters died before her-one from
  breast cancer. Her one source of comfort has been
  her only child, a computer specialist, who took
  leave from his work 6 months ago to be with his
  mother during the final episode of her life.
• As the patient slips in and out of consciousness
  and her pain control medications increase she
  asks for her son Mark, Why isnt he here? Is
  Mark alright? Yesterday her doctor and nursing
  staff were informed that Mark had died in the
  family house, an apparent suicide. He had become
  despondent over his mothers approaching death.
  According to a note he wanted to be there with
  his aunts and father before his mother arrived.
• Should the health care providers tell the patient
  about her sons death?

14
Deontology

• Duties and obligations
• Assumes people naturally act morally
• Nothing can be imposed on anyone without their
  will or consent

15
Deontology 2

• Strengths
• Avoids rationalisation and delusions to justify
  personal actions
• Corrects inauthentic reasons for being moral
• Above constraints overrule the common good
• Weaknesses
• Cannot resolve conflicts between moral persons
  who disagree
• No room for compromise

16
Dying widow

• A 71-year-old widow is dying of end stage breast
  cancer with secondaries in brain and bone. She
  can still converse well. Her husband died 8 years
  ago. Her two sisters died before her-one from
  breast cancer. Her one source of comfort has been
  her only child, a computer specialist, who took
  leave from his work 6 months ago to be with his
  mother during the final episode of her life.
• As the patient slips in and out of consciousness
  and her pain control medications increase she
  asks for her son Mark, Why isnt he here? Is
  Mark alright? Yesterday her doctor and nursing
  staff were informed that Mark had died in the
  family house, an apparent suicide. He had become
  despondent over his mothers approaching death.
  According to a note he wanted to be there with
  his aunts and father before his mother arrived.
• Should the health care providers tell the patient
  about her sons death?

17
Virtue theory

• Virtues (habits) formed by personality, parental
  and social training, professional training and
  standards
• All human beings have an inborn routine that
  tends to the good in moral action (needs
  moulding)
• Examples of virtue courage, love, friendship,
  responsibility, faithfulness, truth telling
• Doctors also need compassion, humility and
  integrity (respect for science)

18
Virtue theory 2

• Strengths
• Health professionals character is crucial as
  they interpret and apply the ethical theory
• Encompasses duty of professional (deontological)
  and goodness of actions (teological)
• Do good and avoid evil (Thomas Aquinas)
• Weaknesses
• Agreement of what is virtuous is often difficult
• Society need to agree what is right and good

19
Dying widow

• A 71-year-old widow is dying of end stage breast
  cancer with secondaries in brain and bone. She
  can still converse well. Her husband died 8 years
  ago. Her two sisters died before her-one from
  breast cancer. Her one source of comfort has been
  her only child, a computer specialist, who took
  leave from his work 6 months ago to be with his
  mother during the final episode of her life.
• As the patient slips in and out of consciousness
  and her pain control medications increase she
  asks for her son Mark, Why isnt he here? Is
  Mark alright? Yesterday her doctor and nursing
  staff were informed that Mark had died in the
  family house, an apparent suicide. He had become
  despondent over his mothers approaching death.
  According to a note he wanted to be there with
  his aunts and father before his mother arrived.
• Should the health care providers tell the patient
  about her sons death?

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Branches of medical ethics

• Public policy ethics
• Applied medical ethics
• Clinical medical ethics

• Age based rationing
• Medical research
• Treatment availability
• Professional codes
• Abortion
• Euthanasia
• Fertility
• Genetic manipulation
• Case analysis
• Patient family involved

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Four principle approach (Beauchamp Childress)

• Autonomy
• Beneficence
• Non-malificence
• Justice

22
Four principle approach 2

• Strengths
• Compatible with deontological and
  consequentialist theories some aspects of
  virtue theory
• Objective, specific, works well in clinical
  situations
• Weaknesses
• Conflict between autonomy and justice,
  beneficience and non-maleficence
• Need to weight one principle over another

23
Alternative approaches

• Normative ethics
• Libertarianism
• Beneficence in trust
• Communitarian ethics
• Narrative ethics
• Feminist ethics

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Autonomy

• Informed consent
• Confidentiality
• Keeping promises
• Lack of deceit
• Empowerment

25
Beneficence non-maleficence

• Any effort to help may result in harm
• Education and training
• Risk, probability of benefit and harm

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Justice

• Fair adjudication between competing claims
• Personal decision making
• Organisational, professional and societal
  decisions

27
Scope

• To whom or to what we owe moral obligations
• Patients
• Children
• Mentally ill or impaired
• Right to life
• Not to be unjustly killed
• Right to be kept alive

28
Change of mind over advanced directive

• Mr Z made a written advance directive 5 years
  ago. Mr Z suffers from chronic obstructive
  pulmonary disease and the advance statement
  provides that if he is admitted in respiratory
  failure he will not be ventilated. The advance
  directive is placed in his notes. Mr Z is brought
  into AE in respiratory failure and is acutely
  confused because of low oxygen levels in his
  blood. He states that he wants 'everything done'
  in order to save him. The doctor in charge of his
  care decides to ventilate him.

29
Refusal of Treatment by an Incompetent patient

• Mrs Y is 56 years old. She has a learning
  disability and lives in a care home. She is
  admitted to hospital with an ovarian cyst. The
  cyst is blocking her ureter and if left untreated
  will result in renal failure. Mrs Y would need an
  operation to remove the cyst. Mrs Y has indicated
  quite clearly that she does not want a needle
  inserted for the anaesthetic for the operation to
  remove the cyst - she is uncomfortable in a
  hospital setting and is frightened of needles.
• The clinician is concerned that if the cyst is
  not removed Mrs Y will develop renal failure and
  require dialysis which would involve the regular
  use of needles and be very difficult to carry out
  given her fear of needles and discomfort with
  hospitals. The anaesthetist is concerned that if
  Mrs Y does not comply with the procedure then she
  would need to be physically restrained. Mrs Y's
  niece visits her in the care home every other
  month. The niece is adamant that her aunt should
  receive treatment.
• Should the surgeon perform the operation despite
  Mrs Ys objections?

30
Prevention or Treatment?

• Decisions about setting priorities for treatments
  and services on a larger scale raise difficult
  ethical issues for PCTs. A PCT may seek advice on
  the ethical issues arising from these
  macro-level decisions from a priorities forum,
  or a PCT may develop their own ethics committee
  to inform these decisions.
• Metroville PCT has a sum of recurring money that
  has been ring-fenced for use in the area of
  ischaemic heart disease. The PCT has two
  proposals for developing services in this area
  and must decide which proposal to fund.
• Proposal 1 is from the local acute trust and is
  for an increase in angiography and angioplasty
  services. The proposal cites evidence from
  research studies to show that reducing waiting
  times for angioplasty will save lives and is a
  cost effective use of resources.
• Proposal 2 is from the local diabetes group and
  is for a project that will focus on the small
  Asian community within the population. This
  community has a high prevalence of diabetes and
  ischaemic heart disease and traditionally has
  tended to use health care services only when they
  are acutely ill rather than attending for regular
  care of their chronic diseases. The proposal is
  to provide a specialist diabetes nurse and health
  advocate for this population and an educational
  programme for the whole community focusing on
  prevention of diabetic complications and
  promotion of life-style changes to reduce the
  incidence of new cases of diabetes. There is no
  research evidence for this intervention but there
  is some anecdotal evidence from other areas that
  this approach has some success.
• The PCT must choose one of these proposals.

31
Confidentiality and HIV

• Bob has attended the genito-urinary clinic at his
  local Trust hospital. Bob is seen by Dr Gomez who
  informs him that he is HIV positive. Dr Gomez
  counsels Bob to contact his sexual partners to
  inform them of his status. Bob starts a course of
  treatment.
• For the last 18 months Bob has been in a
  relationship with Sue. They are expecting a baby
  in 2 months time. Before this relationship Bob
  had a series of sexual partners.
• On a subsequent visit to the clinic it becomes
  clear to Dr Gomez that Bob has not told Sue of
  his HIV status. Dr Gomez is aware of the
  impending arrival of their baby and tells Bob
  that steps should be taken to assess whether Sue
  is HIV positive and whether the baby is at risk
  so that if necessary treatment may be started.
• Bob adamantly refuses to tell Sue and says that
  if she is told without his consent then he will
  stop his course of treatment.
• What should Dr Gomez do? Should he inform Sue, or
  Bobs GP?

32
Parents refuse to withhold Rx

• Baby C born 8 weeks prematurely and contracted
  meningitis soon after birth. As a result she
  suffered severe brain damage and an inability to
  respond to stimuli. She was receiving artificial
  ventilation. The treating team thought that it
  was not in the baby's best interests to continue
  with artificial ventilation, without which she
  would die within an hour. With continuance of
  such treatment she would live for at most one
  year, probably experiencing pain and distress.
  For religious reasons her parents could not agree
  to withdrawal of treatment.
• What issues should an ethics committee consider
  in reviewing such a case?

33
Competent patient refuses Rx

• Mrs X is 35 and is in need of dialysis. She is
  refusing treatment because she is scared of
  treatment which she believes is invasive. She has
  been counselled about the nature of the treatment
  - there are no alternatives that would be of
  practical benefit. She is competent to make
  treatment decisions. She understands that if she
  refuses dialysis she will die. She has a daughter
  of 15 years who lives at home. The clinician
  feels very strongly that she should receive
  dialysis but despite numerous attempts to
  persuade her she refuses.
• Can the clinician treat her?

34
Who should have the bed?

• Barry is a 32 year old man with meningitis and is
  brought into the AE department of hospital A. He
  is unconscious with an extremely low blood
  pressure and evidence of renal failure. His
  condition is grave and without intensive care
  support he is almost certain to die. With
  intensive care support he may make a full
  recovery. Until this illness he has been fit and
  well. The Intensive Care Unit (ICU) in hospital A
  is full, with some patients critically ill and
  some in a relatively stable condition but for who
  optimum care would still require the facilities
  of an ICU. There is evidence that moving a
  patient from an ICU early increases their chances
  of complications and may increase mortality.
  There is an available bed in an ICU in hospital
  B, which is fifty miles away. The intensive care
  consultant on call must decide if Barry should be
  moved to hospital B or if a patient already in
  ICU should be transferred to allow Barry to be
  admitted. The clinical ethics committee is asked
  to review the case retrospectively and advise on
  how such cases should be approached in the future