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The four bioethical principles • Autonomy - respect for the individual and their ability to make decisions with regard to their own health and future. Actions that enhance autonomy are thought of as desirable and actions that 'dwarf' an individual and their autonomy are undesirable. • Beneficence - actions intended to benefit the patient or others • Non-malfeasance - actions intended not to harm or bring harm to the patient and others • Confidentiality- Justice being fair or just to the wider community in terms of the consequences of an action
Confidentiality • Shows respect for an individual's autonomy and their right to control the information relating to their own health • In keeping information about the patient secret the doctor is acting beneficently. • Disclosing information without the patient's consent can damage the patient. Get written consent prior to doing disclosure.
Malfeasance • Revealing privileged information would be the very reverse of beneficent i.e. malificent Maintaining confidentiality can therefore also be seen as non-maleficent. • Maintaining confidentiality can therefore also be seen as Non-malfeasant.
Breaking confidentiality • if there is a risk to a third party • conflict of duty • “patient may, for instance, disclose to his doctor that he believes his sister is an evil witch. His delusion is also linked to a plan to kill her” • a duty to protect the unknown sister • breaking of the confidence in the example above would be seen as reasonable
Some examples of reasons to break confidentiality: • where serious harm may occur to a third party, whether or not a criminal offence, e.g. threat of serious harm to a named person • where a doctor believes a patient to be the victim of abuse and the patient is unable to give or withhold consent to disclose • where, without disclosure a doctor would not be acting in the overall best interests of a child or young person who is his/her patient and incapable of consenting to disclosure • when, without disclosure the task of preventing or detecting a serious crime by the police would be prejudiced or delayed • when, without disclosure the task of prosecuting a serious crime would be prejudiced or delayed (e.g. a patient tells you that he killed someone several years ago) • where a doctor has a patient who is a health professional and has concerns over that person’s fitness to practice and posing a seriousdanger to patients in his or her care • where a doctor has concerns over a patient’s fitness to drive.
The law should never be a substitute for ethical reasoning. • Duties are commonly held to include a duty to protect third parties, a duty to act in the patient's best interests and a duty of confidentiality
Maintaining the professional relationship shows a respect for autonomy, beneficence towards the patient and a desire to act non-maleficently • Sexual relationships with patients cannot be justified, are abusive and inherently harmful for the patient involved.
Six Common Values of Ethics • Beneficence - a practitioner should act in the best interest of the patient. (Salus aegroti suprema lex.) • Non-malfeasance - "first, do no harm" (primum non nocere). • Autonomy - the patient has the right to refuse or choose their treatment. (Voluntas aegroti suprema lex.) • Justice - concerns the distribution of scarce health resources, and the decision of who gets what treatment (fairness and equality). • Dignity - the patient (and the person treating the patient) have the right to dignity. Includes proper draping of the body for dignity/privacy. • Truthfulness and honesty - the concept of informed consent has increased in importance since the historical events of the Doctors' Trial of the Nuremberg trials and Tuskegee Syphilis Study.
Conceptual Model - Linear Conceptual Model - Distinctions
Consider that both disciplines address: access to medical care (provision of care, emergency treatment, stabilization and transfer) informed consent confidentiality of health care information and exceptions to confidentiality (mandatory reporting obligations such as: child and elder abuse, duty to warn) privileged communications with health care providers advance directives abortion physician-assisted suicide Conceptual Model - Interconnectedness
goals of advance care planning • maximize the likelihood that medical care serves the patients goals, • minimize the likelihood of over- or undertreatment, • reduce the likelihood of conflicts between family members (and close friends) and health care providers, and • minimize the burden of decision making on family members or close friends.
Who will need this? • at risk for strokes (e.g., those with hypertension) • experiencing early dementia • engaging in risky behavior that is associated with head trauma and coma (e.g., motorcyclists, riding in cars without seat belts) • experiencing severe, recurrent psychiatric illnesses • terminal illness
Advance directives • written documents designed to allow competent patients the opportunity to guide future health care decisions in the event that they are unable to participate directly in medical decision making. • A 1991 federal law, the Patient Self-Determination Act, requires that patients are informed about their right to participate in health care decisions, including their right to have an advance directive.
Types of Advanced Directives • instructive and proxy. • Instructive directives: allow for preferences regarding the provision of particular therapies or classes of therapies. • Examples: Living wills, no transfusion and no CPR directives
Proxy • Durable Power of Attorney for Health Care (DPAHC), allows for the designation of a surrogate medical decision maker of the patient's choosing. This surrogate decision maker makes medical care decisions for the patient in the event she is incapacitated. • Need not be a relative of the patient, though this person should have close knowledge of the patient's wishes and views.
Client/Practitioner Relationships • Relationships between doctors and patients can create ethical conflicts, since sexual consent may conflict with the fiduciary responsibility of the physician. • Doctors who enter into close personal relationships with patients face the threats of deregistration and prosecution. In the early 1990's it was estimated that 2-9% of doctors had violated this rule
Seven Sins of Health Care Providers- Richard Asher* ‘I keep six honest serving men, They taught me all I knew; Their names are what, and why, and when, And how, and where and who’ -Rudyard Kipling • Obscurity • Cruelty • Bad Manners • Over Specialization • Love of the Rare Diseases • Common Stupidity • Sloth • *STRAIGHT AND CROOKED THINKING IN MEDICINE*
?Love of the Rare • “If you hear hoof-beats, think of horses, not zebras!” • (Seek the mundane first not a bizarre diagnosis)Common diseases presenting uncommonly is more common than finding an uncommon disease!
Health Insurance Portability and Accountability Act • Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs. • Title II of HIPAA, known as the Administrative Simplification (AS) provisions, requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers.(Electronic record keeping.)
