Medical Ethics

1. Medical Ethics VTS 24/09/08

2. Curriculum statement 3.3 Curriculum statement 3.4

3. Timothy McVeigh Timothy McVeigh.doc

4. Should doctors have to swear an oath when they qualify? The Hippocratic Oath.doc Modern Hippocratic Oath.doc AMA Oath.doc

5. What is meant by Ethics? What is meant by morality?

6. What is meant by Ethics? • Ethics – the philosophical study of morality • Morality – a system applying to all rational persons, governing behaviour that affects others, having the lessening of harm as its goal

7. Example from practice - 1 • Microalbuminuria testing in diabetes

8. Example from practice - 1 • Microalbuminuria testing in diabetes • Does this test benefit some patients? • If so, who? • Is it about QOF points? • Could it cause injury? • Is such a process respectful of patients’ views? • It is expensive and if we use much resource doing this is there a knock-on effect on other services? Is this fair? Do others suffer if we use “too much” for a few patients?

9. Example from practice - 2 • Immunisation

10. Example from practice - 2 • Immunisation • Is this process beneficial? If so, to whom? • Individual benefit vs. herd-immunity. • Do we know who is going to benefit? • What about if GPs get paid for immunisations? • Could it cause injury? • If some might suffer from it, is it still right to proceed with it on grounds of benefit for the majority?

11. Example from practice - 3 • Patient empowerment

12. Example from practice - 3 • Patient empowerment • Is choice about treatment options always a good thing? • Information-giving may be good for the doctor-patient relationship but is it a good basis for making treatment decisions? (DXT, chemo) • “What would you do, doc?” • There may be an illusion of choice where there is no real choice • What about Choose and Book? If it is based on historical referral patterns, is there really choice?

13. Example from practice – 4 • Why don’t we just give patients prescriptions if they ask for something?

14. Example from practice – 4 • Why don’t we just give patients prescriptions if they ask for something? • E.g. antibiotics, tranquillisers? • This might be beneficial and patient-centred • Is patient choice more important than avoiding iatrogenesis or medicalisation? Or less? • In any case, how likely is iatrogenesis with such simple, widely used treatments? • Is it fair - to other patients? To colleagues? • Does doctor/nurse-practitioner know best?

15. The First Principle • Do good • This is BENEFICENCE • Such aspects as cure / palliation / comfort / empathy / compassion / treating patients with dignity • Such concepts are well understood by medical and nursing staff

16. Example from practice - 5 • Cholesterol monitoring in the elderly

17. Example from practice - 5 • Cholesterol monitoring in the elderly • How old is elderly? • Is this process beneficent? If so, to whom? • What is the evidence for benefit? • Is it about QOF points? • Could it cause injury? • Is such a process respectful of patient views?

18. Example from practice - 6 • Spirometry

19. Example from practice - 6 • Spirometry • Is this process beneficent? • Do we know who is going to benefit? • Is it about QOF points? • Could it cause injury? • It uses up a lot of time. Do others suffer if we use “too much” for a few patients?

20. Example from practice – 7 • Termination of pregnancy

21. Example from practice – 7 • Termination of pregnancy • What is the purpose in discussing different numbers of weeks of time where abortion is permissible? • Is there a moral difference between abortion at 20 weeks and at 24? • Whose rights need to be considered – just the mother’s? The unborn child’s? • How much guidance do the clauses of the Abortion Act(s) offer?

22. The Second Principle • Do no harm • This is NON-MALEFICENCE • Not injuring patients by what we do • Non-iatrogenesis • Well understood but sometimes happens inadvertently

23. The Hippocratic Oath does notcontain the words “First, do no harm”, (nor was it actually written by Hippocrates, according to many sources). It expresses a similar idea, but does not use these words. • Hippocrates probably did originate the phrase, but did so in his Epidemics, Bk. I, Sect. XI. One translation reads: "Declare the past, diagnose the present, foretell the future; practice these acts. As to diseases, make a habit of two things — to help, or at least to do no harm.“ • The Greek "First, do no harm" becomes "Primum non nocere" in Latin. A translation of the original perhaps, but some sources attribute "Primum non nocere" to the Roman physician, Galen.

24. Example from practice – 8 • Should the cost of prescriptions be an issue?

25. Example from practice – 8 • Should the cost of prescriptions be an issue? • How much should the PCT/DoH tell us what to prescribe? E.g. lansoprazole vs. omeprazole • Is generic prescribing always right? What about when patients feel branded medication is “better”? • Should we prescribe Calpol, cough mixtures, etc? • What about “setting precedents”? • What about top-up payments for “expensive” drugs?

26. Example from practice – 9 • Fertility treatment

27. Example from practice – 9 • Fertility treatment • Is it right to choose the sex of a child produced by fertility treatment? Always? Ever? Never? • What about selective abortion? • Cloning – what about for stem cell research or for treatment of an afflicted child? • How many embryos can be “sacrificed” for the purposes of research? 9 to 1? 99 to 1? 999 to 1? • Should egg and sperm donors be anonymous? • Explanatory Notes to Human Tissue Act 2004.doc

28. Example from practice – 10 • Ethical employment practice

29. Example from practice – 10 • Ethical employment practice • Hiring and firing – are non-discriminatory policies and procedures in place? • Issues of confidentiality for staff • What should be put in a reference? • How much weight and value should be given to the views of non-clinical staff in running a practice? • How much should staff be paid? And doctors?

30. The Third Principle • Act fairly • This is (distributive) JUSTICE • Such aspects as treating equals equally / if people are non-equal they should be treated in proportion to their degree of inequality (? e.g. those in custody, relatives) / ethical rationing – should those who are deprived have more? • A more difficult principle

31. Example from practice – 11 • Is it ever right to break confidentiality?

32. Example from practice – 11 • Is it ever right to break confidentiality? • Who has a “right” to know your medical history? • At what point does “need to know” override “need for confidentiality”? • HIV in a partner? Open TB in a family member? • Suspected murder? Driving while fitting? Driving whilst under the influence of drugs? If someone has “gone missing”? Who might you speak to – police, family, concerned neighbours? • Court may give an order to release medical records in some circumstances

33. Example from practice – 12 • Should doctors always tell patients their diagnosis?

34. Example from practice – 12 • Should doctors always tell patients their diagnosis? • What about uncertainty in diagnosis? Is it right to make patients share this? • Is it ever right to suppress diagnoses – what about stigmatising diagnoses, e.g. MS, dementia, HIV, psychiatric diagnoses? • What if relatives ask doctors not to disclose diagnoses to patients?

35. Example from practice – 13 • Euthanasia

36. Example from practice – 13 • Euthanasia • What about withdrawing feeding tubes when someone is in a persistent vegetative state? • Who could make such a decision? Who should? • What role should relatives have in these matters? • What about Living Wills? • Do we all “have a responsibility” not to be a burden on society under certain circumstances?

37. Example from practice – 14 • Should mentally disabled babies be prevented from growing/maturing?

38. Example from practice – 14 • Should mentally disabled children be prevented from maturing? • Has no awareness • Life should be as comfortable as possible • No sexual development – no periods • Perhaps remain light enough to be treated like a baby • Quality of life issues • But….?

39. The Fourth Principle • Allow people to determine their own futures • This is AUTONOMY • Such aspects as honesty / telling the truth / informed consent / decision sharing / maximising the ability of patients to make choices • CONFIDENTIALITY comes under this principle

40. A further aspect • There is another aspect to this and that is SCOPE • To whom do we owe these duties? • Who are the interested parties? • Individuals or patients as a group? The Practice? The NHS? Society? Government?

41. Example from practice – 15 • Ethical research

42. Example from practice – 15 • Ethical research • Blood tests without specific consent • Blinding patients / consent • Taking tissue • Keeping tissue • Human Tissue Act 2004

43. Example from practice – 16 • Practice-based commissioning

44. Example from practice – 16 • Practice-based commissioning • Whose interest does this serve? • Is allocation of funds based on historical referral patterns a fair way to do it? Should some practices/patients/areas of deprivation have more? • Who decides on the amount? Should one practice which “saves” support others who “overspend”? • What about the time used in such a process? • Whose responsibility is it if overspends occur? The practice’s? The patients’? The PCT’s? The NHS’s? The Government’s? • What if PBC destabilises or damages secondary care providers’ services?

45. Example from practice - 17 • Do violent patients lose their right to confidentiality?

46. Example from practice - 17 • Do violent patients lose their right to confidentiality? • They may have to go somewhere “special” – different – for treatment; they may be in custody • They may have injured one of your colleagues and you may want or be asked to report something to the police • GMC advice is that information may be shared without consent where the public interests outweigh the benefits of keeping the information confidential - but may need a court decision

47. Example from practice – 18 • Having health provision

48. Example from practice – 18 • Having health provision • “Great physicians and nurses, skilled, caring and unparalleled in their training, intervened in my life and probably saved it. I was lucky but other Americans are not. It is time to speak again and stand again for the ideal that in the richest nation ever on this planet, it is wrong for 41 million Americans, most of them in working families, to worry at night and wake up in the morning without the basic protection of health insurance.”   • Senator John Kerry

49. The “Four Principles” of medical • ethics are: • Do good • Do no harm • Act fairly • Allow people to determine their own futures

50. Moral framework • The model of the Four Principles was suggested by the American ethicists Beauchamp and Childress • Popularised in UK by Ranaan Gillon • A moral framework such as this can help to give consistency in decision making • It is claimed that “Any ethical problem can be solved by considering these four principles” • But…