Introduction to Clinical Ethics

1. Introduction to Clinical Ethics Ben Faneye, OP, DHCE West African Bioethics Training Program

2. Historical Background • Evolution of clinical ethics, attributed to certain needs: • Need for bedside teaching of ethics – William Osler’s medical teaching tradition • Need for a method of ethical enquiry most suitable to individual clinical settings • Need to create a bridge btw academic world of bioethics & the world of clinicians and pts.

3. Clinical Ethics: Its Content • Concerned with restoring and strengthening bonds between professionals, patients and families. This is contrary to the conflicting principles of bioethics. • Uses cases and relies on the clinician-patient relationship/encounter in contributing to research on ethical issues.

4. Clinical Ethics: Its Content • Focuses on issues of concern to clinicians, patients & the general society • Issues stemming out of real life encounters • Uses its empirical findings to encourage reform practices among clinicians, which helps establish the 2-world relationship.

5. Clinical Ethics: Services • To provide clinical ethics education to clinicians, patients, surrogates and the larger community • Policy studies and recommendations for institutional guidelines on ethical issues in pt. care.

6. Clinical Ethics: Services • Providing a process for case consultation at the bedside or the conference room • Researching ethical problems and initiating prevention plans for such problems often encountered.

7. Clinical Ethics: Its Practice • Ethical Obligations: Basis for praxis • Stem from the concept of duty, which is the necessity of action done out of respect for the law. • Connotes what one is bound to do in situations arising from patient care. • A recognition of one’s duty in upholding another’s rights (pt’s rights).

8. Ethical Obligations In Cases • Respecting Privacy & Confidentiality • Right to privacy: which is a person’s claim to those things that define one as such, e.g., thoughts, feelings, aspirations, information, physical body.

9. Ethical Obligations In Cases • Privacy rights: Its types • Negative right is right to non-interference or to be left alone, e.g., right to bodily integrity. It is a right that restricts others. • Positive right is a person’s prerogative to control access to and distribution of information about the self, e.g., patient’s control over treatment. This ordinarily requires the active participation of others.

10. Ethical Obligations In Cases • Confidentiality: Corresponding duty • Mechanism by which a person’s right is recognized and respected • Based on a fiduciary relationship, some sort of promise, whereby a clinician recognizes one’s duty to safeguard a patient’s rights • Basis for intimacy between persons, clinicians and patients and families

11. Ethical Obligations In Cases • Confidentiality: Why? • Public knowledge of health records can cause discrimination and embarrassment • Required by law and professional code, a breach of which can lead to disciplinary and legal action against an organization and employee

12. Ethical Obligations In Cases • Confidentiality: What is covered? • Personal information that can identify a pt • Treatment information • Details about illness and/or diagnosis • Medical Record • Conversation btw clinician and pt and/or family.

13. Ethical Obligations In Cases • Confidentiality: Basis of duty • Hippocratic Oath – “And whatever I shall see or hear . . . I will never divulge, holding such things to be holy secrets.” • T. Percival in his Code for Medical Ethics (later adopted by AMA in 1847)states: “Patients should be interrogated concerning their complaint in a tone of voice which cannot be overheard.”

14. Ethical Obligations In Cases • Confidentiality: Basis of duty • International Council of Nurses’ Code – “the nurse holds in confidence personal information and uses judgment in sharing this information.”

15. Ethical Obligations In Cases • Respect for Patients’ Decision-Making Capacity • Duty towards pts stems out of pt’s right of autonomy • Autonomy is a person’s right to determine what happens to, or is done to the self (paternalism, an issue).

16. Ethical Obligations In Cases • Respect for Patients’ Decision-Making Capacity • Corresponding to this right is clinician’s duty to ascertain and enable the pt in exercising autonomy right (duty to inform). • A determination of pt’s capacity considers: • Individual abilities of pt, e.g., sound mind or not • Importance of the decision at hand • Consequence likely to follow from decision

17. Ethical Obligations In Cases • Respect for Patients’ Decision Making Capacity • Where pt is deemed incapable, there are standards in place for surrogate decision makers.

18. Ethical Obligations In Cases • Standards for Surrogate decision-makers: • Substituted Judgment: decision made based on the known & perceived wishes of the pt. • Best Interest: decision made based on what a reasonable person would do. Risks & benefits of treatment analyzed, with goal of maximizing benefits and minimizing harms.

19. Ethical Obligations In Cases • Decisional Capacity: What is it? • “Ability to make a decision” • Exercise of free power of choice (no force) • Crucial aspect of voluntary consent • Focuses on giving or withholding consent for treatment.

20. Ethical Obligations In Cases • Respect for Decision Making Capacity: Its Challenges • Incapable pts giving consent does not validate treatment by clinician (possibility of self-harm) • Clinician who withholds treatment from an incapable pt who refuses treatment risks liability if other legally valid treatment authorization steps are not sought.

21. Other Obligations In Clinical Cases • Communication: • Ability to listen to and understand the pt’s story & body language • Truth-telling: • Clinician’s professional integrity imposes a negative duty not to lie, as well as a positive duty to tell the truth about what the pt has right to know.

22. Other Obligations In Clinical Cases • Disclosure: • Duty to provide information about care to be given to the pt. Clinician determines what information is too much/little. • Therapeutic privilege, an exception to informed consent N.B.: These 3 obligations are derived from the principle of respect for pt’s autonomy.

23. Clinical Ethics & Principles • Major bioethics principles provide basis for the ethical obligations in clinical ethics • Practical orientation adopted by clinical ethics in light of the dynamism of interpersonal (clinician, pt, family) relationships.