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Medical ethics

Medical ethics. Dr D Grace MD. FFARCSI. Dip.ICM. Dept of Anaesthesia & Critical Care Medicine Altnagelvin Area Hospital. 1. Aims. Define and discuss (medical) ethical principles Outline practicalities & challenging issues arising in medical practice. 2. Ethics.

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Medical ethics

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  1. Medical ethics Dr D Grace MD. FFARCSI. Dip.ICM. Dept of Anaesthesia & Critical Care Medicine Altnagelvin Area Hospital 1

  2. Aims • Define and discuss (medical) ethical principles • Outline practicalities & challenging issues arising in medical practice 2

  3. Ethics • A branch of moral philosophy & the theoretical study of practical morality • Medical ethics - value judgements applied in a professional context • Ordinary morality 3

  4. Principles of medical ethics • Autonomy • Beneficence • Non-maleficence • Justice, equity, utility 4

  5. Autonomy • The capacity to think, decide and act freely and independently on the basis of such thought & decision Linked to autonomy are issues pertaining to: • Consent • Competence • Advance directives 5

  6. Consent - principles • “Every adult has an inviolable right to determine what is done to his or her body” Lord Donaldson • Required for examination, treatment, care • Verbal, written, implied, presumed • Given voluntarily • Informed / valid if the quality & clarity of information given is adequate and appropriate 6

  7. Competence • > 15 years of age competence is presumed unless evidence to the contrary • Adults may be competent to make some decisions but not competent to make others • Mental disorder / impairment does not of itself imply incompetence • Implies that one can understand, retain, evaluate and choose freely 7

  8. Advanced statements • Autonomy (expression of) • Facilitate communication • A useful guide to wishes • Facilitate a good death • Uptake limited • Impact limited • Potential for disagreement • Wording crucial • Circumstances unanticipated 8

  9. Beneficence / non-maleficence • The promotion of what is best for the patient - do good • Objective professional assessment v autonomous choice by patient - paternalism v autonomy • Non-maleficence - do no harm • Sanctity of life - quality > duration • Futility - inappropriate provision of life-prolonging therapies when there is no expectation of survival 9

  10. Justice • Right to be seen, heard, examined, treated • Healthcare resources are finite • One strives for a fair distribution of resources • Funds are rationed / treatment options are restricted • Advocates and rationers - medical profession, patient groups, individuals, government • Futility is very costly 10

  11. Utility • The maximizing of outcomes / preferences • Tension exists between utility & equity • Utility implies making service & provision choices • Concentrate resources? • Requires measurement and research 11

  12. Challenging scenarios • Right to treatment • Ordinary v extraordinary measures • Futility & treatment limitation • End of life issues and care • Commissions and omissions • Do not attempt resuscitation • Death & organ donation • Research 12

  13. Should all patients be treated? • Natural claim to care / natural duty & professional duty • Statutory “right” to care (consultation, advice, treatment) • Right to be received, respected, heard, advised, treated appropriately - if available • Responsibility for the treatment chosen rests with the clinician • When consulted Courts authorize but do not order care 13

  14. Ordinary / extraordinary treatment • Treatments with a reasonable probability of benefit with minimal burden • Actions may involve pain + distress • Proportionate v disproportionate measures • Duty to provide proportionate care 14

  15. End of life (E.O.L.) considerations in ICU • ICU aims to restore patients to well-being or to a functional existence • Medical intervention may prolong life / postpone death • E.O.L. issues including symptom palliation arise 15

  16. Futility + withdrawal • Balance likelihood of survival to discharge against risks & burdens of therapy • Institute/continue/escalate v non-instituting/ limiting/withdrawing treatment - all ethically equivalent • Communication is paramount • Ensure dignity, rights, comfort, wishes (of patient or proxy) • G.M.C., B.M.A., professional bodies provide guidelines & standards 16

  17. Omissions, commissions, & double effect • I context of inability to “cure” • Withholding & withdrawing differ from killing • Intent v foresight / double effect: palliation & cardiorespiratory depression - relieve burden + allow to die • Physician-assisted suicide / active euthanasia – illegal 17

  18. D.N.A.R. / P.N.D.(do not attempt resuscitation – permit natural death) • Cardiorespiratory arrest may -> cardiopulmonary resuscitation (C.P.R.) • C.P.R. success is circumstance-dependent • Consent (for C.P.R.) when unknown is invariably assumed • Communication re E.O.L. care is absolutely essential • Patient’s wishes & preferences determined • Multi-disciplinary input to decision invaluable • Treatment status / wishes recorded & reviewed 18

  19. Death • Death = the irreversible loss of the capacity to breathe and the capacity for consciousness - occurs when the brain stem ceases to function • Brain stem - the critical part of the critical organ • Traditional cardiorespiratory death v B.S.D. • Brain stem or “beating heart” death (B.S.D.) 19

  20. Organ donation • Demand rising, supply falling • Beating-heart (D.B.D.) & non-beating heart (D.C.D.) • Life-saving & life-enhancing • Requires consent / assent – patient or N.O.K. (next of kin) • Advance statement - register as potential donor - http://www.organdonation.nhs.uk • Presumed consent / opt out largely irrelevant as N.O.K.’s wishes actually paramount 20

  21. Medical research • An imperative – today’s research is tomorrow’s medicine • Requires funding & regulation • Potential conflict b/n public & personal interests? • Nuremberg code (1946) • Declaration of Helsinki (1964/2000) – concern for the interests of the individual must prevail over the interest of science & society. 21

  22. Research guidelines • Respect autonomy of potential participants thus rigorous consenting: (i) research (ii) not contrary to subject’s interests (iii) outcome unpredictable (iv) freedom to withdraw • Risk of harm – identifiable & quantifiable? Ideally risk < minimal! • Research of quality and of value 23

  23. Summary • Ethical concepts, definitions & context outlined • Autonomy, beneficence & non-maleficence, equity, justice & utility - the pillars of medical ethics • Consent + associated difficulties considered • Futility, commission, omission & double effect discussed • Special circumstances – D.N.A.R. - P.N.D. / death & organ donation 23

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