Medical Ethics

1. Medical Ethics Antony Vaughan General Practitioner

2. Medical ethics principles • Beneficence • Non-maleficence • Autonomy • Justice • Dignity • Truthfulness

3. Medical Business Environmental Legal Political Feminism Animal rights Bioethics Gay rights Ethics: the study of the moral value of human behaviour

4. Philosophy • Logic • Metaphysics • Ethics

5. 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 History of ethics

6. 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 patient’s 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 • Society’s 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 isn’t 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 mother’s 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 son’s 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 isn’t 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 mother’s 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 son’s 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 isn’t 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 mother’s 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 son’s death?

20. 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 Branches of medical ethics

21. 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

24. 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

26. 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 A&E 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 Y’s 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 Bob’s 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 A&E 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