Medical Ethics

1. Medical Ethics Sarah Kelt

2. Disclaimer “I’m not an ethicist but I do ethics”

3. Beginnings and endings • Ethical dilemmas cluster at the beginning and end of life • My experience is end of life • I won’t cover abortion, fertility treatment, premature babies etc

4. Ethical theories I know nothing about • Metaphysics • Teleology • Kantian ethics • Deontology • Utilitarianism

5. Ethics I know a little about • 4 principles of modern bioethics • Beauchamp and Childress 1979 • Autonomy • Justice • Benificence • Non-maleficence

6. Autonomy • Paramount • Being self-governing • Able to exercise free will in making a personal decision • A right to withhold consent • Applicable to anyone who has capacity

7. Beneficence • Literally being charitable or doing good • Performing care so as to maximise patient wellbeing • Exercising clinical judgement • Going beyond the minimum standards required

8. Non-malificence • Doing no harm • Avoidance of putting a person at risk of avoidable harm • A 1st step towards beneficence • Defined under the Hippocratic oath

9. Justice • No single definition • Usually distributive justice when applied to medical ethics • Fairness • Equity • Method of righting wrongs

10. Limitations • Very simplistic • Autonomy trumps the other principles • Role of justice • No coherent approach to resolving conflicting principles

11. Patient expectations Family expectations Genuine uncertainty Wishes of patient Wishes of family Cultural values Religious values Preferences of professionals Power balance within the healthcare team Trust policies Financial issues Legal issues Other factors

12. You are a doctor in a hospice Ken 45-year-old has always lived with mum Barbara. He is dying of mouth cancer. He wants to eat but when he does he chokes. The nurse asks you to sedate Ken as Barbara can’t bear to see him choking. Will you give him sedation? What will you say to the nurse and Barbara?

13. Dilemmas and topical issues

14. Replaced best practice and common law Adults who may be unable to make a decision Decision specific Time specific Assessment Presumption of capacity Support to make decisions Unwise decisions Best interests Least restrictive option Mental capacity act

15. Terms • LPA • Court appointed deputy • Court of protection • Public Guardian • IMCA

16. Advance decision to refuse treatment • Validity • Has to be made when competent • Applicability • Have anticipated the situation • And the implications of the decision • If relating to withdrawing or withholding life sustaining treatment • In writing, signed, witnessed • Express “even if life is at risk”

17. You are a young doctor in A&E Mary 80-year-old lady admitted to hospital this morning with a stroke. She has collapsed and her heart has stopped. The nurse tells you Mary told a student nurse she didn’t want CPR if she collapsed. Will you resuscitate her?

18. Euthanasia/PAS/slow euthanasia • Euthanasia • Active – an intentional act • Passive – due to an omission • Voluntary • Involuntary - ?killing • PAS – Carried out by patient with help of another • Slow euthanasia – sometimes used for terminal sedation

19. Joan 94-year-old with advanced lung cancer. All treatment has failed. She is admitted to the hospice as her family can’t manage to look after her at home. She isn’t able to wake up or speak but she is very distressed and agitated. You feel she is dying and start her on sedatives to settle her agitation. She dies the next day – peacefully.

20. What happened next Joan’s daughters say “She was fine before she came in. The sedative you gave killed her. Why didn’t you give her a drip when she couldn’t drink?” • Did you kill her • Morally? • Legally? • Should you have given her a drip?

21. Doctrine of double effect Thomas Aquinas and Dr Adams • An action having good and bad consequences is defensible if: • The nature of the act is good • The intention is for the good effect • The good effect outweighs the bad and the situation is grave enough to risk yielding to the bad effect • The good effect does not depend on the bad effect

22. Dr Adams British GP and suspected serial killer. Edith Alice Morrell was paralysed by a stroke. She was given a cocktail of morphine, diamorphine (heroin) and barbiturates to treat cerebral irritation and help her sleep. He arranged her cremation on the day of her death, stating on the form her had no pecuniary interest. He received a Rolls Royce, silver cutlery and a lamp.

23. Question The doctrine of double effect became well known through this case. Does it apply?

24. Withholding and withdrawing treatment • Are they any different • In theory? • In practice? • Are nutrition and hydration basic care or a medical treatment • When given by mouth? • When given through tubes?

25. You are a doctor in a hospice Jane 36-year-old lady with breast cancer. Has a supportive husband, no children. Her GP send her to the hospice to die. Jane has been told by her GP that the hospice will give her intravenous antibiotics and blood transfusions to make her better. You feel that she is dying and no treatment will help. These treatments aren’t possible in the hospice.

26. Dilemmas • What do you tell Jane? • What do you tell her husband? • What treatment do you give • Send to hospital for aggressive treatment but poor end-of-life care? • Give oral treatment that you know won’t work? • Give no treatment, just supportive care?

27. Allocation of scarce resources • Resources available are not infinite • Drug companies exist to make a profit • The development of new treatments is motivated by profit • How do we decide which treatments should be funded?

28. You are the chief exec of the local PCT You have overspent on last year’s drug budget by several million. You have been asked to fund several programmes but can only afford to support one of them. • Which of the following programmes would you support? • What factors would influence your decision?

29. Your options • Herceptin for early breast cancer • A drug for those at risk of stroke that costs £10 per week and decreases risk of stroke by 60% • A programme that would provide care for terminally ill people to die at home • Increased staff parking at the local hospital

30. Endings • Ethical decisions are an everyday occurrence • Situations often complex • Consider all the factors • Consider each decision individually • Does autonomy really trump all other considerations?