Transcript Document

Medical Ethics
VTS 24/09/08
Curriculum statement 3.3
Curriculum statement 3.4
Timothy McVeigh
Timothy McVeigh.doc
Should doctors have to swear
an oath when they qualify?
The Hippocratic Oath.doc
Modern Hippocratic Oath.doc
AMA Oath.doc
What is meant by Ethics?
What is meant by morality?
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
Example from practice - 1
• Microalbuminuria testing in diabetes
Example from practice - 1
• Microalbuminuria testing in diabetes
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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?
Example from practice - 2
• Immunisation
Example from practice - 2
• Immunisation
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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?
Example from practice - 3
• Patient empowerment
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?
Example from practice – 4
• Why don’t we just give patients
prescriptions if they ask for something?
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?
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
Example from practice - 5
• Cholesterol monitoring in the elderly
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?
Example from practice - 6
• Spirometry
Example from practice - 6
• Spirometry
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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?
Example from practice – 7
• Termination of pregnancy
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?
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
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The Hippocratic Oath does not contain 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.
Example from practice – 8
• Should the cost of prescriptions be an
issue?
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?
Example from practice – 9
• Fertility treatment
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
Example from practice – 10
• Ethical employment practice
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?
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
Example from practice – 11
• Is it ever right to break confidentiality?
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
Example from practice – 12
• Should doctors always tell patients their
diagnosis?
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?
Example from practice – 13
• Euthanasia
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?
Example from practice – 14
• Should mentally disabled babies be
prevented from growing/maturing?
Example from practice – 14
• Should mentally disabled children be
prevented from maturing?
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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….?
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
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?
Example from practice – 15
• Ethical research
Example from practice – 15
• Ethical research
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Blood tests without specific consent
Blinding patients / consent
Taking tissue
Keeping tissue
Human Tissue Act 2004
Example from practice – 16
• Practice-based commissioning
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?
Example from practice - 17
• Do violent patients lose their right to
confidentiality?
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
Example from practice – 18
• Having health provision
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
The “Four Principles” of medical
ethics are:
• Do good
• Do no harm
• Act fairly
• Allow people to determine their own futures
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…
Critique of this model
• It is not a coherent ethical theory
• Rather it is a mish-mash of ideas
• What about when there is conflict?
• How do these ideas fit with underlying ethical
theories?
Ethical theory
• The problem is that there is no single agreed
underlying ethical theory
• The task of Ethics is to try to arrive at some
conclusions without reference to religious ideas or
gut instinct
• There are two main ways of thinking about the
rightness or wrongness of an action –
Consequentialism and Deontology
Consequentialism
• This holds that the only thing that matters is the
consequences of an action
• Best known example of this type of idea is
UTILITARIANISM which proposes that the morally correct
course of action is that which results in the greatest good
for the greatest number of those affected by the action
• These ideas were developed and set down by the English
philosophers Jeremy Bentham – “An Introduction to the
Principles of Morals and Legislation” (1789) – and John
Stuart Mill – “Utilitarianism” (1861)
Good things about Utilitarianism
• “The central insight of Utilitarianism, that one ought
to promote happiness and prevent unhappiness
whenever possible, seems undeniable”
• Provides support for democracy as the way to
ensure that the interests of government coincide
with the general interest
• Socially beneficial e.g. in 19th century - anti-slavery
movement, promotion of women’s rights and
spread of suffrage
Bad things about Utilitarianism
• Disregards the distribution of benefits and burdens on
individuals
• Can we correctly work out what the consequences of an
action are?
• How can the sum of the benefits of actions be calculated?
• Difficult to compare alternatives
• Is more to morality than simply consequences?
Bad things about Utilitarianism
• Might sometimes justify killing – killing Hitler as a child
could have saved millions of lives
• Deciding how to use limited resources – water, food,
oxygen – in critical conditions - choosing one Siamese twin
to survive after separation surgery instead of neither
• Triage and rejection of critically injured patients after
terrorist atrocities
• If there are problems with Utiltarianism under these
conditions, is there a general problem?
Deontology
• These sorts of ethical theories regard obligation as
deriving from reason or as residing primarily in
certain specific rules of conduct rather than in the
maximisation of some good
• Concepts like duty, moral obligation, moral
commitment, what you should and should not do
Good things about Deontology
• Usually some sort of coherent system
• Might give a set of answers to a range of problems
• Chimes with what individuals feel about things
• Fits with ideas of rules, laws, commandments
3 ¶ Thou shalt have no other gods before me.
4 ¶ Thou shalt not make unto thee any graven image, or any likeness of any thing
that is in heaven above, or that is in the earth beneath, or that is in the water under
the earth:
5 thou shalt not bow down thyself to them, nor serve them for I the LORD thy God
am a jealous God, visiting the iniquity of the fathers upon the children unto the third
and fourth generation of them that hate me;
6 and showing mercy unto thousands of them that love me, and keep my
commandments.
7 ¶ Thou shalt not take the name of the LORD thy God in vain for the LORD will not
hold him guiltless that taketh his name in vain.
8 ¶ Remember the sabbath day, to keep it holy.
9 Six days shalt thou labor, and do all thy work:
10 but the seventh day is the sabbath of the LORD thy God: in it thou shalt not do
any work, thou, nor thy son, nor thy daughter, thy manservant, nor thy maidservant,
nor thy cattle, nor thy stranger that is within thy gates:
11 for in six days the LORD made heaven and earth, the sea, and all that in them
is, and rested the seventh day: wherefore the LORD blessed the sabbath day, and
hallowed it.
12 ¶ Honor thy father and thy mother that thy days may be long upon the land
which the LORD thy God giveth thee.
13 ¶ Thou shalt not kill.
14 ¶ Thou shalt not commit adultery.
15 ¶ Thou shalt not steal.
16 ¶ Thou shalt not bear false witness against thy neighbor.
17 ¶ Thou shalt not covet thy neighbor's house, thou shalt not covet thy neighbor's
wife, nor his manservant, nor his maidservant, nor his ox, nor his ass, nor any thing
that is thy neighbor's.
Code of Hammurabi - laws from the sixth
king of the Amorite Dynasty of Old Babylon
c. 1760 BC – contains medical aspects
Code of Hammurabi.doc
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“The essence of Buddhism is very simple:
it is finding ways to transform oneself. It
could be summed up as 'learning to do
good; ceasing to do evil; purifying the
heart' (as the Dhammapada says)”.
Bad things about Deontology
• Deontology depends on a variety of ideas • The fundamental principles of right and wrong are
authoritative by virtue of being self-evident truths
• There are axiomatic or intuitive ideas of rightness or
wrongness
• (Some consider that) moral principles are based on Godgiven laws for humanity
• But..
• Not all accept appeals on such “absolute” grounds
• It is easy to say if something is “square” but is it similar
when something is described as “right”?
Conclusions and implications
• Things are not always as straightforward as
they may seem
• There are ethical aspects to many medical
situations
• If the problem is an ethical one, try to
generate lots of options – rule nothing out
• Assess the advantages and disadvantages
of each solution using the four principles
• Consider consequential and deontological
theory
Conclusions and implications
• There may be legal precedents
• There are sources of help and advice –
colleagues, GMC, medical defence
companies, RCN
• Impart decisions to patients in an
ethical way
• Record everything