Medical Ethics Daniel Chase, MD Overview What is medical

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Medical Ethics

• Daniel Chase, MD

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Overview

• What is medical ethics?
• What are the generally accepted principles of
  medical ethics?
• How have medical ethics developed to the form we
  know today?
• What are codes of medical ethics, and which ones
  do we follow?

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Defining our Terms

• Morality - our belief about right and wrong
  (usually subjective and unexamined).
• Ethics - (a) the study of principles for choosing
  right action when doing right may also involve
  doing harm or wrong (b) the use of ethical
  theory to choose the best course of action (c )
  the study of what is good and bad in human
  character and conduct.

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Morality is our personal, subjective sense of
right wrong. Its sources include

• Up-Bringing
• Religion
• Peer Pressures
• Experience
• Local Rules
• The Media
• Self Interest

• Values
• Laws
• Loyalty
• Public Opinion
• Sense of Responsibility
• Attitudes, for example, Toward Science

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Ethical theories somewhatdiscourage such sliding
around. They force us to moresystematically
define the assumptions that underlie our
decisions about of what is the right action to
take in a given situation.
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Where Does Ethics Come From?

• Tradition
• Thats the way its
• always been.

• Authority
• Thats the way I
• was taught to do it.

• Reason
• Thats the way
• reality determines
• we ought to behave.

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Definition and Scope of Medical Ethics

• - System of values common to the medical
  profession.
• - Systematic application of values concerning the
  practice of medicine.
• - Standards of behaviour by which the physician
  may evaluate his/her relationships with
  patients, colleagues and society.
• - Scope of medical ethics includes
• development of ethical codes and guidelines
• promotion of ethical practice
• prevention of ethical breaches
• recognition of ethical dilemmas
• resolution of ethical conflicts

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Components of Medical Ethics

• The Physician -- Patient Relationship
• The Physician -- Physician Relationship
• The relationship of the Physician to the System
  of Healthcare
• The Relationship of the Physician to Society

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What are the Medical Ethical Principles?

• What are the Medical Ethical Principles?
• Beneficence?
• Non-Maleficence?
• How about . . .

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Current Operative Principles of Medical Ethics

• The Principle of Make-more-money-ence
• The overriding principle of all physician
  behavior, this above all dictates patient care
  decisions.

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Current Operative Principles of Medical Ethics

• The principle of Dont-get-sued-ience
• Second only to make-more-money-ence, this most
  important principle is behind many unnecessary
  tests and consults.

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Current Operative Principles of Medical Ethics

• The Principle of Turficence
• Learned early in med school or residency, this
  principle requires the physician to always ask
  the question, could I turf this patient to
  someone else?

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Current Operative Principles of Medical Ethics

• The Principle of Distributive Justice
• Distribute the blame of your failure to as many
  other people as possible, including the patient.

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Current Operative Principles of Medical Ethics

• The Principle of Malevolence
• The more of a jerk you are to the staff, the
  farther youll go.
• Screaming and yelling is a perfectly acceptable
  practice and has a long, proud tradition in
  medicine.

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Current Operative Principles of Medical Ethics

• OK, time to be serious so I dont get fired.

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THE PRINCIPLES IN MEDICAL ETHICS

• The Principle of Non-Maleficence
• The Principle of Beneficence
• The Principle of Autonomy
• The Principle of Veracity
• The Principle of Confidentiality(or Fidelity)
• The Principle of Social Responsibility and Justice

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The Principle of Non-Maleficence

• first do no harm Primum non nocere
• sanctity of life
• calculated risk or risk benefit

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Impaired Physician

• Physicians have the obligation to report impaired
  behavior in colleagues

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Beneficience

• Obligation to preserve life, restore health,
  relieve suffering and maintain function
• To do good
• Nonabandonment obligation to provide ongoing
  care
• Conflict of interest must not engage in
  activities that are not in patients best interest

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Autonomy

• Right to self-determination
• Requires decision making capacity
• Lack should be proven not assumed
• Competence legal determination
• Liberty freedom to influence course of
  life/treatment

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The Principle of Veracity

• Truth telling
• Obligation to full and honest disclosure

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The Principle of Confidentiality

• Based on loyalty and trust
• Maintain the confidentiality of all personal,
  medical and treatment information
• Information to be revealed with consent and for
  the benefit of the patient
• Except when ethically and legally required
• Disclosure should not be beyond what is required

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The Principle of Justice and Social Responsibility

• Actions are consistent, accountable and
  transparent
• not to discriminate on age, sex, religion, race,
  position or rank
• Allocation of medical resources must be fair and
  according to need
• Physicians should not make decisions regarding
  individuals based upon societal needs

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What is an Ethical Dilemma?

• A conflict between moral imperatives, i.e., what
  is the right thing to do?
• What is medically right vs. patient preference
• Jehovahs Witnesses and transfusions
• What is preferred by patient vs. proxy decision
  maker
• Rights of minor vs. legal guardians
• What is best for patient vs. what is best for
  society
• Commitment laws, notification of sexual partners
  of patients with HIV

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Resolution of Ethical Dilemmas

• Principles
• Ethical codes
• Clinical judgement
• Reasoned analysis
• Ethical committees
• Ethical tests

• Declarations
• Oaths Pledges
• Common Sense
• Debate
• Ethical Consults
• The Law

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Key Moments in History of Medical Ethics

• The Hippocratic texts display a sustained
  appreciation for the limits of medicine and the
  need to prevent unnecessary iatrogenic harm to
  the sick
• The Art
• ... I will define what I conceive medicine to
  be. In general terms it is to do away with the
  sufferings of the sick, to lessen the violence of
  their diseases, and the refuse to treat those who
  are overmastered by their diseases, realizing
  that in such cases medicine is powerless.

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Key Moments in History of Medical Ethics

• Central themes of the Hippocratic texts
• Hippocratic physicians were in a crowded, harsh,
  and unforgiving medical market place
• Physicians and other practitioners with high
  mortality rates faced failure and poverty
• Reputation for being a good physician, whose
  patients die only from their incurable diseases
  and injuries, becomes paramount
• Leaving off the care of the dying becomes a
  matter of urgent self-interest and good
  reputation
• My patients die from their incurable diseases and
  injuries, not anything that I do
• Prognosis emerges in the Hippocratic text as the
  central clinical skill of the physician

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Key Moments in History of Medical Ethics

• Scottish physician-ethicist, John Gregory
  (1724-1773), wrote the first modern work on
  professional medical ethics in the English
  language
• Used philosophy of medicine and philosophical
  ethics to reform medicine into a profession
• Gregory changed the ethical standard of care for
  dying patients

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Key Moments in History of Medical Ethics

• John Gregory, Lectures on the Duties and
  Qualifications of a Physician (1772)
• Medicine, or the art of preserving health, of
  prolonging life, of curing diseases, and of
  making death easy.

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Key Moments in History of Medical Ethics

• Thomas Percival (1740-1804) was an English
  physician best known for crafting perhaps the
  first modern code of medical ethics. He drew up a
  pamphlet with the code in 1794 and wrote an
  expanded version in 1803, in which he reportedly
  coined the expression "medical ethics
• Percival's Medical Ethics served as a key source
  for American Medical Association (AMA) code,
  adopted in 1847.

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Nuremberg Trials
See anyone we know?
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Key Moments in History of Medical Ethics

• The International Military Tribunal of 1946,
  convened by the U.S., British, French and
  Soviets, which convicted the major Nazi leaders
  who survived World War II
• AND
• Twelve cases tried by U.S. military tribunals at
  Nuremberg from1946-9 of groups of doctors,
  lawyers, industrialists, Einsatzgruppen and more.

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Key Moments in History of Medical Ethics

• Nuremberg Code of Ethics
• Informed Consent mandatory and exercised freely
• Experiments must avoid physical and mental
  suffering
• Experiments must be avoided if death or disabling
  injury a possibility
• Information from Nazi experiments is taboo

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Medical Codes

• Professional ethics of codes
• Developed through a process of collaboration,
  consensus, and finally codification
• Notion of professional self-regulation

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AMAs Code of Medical Ethics
1847 Edition
2001 Edition
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AMAs Code of Medical Ethics

• The Code first drafted by Drs. Bell and Hays was
  based on Percivals conceptions of professional
  ethics
• A living compendium of ethical guidelines for
  physicians that is continually revised and
  updated by the Council on Ethical and Judicial
  Affairs
• The Code is freely accessible at
• www.ama-assn.org/ceja

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Awareness of the Code

• Routinely cited in legal cases and frequently
  referenced by judges, lawyers, legal scholars,
  and state licensing boards
• Ironically, physicians are generally unaware of
  the ethical guidance embodied in the Code
• Illustrative example
• - Capital punishment

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Capital Punishment
Disallowed actions include Starting
intravenous lines for lethal injection drug
Determining death during execution
Administering the lethal drug Supervising
personnel who give the lethal drug
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Capital Punishment
Disallowed actions include Ordering lethal
drugs for the prison pharmacy Maintaining or
inspecting lethal injection devices
Monitoring vital signs during execution
Selecting injection sites for lethal drugs
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Physician Attitudes about Capital Punishment

• 80 indicated that at least 1 of the disallowed
  actions was acceptable
• 53 indicated that 5 or more were acceptable
• 34 approved all 8 disallowed actions

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Northsides Code of Ethics

• Do you know what it is?

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House Staff Manual

• Resident Physicians are governed by and are
  expected to abide by the policies and procedures
  which have been approved by the Graduate Medical
  Education Committee. In addition, it is expected
  that residents will follow all established
  practices, policies, and procedures of the
  hospital which may be determined by the
  professional staff, board of trustees, and the
  administration of the hospital.

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Professional Conduct

• All resident physicians shall maintain
  satisfactory performance in relation to the
  educational program, patient care, professional
  ethics, morals, personal integrity and demeanor.

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Personal Demeanor

• No smoking in facilities
• No drugs or alcohol at work
• No sexual harassment

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Miscellaneous

• Wear lab coats and ID badges, business attire,
  including pantyhose.
• Attend the educational program
• Complete Medical Records

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Doctor-Patient Relationship

• The conduct of the resident physician will
  always be directed toward the best interest of
  the patient.
• Dont criticize patients management in front of
  them.
• The resident should render all possible aid and
  comfort to the patient. . . Courtesy and
  consideration for others, especially patients and
  the patients family are essential.

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Relations with Attending Physicians

• Notify attending physician of changes in patient
  status or death.

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Summary

• Medical Ethics is the systematic application of
  principles of behavior to the practice of
  medicine
• Commonly agreed on principles include
  Non-Maleficence, Beneficence, Autonomy, Veracity,
  Confidentiality, and Justice.

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Summary

• Starting in the 18th and 19th centuries, medical
  ethics has become a recognized discipline. Based
  on earlier traditions and principles more
  recently articulated, it seeks to provide a
  useful framework for understanding and resolving
  ethical conflicts.

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Summary

• Ethical codes have been published by various
  medical organizations, and provide a guideline
  for behavior for physicians.