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Medical Ethics

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Medical Ethics Antony Vaughan General Practitioner Medical ethics principles Beneficence Non-maleficence Autonomy Justice Dignity Truthfulness Ethics: the study of ... – PowerPoint PPT presentation

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Title: Medical Ethics


1
Medical Ethics
  • Antony Vaughan
  • General Practitioner

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

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

4
Philosophy
  • Logic
  • Metaphysics
  • Ethics

5
History of ethics
  • 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

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 patients 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
  • Societys 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 isnt 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 mothers 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 sons 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 isnt 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 mothers 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 sons 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 isnt 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 mothers 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 sons death?

20
Branches of medical ethics
  • 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

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 AE 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 Ys 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
    Bobs 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 AE 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
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