Introduction to medical ethics

1. Introduction to Medical Ethics
Lecture 1
Medical Ethics: Theories and
Principles

2. Programme aims
 Definition of Medical Ethics
 Scope of Ethics in Medical Practice
 Theories and principles
 Duties of a Doctor

3. Objectives
 Within small groups and by using case
based material you will be able to:
 1)Recognise ethical issues
 2)Recognise ethical conflicts
 3)Practice verbal reasoning skills
 4)Be aware of own and others moral
values

4. “Patients are entitled to good standards of
practice and care from their doctors.Essential
elements of this are professional competence,
good relationships with patients and colleagues
and observance of professional ethical
obligations.”
From Good Medical Practice, GMC.

5. Importance of Medical
Ethics
1. Increasing profileRecent press
headlines:
 Dr Cox (euthanasia)
 Alder hay Enquiry
 Jodie and Mary
 Destroying frozen embryos
 Refusal to fund marrow
transplantsnew drugs

6. Importance of Ethical
Issues (contd.)
2)Increase in technology
3)Better informed society
4)Doctors in Management
5)Public scrutiny

7. Scope of ethics in
Medical Practice
1. Historical background
• Hippocratic oath
• Geneva(1947)
• Sydney(1968)
• Tokyo(1975)
• Lisbon(1981)
1. Multidisciplinary nature

8. Four Misconceptions
1. Clear distinction :clinical and ethical analysis
2. Clear distinction: profess. and everyday ethics
3. Enshrined in lead
4. Medical ethics=matter of opinion
Doctor X is considering whether or not to break
a confidence.
Patient has presented with an STD which he
wishes to have treated confidentially.His wife
is also your patient.What do you do?

9. DEONTOLOGICAL THEORIES
Some principles are intrinsically right
- regardless of resulting consequences.
CONSEQUENTIALIST THEORIES
Consequence alone determines right and
wrong.
- greatest happiness of the greatest
number.

10. Principles
1. Beneficence
2. Non-Maleficence
3. Autonomy
4. Truth telling
5. Confidentiality
6. Preservation of Life
7. Justice

11. Beneficence and Non-
Maleficence
Questions:
1)Is the patient your only concern?
(possible conflict with utility)
2)Do we always know what is good for
the patient?
(patient’s view may differ from ours)

12. 3 constraints on
Beneficence
1. Need to respect autonomy-patient and
doctor may differ re. Management
2. Need to ensure health is not bought at
too high a price
3. Need to consider rights of others

13. Autonomy
1. Capacity to think, decide, take action
2. Mental incompetence= no autonomy
3. Autonomy –v-Paternalism
When patient not autonomous –no
clash. When patient autonomous-
questionable procedure

14. Truth Telling
“In much wisdom is much
grief:and he that increaseth
knowledge increaseth
sorrows”
(Ecclesiastics 1,18)

15. Truth telling (cont)
If you override it you endanger
doctor/patient relationship(based on
trust)
You offend against the principle of
autonomy(Dr.C Mooreland)
At times there are good reasons for
overriding the truth telling principle

16. The case for deception
is founded on three
fallacies
1. Hippocratic obligations
2. Not in a position to know the
truth
3. Patients do not want the truth
if the news is bad

17. Confidentiality
 Act against this principle and you
destroy patient’s trust
 Clash –when keeping confidentiality
would harm others eg child abuse
 Should patients have access to their
notes?

18. Against
 Layman unable to cope with data
 Opinions not facts cause anxiety
 Third party information
 Defensive medicine

19. For
 Data belongs to patient
 Accuracy improved by sharing

20. Access to Records
 Data Protection Act (1998)
 What records are covered?
 Does it matter when the record was made?
 Who can apply?
 Are their exemptions?
 Must copies be given if requested?
 Access to records of deceased patients?

21. Exceptions to Medical
Confidentiality
 Pt gives written and valid consent
 To other participating professionals
 Where undesirable to seek patients consent
info can be given to a close relative
 Statutory requirements
 Ordered by Court
 Public interest
 Approved Research

22. Preservation of Life
 At what stage does human life begin?-
coil, pill
 Can we assess another persons quality
of life?-Jehovah's Witness

23. Euthanasia
 Active: an active intervention to end life
 Passive:deliberately withholding treatment
that might help a patient live longer
 Voluntary :euthanasia is performed
following a request from a patient
 Doctor assisted suicide : a doctor
prescribes a lethal drug which is self
administered by the patient
 Non-voluntary :ending the life of a patient
who is not capable of giving permission
 Involuntary:ending life against a patients will

24. Other Moral doctrines
 Acts and Omissions Doctrine -held
by those who believe that passive
euthanasia is not killing(killing is an
act,and an omission is not an act)
 Doctrine of Double effect -makes a
distinction between what I intend and
what I merely foresee

25. Living Wills
 Patient unconsciousseverely mentally
disabled , and two docs agree it unlikely
he will be able to communicate
treatment decision
 Refuse treatment if prolongs life with no
further benefit to patient

26. Justice
 How to allocate scarce healthcare
resources?
1. Medical need
2. Medical Benefits
3. Social worth-discriminates against
underprivileged
4. Merits/contribution to society-very
contentious
5. Desert
6. Market Forces
7. A lottery

27. Contaception and Minors
1. Jane aged 15 yrs requests the OCP
2. Her mum phones you the next day
3. Several weeks later she tells you her
boyfriend slapped her across the face
4. Her boyfriend is her history teacher

28. Lord Fraser’s
reccomendations
 The doctor should assess whether the
patient understands hisher advice
 The doctor should encourage parental
involvment
 The doctor should take into account
whether the patient is liekly to have sexual
intercourse without contraceptive treatment
 The doctor should assess whether the
patient’s physicalmental healthare likely to
suffer if she does not receive
advicetreatment
 The doctor must consider whether the
patient’s best interestsrequire himher to
provide contraceptive advicetreatment

29. 4th Year- Case history
 A 25 yr old lady comes to the treatment
room requesting syringes.She is a
lesbian and wishes to inseminate
herself.
 1) What else would you like to know
 2)What are the ethical issues
 3)What would you do

30. Duties of a Doctor
Please apply ethical principles
to the above list as described
in “Good Medical Practice”

31. Truth Telling Video clip
1. How much information should be
given to patients preoperatively?
2. When/how should we relay
information to a postoperative patient?
3. What lessons can be learned from this
tape?