Ethical issues in adult and child neurology

1. ETHICAL ISSUES IN ADULT
AND CHILD NEUROLOGY
Dr. Shubham Garg
SR Neurology
GMC Kota

2. INTRODUCTION
• Ethics is the study of actions taken by moral
agents, to determine if they are good
(praiseworthy) or bad (blameworthy).
• Clinical ethics is the application of ethical
theories, principles, rules, and guidelines to
clinical situations in medicine.
• Clinical ethics is the branch of medical ethics that
applies to practitioners involved in caring for
patients.

3. • Ethical and moral dilemmas are common in
clinical practice, especially in neurology practice.
• Guidelines are few, and there are often
conflicting opinions on various issues.
• It is important to understand or discuss the
ethical issues so as:-
To satisfy patients or families
To keep our conscience clear and
To prevent medical law suits .

4. SUBDISCIPLINES WITHIN ETHICS
• Biomedical ethics (bioethics) : deals with the ethical
implications of biology in patient care, research and
policy development.
• Neuro-ethics : are the ethical, legal and social policy
implications of neurosciences, including clinical care and
neuroscience research (Illes and Bird, 2006).
• Most of the ethical issues that the neurologist will
encounter fall within the classification of clinical ethics,
although some issues will extend beyond traditional
medical situations .

5. • Virtue-based ethics, with its emphasis on the
moral character of the physician, may be of
particular interest.
• It focuses attention on the motivations behind
and the behavior that make up a physician’s
practice of medicine.
• Activities that enhance the physician’s virtuous
behavior will result in greater good for the
patient.

6. INTERPLAY BETWEEN ETHICS AND LAW
• Ethical statements are neither binding nor
enforceable in contrast, laws are both binding and
enforceable.
• Overlap between ethics and law is related to three
factors:
i. The purpose of each discipline,
ii. The character of medicine as a traditional profession,
iii. Societal responses to past ethical abuses by
physicians and scientists.

7. ETHICAL THEORIES
• Consequentialism
• Deontology
• Virtue ethics

8. ETHICAL PRINCIPLES
1. Respect for patient autonomy
2. Avoiding deception
3. Beneficence
4. Non-maleficence
5. Justice

9. ETHICS MANIFESTED IN LAW EXAMPLES
RELEVANT TO NEUROLOGY PRACTICE
• Non-maleficence : voluntary active euthanasia
and physician-assisted suicide
• Beneficence : - ending a patient–physician
relationship
- conflict of interest
• Respect for autonomy: Informed consent
• Justice

10. NON MALEFICENCE
• It refers to the physician’s responsibility not to harm his or
her patient.
• It is a prominent ethical principle that underlies laws
about physicians’ involvement in voluntary active
euthanasia and physician-assisted suicide. (in end-of-
life care )
• It is also a core principle with a extremely common
aspect of everyday neurologic practice - respect for
patient privacy.

11. • Active voluntary (after consent from
patients/relatives) euthanasia is legal only in
Netherlands, Belgium, Columbia and Luxembourg.
• It requires administration of an agent to hasten
death.
• Passive euthanasia involves withdrawal/withholding
of supportive treatments (such as antibiotics,
adrenaline, ventilator, etc) and is legal in US.

12. Reasons for the prohibition of voluntary active
euthanasia in codes of professional behavior includes-
• The possibility that the practice might be extended
to unwilling persons,
• The potential for coercion of members of vulnerable
populations
• The potential for reduced trust in the medical
profession

13. EUTHANASIA IN INDIA
• Active euthanasia by administering an injection is illegal in India
• Passive euthanasia is legal in India after a March 2011 judgment by
Supreme Court. (Aruna Shanbaug case)
• It is permitted by Supreme Court in two situations-
1. Brain dead patient, where the ventilator can be switched off.
2. Persistent vegetative state, where the feeds/water can be tapered
off, along with addition of pain-managing palliatives.

14. • Guidelines as laid down by the Supreme Court:
1. The decision can be taken by parents, spouse, other relatives, or
friend. Can be taken even by the doctor. It should be in the best
interest of the patient.
2. Even if the decision to withdraw life supports has been taken by
close relatives, prior approval from High Court is required to execute
the decision.
3. Chief Justice of High Court would constitute a bench of at least two
judges, who would decide to grant approval or not.

15. PHYSICIAN-ASSISTED SUICIDE
• Physician’s active assistance in implementing a patient’s
suicide plan, usually through prescribing drugs that will
be used in the suicide and possibly providing instruction
on their use for that purpose.
• It is legal in Switzerland and the US states California,
Oregon, Washington, Montana and Vermont.

16. PRIVACY
• The obligation of physicians to respect patient privacy, including the
embedded obligation to maintain patient confidentiality, was
articulated in the Hippocratic Oath (Hippocrates, 2002).
• Arguments supporting respect of privacy include -
• The deontologic rationale ( as a result of their special relationship,
with special knowledge about patient not available to the general
public)
• The utilitarian rationale ( patients will make full disclosures to their
physicians, when they are confident that the private aspects of their
lives will remain private) .

17. • The requirements that physicians respect privacy
and maintain confidentiality are not legal (or
ethical) absolutely
• Because there are legal rules that balance a
physician’s duty to protect patient privacy with
society’s need to have information for public
health and safety.

18. BENEFICENCE
• It is the ethical duty of physicians to act in the
patient’s best interest.
• Beneficence may involve actions to prevent
harm or actions to accomplish good.
• These include advocating for a patient’s needs,
caring for a difficult patient, seeing a patient
outside usual office hours, and avoiding conflicts
of interest.

19. Professional conduct
• Initiation of the physician- patient relationship
• Communication
• Therapeutic privilege
• Disclosure of medical errors
• Electronic communication
• Confidentiality

20. Professional misconduct
• Termination of the physician- patient relationship
• Conflicts of interest
• Disclosure of conflicts
• Reporting impaired physicians

21. Initiation of the physician- patient relationship
• Free to decide whether to undertake particular
patient
• Not decline on basis of race, religion, nationality,
sexual orientation, gender
• Provide care until care complete, patients ends
the relationship or is referred back to referring
physician

22. Communication
• Duty to communicate effectively with patient
• Convey relevant information
• Allow patients to raise question

23. Therapeutic privilege
• Withholding of relevant health information from the patient if
nondisclosure is believed to be in the best interests of the
patient.
• Disclosure ethically required in all but in extreme situations,
not mandatory disclose all information immediately.
• Physician’s own discomfort in delivering difficult news and to
avoid emotional suffering for the patient can never justify
withholding.

24. Disclosure of medical errors
• A medical error is the failure of a planned action to be completed as
intended or the use of a wrong plan to achieve an aim.
• Ethical obligation to disclose the error in a timely fashion
• Disclosure should include :
i. Explicit acknowledgment that an error has occurred,
ii. A description of the circumstances surrounding the error (including
what it was and how it happened),
iii. A description of how similar errors will be prevented in the future,
and
iv. An apology

25. • prompt and honest disclosure of errors
i. Increases patient satisfaction,
ii. Trust in medical system,
iii. And positive emotional responses ,
iv. Reduce the likelihood of legal action in the event
of an error.

26. • Failure to disclose medical errors is driven by a variety of
factors.
i. Fear of litigation,
ii. Lack of training in disclosure ,
iii. Physician’s perception of an error’s severity,
iv. Perceived responsibility for the error,
v. Fear that disclosure might distress the family or patient,
vi. Confusion about how much information to disclose

27. CONFIDENTIALITY
• Physicians have a primary ethical obligation to maintain
confidentiality of patient medical information
• This includes
i. Handling written documentation,
ii. Avoiding use of the patient’s identifiable health
information in general discussions with colleagues,
iii. Patients anonymous when discussing their medical
information in conferences or other educational forums

28. ELECTRONIC COMMUNICATION
• Physicians increasingly are using electronic forms of communication to
communicate with patients.
• Physicians should explain
i. What type of electronic communication is acceptable for that patient.
ii. The limitations of providing medical advice over electronic media.
iii. Quickly patients can reasonably expect the physician to respond to
electronic communication
iv. Physicians must take proper steps to protect the confidentiality of
information that is conveyed electronically, including, for example, properly
encrypting electronic devices

29. DUAL RELATIONSHIPS AND
PROFESSIONAL BOUNDARIES
• Physician maintain appropriate professional
boundaries by avoiding dual relationships that risk
excessive emotional proximity
• Unethical for a physician to engage in a sexual
relationship with a current patient.
• Physician’s position of authority and the patient’s
position of vulnerability raise the risk of exploitation
of the patient by the physician

30. • Sexual relationships between physicians and former
patients similarly unethical.
• Other potentially problematic dynamics include
business transactions between physicians and
patients and the acceptance of gifts by physicians.
• Should avoid accepting any gift that has the potential
to create an expectation of favoritism.

31. TERMINATION OF PHYSICIAN- PATIENT
RELATIONSHIP
• When there is a mutual decision on the part of the patient and
the physician to end a treatment relationship, no issue occurs.
• A patient may unilaterally end the professional relationship
with a physician at any time for any reason and without
permission or notice.
• Ethical statements note that the physician should attempt
to salvage the relationship even with a difficult patient.

32. • A patient should be dismissed from a physician’s
practice only for good reasons and after adequate notice
and identification of an alternative care provider.
• Legally, if a physician does not properly release a patient
from his or her practice, physician may be found liable for
patient abandonment.
• Can lead to investigation and disciplinary action by the
medical board of the state in which the
physician practices.

33. Conflict of Interest
• A conflict of interest occurs when a physician’s
professional judgment or actions toward a patient
(the physician’s primary interest) is unduly influenced
by circumstances that includes
i. Money (financial conflict of interest)
ii. Personal relationships,
iii. Stock ownership, gifts, meals,
iv. Desire for status, and feelings of obligation .

34. • Conflicts are to be avoided whenever
possible and managed.
• The goal in avoiding and managing conflicts of
interest is:
a) To avoid any actual wrong-doing or
b) To avoid perception that result in patient
discomfort or lack of trust in a physician.

35. RESPECT FOR AUTONOMY
• Respect for autonomy requires a physician to
foster and respect an individual patient’s right of
self determination.
• Informed medical decision making ( informed
consent ) is a fundamental ethical doctrine
grounded in the principle of respect for
autonomy.

36. • Patient competence consists of two parts: legal
competence and clinical competence.
• Adult patients and emancipated minor is legally
competent for all medical decision-making.
• In clinical competence, the patient can understand
information, formulate a decision, and communicate that
decision.

37. • Neurologists are often involved in the care of
patients for whom a question of clinical
competence exists.
• It may fluctuate across time, on the basis of
disease process, medication, and even time of
day.

38. Reporting impaired Physician
• Physicians may hesitate to intervene when
colleagues impaired by alcohol abuse, drug
abuse, or psychiatric or medical illness
• This place patients at risk. However, society
relies on physicians to regulate themselves.
• If colleagues of an impaired physician do not
take steps to protect patients, no one else may
be in a position to do so.

39. Responsibilities Of Physician To Each Other
 Dependence of Physicians on each other
• Should consider it as a pleasure and privilege to
render gratuitous service to all physicians and their
immediate family dependants.
 Conduct in consultation
• Respect should be observed towards the physician in-
charge of the case and no statement or remark be
made.

40.  Appointment of the substitute
• only when he has the capacity to reduce the additional
responsibility along with his / her & other duties
 Visiting another Physician's case-
• avoid remarks upon the diagnosis or the treatment that
has been adopted.

41.  Physicians as citizens
• Should particularly co-operate with the authorities in the
administration of sanitary/public health laws and
regulations.
 Public and community health
• Should enlighten the public concerning quarantine
regulations and measures for the prevention of epidemic
and communicable diseases.
 Pharmacists/nurses
• Should promote and recognize their services and seek their
cooperation.

42. INFORMED CONSENT
• The purpose of informed consent is to promote
patient autonomy through shared decision-making
between the patient and the physician.
• For that four requirements must be met –
i. The patient must be competent.
ii. The patient must be given adequate information on
which to base a decision.
iii. There must be no duress, the patient’s decision
must be made voluntarily.
iv. The patient must agree to the propose intervention.

43. EXCEPTION
• In emergency situations (Comatose patients after severe
head injury or massive brain stroke, or suicidal attempts) in
which the patient cannot provide consent and no surrogate
decision-maker, treatment should proceed.
• The physician’s therapeutic privilege to the treatment without
consent.
• When a patient is not competent to make medical decisions, a
surrogate decision-maker becomes responsible for
making decisions on behalf of the patient.

44. JUSCTICE
The ethical principle of justice embodies several
concepts:
• Fairness to persons within and across groups,
• Similar treatment of similar situations, and
• The allocation of scarce resources across society
in equitable manner.

45. Ethical considerations in pediatric
neurology
• Pediatric neurologists are entrusted with
considerable responsibility at multiple levels. This
includes
• planning and implementation of advanced and
complex investigations and therapies,
• individual and family counseling,
• longitudinal follow-up from fetal life throughout
childhood and adolescence,
• shepherding the transition to adult care,
• and societal advocacy on behalf of populations with
special needs.

46. Evidence-based medicine
• Practicing evidence based medicine and
maintaining continuing medical education have
become professional ethical responsibilities for
neurologists.
• Greatest challenge posed by evidence-based
medicine lies precisely in the application of
evidence obtained from research into clinical
practice.

47. Clinical practice and research
• Scientific responsibility neurologists may create
confusion between two distinct roles that may at
times be conflicting – namely the tension between
the neurologist’s healthcare duties toward individual
patients and their obligations as scientists to
contribute to knowledge.
• Both roles are justified and important, it is essential
that the neurologist as well as the patient and family
know which role is being adopted at any specific
moment, especially when decision-making is
involved.

48. • part of a study (i.e., not knowing which treatment
is being administered), or undergoing procedures
that are not proven essential for individual care,
are acceptable options only as part of clear
approved research protocols that comply with
ethical rules (including informed consent).

49. Technological imperative

50. Societal role
• Society has accorded physicians, including neurologists ,a level of privileged
trust, thereby imposing additional ethical and social obligations. Examples of
our broader professional duties include
(1) advocacy regarding social equality,
(2) support of lay patient organizations,
(3) education of the public including knowledge translation for many audiences,
(4) provision of evidence-based guidance to the courts and public policy makers,
(5) monitoring the quality of the ever-growing but often uncritical medical news
stories,
(6) interacting in a constructive and accountable engagement with journalists
and news media to ensure objective communications
(7) anticipating the social impact of potential new technologies, and
(8) whistle-blowing regarding neglect or abuse of vulnerable populations with
disability.

51. Research ethics
Principles in Ethical Research
 Social Value –
• The study should help researchers determine how to
improve people’s health or well-being.
 Scientific Validity –
• The research should be expected to produce useful
results and increase knowledge .

52.  Fair Subject Selection
 Favorable risk-Benefit ratio-
• Any risks must be balanced by the benefits to subjects,
and/or the important new knowledge society will gain.
 Independent review –
• A group of people who are not connected to the research
are required to give it an independent review.

54. • Ethical dilemmas are common in routine neurology
practice .
• Good knowledge of laws regarding these issues is
needed.
• Patient/family should be properly counseled.
• Informed consent is a must.
• Further debates among public and lawmakers are
needed to further resolve the issues.

56. REFERENCE
1. American Academy of Neurology (2005). AAN
Qualifications and Guidelines for the Physician Expert
Witness.
2. Bernat J (2008). Ethical Issues in Neurology. 3rd edn.
AAN Press, Lippincott Williams & Wilkins, Philadelphia.
3. Handbook of Clinical Neurology, Vol. 118 (3rd series)
Ethical and Legal Issues in Neuroloy.
4. Ethical Issues in Clinical Medicine.Harrisons Principles of