1. Ethics and Medico-legal issues in
Critical care
Dr Saurabh Debnath

2. What is Ethics
• Ethics is the study of how one ought to
behave.
• In contrast, the law defines how one must
behave to avoid punishment
• Ethics is concerned with differentiating right
from wrong behaviour
• “Innate”

3. Medical Ethics
Relationship between :
• healthcare practitioners and patients
• in-between healthcare practitioners
• health care practitioners and society

4. Ethical framework
• Autonomy : right to self determination
• Beneficence : “doing good”
• Nonmaleficence : “primum non nocere”
• Fidelity : duties and obligations
• Distributive justice : impartiality
• Utility : most good for most
• Confidentiality

5. Ethical conflicts in Critical Care
Commonly it is the end-product of
…………….“clash of values”

6. End of Life management

7. • Critical care : progress in capacity and
capability
• Greater demand for resources
• Life support systems : “stalemate situation”
• Not to confuse with : “financial exhaustion”

8. • Life is valuable : offset when it is brief, painful
and non-interactive
• Death when imminent : deferment at any cost
seems inappropriate
• Futile prolongation of life may challenge the
rights of salvageable and in need

9. • The “collective” has a Ethical right to choose
access to “therapy”
• The Intensivist doesn’t have Ethical right to
unilaterally select or withhold
• Communication is the “key”

10. • Dying in discomfort
• Receiving unwanted unhelpful therapy
• Dying with lack of dignity
• Patient wishes are commonly unknown
• Variation of practice
• Gradual treatment limitation

11. Practical considerations
• Burden vs Benefit
• Based on “probability” than “certainty”
• Decision making is an evolving process
• CollaborativeCommon desireConsensus
• Nurses to participate in discussions
• Withdraw treatment : not Care
• Palliative plan

12. Advance directives
• Not common
• Legal standing is variable
• Self determination : considerable Ethical
validity
• Warrants respect

13. Euthanasia
• Active termination of life
• Usually at the request of a patient
• Terminal / Debilitating / Incurable illness
• “Physician assisted suicide”
• Legal in small number of countries
• NOT LEGAL IN INDIA

14. Informed Consent
• Treatment and Research
• General consent
• Procedure / Investigation / Therapy
• Principle of Autonomy
• Voluntary : free from coercion
• Patient interest is paramount
• Teaching consent
• Waived for emergency

15. Rationing
• Removed from bedside
• Treatment must not be withdrawn or withheld
because there is a “more deserving” patient
but because it would always be withdrawn or
withheld under the particular clinical
circumstances

16. Professionalism
• Unique, usually a privileged position
• Well covered “Code of Conduct”
• Hippocratic oath
• Maintenance of competancy
• Appropriate professional relationship
• Respect for patient and staff confidentiality
• Respect for the tenets of law

17. Industry and Conflict of Interest
• Doctors vs Med Tech vs Pharmaceutical
• Complex interaction
• Interdependent
• Doctors are entitled to fair consideration for
their skills and effort
• Overt and scrutinised
• Diverse nature of rewards : direct and indirect

18. Research
• Critically ill patients are rarely in a position to
consent
• But in a position to derive benefit from earlier
research projects
• Surrogate decision maker
• “slippery slope”
• Careful scrutiny

19. • Ethical conflicts most commonly arise when
there is a clash of values or interests
• Resolution is often difficult because of
entrenched positions and convictions
• Ethics committee has an important role in
establishing framework

20. Thank you