Ethics

What are the 4 key principlesof medical ethics?

Ethical Principles

Ethical Principles

• Respect for patient autonomy • Beneficence • Non-maleficence • Justice

What is respect for patient autonomy?

Respect for patient autonomy

Giving competent patients control over what happens to their body. Autonomy = self-rule

What is beneficence?

Beneficence

Doing good to patients. But who decides…?

Related to utilitarianism...

Beneficence and respect for autonomy can be in conflict.

What is non-maleficence?

Non-maleficence

Doctors have a duty to do no harm (from the Hippocratic Oath).

• Doctrine of double effect

What is justice?

Justice

Treating people fairly: fair access to treatments and fair allocation of scarce medical resources…

Four components:• Distributive• Respect for the law• Rights• Retributive

Ethical theories

What are the 3 main ethical theories?

Ethical theories

• Deontology• Utilitarianism• Virtue ethics

What is deontology?

Deontology

This is duty-based ethics.

Some kinds of action are wrong or right in themselves, regardless of the consequences.

What is utilitarianism?

Utilitarianism

A form of consequentialism: “the morally right action is the one with the best overall consequences”.

Greatest good for the greatest number (Bentham 1776).

What is virtue ethics?

Virtue Ethics

This is character-based ethics.

A ‘right’ act is the action a virtuous person would do in a situation.

Consequence

Action

Virtue ethics

Deontology

Consequentialism

Ethical theories

• Virtue ethics: looks at the person• Deontology: looks at the act• Utilitarianism: looks at the consequences

(‘greatest good for greatest number’)

Why does it matter?

Confidentiality

Confidentiality

Confidentiality is pivotal to the doctor-patient relationship. It must be maintained in almost all situations.

When should doctors break confidentiality?

Doctors have to break confidentiality in the cases of:• Notifiable diseases (e.g. smallpox)• Court order• Public safety (e.g. HIV patients refusing to tell

their partner, or warning the DVLA about an unsafe driver who refuses to stop driving)

Breaking Confidentiality

Competence

Competence = Capacity

Competence is decision-specific.

What does a person have to be able to do to be ‘competent’?

Competence

• Understand the information• Retain it long enough to…• Weigh it up • Communicate their decision to the doctor

Competence is presumed from what age?

Competence is presumed from 16 years of age.

What happens for under 16s?

Competence

Gillick Competence

A child (under 16 years old) is presumed to lack capacity to consent to treatment. However, a child who is deemed to have capacity (Gillick competent) can give consent.

Valid Consent

What’s needed for valid consent?

• Competence (right mind)• Non-coercion (right person)• Information (right understanding)

Valid Consent

• Use layman’s terms• Carefully explain the patient’s options,

associated risks/complications…• Allow time for questions• Ask your patient to explain the situation to

you in their own words.

Information

Informed Consent

Doctors need to get informed consent to carry out ANY medical intervention (take bloods, chest exam, surgery…).

No consent = crime (battery)

Can patients refuse life-saving treatment?

Yes, providing the patient is competent and not pushed into the decision (non-coercion).

This is ‘respect for patient autonomy’ in action.

Refusal of life-saving treatment

Incidental Finding

Whilst operating on a patient’s colon, the surgeon finds a severely inflamed appendix. She estimates the patient has only hours before the appendix ruptures.

What should the surgeon do?

The surgeon needs consent.

Wake patient up, obtain consent. Anaesthetise and operate.

…but was the patient really competent?...

NB: This is a real case from years ago, we have moved on from these times…

Incidental Finding

Patient’s Best Interests

• Past and present wishes and feelings (including any written statements)

• Beliefs and values• Other things the patient might consider, if

possible (e.g. altruism)

Consult family/partner to find out the above.

Negligence

When is a doctor deemed to be negligent?

A doctor is negligent if there’s a breach in duty of care AND harm is done.

How is negligence assessed?

Negligence

Bolam Test

A doctor is not negligent if other doctors would have done the same thing (“the court is satisfied that there is a responsible body of medical opinion that would consider that the doctor had acted properly”).

What do you know about abortion?

Abortion

Abortion

• Abortion Act (1974, 1990)

• 24 week limit• 2 doctors needed• Conscientious objection… …pass on.

• ‘risk’ to physical or mental health of the pregnant woman or any existing children of her family

• ‘risk’ that the child were born with serious physical and mental abnormalities

Key stages in pregnancy

• Fertilisation• Implantation• Organogenesis • Viability• Birth

Personhood and gradualist approach

• Religion: sanctity of life• Philosophy: dignity of life, personhood• Economics: ‘quality of life’, cost

Autonomy (of woman) vs. non-maleficence (killing of foetus).

Abortion

What do you know about euthanasia?

Euthanasia

Euthanasia

• Voluntary vs. involuntary vs. non-voluntary• Active vs. passive

Balance between non-maleficence, beneficence, and autonomy.

• Doctrine of double effect• Slippery slope• An end-in-itself (we exist, so we have value)

Euthanasia

Certain criteria have to be met in the Netherlands:• Unbearable suffering• Informed and voluntary request• Doctor and patient must be convinced there

are no other solutions• Second medical opinion• End life using correct drugs

Assisted reproduction technologies

• IVF ET (in vitro fertilization/embryo transfer) • ICSI (intracytoplasmic sperm injection)

• PGD (preimplantation genetic diagnosis) • Is PGD eugenic?

• donor/recipient relationship (anonymity, compensation, surrogacy, family relationships...)

• reduction of embryos / foetuses • preservation of embryos and further use • confidentiality of genetic information

Assisted reproduction technologies

Neonates - Groningen Protocol

Ending of life in severely ill newborn • Certainty on diagnosis and prognosis • Presence of ‘hopeless and unbearable’

suffering • Condition confirmed by at least one

independent doctor • Both parents must give informed consent

Children

• Consent and confidentiality• Role of doctor: advocate, diagnosis +

treatment, support family, safeguard.• Role of parents/guardians, other healthcare

staff and the courts• Child protection

Thought experiments

• Run-away train– Change tracks– Fat man pushed off bridge

• Rich nephew and food packets• The famous violinist