Medical Ethics

Olufemi Aworinde

Lecturer/ Consultant Obstetrician and Gynaecologist,

Bowen University, Iwo

Ethics is the understanding of moral values.

Medical ethics is a field of applied ethics, the study of moral values and judgments as they apply to medicine

Moral principles, guiding medical professionals in the course of their practice of medicine and in relationship with their patients and other members of the profession

It is a code of conduct aiding medical professionals to render the best possible service to humanity and to maintain the honor and dignity of the profession.

A History of Ethics Principles460-377 B.C Hippocrates of Cos

1792 Percival: Manchester Infirmary Committee

1803 Percival: Medical Ethics: A Code of Ethics and Institutes

Adopted to the Professions of Physic and Surgery

1808 Boston Medical Society (self-regulation)

1847 AMA: “Code of Ethics”

1903 AMA: “Principles of Medical Ethics”

1912 AMA: revised “Principles”

1957 AMA: concise “Principles”, “Opinions”

1980 AMA: FTC-imposed Principles revision

1981 AAPS: “Principles of Medical Ethics”

1980s-1990s ACP Code, and many others

2001 AMA: revised “Principles”

Where Does Ethics Come From?Tradition

“That’s the way it’s always been.”

Authority

“That’s the way I was taught to do it.”

Reason

“That’s the way reality determines we

ought to behave.”

Ethical theories

There are many ethical theories and even more ethical philosophers.

We will consider two major ones:-

Concern for the right act (Deontological)

Concern for the consequence (Teleological)

Human Cloning

“Is wrong and should be absolutely prohibited, as this is playing God.”

(Deontological)

“Can save many lives and should therefore be supported.”

(Teleological)

Deontological ethics (Rights)Based on natural law and divine command e.g. the laws of

gravity – such natural rights are “built into the universe”.

Based on common humanity e.g. all human beings have rights simply by virtue of being “human”.

Based on rationality e.g. people who are capable of rational, autonomous thought are entitled to claim moral rights.

Based on interests e.g. To claim rights meaningfully, one must have interests.

Types of “Rights”

Inalienable rights – cannot be transferred e.g. “the right to life”

Example –

In such a situation suicide or martyrdom would be condemned as morally wrong.

A mother who sacrificed her life for her child would be similarly condemned.

Absolute right

Absolute right – cannot be overridden by any circumstances

Example – A right to life

If this is so, the taking of life is always wrong, be it in war, in self-defense, capital punishment or abortion

Prima facie right

Prima facie rights – rights which may be overriden by stronger moral claims

Example – A right to privacy would be overridden by a right to life in an emergency.

Rights and duties

Having a right requires a corresponding duty to respect that right.

Generally such claims impose a “duty to act”

Problems with rightsRights and interests can compete and conflict with one another

Difficult to establish the extent a right entails a corresponding duty

Disagreements on who/what have rights

Difficult to satisfy the rights claims of all

Moral DutyA moral duty is an act that a person ought to do.

Contrast with legal, civil or professional duty.

Specify that some type of action or conduct is either prohibited, required or permitted in certain circumstances

Moral principlesMoral principles commonly used in medical practice:

Autonomy

Non maleficence (Do no harm)

Beneficence (Do good)

Justice

AutonomyA person’s ability to make or exercise self-determining choices

A person should be free to choose and isentitled to act on their preferences provided their decisions and actions do not violate or impinge on the significant moral interests of others.

Example

In your opinion, a patient needs surgery.

The patient however can refuse and their refusal has to be respected.

This right to autonomy (self-determination) underpins the medicolegal understanding of INFORMED CONSENT.

Against the principle of autonomyTreating patients without their consent

Treating patients without giving them all the relevant information necessary for making an informed and intelligent choice (informed consent)

Witholding information from patients when they have expressed a reflective choice to receive it or lying to them

Forcing information on a patient when they have expressed a reflective choice not to receive it.

Forcing anyone to act against their reasoned moral judgment or conscience.

Non Maleficence (Do No Harm)

Above all, do no harm.

Stringent duty not to injure others

Example

You have a terminally ill patient and you feel you can no longer offer him anything that could cure him.

He heard that the taking of arsenic may cure him and asked you to give him arsenic

Arsenic is a poison.

Against the principle of non-

maleficenceSawing off someone’s good leg.

Operating on someone who did not have appendicitis

Puncturing the heart whilst doing a bone marrow aspiration

Beneficence (Do good)

Provision of benefits

Preventing and removing harm

If an act does not bestow benefit or fails to address an imbalance of harms over benefits, the act could rightly be condemned.

Example

A patient cut his fingers on a machine. He had lost a lot of blood.

You gave him a matched blood-transfusion

You stopped the bleeding and repaired the wounds on his hand.

Against beneficence

Refusing to provide treatment

Refusing to help an accident victim

Refusing to help a prisoner or a suspect of crime

What is Justice?

No common agreement

Retributive justice – “an eye for an eye”

Justice as mercy

Justice as harmony in the soul

Justice as equality

Justice as what is deserved

Justice as love

Justice

Practically

Justice as fairness

• What is deserved

Justice as equality (distributive justice)

• All are required to bear an equal share of society’s burdens and benefits

• All patients have a right to your best diagnosis and treatment.

Against justice

Favouring one patient over another

Senior and experienced doctors treats private patients only.

Conflicts

It is not uncommon that in every day clinical practice you will encounter situations where even the four basic principles are in conflict.

There is no simple answer and each case must be considered and weighed.

Seek help and discuss the issues with colleagues.

Conflicts

During the delivery of a baby, problems develop and you are faced with a choice.

The mother or the child?

Whose autonomy prevails?

Non-maleficience (but to whom?)

Beneficence (to whom?)

Justice (to whom?)

Conflicts

If the mother said – “save the baby”

Does this resolve your conflicts?

Is the mother’s autonomy absolute?

Is non-maleficience physical, psychological or holistic?

Conflicts

A baby is born anencephalic (no brain matter).

Is there autonomy?

What about beneficence?

What about non-maleficience?

What about justice?

Conflicts

The anencephalic baby develops a chest infection.

Do you treat with antibiotics?

Autonomy

Non-maleficience

Beneficence

Justice

A young teenage mother who was a victim of rape came to the hospital for an abortion.

What will you do?

What moral principles?

Ethical Dilemma (1)

The abortion was performed but the abortus was “alive”.

What will you do?

What moral principles?

Ethical Dilemma (2)

A patient is admitted into hospital in coma and requires resuscitation and respirator and ICU care.

What will you do?

What moral principles?

The patient is moved into the ICU, but it soon becomes clear his liver is completely damaged. The cause of his liver failure was chronic alcoholism.

What do you do?

What ethical principles?

His family begs you to keep him alive by whatever means. A victim of a car accident has just arrived at the hospital and needs an ICU bed. There are no more ICU beds available.

What do you do?

What moral principles?

The son of a colleague has come forward to offer part of his liver for a “live donor transplant”.

What would you do?

What moral principles?

The victim of traffic accident dies, the family has agreed to donate his liver. There are however others on the waiting list. The cause of their liver failure were due to allergies to medication given by doctors.

What would you do?

What moral principles?

Ethical Dilemma 3: Refusal of treatment

Chest physiotherapy is prescribed for an elderly cancer patient by the attending doctor, but he refuses. Must the physiotherapist insist on carrying out the treatment plan?

Is it unethical to go against the patient’s wish (to refuse)?

Dilemma 4: Autonomy and family member

A patient’s son insisted that the doctor should not tell his mother that she has been diagnosed with chronic leukemia, otherwise he will take her home against medical advice.

The mother seems to be generally passive and submissive to the son’s decisions related to her health care

How should the patient’s right be addressed?

Dilemma 5: Demand of Alternative Medicine

A 20 year old patient with severe head injury from traffic accident did not improve with rehabilitation. He cannot comprehend or communicate

The mother demands the hospital to provide hyperbaric oxgyen therapy (high pressure oxygen treatment in a closed chamber)

What is the extent of the mother’s right in this case?

How should the patient’s rights be addressed?

Dilemma 6: Demand of medical treatmentA patient with mental illness demanded to be treated with the newest psychiatric drugs

The doctor assessed and found that the patient was not suffering from significant side effect from the existing drug, which is also one of the newer drugs that had passed the patent period (cheap generic drug is locally available)

What is the extent of patient right in this case?

Ethical Dilemma 7: Right to die?

A tetraplegic patient on chronic assisted ventilation requested for euthanasia

Does a patient have ‘right to die’?

Dealing with refusal of treatment

When mentally competent and properly informed, the patient’s refusal must be respected. [Principle of respect for autonomy]

Assess mental capacity

Provide adequate and appropriate information

Treatments can be provided to mentally incapacitated persons based on ‘best interests’ principle [Principle of beneficience]

Resolving ethical dilemma related to autonomy

Listen carefully – do not jump to conclusion of “patient not cooperative” too easily

Gather more information relevant to the case

Consider your own bias and assumptions

Explore reasonable options of compromise

Involve carers and friends trusted by patient

Contemporary Ethical IssuesInforming patients of errors

Profiting from company retainership

Lying to insurance companies

Crossing interpersonal boundaries

Accepting gifts from industry

Telling the truth to terminally ill patients

Altering transplant/donor list to gain priority

Responsibilities to medically indigent

Advertising of favorable outcome statistics

Making decisions to end life

Process of making ethical decisionsAwareness—Is there a moral issue here?

What is its nature? How important?

What are the facts?

What are the issues?

What rules or values apply here?

To whom or what do I owe a duty?

How should they be applied?

Who needs to decide and act? Who ought to?

To what am I obligated because of role/position?

What are the consequences?

What are the options?!

Duties to whom or what?Individuals

PatientsPatients’ families/guardiansColleaguesCo-workersSelf

GroupsProfessionSocietyThe weak

Ideas/PrinciplesThe LawTruthJusticeIndividual value

Duties—SourcesLegal Obligations

Health insurance

Emergency treatment

Reporting duties

Institutional Obligations

Practices of hospital

Professional norms and obligations

Inherent with being a physician

How do individuals decide what is ethical?

1. Non-rational (not irrational) approaches:

- Obedience - following the rules or instructions of those in authority, whether or not you agree with them (common way: children and those who work with authorities)

- Imitation - following the example of the role model

- Feeling or desire (subjective approach)

- Intuition - location in the mind (rather than the will)

- Habit – there is no need to repeat a systematic process each time a moral issue arises similar to one that has been dealt with previously

How do individuals decide what is ethical?

2. Rational approaches:

-Deontology (search for well-founded rules)

-Consequentialism (the right action is the one that produces the best outcomes; the best known is utilitarianism uses “utility” as a measure: “the greatest good for the greatest number”)

-Principalism (often clash of principles)

-Virtue ethics (a type of moral excellence; important virtues: compassion, honesty, prudence, dedication)

Framework for ethical decision-making in practice1. Determine whether the issue at hand is an ethical one.

2. Consult authoritative sources to see how physicians generally deal with such issues.

3. Consider alternative solutions.

4. Discuss your solution with those whom it will affect.

5. Make your decision and act on it.

6. Evaluate your decision and be prepared to act differently in future.

ASSIGNMENT

Critically appraise the Nigerian patients' bill of right

SUMMARY ?

Professional behavior, honesty

Report incompetent, unethical colleagues

Free to choose patient, cannot abandon

Fee-splitting prohibited

Continuously self-educate

Privacy and confidentiality respected

Consult colleagues freely

Respect the law, not blindly obey it

Primary professional obligation to patient

Should not solicit patients

SUMMARY?

Fee set with pt, limited to professional service

Cannot accept limits on judgment re pt care

Participate in betterment of public health

Explicitly support access to medical care

May participate in legal abortions

May assist suicide or commit euthanasia

Collective obligation to care for all patients

Justice defined as ‘distributive justice’

THANK YOU!

THANK

YOU!THANK

YOU!