1- Ethical Issues
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INTRODUCTION TO MEDICAL ETHICS:
AN ESSENTIAL COMPETENCE FORCLINICIANS
SMA-SGHSEMINARS ON MEDICAL ETHICS
AND HEALTH LAW 2003
Dr Chin Jing Jih
Chairman, SMA Ethics CommitteeDeputy Director, SMA Centre for Medical Ethics & Professionalism
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What is medical ethics?MORALITY
= social conventions [beliefs and practices] about
right and wrong human conduct that are so
widely shared that they form a stablecommunity consensus
ETHICS
= a systematic reflection on and analysis of
moralityA generic term for various ways ofunderstanding and examining the moral life.
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What is MEDICAL ETHICS ? Developed from the view that ethical problemsfrom medicine can be resolved by applying
principles of moral philosophy.
Objectivemaking choices in ethically
significant matters in the practice of medicine
the practical and structured approach toassist physicians (and health care workers) in
identifying, analysing and resolving ethical
issues constructively in clinical medicine.
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Role of MEDICAL ETHICS
in daily clinical practice
For those situations in which we already know
what is right and what is wrongit should help us explain why the one choiceis right and the other wrong
For those situations in which it is not obviouswhat is right and what is wrong
it should guide us to discover what is theright thing to do
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MEDICAL (HEALTH CARE) ETHICS :
3 LEVELS OF RELEVANCE
Doctor-patient
relationship
Policies in
health care institutions
Health care policies in society
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GOALS OF MEDICINEThe goal of medicine: Setting new priorities.
Hasting Center Report, special supplement Nov-Dec 1996.
Prevention of disease and injury
Promotion and maintenance of health
Relief of pain and suffering
Care and cure of those with malady Avoidance of premature death
Pursuit of a peaceful death
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ETHICS & LAW:LAW
Seeks to educate and to regulate
by announcing a minimal
standard ofconduct. Looks
mainly at due Process
Establishes negative sanctionsfor ignoring the standard,
which has the power of
official coercion
ETHICS
Extends beyond thelaw to
prescribe desirable conduct and
articulate ideas andvirtues to
which we should aspire
Ethical sanctions- generally
non-coercive, and include the
praise or blame of colleagues or
others. Power resides primarily
in the strength ofreasoning,
unaccompanied by stateendorsement
Because respecting law is an important moral duty, the legal cases have
ethical relevance. However, what is legally permitted may not be ethically
justifiable in a particular case
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Normative Theories of ethics
Deontological theory
Greek:deonto = duty
DUTY-BASED action > consequensces
==> obligations and
duties in the forms of
rules and principles
Teleological theory
Greektelos = end
CONSEQUENT-BASED
consequences ==> right or
wrong
right action = one which
causes maximum beneficial
results
e.g. utilitarianism
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4-Principle Approach:
NONMALEFICENCE
= the obligation to avoid the
causation of harm
requires merely the omission of
harm-causing activities
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4-Principle Approach:
BENEFICENCE
= the obligation to provide
benefits and to balance
benefits against risks
requires positive steps tohelp others
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4-Principle Approach:
RESPECT FOR AUTONOMY
= the obligation to respect the
decision-making capacities ofautonomous activities
rooted in the liberal western tradition of
the importance of individual freedom,both for political life and for personal
development
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4-Principle Approach:JUSTICE
= obligations of fairness in thedistribution of benefits
and risks
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4-principle Approach(Beauchamp, Childress)
The principles areprima facie, i.e. always
binding unless they conflict with obligations
expressed in another moral principleBalancing of the demands of the conflicting
obligations
which principle overrides in case of conflict
depends on the particular context, which is
likely to have unique features
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4-principle Approach(Beauchamp, Childress)
The exercise ofjudgement in circumstances of
uncertainty is inevitable.
A justifiable infringement of a moral principle
or rule must:
be necessary in the circumstances in the sense
that there are no morally preferable alternative
actions that could be substituted
be the least infringement possible
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4-BOX APPROACH
CASE HISTORY [casuistic approach]
Contextual
features
Quality of life
Patientpreference
Medicalindications
recommendations
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MEDICAL INDICATIONS1. What is patients medical problem ? diagnosis?prognosis?
2. Is problem acute? chronic? critical? emergent?
reversible?
3. What are goals of treatment?
4. What are probabilities of success?
5. What are plans in case of therapeutic failure?In sum, how can this patient be benefited by
medical and nursing care, and how can harm
be avoided?
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Tell me what you are thinking?
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PATIENT PREFERENCE1. What has the patient expressed about preferences for
treatment?
2. Has patient been informed of benefits and risks,understood, and given consent?
3. Is patient mentally capable and legally competent? What
is evidence of incapacity?4. Has patient expressed prior preferences, e.g., Advance
Directives?
5. If incapacitated, who is appropriate surrogate? Issurrogate using appropriate standards?
6. Is patient unwilling or unable to co-operate with medicaltreatment? If so, why?
In sum, is patients right to choose being respectedto extent possible in ethics and law ?
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QUALITY OF LIFE1. What are the prospects, with or without treatment, for a
return to patients normal life?
2. Are there biases that might prejudice providers evaluation
of patients quality of life?
3. What physical, mental, and social deficits is patient likely to
experience if treatment succeeds?
4. Is patients present or future condition such that continuedlife might be judged undesirable by them?
5. Any plan and rationale to forgo treatment?
6. What plans for comfort and palliative care?
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CONTEXTUAL FEATURES1. Are there family issues that might influence treatment
decisions?
2. Are there provider (physicians and nurses) issues that might
influence treatment decisions?
3. Are there financial and economic factors?
4. Are there religious, cultural factors?
5. Is there any justification to breach confidentiality?
6. Are there problems of allocation of resources?
7. What are legal implications of treatment decisions?
8. Is clinical research or teaching involved?
9. Any provider or institutional conflict of interest?
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4-BOX APPROACH
A device for teaching and discussion
User (health care providers + families) friendlyvocabulary
A practical review method to move a discussionof an ethical problem toward a resolution
Begins with the factual features of a case.Principles and rules are referred to as they arise
in the discussion of each box/topic.
Moral rules and principles are best appreciatedin the specific context of the actualcircumstances of a case.
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Facts + Principles Judgement No escape from the exercise of judgement in
circumstances of uncertainty
BUT not just any judgement will be
acceptable.
No system of guidelines could reasonably
anticipate the full range of conflicts to provide
mechanical solutions or definitive procedures
for decision-making about moral problems inmedicine.
Experience and sound judgement are
indispensable allies
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CONFLICTS & DILEMMAS Treatment : effective + humane & dignified
Medical goals from the perspectives of doctors,
are NOT necessary the only and mostimportant goals of patients
Judgements and decisions are frequently
- value laden- role-dependent
- influenced by self- and other interests
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COMMON ETHICAL PROBLEMS IN
HOSPITAL PRACTICE Patients and/or families demand for
everything be done regardless of medical
futility Patients refusal of treatment / placement
Familys insistent of withholding diagnosis
Use of tube feeding in demented patients Issues related to informed consent
Confidentiality issues
Justice / Distribution issues
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COMMON PRETENDERS OF ETHICAL
PROBLEMS
Inappropriate medical indications
Treatment options inadequately explored
Communication problems Breakdown in therapeutic relationships due to
bad outcomes
Discharge problems
Legal problems
Assessment of decisional capacity of a patient
Obtaining informed consent
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CLINICAL ETHICS VERSUS RESEARCH ETHICS
CLINICAL ETHICS RESEARCH ETHICS
RELATIONSHIP Doctor-patient Researcher-patient competing
and conflicting interests
PRIMARYOBJECTIVE
Fiduciary therapeuticeffect to benefit patient
Generalisable knowledge tobenefit society
NON-
MALEFICENCE
Above all, do no harm. Risk of harm always exists
risk-benefit ratio
INTERVENTION Proven or established
treatments
Experimental treatment
clinical equipoise
CONSENT Implied and verbal
consent applies except
for high risk treatment
Full informed consent process
and document except for minimal
risk research
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The Belmont Report : Ethical Principles and
Guidelines for the Protection of Human
Subjects of Research
[The National Commission for the Protection of Human Subjectsof Biomedical and Behavioral Research (April 18, 1979)] Nuremberg
War Trials; Tuskegee Experiment
1. Respect for persons
infromed consent
2. Benficenceassessment of benefits and risks
3. Justice
patient selection
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ETHICS CONSULTATION
SERVICEAssists hospitals health care professionals in the
analysis and resolution of ethical issues
encountered in daily clinical practice. Clarifies complex issues
Improves communication
Offers options and/or specific recommendations
Provides reassurance and guidance
Ultimately improves patient care
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ETHICS CONSULTATION
SERVICE
NOT to takeover the duties or rights of
individual doctors to make decisions
NOT to interfere with treatment or
management
NOT to police the doctors NOT to provide legal immunity /
coverage
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The practice of medicinein a thoughtful, ethical,compassionate and
effective mannerhelps to make doctoring
a satisfying, sustainableand enjoyable part of ourlives.