APPLIED HEALTH ETHICS

APPLIED HEALTHETHICSPrinciple of AutonomyAuto meaning selfNomous meaning determination

The right of the patient to accept or refuse the physicians treatment. His option to choose is based on respect of his free will.Essential Elements:The relationship of physician and patient is governed by a moral contract, something that cannot be legislated.The doctor promises to treat his patient according to his best judgment. This is subjective considering that what may be best for one may not be best for the other.3. The doctor, although he believes he knows best, should fully inform his patient and defer to the patients option to accept or reject the proposed plans of management.4. When the patient is incompetent, proxy should be sought.5. The patients right to decide is called autonomy and should be respected unless his actions constitute an evil act.

Are all minors considered incompetent?Emancipated minors below 18 but economically stable.

Double Power Attorney a person can assign someone to decide for him in case he gets incapacitated.

Who can be a legal proxy for patients of minor age, adult age, and the aged? Minor age-parents-eldest sibling-great grandparents-great great grandparentsAdult age-wife-eldest child-great grandparents-great great grandparentsAged-children-grandchildren-great great grandchildren In cases of emergency, a doctor can perform a surgery under the Principle of Therapeutic Privilege.In the absence of the parents, the doctor can act as Loco Parentis.

Life vs. Cultural Belief Primacy of life is Life vs. Religious Belief supreme overLife vs. Legal Belief everythingPrinciple of Free and Informed ConsentTo protect the basic need of every human person for health care and the persons primary responsibility for his or her own health.No physical or psychological therapy maybe administered without the free and informed consent of the patient, orIf the patient is incompetent, consent should be secured from the persons legitimate guardian acting for the patients benefit and as far as possible, in accordance with the patients known and reasonable wishes.ELEMENTS OF INFORMED CONSENTINFORMATION ELEMENTSDisclosureComprehension of information

CONSENT ELEMENTSVoluntarinessCompetence to consent

INFORMATION ELEMENTS

Disclosure of information- a person needs information base on which to weigh risks/benefits in the light of ones values and goods, deliberate and make rational choices.A HEALTH PROFESSIONAL HAS A DUTY TO GIVE INFOMRATION TO THE CLIENTS.Information elementsgeneral standards of adequate disclosureProfessional practice standard- based on the traditional disclosure practices of the community. Acceptable and necessary information physicians need to disclose

Reasonable practice standard- based on what a hypothetical reasonable person would judge as pertinent to the decision making process.Information elementsgeneral standards of adequate disclosureSubjective standard- based on what a particular patient needs to knoweg: a patient may ask the composition of a particular drug because of his own multiple allergies

INFORMATION ELEMENTSNECESSARY ITEMS TO DISCLOSE:Patients current medical status including the likely course if no treatment is provided.The contemplated procedure or medication.Alternative available procedures or medication.Anticipated risks and benefits of both the proposed and alternatives including the costs.

INFORMATION ELEMENTSNECESSARY ITEMS TO DISCLOSE:A statement offering the patient an opportunity to ask further questions.In case of research, his right to withdraw anytimeA professional opinion about the alternatives.

INFORMATION ELEMENTScomprehension of informationA person must understand the information. The health professional must give clear and simple information.Questions should be asked to assess understanding.Consent elements

VOLUNTARINESS a person can exercise his choice, free of coercion and other forms of controlling influence by others.

Consent elements

COMPETENCECapacity to decide about a recommended procedure or about participation in a researchThe patient is competent if he can make decisions based on rational reasonsMust understand the procedure and weigh the risks and benefits.

Principle of Truthful/Professional CommunicationTo fulfill their obligation to serve patient, health care professionals have the responsibility to do the following:Strive to establish and preserve trust at both the emotional and rational levels.Share such information as they possess which is legitimately needed by others in order to have an informed conscience.

c) Refrain from lying or giving misinformation.d) Keep secret information which is not legitimately needed by others and that if revealed might harm the patient or other or destroy trust.

Tips on Delivering Bad News WellSerious matters about ones health should be discussed face-to-face in a quiet, comfortable private place, not in the hall, on the phone or in the middle of the ground rounds with strangers around.Ideally, a caring relative or friend should be present to provide emotional support and assist in gathering critical information.3. When imparting bad news, the physician should allow an open-minded amount of time free of interruption, sit close to the patient at eye level, look directly to the patient and if appropriate, touch the patient.4. Patients should be given as much information as needed to understand the condition, its treatment and the likelihood that treatment will cure the illness or control its symptoms.

5. Treatment options and the reasons for more tests should be clearly described along with their likely or possible side effects so that patients can make intelligent choice.

PRINCIPLE OF CONFIDENTIALITYTo hold in confidence a secret or private matter, privacy.

Not to be divulged or communicated to others.

Protects the client from unauthorized disclosure of any sort by the professional without the informed consent of the client.Development of, and Basis for, ConfidentialityGrounded in the moral rules of:do not deprive of freedom or opportunity, anddo not break your promises.Integral to the principle of respect for autonomy.Individuals ordinarily have the right to determine to what extent their thoughts, feelings, and sentiment shall be communicated to others.A promise of confidentiality and silence creates an obligation beyond just respect for another, it creates a special bond.Professional confidentiality imposes additional responsibility. Professionals grant clients / patients secrecy even when they might otherwise have a reason to speak out.

Professional ConfidentialityPatients believe that what they tell a health professional is confidential.Patients take for granted that health professionals owe them secrecy even in the absence of an explicit verbal request; such is a component of the implied professional covenant / contract.BenefitsConfidentiality in the professional / patient relationship protects the autonomy of the patient.Confidentiality encourages full disclosure by patients of information that may be sensitive but essential to treatment.Confidentiality allows patients to seek help they might not otherwise seek if they thought their disclosures would be shared with others.Medical confidentialitywhen is it criticalsexual history & STDadolescent sexualityalcohol & drug dependencepsychiatric conditionsmarginalized persons

Medical confidentiality-principles of disclosureMedical confidentiality is not absoluteDisclosure - to proper authorities- need to know not beyond what is required or relevant reason for disclosure documented in the medical records inform patient that such disclosure is required

Medical confidentiality- disclosurewith patients consentfor benefit of patientprevent harm to otherswhen required by LawMedical research,audit,registriesMedical confidentiality- disclosure with patients consentShould be attempted at all times possiblePatient understands nature &effects of disclosureReports to 3rd parties(insurance, employer,) must always be with consent - written consentHusband/ wife/ family cannot be implied

31Medical confidentiality-disclosure with patients consentConsent should be written, original , addressed to a named doctorClear indication of reason & materialInformed vs Valid Consent - capacity, voluntaryHand document to patient - free to pass on himselfMedical confidentiality- disclosure for patients benefitIn times of emergencyPatient is incompetentImplied consent when care is shared among professionals - only necessary information for effective care of patientFor the benefit of patients care To prevent harm to patient - epilepsy, child abuse

33Medical confidentiality-disclosure to prevent harm to othersWhen harm to others outweighs his duty to the patientseriousness of harm vs likelihood of occurrence of harmto whom to tell; how to telldisciplinary action against doctorMedical confidentiality-disclosure required by LawOrder of court - medical litigation, coroners court, criminal cases, compensationDrug abusePublic health risk - Infectious Diseases ActFactories (Medical Examinations) Regulations 1985Enlistment Act for national serviceMedical confidentiality-disclosure for medical audit, research,registeriesapproved by ethics committeeensure no harm to patientdelink patients identifiable dataregistries operated under principle of medical confidentialitywhere feasible get consent or inform patientMedical confidentiality- medical certificatesMedical certificates for claiming benefitsPatients and NOT doctors responsibility to pass the informationDoctor hands the info to the patient - marked Private & ConfidentialCorrect diagnosis written after informing patient the possible implications sMedical confidentialityethical dilemmas/special situationsCompany/Managed care Occupational physiciansMaids Employment examinationArmed Forces Medical OfficerPolice & Prisons DoctorElectronics Medical RecordsMedical confidentiality-a culture of professionalismLoose talk, corridor and lift gossipDoctors not to look at MR of patients not in their careNurses, secretaries and attendantsConversation, MR, telephone & faxesConfidentiality consciousness

CASEA 30 year old married man consults a physician complaining about his difficulty in urinating. He attributes this to what he had taken five days ago when he attended a convention. After examinations of his blood and urine, he was told that he has Gonorrhea. He was afraid the his wife might discover it. So he told the Doctor not to tell anyone, including his wife for fear the she might leave him. He loves his wife and family. The wife however, after a week, asks the doctor as to the condition of her husband because she was a bit worried why her husband does not want to make love with her. If you are the doctor, should you confide to the wife about her husbands condition knowing that you know the obligation attached to the Principle of Confidentiality/ConfidentialityCASEJane is 14 years old and pregnant as a result of incest with her father. On routine visit to the family physician, Dr. XXX, she explains what has happened and he confirms the pregnancy. She begs him not to tell her parents, because then her mother will discover what has happened. She is convinced that her mother will blame her, rather than her father, because her relations with her mother are very bad. Dr. XXX tells her he never performs abortions so Janess asks him to refer her to some physician who does. Dr. XXX wonders whether professional confidentiality and perhaps even legal complications forbid him from informing the mother and trying to stop the abortion and the continuation of the incestuous relationship. But he is also worried that Jane will go to a disreputable and unsafe abortionist. What principles will help solve his problem?