1- ethical issues

7/31/2019 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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BENEFICENCE

= the obligation to provide

benefits and to balance

benefits against risks

requires positive steps tohelp others


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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.

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