1. Introduction to Clinical Ethics Ben Faneye, OP, DHCE West African Bioethics Training Program

2. Historical Background Historical Background Evolution of clinical ethics, attributed to certain needs: Evolution of clinical ethics, attributed to certain needs: –Need for bedside teaching of ethics – William Osler’s medical teaching tradition –Need for a method of ethical enquiry most suitable to individual clinical settings –Need to create a bridge btw academic world of bioethics & the world of clinicians and pts.

3. Clinical Ethics: Its Content Clinical Ethics: Its Content Concerned with restoring and strengthening bonds between professionals, patients and families. This is contrary to the conflicting principles of bioethics. Concerned with restoring and strengthening bonds between professionals, patients and families. This is contrary to the conflicting principles of bioethics. Uses cases and relies on the clinician- patient relationship/encounter in contributing to research on ethical issues. Uses cases and relies on the clinician- patient relationship/encounter in contributing to research on ethical issues.

4. Clinical Ethics: Its Content Clinical Ethics: Its Content Focuses on issues of concern to clinicians, patients & the general society Focuses on issues of concern to clinicians, patients & the general society Issues stemming out of real life encounters Issues stemming out of real life encounters Uses its empirical findings to encourage reform practices among clinicians, which helps establish the 2-world relationship. Uses its empirical findings to encourage reform practices among clinicians, which helps establish the 2-world relationship.

5. Clinical Ethics: Services Clinical Ethics: Services To provide clinical ethics education to clinicians, patients, surrogates and the larger community To provide clinical ethics education to clinicians, patients, surrogates and the larger community Policy studies and recommendations for institutional guidelines on ethical issues in pt. care. Policy studies and recommendations for institutional guidelines on ethical issues in pt. care.

6. Clinical Ethics: Services Clinical Ethics: Services Providing a process for case consultation at the bedside or the conference room Providing a process for case consultation at the bedside or the conference room Researching ethical problems and initiating prevention plans for such problems often encountered. Researching ethical problems and initiating prevention plans for such problems often encountered.

7. Clinical Ethics: Its Practice Clinical Ethics: Its Practice Ethical Obligations: Basis for praxis Ethical Obligations: Basis for praxis –Stem from the concept of duty, which is the necessity of action done out of respect for the law. –Connotes what one is bound to do in situations arising from patient care. –A recognition of one’s duty in upholding another’s rights (pt’s rights).

8. Ethical Obligations In Cases Ethical Obligations In Cases Respecting Privacy & Confidentiality Respecting Privacy & Confidentiality –Right to privacy: which is a person’s claim to those things that define one as such, e.g., thoughts, feelings, aspirations, information, physical body. which is a person’s claim to those things that define one as such, e.g., thoughts, feelings, aspirations, information, physical body.

9. Ethical Obligations In Cases Ethical Obligations In Cases –Privacy rights: Its types Negative right is right to non-interference or to be left alone, e.g., right to bodily integrity. It is a right that restricts others. Negative right is right to non-interference or to be left alone, e.g., right to bodily integrity. It is a right that restricts others. Positive right is a person’s prerogative to control access to and distribution of information about the self, e.g., patient’s control over treatment. This ordinarily requires the active participation of others. Positive right is a person’s prerogative to control access to and distribution of information about the self, e.g., patient’s control over treatment. This ordinarily requires the active participation of others.

10. Ethical Obligations In Cases Ethical Obligations In Cases Confidentiality: Corresponding duty Confidentiality: Corresponding duty –Mechanism by which a person’s right is recognized and respected –Based on a fiduciary relationship, some sort of promise, whereby a clinician recognizes one’s duty to safeguard a patient’s rights –Basis for intimacy between persons, clinicians and patients and families

11. Ethical Obligations In Cases Ethical Obligations In Cases Confidentiality: Why? Confidentiality: Why? –Public knowledge of health records can cause discrimination and embarrassment –Required by law and professional code, a breach of which can lead to disciplinary and legal action against an organization and employee

12. Ethical Obligations In Cases Ethical Obligations In Cases Confidentiality: What is covered? Confidentiality: What is covered? –Personal information that can identify a pt –Treatment information –Details about illness and/or diagnosis –Medical Record –Conversation btw clinician and pt and/or family.

13. Ethical Obligations In Cases Ethical Obligations In Cases Confidentiality: Basis of duty Confidentiality: Basis of duty –Hippocratic Oath – “And whatever I shall see or hear... I will never divulge, holding such things to be holy secrets.” –T. Percival in his Code for Medical Ethics (later adopted by AMA in 1847)states: “Patients should be interrogated concerning their complaint in a tone of voice which cannot be overheard.”

14. Ethical Obligations In Cases Ethical Obligations In Cases Confidentiality: Basis of duty Confidentiality: Basis of duty –International Council of Nurses’ Code – “the nurse holds in confidence personal information and uses judgment in sharing this information.”

15. Ethical Obligations In Cases Ethical Obligations In Cases Respect for Patients’ Decision-Making Capacity Respect for Patients’ Decision-Making Capacity –Duty towards pts stems out of –Duty towards pts stems out of pt’s right of autonomy –Autonomy is a person’s right to determine what happens to, or is done to the self (paternalism, an issue).

16. Ethical Obligations In Cases Ethical Obligations In Cases Respect for Patients’ Decision-Making Capacity Respect for Patients’ Decision-Making Capacity –Corresponding to this right is clinician’s duty to ascertain and enable the pt in exercising autonomy right (duty to inform). –A determination of pt’s capacity considers: Individual abilities of pt, e.g., sound mind or not Individual abilities of pt, e.g., sound mind or not Importance of the decision at hand Importance of the decision at hand Consequence likely to follow from decision Consequence likely to follow from decision

17. Ethical Obligations In Cases Ethical Obligations In Cases Respect for Patients’ Decision Making Capacity Respect for Patients’ Decision Making Capacity –Where pt is deemed incapable, there are standards in place for surrogate decision makers.

18. Ethical Obligations In Cases Ethical Obligations In Cases Standards for Surrogate decision-makers: Standards for Surrogate decision-makers: –Substituted Judgment: decision made based on the known & perceived wishes of the pt. –Best Interest: decision made based on what a reasonable person would do. Risks & benefits of treatment analyzed, with goal of maximizing benefits and minimizing harms.

19. Ethical Obligations In Cases Ethical Obligations In Cases Decisional Capacity: What is it? Decisional Capacity: What is it? –“Ability to make a decision” –Exercise of free power of choice (no force) –Crucial aspect of consent –Crucial aspect of voluntary consent –Focuses on giving or withholding consent for treatment.

20. Ethical Obligations In Cases Ethical Obligations In Cases Respect for Decision Making Capacity: Its Challenges Respect for Decision Making Capacity: Its Challenges –Incapable pts giving consent does not validate treatment by clinician (possibility of self-harm) –Clinician who withholds treatment from an incapable pt who refuses treatment risks liability if other legally valid treatment authorization steps are not sought.

21. Other Obligations In Clinical Cases Communication: Communication: –Ability to listen to and understand the pt’s story & body language Truth-telling: Truth-telling: –Clinician’s professional integrity imposes a negative duty not to lie, as well as a positive duty to tell the truth about what the pt has right to know.

22. Other Obligations In Clinical Cases Disclosure: Disclosure: –Duty to provide information about care to be given to the pt. Clinician determines what information is too much/little. –Therapeutic privilege, an exception to informed consent These 3 obligations are derived from the principle of respect for pt’s autonomy. N.B.: These 3 obligations are derived from the principle of respect for pt’s autonomy.

23. Clinical Ethics & Principles Major bioethics principles provide basis for the ethical obligations in clinical ethics Major bioethics principles provide basis for the ethical obligations in clinical ethics Practical orientation adopted by clinical ethics in light of the dynamism of interpersonal (clinician, pt, family) relationships. Practical orientation adopted by clinical ethics in light of the dynamism of interpersonal (clinician, pt, family) relationships.