1. Ethical Principles, Consent and Confidentiality Richard Dawson

2. Aims To provide to time discuss ethical principals, consent and confidentially issues in relation to primary care.

3. Objectives: Scope of session Raise awareness of ethical and legal dimensions of clinical decision making Practise skills in ethical analysis and its application to clinical situations (especially in GP context) Provide overview of key areas of English law relating to clinical practice

4. Why learn about ethics? Previously Drs have used a pragmatic system governed by the use of experience, intuition and common sense?

5. Why learn about ethics? More chance of recognising the full range of issues in any given situation Could promote a wider choice of options for action Gives insight into deep-seated attitudes and prejudices that influence decisions Could provide impartiality and the chance of better outcomes for patients

6. Some areas raising ethical considerations Professional duties Confidentiality Consent Reproductive issues End of life issues Mental health Children Screening Rationing (resource allocation) Genetics Research

7. The 4 ethical principles Approach should be applicable by anyone, whatever their personal philosophy, religion etc Respect for autonomy Beneficence Non maleficence Justice They may conflict with each other A framework for analysing ethical dilemmas, not a formula for solving them

8. Four Ethical Principals. Autonomy (self rule) –Help patients to make their own decisions and respect these decisions even if you disagree –Understanding, Freedom from coercion, Capacity Beneficence (Do Good) –Doing what is best for the patient – but what is the best? May conflict with autonomy Non-maleficence (Do no Harm) Justice/Equity –time and resources –Societal justice

9. Consent The agreement by a person to a procedure or intervention Form of consent (implied or explicit) Legal: Intention, Voluntariness, Competence Autonomy: Understanding, Freedom from coercion, Capacity Treatment without consent could lead to charge of battery (criminal or civil law) or negligence (civil law)

10. To have capacity to consent, patient must be able to understand in simple language what the medical treatment is, its purpose and why it is being proposed understand its principal benefits, risks and alternatives understand in broad terms what will be the consequences of not receiving the proposed treatment retain the information for long enough to use it and weigh it in the balance in order to arrive at a decision

11. Who is competent (has capacity to consent)? People over 16 presumed to be competent unless there is evidence to the contrary Under 16s are only considered competent if they have sufficient intelligence and understanding to understand fully what is proposed Parent can consent on behalf of anyone under 18 who lacks capacity If someone over 18 lacks competence, no one can consent on their behalf - decision to be made by medical team in the best interests of the patient; consulting relatives considered good practice to help medical team make decision

12. Power of Attorney Enduring Power of Attorney (pre 2007) only applied to financial affairs Lasting Power of Attorney (since Mental Capacity Act 2005, implemented 2007) - 2 kinds – Property and Affairs LPA (like Enduring Power of Attorney pre 2007) –Personal Welfare LPA which can specifically include health decisions. Attorneys decision could override Advance Directive made prior to the POA being registered

13. Advanced directives Advanced directive specifies how you want to be treated if circumstances arise when you dont have capacity to make decisions Now considered binding in Common Law and under the Mental Capacity Act 2005 Not valid if –Unsigned –Doubt re authenticity (e g not witnessed) –Concern it was written under duress –Concern about mental state at time of signing Advisable to discuss with family before writing

14. Confidentiality All personal info given to a health professional must be treated confidentially except in particular circumstances This includes friends and relatives Duty of confidentiality continues after death Most breaches of confidentiality are inadvertent

15. Confidentiality Underlying ethical principals: –Non-maleficence: damage to relationship, career etc –Autonomy: the right of the patient to determine want information is passed on and to whom –Societal Justice: where serious harm may be prevented by disclosure without consent

16. Exceptions to confidentiality Patients consent Need to know Statutory duty (eg DVLC) Instruction from Judge (in Court or via a warrant under Police and Criminal Evidence Act Wider public interest Child Protection

17. Access to information Data Protection Act 1984 (computer records) Access to Health Records Act 1991(manual records) Access to Medical Records Act 1988 (medical reports) Data Protection Act 2000 (access to all records) Safeguards against having to disclose harmful or third party information

18. Other important legal areas Mental Health Act Reproductive Issues End of Life Issues Human Rights Act

19. When you have an ethical dilemma, consider Talking to colleagues Getting advice from your defence organisation

20. Your experience of an ethical dilemma Write down the story What made it an ethical dilemma? (not just a situation where you didnt know what to do) What was most important to you about the decision you had to make? (e g getting it right, protecting yourself, avoiding conflict) What did you base your decision on? (e g guidelines, law, advice (who from?), your moral values or just feeling it was the right thing to do) What was the most difficult thing about it? (e g not having enough information, upsetting other people, or the responsibility you had)

21. Further info RCGP curriculum statement refs GMC website BMA website Ethics in General Practice - a practical handbook for personal development - Anne Orme-Smith and John Spicer. Radcliffe Medical Press 2001