1. Introduction to medical ethics Dr Leena Al-Qasem

2. Topics covered:  Introduction  Definition of Ethics  Principles of ethical guidelines  Informed consent  Confidentiality

3. Page  3 Philosophy Ethics Descriptive Ethics Metaethics Normative ethics Bioethics EpistemologyLogicMetaphysics

4. Page  4 Why was ethics born: Clinical ethics Research ethics  Expansion of technological capacities  Extend human life  ? the quality of patient’s lives  Control cost  Moral and legal interests of individuals  Beecher, Berber, and paperworth  Chronic disease hospital  Tuskegee syphilis study  Willobrook hepatitis study  Radiation experiments  Oral contraceptives trials  Thalidomide  Holmesburg prison experiments  Allen memorial/ CIA, prison experiments (hallucinogenic drugs)

5. Page  5 What does ethics mean to you?

6. Case I: You are caring for a patient with cancer. She is refusing to undergo surgery or receive chemotherapy for the treatment of her condition. What would the right action be in this case?

7. Case II: A patient is being treated by you for a certain condition. He wishes to use alternative forms of treatment for this condition, treatment which you do not believe is effective, due mainly to lack of scientific evidence. Moreover, you believe that the alternative treatment might interfere with the standard treatment and cause the patient’s condition to worsen. How you would handle this case?

8. Case III: You are a physician working in an intensive care unit with a capacity of five beds, four of which are occupied. You receive a call from the A&E where they have two patients needing ICU admission. The mother of one of those patients, whom you know, pleads with you to save her young son. The other patient, as you find out later is a foreigner with no relatives in the country. What would be the right action in this case?

9. Case IV: A 32 years old male is diagnosed with bacterial meningitis. After the physician explained his diagnosis to him, the risks and benefits, the patient refused to be treated for his illness and insisted on going home.

10. Principles of ethical guidelines:  Autonomy  Beneficence  Nonmaleficence  Social Justice

11. Autonomy:  Self-determination, independence, and freedom.  Patients may choose among medically feasible alternatives.  Patients may refuse unwanted medical interventions.  patients have the right to make choices that conflict with the wishes of family members or the recommendations of their physician.

12. Autonomy: Treating patients with respect entails several ethical obligations 1.Physicians must respect decisions of autonomous persons. 2.respect for persons with impaired decision making capacity 3.avoiding misrepresentation, maintaining confidentiality, and keeping promises

13. Autonomy is not absolute  may be justifiably restricted for several reasons: –person is incapable of making informed decisions. Respecting autonomy < important than acting in the best interest of the patient. –constrained by the needs of other individuals or society at large. –not free to act in ways that violate the autonomy of other people, harm others, or impose unfair claims on society's resources.

14. Page  14  Requires physicians to take positive actions for the benefit of patients.  Because patients do not possess medical expertise and maybe vulnerable because of their illness, they rely on physicians to provide sound advice and to promote their well being. Beneficence:

15. Page  15  Promotes patient best interest by: Understanding patient perspective Address misunderstandings and concern Try to persuade patient Negotiate a mutually acceptable plan of care Ultimately let the patient decide

16. Page  16  The physician cannot be required to violate fundamental personal values, standards of scientific or ethical practice, or the law.  If the physician is unable to carry out the patient’s wishes, the physician must withdraw and/or transfer care of the patient

17. Page  17 DO NO HARM" forbids physicians:  From providing ineffective therapies  From acting maliciously or selfishly  provides limited guidance since many interventions also entail serious risks and side effects.  Provide standard care  If no benefit, at least do not harm or make situation worse  If benefit equals harm, do not intervene Nonmaleficence:

18. Social Justice: The term in a general sense means fairness. In the health care setting, justice usually refers to the a. In the health care setting, justice usually refers to the allocation of health care resources. Allocation is usually unavoidable because resources are limited and could be spent on other social goods, such as education or the environment, instead of health care

19. Social justice:  Ideally allocation decisions are made by public policy and set by government officials  Physicians should participate in debates about allocation and help set policies.

20. Social justice: In general however, rationing medical care at the bedside should be avoided because it may be: –inconsistent, – discriminatory – ineffective. –At the bedside, physicians usually should act as patient advocates within constraints set by society and sound practice.

21. Social justice: If patients compete to limited resource e.g. time of physicians or bed in ICU Rationing by physicians should be done according to patient's medical needs probability and degree of benefit.

22. Page  22  However guidelines may be difficult to apply in new cases for several reasons Difficulty with guidelines:

23. Page  23  Case to case variations inherent  Different priorities and goals for care  Distinguishing cases in ethically meaningful ways 1. Guidelines need to be interpreted in the context of specific cases:

24. Page  24  Guidelines are not absolute  cases may have distinctive features  To ensure fairness, physicians who make an exception to a guideline should justify their decision  The justification should apply to all similar cases faced by other physicians 2. Exceptions to guidelines may be appropriate:

25. Page  25  In many situations, following one ethical guideline would require the compromise of another guideline.  much easier if there were a fixed hierarchy of ethical guidelines 3. Different guidelines may conflict:

26. Questions?