1. Medical ethics Dr D Grace MD. FFARCSI. Dip.ICM. Dept of Anaesthesia & Critical Care Medicine Altnagelvin Area Hospital 1

2. Aims Consider medical ethics & clinical practice Outline and define ethical principles Outline practicalities & challenging issues arising in medical practice 2

3. Ethics A branch of moral philosophy & the theoretical study of practical morality Medical ethics - value judgements applied in a professional context Ordinary morality 3

4. Principles of medical ethics Autonomy Beneficence Non-maleficence Justice, equity, utility 4

5. Autonomy The capacity to think, decide and act freely and independently on the basis of such thought & decision Linked to autonomy are issues pertaining to: Consent Competence Advance directives 5

6. Consent - principles “Every adult has an inviolable right to determine what is done to his or her body” Lord Donaldson Required for examination, treatment, care Verbal, written, implied, presumed Given voluntarily Informed / valid if the quality & clarity of information given is adequate and appropriate 6

7. Competence > 16 years competence presumed unless evidence to the contrary Adults may be competent to make some decisions but not competent to make others Mental disorder / impairment does not of itself imply incompetence Implies that one can understand, retain, evaluate and choose freely 7

8. Advanced statements Autonomy (expression of) Facilitate communication A useful guide to wishes Facilitate a good death Uptake limited Impact limited Potential for disagreement Wording crucial Circumstances unanticipated 8

9. Beneficence / non- maleficence The promotion of what is best for the patient - do good Objective professional assessment v autonomous choice by patient - paternalism v autonomy Non-maleficence - do no harm Sanctity of life - quality > duration Futility - inappropriate provision of life-prolonging therapies when there is no expectation of survival 9

10. Justice Healthcare resources are finite One strives for fair distribution Futility is very costly Funds are rationed / treatment options are restricted Advocates and rationers - medical profession, patient groups, government 10

11. Utility The maximizing of outcomes / preferences Tension exists between utility & equality Concentrate resources? Utility implies making service & provision choices Requires measurement and research 11

12. Challenging scenarios Right to treatment Ordinary v extraordinary measures Futility & treatment limitation End of life issues and care Commissions and omissions Do not attempt resuscitation Death & organ donation Research 12

13. Should all patients be treated? Natural claim to care / natural duty & professional duty Statutory “right” to care (consultation, advice, treatment) Right to be received, respected, heard, advised, treated appropriately if available Responsibility for the treatment chosen rests with the clinician When consulted Courts authorize but do not order care 13

14. Ordinary / extraordinary treatment Treatments with a reasonable probability of benefit with minimal burden Actions may involve pain + distress Proportionate v disproportionate measures Duty to provide proportionate care 14

15. End of life (E.O.L.) considerations in ICU ICU aims to restore patients to well-being or to a functional existence Medical intervention may prolong life / postpone death E.O.L. issues including symptom palliation arise 15

16. Futility + withdrawal Balance likelihood of survival to discharge against risks & burdens of therapy Institute/continue/escalate/limit/withdraw treatment - all ethically equivalent Communication is paramount Ensure dignity, rights, comfort, wishes (of patient or proxy) G.M.C., B.M.A., professional bodies provide guidelines & standards 16

17. Omissions, commissions & double effect Inability to benefit Withholding & withdrawing differ from killing Intent v foresight / double effect: palliation & cardiorespiratory depression - relieve burden + allow to die Physician-assisted suicide / active euthanasia – illegal 17

18. D.N.A.R. / P.N.D. (do not attempt resuscitation – permit natural death) Cardiorespiratory arrest may -> cardiopulmonary resuscitation (C.P.R.) C.P.R. success is circumstance-dependent Consent (for C.P.R.) is invariably assumed when unknown Communication re E.O.L. care absolutely essential Patient’s wishes & preferences determined Multi-disciplinary input to decision invaluable Treatment status / wishes recorded + reviewed 18

19. Death and B.S.D. (brain stem death) Death = the irreversible loss of the capacity to breathe and the capacity for consciousness - occurs when the brain stem ceases to function Brain stem - the critical part of the critical organ Traditional cardiorespiratory death v B.S.D. Brain stem or “beating heart” death 19

20. Organ donation Demand rising, supply falling Beating-heart (B.S.D.) & non-beating heart Life-saving & life-enhancing Requires consent/assent – patient or N.O.K. (next of kin) Advance statement - register as potential donor - http://www.organdonation.nhs.uk http://www.organdonation.nhs.uk Presumed consent / opt out largely irrelevant as N.O.K.’s wishes actually paramount 20

22. Medical research An imperative – today’s research is tomorrow’s medicine Requires funding & regulation Potential conflict b/n public & personal interests? Nuremberg code (1946) Declaration of Helsinki (1964/2000) – concern for the interests of the subject must prevail over the interest of science & society. 21

23. Research guidelines Respect autonomy of potential participants thus rigorous consenting: (i) research (ii) not contrary to subject’s interests (iii) outcome unpredictable (iv) freedom to withdraw Risk of harm - quantifiable, identifiable? Ideally risk < minimal! Research of quality and of value Justice 23

24. Summary Ethical concepts, definitions & context outlined Autonomy, beneficence & non-maleficence, equity justice & utility - the pillars of medical ethics Consent + associated difficulties considered Futility, commission, omission & double effect discussed Special circumstances – D.N.A.R. - P.N.D. / death & organ donation 23