1. Introduction to Medical Ethics
Lecture 1
Medical Ethics: Theories and Principles

2. Programme aims Definition of Medical Ethics
Scope of Ethics in Medical Practice
Theories and principles
Duties of a Doctor

3. Objectives
Within small groups and by using case based material you will be able to:
1)Recognise ethical issues
2)Recognise ethical conflicts
3)Practice verbal reasoning skills
4)Be aware of own and others moral values

4. “Patients are entitled to good standards of practice and care from their doctors.Essential elements of this are professional competence, good relationships with patients and colleagues and observance of professional ethical obligations.”
From Good Medical Practice, GMC.

5. Importance of Medical Ethics
1. Increasing profile\Recent press headlines:
Dr Cox (euthanasia)
Alder hay Enquiry
Jodie and Mary
Destroying frozen embryos
Refusal to fund marrow transplants\new drugs

6. Importance of Ethical Issues (contd.)
2)Increase in technology
3)Better informed society
4)Doctors in Management
5)Public scrutiny

7. Scope of ethics in Medical Practice
Historical background
Hippocratic oath
Geneva(1947)
Sydney(1968)
Tokyo(1975)
Lisbon(1981)
Multidisciplinary nature

8. Four Misconceptions
Clear distinction :clinical and ethical analysis
Clear distinction: profess. and everyday ethics
Enshrined in lead
Medical ethics=matter of opinion
Doctor X is considering whether or not to break a confidence. Patient has presented with an STD which he wishes to have treated confidentially.His wife is also your patient.What do you do?

9. DEONTOLOGICAL THEORIES
Some principles are intrinsically right
regardless of resulting consequences.
CONSEQUENTIALIST THEORIES
Consequence alone determines right and wrong.
- greatest happiness of the greatest number.

10. Principles Beneficence Non-Maleficence Autonomy Truth telling
Confidentiality
Preservation of Life
Justice

11. Beneficence and Non-Maleficence
Questions:
1)Is the patient your only concern?
(possible conflict with utility)
2)Do we always know what is good for the patient?
(patient’s view may differ from ours)

12. 3 constraints on Beneficence
Need to respect autonomy-patient and doctor may differ re. Management
Need to ensure health is not bought at too high a price
Need to consider rights of others

13. Autonomy Capacity to think, decide, take action
Mental incompetence= no autonomy
Autonomy –v-Paternalism
When patient not autonomous –no clash. When patient autonomous-questionable procedure

14. Truth Telling “In much wisdom is much grief:and he that increaseth knowledge increaseth sorrows” (Ecclesiastics 1,18)

15. Truth telling (cont) If you override it you endanger doctor/patient relationship(based on trust) You offend against the principle of autonomy(Dr.C Mooreland) At times there are good reasons for overriding the truth telling principle

16. The case for deception is founded on three fallacies
Hippocratic obligations
Not in a position to know the truth
Patients do not want the truth if the news is bad

17. Confidentiality
Act against this principle and you destroy patient’s trust
Clash –when keeping confidentiality would harm others eg child abuse
Should patients have access to their notes?

18. Against Layman unable to cope with data
Opinions not facts cause anxiety
Third party information
Defensive medicine

19. For
Data belongs to patient
Accuracy improved by sharing

20. Access to Records Data Protection Act (1998) What records are covered?
Does it matter when the record was made?
Who can apply?
Are their exemptions?
Must copies be given if requested?
Access to records of deceased patients?

21. Exceptions to Medical Confidentiality
Pt gives written and valid consent
To other participating professionals
Where undesirable to seek patients consent info can be given to a close relative
Statutory requirements
Ordered by Court
Public interest
Approved Research

22. Preservation of Life At what stage does human life begin?-coil, pill
Can we assess another persons quality of life?-Jehovah's Witness

23. Euthanasia Active: an active intervention to end life
Passive:deliberately withholding treatment that might help a patient live longer
Voluntary :euthanasia is performed following a request from a patient
Doctor assisted suicide: a doctor prescribes a lethal drug which is self administered by the patient
Non-voluntary :ending the life of a patient who is not capable of giving permission
Involuntary:ending life against a patients will

24. Other Moral doctrines
Acts and Omissions Doctrine-held by those who believe that passive euthanasia is not killing(killing is an act,and an omission is not an act)
Doctrine of Double effect-makes a distinction between what I intend and what I merely foresee

25. Living Wills
Patient unconscious\severely mentally disabled , and two docs agree it unlikely he will be able to communicate treatment decision
Refuse treatment if prolongs life with no further benefit to patient

26. Justice How to allocate scarce healthcare resources? Medical need
Medical Benefits
Social worth-discriminates against underprivileged
Merits/contribution to society-very contentious
Desert
Market Forces
A lottery

27. Contaception and Minors
Jane aged 15 yrs requests the OCP
Her mum phones you the next day
Several weeks later she tells you her boyfriend slapped her across the face
Her boyfriend is her history teacher

28. Lord Fraser’s reccomendations
The doctor should assess whether the patient understands his\her advice
The doctor should encourage parental involvment
The doctor should take into account whether the patient is liekly to have sexual intercourse without contraceptive treatment
The doctor should assess whether the patient’s physical\mental healthare likely to suffer if she does not receive advice\treatment
The doctor must consider whether the patient’s best interestsrequire him\her to provide contraceptive advice\treatment without parental consent

29. 4th Year- Case history
A 25 yr old lady comes to the treatment room requesting syringes.She is a lesbian and wishes to inseminate herself.
1) What else would you like to know
2)What are the ethical issues
3)What would you do

30. Duties of a Doctor Please apply ethical principles to the above list as described in “Good Medical Practice”

31. Truth Telling Video clip
How much information should be given to patients preoperatively?
When/how should we relay information to a postoperative patient?
What lessons can be learned from this tape?