1. Ethics in Family Medicine Nita Arisanti Department of Public Health

2. Learning objectives O Describe the principles of medical ethics O Understand the implementation of medical ethics in family medicine cases O Describe the ethical issues in several cases: O Confidentiality O Consent O Non-compliant patient

3. O Ethics is an understanding of the nature of conflicts arising from moral imperatives and how best we may deal with them O Ethics does NOT decide what is morally right or wrong; rather it considers how we should act best in the light of our duties and obligations as moral agents.

4. Medical Ethics O Medical ethics is the discipline of evaluating the merits, risks, and social concerns of activities in the field of medicine.

5. THE PRINCIPLES IN MEDICAL ETHICS O The Principle of Non-Maleficence O The Principle of Beneficence O The Principle of Autonomy O The Principle of Veracity O The Principle of Confidentiality(or Fidelity) O The Principle of Social Responsibility and Justice

6. The Principle of Non- Maleficence

7. O first do no harm O sanctity of life O calculated risk or risk benefit

8. The Principle of Beneficence

9. O do only that which benefits the patient O patient ’ s welfare as the first consideration O care consideration competence

10. The Principle of Autonomy

11. O right to information and self determination O free and informed consent O free will and accord - intentional participation in treatment O respect and dignity maintained

12. The Principle of Veracity

13. O Truth telling O Obligation to full and honest disclosure

14. The Principle of Confidentiality

15. O Based on loyalty and trust O Maintain the confidentiality of all personal, medical and treatment information O Information to be revealed with consent and for the benefit of the patient O Except when ethically and legally required O Disclosure should not be beyond what is required

16. The Principle of Justice and Social Responsibility

17. O Actions are consistent, accountable and transparent O not to discriminate on age, sex, religion, race, position or rank O greater good of society O respect of the Law O equity and distribution of burden & benefits

18. Components of Medical Ethics O The Physician -- Patient Relationship O The Physician -- Physician Relationship O The relationship of the Physician to the System of Healthcare O The Relationship of the Physician to Society

19. THE MEDICAL ECOSYSTEM - Enlarging Circle of Influence DOCTOR PATIENT Disease DiagnosisHealth Promotion Disease Prevention Therapy Medical Insurance Managed Care Hospital Laboratories Pharmaceutical Industry Patients ’ Family, Culture, Religion Patients ’ Work, Employer Other Doctors Paramedics Clinic Management Public Health Medical Researc h Medical Students CME, CPD Doctor ’ s Employer Doctor ’ s Family Doctor ’ s Employee Practice Management MDO Medical Council The LAW Government Bodies Medical Charities Patient Organisation Alternative Medicine Press, Media National Community International Community Natural Disasters Political Upheaval, War

20. Special problems in primary care setting

21. Confidentiality O The principle of medical confidentiality-that doctors must keep their patients' secrets-is one of the most venerable moral obligations of medical ethics.

22. O The Hippocratic Oath enjoins: "Whatever, in connection with my professional practice, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret."

23. What is "medical confidentiality"? Essentially medical confidentiality is the respecting of other people's secrets Confidentiality is important as a way to encourage patients to be frank

24. O people's better health, welfare, the general good, and overall happiness are more likely to be attained if doctors are fully informed by their patients, and this is more likely if doctors undertake not to disclose their patients' secrets.

25. Case O Patient requests a statement certifying that he or she is fit to return to work O Insurance company requests for a patient’s condition O Teenage patient seeking abortion and contraceptive advice O Demented elderly patient

26. The General Medical Council (GMC) ’ s lists the following legitimate exceptions: (a) when the patient "or his legal adviser" gives written and valid consent; (b) when other doctors or other health care professionals are participating in the patient's care;

27. c) when the doctor believes that a close relative or friend should know about the patient's health but it is medically undesirable to seek the patient's consent; (d) exceptionally when the doctor believes that disclosure to a third party other than a relative would be in the "best interests of the patient" & when the patient has rejected "every reasonable effort to persuade";

28. (e) when there are statutory requirements to disclose information; (f) when a judge or equivalent legal authority directs a doctor to disclose confidential medical information;

29. (g) (rarely) when the public interest overrides the duty of confidentiality "such as for example investigation by the police of a grave or very serious crime"; and (h) for the purposes of medical research approved by a "recognised ethical committee."

30. In general, patient confidentiality can be breached for three broad reasons O avoiding harm to others O benefiting the patient O public health reporting

31. Consent O The principle’s basic mandate is that a physician must obtain the free and informed consent of a patient or of the surrogate before medical treatment is provided

32. Exceptions… Exceptions to the General Rule of Disclosure Patient is unconscious or otherwise incapable of consenting (Emergency treatment) –Harm from failure to treat is imminent –Outweighs any harm threatened by proposed treatment Therapeutic Privilege –Risk disclosure poses such a threat of detriment to a patient as to become unfeasible or contraindicated from a medical point of view –Does not accept the paternalistic notion that the physician may remain silent because divulgence might prompt the patient to forego therapy the doctor believes the patient must receive

33. The information includes i. The nature of the patient’s condition ii. Purpose of the treatment iii. The potential benefit iv. The foreseeable risks and discomfort v. The available alternatives vi. Cost

34. Informed consent for Incompetent adults: O Obtain from surrogate Case: what, however should one do when patient’s mental capacities are impaired but present to some degree?

35. O Informed consent for children O Children Unable to Participate in decision making: From new-born period to early childhood. Parents are viewed as their surrogate decision makers

36. A Hypothetical Case Mrs. H O 83 year old Hispanic female O Alert and oriented O Terminal advanced COPD O Family agrees to hospice care for patient provided: O Patient not be told she is dying and on hospice O Hospice staff remove name badges when visiting O Hospice staff not tell patient why they have come to see her Question: O Does this violate the concept of informed consent?

37. A Hypothetical Case O During the initial visit by hospice staff: O Patient is given hospice papers and signs them without reading them O Patient is told by family to sign papers without reading them, which she does O Family member signs papers for patient without the patient even knowing this was done Question: O Which of these scenarios, if any, violate the concept of informed consent?

38. The non compliant patient O Patient choose not to comply with the physician’s recommendations

39. Case O Consider a patient who refuses to stay in the hospital O Patient does not fill the prescription that the doctor writes

40. The non compliant patient O Patient choose not to comply with the physician’s recommendations O Mutually acceptable alternative treatments are often available

41. Evaluation of noncompliance causeClinical response Problem in communication Patient should be reinformed about the need for treatment Failure to trustAddress question of mistrust; involved other health professionals who may be trust Psychological factorsTreat anxiety… Value conflictRespect patient wishes