Medical Ethics in Family Practice

Case Scenarios

1. The Employer of a patient of yours requests access to his records for recurrent ill health.

How would you manage the request?

2. A 16 year old daughter of a friend presents requesting TOP. She is 8 weeks amenorheic. She does not want her parents to know.

How would you manage her?

3. A 13 year old girl is brought to you by her parents for some recurrent ‘vague’ symptoms. She confides in you that she has been sexually active since she was abused at 8 years by her maternal cousin living with them. She has a strained relationship with the parents. She does not want you to tell her parents.

How would you handle this?

What is Ethics

Ethics is not any of the following:

• Not the same as feelings
• Not religion
• Not following the law
• Not following culturally accepted norms
• Not science

What is Ethics?

Ethics deal with the codes, values, principles, and customs of society. Ethics have to do with:

• Moral Principles
• What is good and bad
• What is right and wrong
• Based on a value system

Ethical norms are not universal – depends on the sub culture of society.

Ethics refer to rules and principles that ensure right conduct and it touches on virtually every facet of life.

Medical Ethics

It is the study of moral values and judgment as they apply to medicine. Refers to medical oaths and codes that prescribe a physician’s character, motives, and duties which are expected to produce right conduct and should guide the members of the medical profession in their dealings with one another, their patients, and with their states.

What is Medical Ethics

Medical Ethics are the moral principles for registered medical practitioners in their dealings with each other, their patients, and the state. It guides the conduct of Healthcare Workers: Doctors, Dentists, etc., in their relationships with patients, colleagues, and society in general.

It refers to the medical oaths and codes that order a physician’s character, motives, and duties which are expected to produce a right conduct and this should guide the members of the medical profession in their dealings with one another, their patients, and with their states.

Ethical principles were derived from the Hippocratic Oath, Geneva Convention, and handbooks guiding professional practice. Based on these, each stakeholder has certain duties.

Doctor's Duties to His Patient

1. Treatment of the patient is an implied contract
2. Duty to the sick
3. Continue treatment
4. Duty to earn confidence
5. Duty to children and infirm
6. Charge for professional service
7. Right to choose a patient
8. Duty to give proper directions
9. Duty to offer a proper regime of treatment
10. Duty to notify communicable diseases
11. Examination and consent
12. Duty as regards the result of examination

Professional secrecy

Privileged communication: Bonafide statement of a registered medical person on a subject matter of public interest to the concerned authority to protect the interest of the community.

Conditions of Privileged Communication

1. Infectious diseases
2. Venereal diseases
3. Employers & employees
4. Notifiable diseases
5. Suspected crime
6. Patient’s own interest
7. In courts of law

Doctor's Duty to The State

1. Notification of infectious diseases
2. Notice to police
3. Notification of births and deaths
4. Issuing of certificates
5. Respond to emergency military services

Doctor's Duty Towards Colleagues

1. Extend same honour, respect & good behavior as expected from them
2. Should not do or utter anything to lower down the name of colleagues
3. Should not entice patients away from colleagues
4. Free medical service to fellow colleagues

• Autonomy
• Beneficence
• Non-maleficence
• Justice

Principles of Medical Ethics

• Autonomy: Implies that the patient has the right to decide what shall happen to his own body. The physician should adequately inform the patient and thereafter respect their well-informed decisions/wishes.
• Beneficence: Implies that the physician must always act in the best interest of the patient.
• Non-Maleficence: 'Above all, Do no Harm' (or the least harm as the case may be). Note: When the physician’s treatment produces the desired positive outcome but causes harm, it is known as the "double effect." For example, using morphine to relieve cancer pains in an elderly dying patient, which can hasten his demise through respiratory suppression.
• Justice:The principle of “fairness and equality” in deciding who gets what when distributing scarce resources. It implies equal distribution among all groups in the community of the burdens and benefits of new or experimental treatments. Here are four main areas to note in considering justice:
1. Fair distribution of scarce resources
2. Competing needs
3. Rights and obligations
4. Potential conflicts with established legislations

Medical Etiquette

Medical etiquette refers to conventional laws and customs of courtesy observed between members of the medical profession. Don’t forget that there is ‘heirarchy in Medicine’.

Confidentiality

This means keeping as top secret your dealings with the patient. It is wrong for a doctor to divulge the information about his patient to another person without the patient’s consent.

Exceptions are:

1. When the patient gives written and valid consent
2. Divulging the information to other health care providers in the course of the patient’s management
3. Close relatives can be informed when it is undesirable to seek consent
4. Statutory requirement or court order that a given information be made public
5. If it is in the interest of the public
6. If in the respect of an approved research

Consent

This is an agreement, compliance, or permission given voluntarily without compulsion. It can be:

• Express
  • Verbal
  • Written
• Implied

Informed Consent

This is the very foundation of the patient-doctor relationship. Most medical litigations revolve around deficiencies in the process of obtaining informed consent for medical care. Informed consent implies consensus or a meeting of minds and not a mere completion of a form. If the essential ingredients are lacking, then of course informed consent cannot be said to exist despite a signed informed consent form.

This principle is based on the fact that “Every human being has a right to determine what shall be done with his own body.”

It requires a full disclosure and discussion of the proposed medical or operative procedure, including its risks, complications, alternatives, and their risks, and reasonable expectations.

It is more than just signing a form. It is a sensitive issue and must never be trivialized.

Documentation of your discussion with the patient is key - whatever was not documented did not occur.

Consent from minors and patients with mental capacity is not valid. Patients below 18 years are Minors in Nigeria - parents or guardians give assent in that case.

• Medical malpractice occurs when a doctor, hospital, or any other healthcare professional, causes injury or death to a patient either by negligence or omission.
• It implies the absence of reasonable care and skill, or wilful negligence of a medical practitioner in the treatment of the patient which causes bodily injury or death.
• Medical negligence is a breach of the healthcare provider’s duty of care to a patient resulting in harm to the patient or even death.
• Medical malpractice is injurious or unprofessional treatment or culpable neglect of a patient by a physician or surgeon.

Medical Malpractice

• Failure of the physician to follow usual practice in the community.
• Lack of skill.
• Ignorance.
• Alcohol or drug abuse.
• Failure to tell patients of the treatment risks.
• Lack of needed equipment, medicine, or staff.

Professional Misconduct

Conduct considered as disgraceful or dishonorable by professional breathren of good repute and competency. Such as-

• Issue of false medical certificates
• Covering up unqualified persons
• Helping quacks
• Canvassing
• To personally open chemist shop
• To prescribe habit-forming drugs
• Disclosing professional secrets of patients
• Failure to notify
• Treating patients under the influence of drink or drugs
• Fee splitting/dichotomy

Established by Medical and Dental Practitioners’ Act of 1963, amended in 1969

• Councils are established to
• Protect qualified from unqualified practitioners.
• Protect the public from qualified practitioners.

Function of MDCN

• Supervision of Medical Education
• Maintaining a Medical Register
• Maintenance of Discipline among registered practitioners

Discuss your opinions of the cases presented earlier

Things to note-

Case 1 - Ethical Issue of Confidentiality/Consent

Ethical issue of confidentiality and consent is a primary concern in this case.

Case 2 - Ethical Issues for Minor Patient

The patient is a minor, and ethical issues include conflict of interest (family friend), confidentiality, autonomy, consent, and non-maleficence concerning the unborn baby. Additionally, the legality of abortion in Nigeria is a key consideration.

Case 3 - Minor Patient in Dysfunctional Family

The patient is a minor in a dysfunctional family, facing issues such as sexual abuse and promiscuity. Ethical concerns include confidentiality, autonomy, and consent.