Introduction to Medical Ethics

Definitions

Autonomy: The concept describing an individual’s self-determination and the right to direct his or her own life through his or her own decisions, actions and beliefs.

Informed Consent: A process of communication between a physician and a patient that addresses the risks benefits, and alternatives of a proposed medical interventions while meeting the core criteria of competence, exchange of information, understanding of exchange information and voluntary authorization.

Normaleficence: defined as “do no harm”. This principle encompasses both the need to prevent harm and to refrain from harmful acts.

Beneficence: The duty to do good on the behalf of others through an active promotion of the good of the patients and shelter from harm.

Justice: The principle of Justice addresses the need to treat all persons fairly. This pertains to both the physician – patient relationship and the public health obligations of physician in the allocation of scarce medical resources.

Guiding Principle – Premum non nocere – first do no harm.

The foundation of the physician-patient relationship is trust and a patient has the right to privacy and respect of privacy allows for patient to disclose the necessary information to be assisted by their physician.

Most aspects of the doctor-patient relationship have an ethical dimension and the potentials to pose ethical dilemma obstetrician and gynecologists deal with the beginning of human life are often involved in complex decision making.

Ethics is the science of morals, the branch of philosophy that is concerned with human character and conduct.

Essential component to every Ethical issue— an actor, an object and an action.

The actor and the object both have moral value. There has to be a relationship between them and something that happens.

Principles and algorithms

Four principles guide and cover all ethical medical decision.

• Beneficence (doing good)
• Nonmaleficence (avoiding harm)
• Respect for autonomy
• Justice

All four principles do not solve all ethical dilemma

How to keep out of ethical trouble

• Firstly try and avoid getting into trouble in the first place
• Document concerns in details and contemporaneously
• If you are stuck, get a second opinion (medical, legal or make use of your local Ethical committed)
• Respect your own moral intuition. If you do not feel quite right, or are being pressurized to do something unusual or out of your department

Consent

Consent is valid only if:

• It is given by a legally competent person
• It is real i.e. the patient has been adequately informed
• Adequate is defined as sufficient to enable the patient to understand in broad terms, the intention, nature and purpose of what is intended
• It is given freely i.e. voluntarily and not because of undue pressure or influence by another or fraud.

Capacity

In order to give valid consent, the patient must have capacity (the way in which the patient arrives at the decision).

Capacity is a legal concept – patient having legal capacity include

• Individual above 16 but under 18 years of age
• Individual under 16 if in the opinion of doctor they are capable of understanding the “nature and possible consequences of the procedure”
• Any above could have refusal overridden by parent or court.

Anyone over the age of 18 years with capacity to have sufficient capacity. There must be:

• An ability to comprehend and retain information
• A belief in the information
• An ability to balance the pros and cons of the proposed treatment in order to make a choice.

Types of Consent

Express or Implied - It need not necessarily be in writing to be valid in law.

Implied consent could be inferred from the outward appearance and conduct of the patient, leading for the conclusion that the patient had consented to the procedure or treatment.

Consent can be withdrawn.

How much information needs to be disclosed:

• The purpose of the treatment
• The known risks and benefits of the treatment
• The known risk of not carrying out the procedure
• The known risks and benefits of alternative intervention(s)
• Further investigations/second opinion.

Good Practice Point:

• Always ask the patient if she has fully understood the information and whether she would ask any more before the makes a decision.
• Always answer all questions as fully and honestly as possible.
• Ensure that the patients has had enough time to fully digest and think about the information prior to signing the consent form.
• Always make contemporaneous notes.
• Remember that no one can consent on behalf of a competent patient.

Confidentiality and Disclosure

Whatsoever things I see or hear concerning the life of men, in my attendance on the sick or ever apart there from, which ought not be noised abroad, I will keep silence thereon counting such things to be as sacred as secrets (The Hippocratic oath, 4th century BC). During the course of any consultation, sensitive or intimate information is disclosed to a doctor for him to manage his patient effectively.

Information is ‘that which informs, instructs, tells or makes aware’.

Confidentiality between a doctor and patient undermine some of the most important principles of good medical practice.

The overriding principle for the duty of confidence stems from the premise that he who has received information in confidence shall not take unfair advantage of it; however we should note that information is not confidential if it is already in public domain.

There is no duty of confidentiality with regard to information that is useless information or trivia.

The duty to respect confidentiality is not absolute and can be overridden by the public interest need for disclosure. Thus is the nature of the information and we circumstances in which it is disclosed that create the duty of confidentiality.

Justification for Disclosure:

Consent of the patient.

Legal capacity and understanding the nature of the disclosure proposed.

Criteria for disclosure to a third party

• Patient must be aware of the purpose of the disclosure and the extent of information that will be given
• The patient must be aware that the information cannot be concealed or withheld
• There must be written consent from the patient to the disclosure
• Only information relevant to the request can be disclosed
• Only factual information that can be substantiated and presented in an unbiased manner can be included.

Disclosure in the public interest:

• Protecting the public
• Protecting the public from crime
• Protecting third parties
• Confidentiality and the Child i.e. contraceptive advice or treatment to a person under 16 years of age without parental consent. The doctor must satisfy that:
• The girl would understand the advice
• She could not be persuaded to inform her parents or allow the doctor to do so
• She was likely to have intercourse with or without contraception
• Unless she received contraceptive advice or treatment her physical and mental health or both were likely to suffer
• Her best interest required her doctor to give her contraceptive advice treatment or both without parental consent.

Conclusion

The doctor – patient relationship is one in which there is an expectation or promise that the doctor will keep secret anything that the patients imparts

The information must have seen conveyed in circumstances that give rise to a position of trust.

The duty of confidence cannot be absolute and there must be exceptions that allow disclosure without legal penalty.