Medical Ethics2

DOCTOR & HEALTH CARE PROFESSIONALS

Dr. E. T. Acevedo Dr. ET Acevedo
January 7, 2011

Though each of us is primarily responsible for our own health and  no jealousy and envy – anathema (no-no) in the world of
health care, still we need the help of others in our endeavors to cure.
maintain or restore health. Thus we need the help of other health  no competing against each other; rather must compete
professionals. how to combat the scourge of disease.
 Health care delivery must be:
Medical Ethics - a must for all physicians to guide them in their o collaborative – especially when co-management
behavior towards is necessary.
* their patients; * their peers; o collegeal
* their associates; & * the society. o ally-based
 Doctors and other health professionals who are fighting
Relationship with their peers & associates is governed by each other are ‘no-no’ in the world of health. They become
Professional Ethics. a disgrace to the profession when they treat one another
as enemies.
A. THE HEALTH CARE FACILITY AS A COMMUNITY: 6. Must have respect for each other – the essence of
The modern health care facility: humanism, and humanism is central to professionalism.
 A mixture of several types of organization and professions 7. Treating each other with dignity and worth.
catering to the health needs and welfare of patients
 Retains its original character of a temporary residence with the Members of the Health Team
primary function of care and custody; The final decision maker is still the patient. He is helped in his
 Place of cure in which the medical staff (physicians, nurses, decision by the health team.
auxiliaries, etc.) provides diagnosis and treatment for patients;
 May also be a school in which there are teachers and 1. Physician
researchers with overlapping roles with their students and His role is more specialized & is focused precisely on the diagnosis &
research staffs. treatment of a pathological condition or its future prevention.
 Administrative staff with not only disciplinary responsibilities Traditionally : the licensed physician is the chief decision
but also the positive duty to unify the multiple functions of the maker in any health team
institution in a manner which permits both the patient and the Modern day medicine: role of the licensed medical doctor as a
staff to perform a truly human community. general practitioner has been altered by the growth of medical
specialization
Types of Health Organizations based on objective: Result: - rapid decline of general practice (family medicine) of
A. Clinical medicine has deprived patients of the advantages of having
B. Preventive their health problems evaluated by someone who knows the
C. Research patient in his family context over a long period and who thinks
D. Academic of the patient as a whole person with a continuous biography.
E. Welfare Organizations
2. Psychiatric Social Worker
Therefore, to maintain this health community, it is necessary to Chiefly concerned with patients in their normal life patterns.
develop a staff not only as an hierarchical structure of command Performs the mediating function:
responsibility, but as an interacting health team.  interview patients to discover possible social factors of ethnic
culture, economic status, and family structure which may have
B. THE HEALTH CARE TEAM contributed to the disease, may hinder treatment, or which
Because of the highly specialized character of modern medicine, may prevent rehabilitation
health seekers must entrust themselves not to a single physician but  help patients regarding both their legal rights & their
to a health care team. opportunities for public financial assistance & other matters
connected with illness;
What compose the health team in today’s modern health  act as liaison with patient’s family & help find ways to assure
community? family stability in the absence of the patient from the home;
A. PRIVATE B. GOVERNMENT undertakes the patient’s re-entry into society.
Physician Physician
Nurse Nurse 3. Other specialists who may be needed for referrals
Pharmacist Midwife  Medical technicians
Lab. Med. Technicians Dentist  Pastor or priest - a regular part of patient care.
Social worker Social worker
Drug representatives Sanitary Engineer
Sanitary Inspectors 4. Doctors with Other Health Professionals in the
Health Educator Government Service
Nurse, Midwife, Dentist, Sanitary Engineer, Sanitary Inspector, Staff,
Other professionals involved in health care – coming from the
Relationship With Other Health Professionals private sector.
Doctors and health professionals are related to each other in a bond
of relationship based on TRUST: 5. Nurse
1. Observe Compliance to one’s duty ; Concerned with patients undergoing the actual experience of
2. Know each other well; sickness & healing.
3. Establish open communication lines between colleagues; Originally, the person most concerned with caring for the
relationship could either be formal or informal; patient, and in continuous contact with the patient, hence,
4. Everyone is recognized in his distinct role, skill and should be the central professional figure.
knowledge; no one has a monopoly of knowledge in the Today - nurses are overburdened by housekeeping tasks ---
immense art of healing. making beds, carrying trays, etc. Although, in some hospitals,
5. Cooperation and coordination must be properly observed: they are relieved of these tasks by auxiliaries they are still

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 burdened with technical tasks: injections, medications,
intravenous feeding, etc.
Nurses as administrators - advanced education.
C. THE DOCTOR-NURSE RELATIONSHIP:
Traditional - the nurse must always follow doctor’ orders.
Today - The climate has changed. Nurses are no longer taught
to carry out unquestioningly doctor’s instructions. Morally,
both those who give instructions and those who carry them out
are equally responsible.
The nurse’s duty is to the patient first.
Exception to the rule: In emergency cases, doctor’s orders
should be followed.
Areas of Conflict
1. Obedience
a. Conflicts in medical judgment – the nurse doubts or disagrees with
a clinical decision made by a doctor. If the nurse feels that the
prescribed treatment might be harmful to the patient. Her
obligation to the patient is primary than her obligation to follow
doctor’s order.
b. Medical experimentation – physician giving of placebo, without
getting patient’s informed consent. Will the nurse refuse to carry out
the order?
c. Specialist and Extended Roles:
*Specialist nurse: acquired expansion of their knowledge and skills;
assigned to a job where her knowledge and skills are most
appropriate. – ICU
> A new doctor is assigned who is not so well-versed in the
procedures.
*Role expectation: Doctors expect that nurse can now perform
certain tasks formerly considered to be medical, might expect that
all nurses can perform those tasks, without verifying whether these
tasks are covered by hospital regulations.
*Circumstances in which obedience is necessary – emergency
situation (cardiac arrest). The physician has to assume control &
others respond to his orders. However, in other situations, judgment
has to be made. Doctors are also human and fallible and their
judgments can be wrong.
In so far as a nurse has an obligation to follow a doctor’s orders it is
only a prima facie obligation and may be overridden in certain
circumstances by other factors. A nurse must be careful not to
confuse a well-grounded prima-facie obligation with blind faith.
---Benjamin & Curtis, 1992
2. Autonomy of the Nurse
Nurses make a contribution to the care of the patient which can be
quite independent of the doctor. This independent function is well
illustrated in the care of the terminally ill patient, who by definition
cannot be ‘cured’ by medical treatment.
---Hargreaves, 1979
 
3. Divided loyalties
a. Loyalty to the doctor
b. Loyalty to the institution
c. Loyalty to the patient
d. Loyalty to the nursing profession
 
Nurses are employees of Health Authority and through the nursing
hierarchy have obligations to their employer. Doctors are employed
on a different basis, and they do not work within the sort of
hierarchical structures that nurses do.
* When conflict arises, nurses must look first at their duty towards
the patient, whose needs are paramount.
 
4. Professional loyalty:
From time to time patients will voice criticisms of the doctor to the
nurse. They may also criticize other nurses or other health workers.
- How will they know if you will not tell them directly,
instead of gossiping it amongst yourselves?
5. In-patient setting: Mutual interdependence
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Neither can function independently of the other. Nurses rely on
aspects of the doctor’s authority and medico-legal responsibility to
support them and help contain the situation.
> Daily decisions, such as agreeing to a patient’s leave or the
need for close observation – rarely delegated to nurses.
> Admission and discharge arrangements - exclusive province
of doctors.
6. Multidisciplinary relationships
As a consequence, doctor-nurse relationship is no longer exclusive.
Interactions with other professionals have an impact on the doctor-
nurse dimension, diluting its ‘specialness’.
7. Patient’s expectation: (patient autonomy)
D-N relationship is affected by what patients think of them because
of increasing patient autonomy
Scene 1
Ms. J. Garcia, a pregnant 22 year-old, considers having a baby
with the help of a nurse-midwife in a government hospital other
than an OB-Gyne. The OB-Gyne already expressed her intention to
attend to Ms. J. Garcia. Ms. Garcia feels more comfortable though with
her nurse-midwife.
a. How would a patient such as Ms. J. Garcia decide on who
among professionals would take care of her?
b. To what extent can Ms. J. Garcia insist on her choice without
hurting the feelings of the OB-Gyne?
c. What happens if complications arise during the delivery and
she will need physician to consult? Should this not be taken
into consideration? How?
8. Conflict in communication and decision-making.
Scene 2
Dr. S comes into the acute unit on Monday morning to attend
a staff meeting and is met by a scowling Nurse T, the ward manager. She
tells him that it has been a dreadful weekend, mostly because of a well-
known young female whom Dr. S had admitted in a frank psychotic
state.
During the staff meeting, Nurse T launches into an attack on
Dr. S, stating that he is not listening to nurses. She describes how the
patient, who is a crack cocaine addict, has been luring patients and
visitors to import drugs into the unit. ‘Its OK for you doctors. You admit
the patient and then go off for the weekend, leaving us nurses to pick up
the pieces.’ She reminds him that in previous conversations over her
care, the nurses had conveyed to him their
disquiet about the patient being readmitted to the unit, because of
her positive HIV status, her flirtatiousness towards male patients
And her total disregard for the consequences of possible sexual
activity with other patients. ‘You’ve gone back on your word. She
was up to all those tricks this weekend. She poured hot tea over
one of the patients, and a nurse was hurt in the fracas whilst trying
to contain her.’
In front of other nursing staff and a junior doctor, who remain
quiet during Nurse T’s diatribe, she says that the problem is poor
communication and that the nurses’ views were not taken into
account. Dr. S reminds Nurse T, that , although he was aware of
the problems, he had had no option as the patient was psychiatrically ill
on admission, that he had had no other place to admit her, and that
these concerns had not been raised when the patient was discussed
during the review before the weekend. He asks her why this matter had
not been brought to his attention then.
With benefit of hindsight, Dr. S, knowing the patient well,
might have anticipated that she was likely to cause havoc during her
initial stay on the unit and should have taken the opportunity of the
ward review to discuss with the nurses beforehand risks and detailed
joint clinical strategies. Had he done this, not only would there have
been an agreed course of action, but also he would have communicated
that he was aware of the potential problems the patient was likely to
create on the unit.
Nurse T is communicating her sense that the doctor does not
‘have the nurses in mind’, and this is what she means by not being
heard, rather than whether there was actual verbal communication
taking place. Dr. S focuses on the fact that the nurses did not mention
their concerns when they had the chance to do so. In future staff
meetings, Dr. S might explore why nurses sometimes have difficulties in
communicating their concerns during his ward reviews.
9. Risk management and defensive practice:
Due to the current culture of litigation, emphasis on risk
management can induce defensive practices on the part of both
doctors and nurses.
What Can Doctors do To Improve Doctor-Nurse Relationship?
1. Engagement
 Make sure you know the names of all nurses on the unit;
 Introduce yourself to new arrivals;
 involve yourself in the orientation of the new staff.
 seek informal opportunities to meet with nurses;
 spend time in informal chat in the nurses’ office, hearing
the issues of the day.
 Familiarize yourself with evolving nursing skills and
changes to their roles and responsibilities.
 Ever considered spending some time with the night staff?
2. Clinical Management:
 Make sure that your clinical decisions are well understood
by others and that you have covered all contingency plans
and set review dates.
 When giving instructions make sure that you address them
to the senior nurse, who will delegate to other nurses if
necessary
 If you pick up any signs of disgruntlement, particularly with
any decisions that you have made, don’t let things fester,
thinking that the problem will go away: be prepared to be
criticized and to make changes to your clinical judgments
when appropriate;
 When delegating, do not presume that nurses are there to
carry out menial tasks or that they are less busy than you
are: it might take the same time to explain what you want
done, as to do it yourself; some tasks, such as finding out
information or sending invitations to care programme
approach meetings, can be carried out by administrative
or clerical staff.
3. Help and support:
 Create a culture in which all team members are encourage
to contribute and air their views.
 Discuss with nurses how they can take a leading role in
ward reviews, organising  priorities for discussion and
timetabling of invitations to outside agencies and carers.
 Be prepared to muck in when there  is a crisis: this may
involve active participation in the control  of a patient who
is aggressive or agitated.
 Ensure that safety is high on your agenda; attend health
and safety meetings with nurses.
 Let nurses know well in advance when you will and will  not
be available.
 When serious incidents occur, such as an
unwarranted physical assault on a member of staff or a
suicide on the ward, attend and lend support at the
debriefing session, share feelings openly with staff
involved and present a united front when having to
address these issues with managers, patients and carers.
 Acknowledge and give recognition to nurses’ skills when
the opportunity arises, and publicize them to outside
agencies and management.
 Emphasize the team approach, the need for collaboration
and mutual dependency on each other’s skills; refer to
yourself as a member of the team.
 Be prepared to support nurses when they have arrived at
decisions and independent judgments in your absence,
even if you have reservations about them or they have had
negative consequences; review judgments fairly in open,
frank discussion in circumstances where all staff can feel
comfortable.
 Have regular staff meetings, preferably chaired by nurses,
and be prepared to take action when required; meet with
the nurse manager and other senior staff to discuss policy,
philosophy of care and management issues.
 If possible, organize away-days with the in-patient team,
with workshops and interactive sessions, attended when
appropriate by an external facilitator; this will give
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everyone time to think about topics that you do not
have time to deal with during everyday practice
 Be aware that your main role is to contain anxiety in a very
stressful environment and one that exerts a considerable
emotional strain on the nursing staff; it is expected that
senior doctors will ‘sort it out’ and that they ultimately
carry clinical responsibility
Areas Of Future Collaboration
The following areas present opportunities for practical arrangements
for joint working.
a. Joint  training updates on:
 control and restraint techniques in the management
of violent, aggressive patients;
 resuscitation, management of anaphylactic shocks
and epileptic seizures;
 child protection issues;
 benefits and housing;
 human rights.
b. Joint assessments, in crisis resolution teams, community
health teams, at the point of admission to hospital, in the
out-patient clinic and during  a domiciliary visits.
c. Joint opportunities for therapeutic interventions,  for
example in ward settings in in-patient groups, in
family work or in consultations with outside agencies and
services.
d. Work on programmes dealing with adherence to
medication regimes.
e. Care programme approach plans and meetings
f. Joint clinical audits examining areas of clinical  practice
g. Arranging for nurses to train junior doctors in their initial
placements on acute wards, or in their first forays  into
community care
h. Arranging for doctors to train junior nurses in aspects of
clinical assessments, diagnosis and treatments
i. Joint presentations and publications on clinical practice
References:
1. Ethics of Health Care – Ashley & O’Rourke;
2. Health ethics: Concepts & Moral Issues, EPH ResearchStaff, 1st
Edition
3. Ethics in Nursing Practice – Graham Rumbold
4. Fundamental Concepts, Principles and Issues in BIOETHICS,
Vol. 1 – Jerry Reb. Manlangit, OP, MHA, PhD
WEIRD, AMAZING WORLD OF MEDICINE
TOP FIVE WEIRD
5. Sarah Yeargain lost the skin on her entire body and the
membranes on her eyes, mouth and throat following Bactrim
therapy for sinusoidal infection. The severe allergic reaction, toxic
epidermal necrolysis, needed a skin graft.
4. Fibrodysplasia Ossificans Progressiva is a very rare disease that
causes parts of the body (muscles, tendons, and ligaments) to turn
to bone when they are damaged. This can often cause damaged
joints to fuse together, preventing movement. There is no cure. It is
so rare that it is often misdiagnosed as cancer, leading doctors to
perform biopsies which can spark off worse growth of these bone-
like lumps. The most famous case is Harry Eastlack whose body was
so ossified by his death that he could only move his lips.
3. Jeanna Giese defied medical odds by being the first person to
survive rabies without a vaccination in 2004. Her doctor
pharmacologically induced a coma to allow her immune system to
combat the virus while preserving her brain. An ongoing study, the
Milwaukee Protocol seeks its feasibility in routine care.
2. August 2007, Baguio City. Two month old Eljie Millapes was
diagnosed with fetus in fetu, a condition where a twin fetus
develops within the other. The fetus in fetu becomes a parasite and
is not capable for a life on its own. The host fetus usually dies before
its birth as it has to supply the needs of the other one.
 1. Brooke Greenberg may have the biological age of 17, but not on
the physical nor mental aspects. She remains to be toddler-like.
Genetic analysis revealed that DNA repair genes were normal but
the genes that were mutated were the ones implicated in rapid
aging diseases like progeria and Werner syndrome . Her disease was
called Syndrome X.

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