Ethical Issues in Medicine

Dr. E. McIntosh April 06

Ethics
A set of principles of right conduct. A theory or a system of moral values

1. ethics (used with a sing. verb) The study of the general nature of morals and of the specific moral choices to be made by a person; moral philosophy. 2. ethics (used with a sing. or pl. verb) The rules or standards governing the conduct of a person or the members of a profession: medical ethics.
(Greek ethika, from ethos: character, custom)

Theories of Ethics
Utilitarianism
An action should be done if it leads to the best possible outcome for the most people

Deontology
Certain actions are right or wrong regardless of the outcome

Principles of Medical Ethics

Beneficence Nonmaleficence Respect for Autonomy Distributive Justice
Beauchamp TL, Childress JF: Principles of Biomedical Ethics. New York, Oxford University Press, 1994, pp 121.

Beneficence
Doing good obligation to do whats best for the patient Preservation of life Restoration of health Relief of suffering Restoration or maintenance of function

Nonmaleficence
Primum non nocere above all do no harm Avoiding anything that may affect the patient adversely
Therapies or intervention with known dangerous side effects Interventions of unproven benefit Interventions with which the practitioner is unfamiliar with or unskilled in

Respect for Autonomy

Respects patients right to selfdetermination
Largely a western philosophy, may not apply in other cultures.

Patients right to consent to or to refuse treatment. Basis for informed consent

Distributive Justice
Principle of Fairness, giving to each person what he deserves. Relates to allocation of health care resources. Every patient has a right to best possible health care without regard to race, social standing, religion, etc.

Ethical Dilemmas
Morally obligated to do two different actions but unable to do both. Physician and patient/proxy in conflict as to what is best for the patient. When if ever, can patients rights/wishes be overruled? Resource limitations who gets what? Who decides?

Ethical Analysis
Who decides? By what criteria? How are conflicts among decision-makers resolved? How is conflict prevented?

Principles of Ethical Analysis

Medical Indications
Nature of medical problem, goals of treatments, complications, etc.

Patient Preferences
Pts right to choose, informed consent etc.

Quality of Life
Impact of treatment/non-treatment

Contexual features
Religious, family, financial, cultural etc.

Making Decisions
Make a decision in perceived best interest of patient and inform them of decision? Give patient the facts and let them decide? Give patient the facts and recommend a course of action? What if patient wants to proceed against advise?

Ethical Decision Making

Determine whether the issue at hand is an ethical one Consult authoritative sources such as medical association codes of ethics and policies and respected colleagues to see how physicians generally deal with such issues Consider alternative solutions in the light of the principles and values they uphold and their likely consequences

Ethical Decision Making cont.

Discuss your proposed solution with those whom it will affect Make your decision and act on it, with due sensitivity to others affected Evaluate your decision and be prepared to act differently in future
WMA Medical Ethics Manual 2005

Elements of Informed Consent

Competence: ability to make rational decisions Adequate disclosure of information
Risks, benefits, consequences and alternatives

Understanding of information Voluntariness: patient decides of own free will, no coersion Authorization: patient gives consent

Informed Consent for Minors

Age of consent Parent or guardian responsible Child still needs to participate in the process of informed consent
Give explanations and allow choices appropriate for age and maturity.

Conflicts
Emergency situations, no relatives available Parent/guardian refuses consent for life saving treatment.

Confidentiality
Prohibit disclosing patient information without patients consent Mandates precautions to prevent unauthorized access to patient information Exceptions
Concern for safety of other specific persons Concern for public welfare

Advanced Directives
Usually relates to end of life issues, palliative care, certain religious beliefs, etc. Living wills
Patient determines in advance what is to done if he becomes incapable of making decisions.

Appointment of proxy or surrogate

Person designated to make decisions on patients behalf if he should lose the ability to make his own decisions

Refusal of Treatment
Competent adult has the right (autonomy)
Conflict for many health care workers

Incompetent adult or minor who decides?

Advanced directive of previously competent adult Parents/guardian of minors, incompetent adult Courts Aim to do what is in best interest of the patient.

DNR Orders
Resuscitation considered futile or inappropriate in light of patients prognosis Must take into consideration patients expressed wishes Must be discussed with patient/proxy and relatives Conflict
Patient/relative disagree with doctor Relatives/spouses/surrogates disagree with each other When to suspend DNR order

Discontinuation of Life Sustaining Treatment

Brain death Persistent vegetative state Multiple irreversible organ failure: futile treatment Conflicts
Definitions: Death, futile care Definition of treatment When can treatment be ethically discontinued? Who decides?

Euthanasia and Assisted Suicide

Active intervention to end life of a person who would not otherwise die Usually
persons suffering with intractable pain Advanced cancer End-stage heart or lung disease Quadriplegics

Ethical and spiritual issues Illegal in most places

Rights of the Physician

Right to respect and courtesy Right to act in accord with his own conscience or moral beliefs Right to refuse involvement in situations which conflict with his own ethical or moral beliefs