INTRODUCTION TO MEDICAL ETHICS: AN ESSENTIAL COMPETENCE FOR CLINICIANS

SMA-SGH SEMINARS ON MEDICAL ETHICS AND HEALTH LAW 2003

Dr Chin Jing Jih Chairman, SMA Ethics Committee Deputy Director, SMA Centre for Medical Ethics & Professionalism

What is medical ethics?

MORALITY
= social conventions [beliefs and practices] about right and wrong human conduct that are so widely shared that they form a stable community consensus

ETHICS
= a systematic reflection on and analysis of morality A generic term for various ways of understanding and examining the moral life.

What is MEDICAL ETHICS ?

Developed from the view that ethical problems from medicine can be resolved by applying principles of moral philosophy.

Objective making choices in ethically significant matters in the practice of medicine

the practical and structured approach to assist physicians (and health care workers) in identifying, analysing and resolving ethical issues constructively in clinical medicine.

Role of MEDICAL ETHICS in daily clinical practice

For those situations in which we already know what is right and what is wrong it should help us explain why the one choice is right and the other wrong For those situations in which it is not obvious what is right and what is wrong it should guide us to discover what is the right thing to do

MEDICAL (HEALTH CARE) ETHICS : 3 LEVELS OF RELEVANCE

Doctor-patient relationship

Policies in
health care institutions

Health care policies in society

GOALS OF MEDICINE
The goal of medicine: Setting new priorities.

Hasting Center Report, special supplement Nov-Dec 1996.

Prevention of disease and injury Promotion and maintenance of health Relief of pain and suffering Care and cure of those with malady Avoidance of premature death Pursuit of a peaceful death

WHAT MAKES THE MEDICAL PROFESSION UNIQUE?

a service profession dedicated to the healing of patients, based on a fiduciary doctor-patient relationship an obligation for doctors do the utmost in caring for patients allows the sick to claim their right to humane and dignified care from doctors

ETHICS & LAW:

LAW Seeks to educate and to regulate by announcing a minimal standard of conduct. Looks mainly at due Process

Establishes negative sanctions for ignoring the standard, which has the power of official coercion

ETHICS Extends beyond the law to prescribe desirable conduct and articulate ideas and virtues to which we should aspire Ethical sanctions- generally non-coercive, and include the praise or blame of colleagues or others. Power resides primarily in the strength of reasoning, unaccompanied by state endorsement

Because respecting law is an important moral duty, the legal cases have ethical relevance. However, what is legally permitted may not be ethically justifiable in a particular case

Normative Theories of ethics

Deontological theory Teleological theory Greek: deonto = duty Greek telos = end DUTY-BASED CONSEQUENT action > consequensces BASED

==> obligations and duties in the forms of rules and principles

consequences ==> right or wrong right action = one which causes maximum beneficial results e.g. utilitarianism

4-Principle Approach: NONMALEFICENCE = the obligation to avoid the causation of harm requires merely the omission of harm-causing activities

4-Principle Approach: BENEFICENCE = the obligation to provide benefits and to balance benefits against risks requires positive steps to help others

4-Principle Approach: RESPECT FOR AUTONOMY

= the obligation to respect the decision-making capacities of autonomous activities
rooted in the liberal western tradition of the importance of individual freedom, both for political life and for personal development

4-Principle Approach:

JUSTICE
= obligations of fairness in the distribution of benefits and risks

4-principle Approach
(Beauchamp, Childress)

The principles are prima facie, i.e. always binding unless they conflict with obligations expressed in another moral principle Balancing of the demands of the conflicting obligations which principle overrides in case of conflict depends on the particular context, which is likely to have unique features

4-principle Approach
(Beauchamp, Childress)

The exercise of judgement in circumstances of uncertainty is inevitable. A justifiable infringement of a moral principle or rule must:

be necessary in the circumstances in the sense that there are no morally preferable alternative actions that could be substituted be the least infringement possible

4-BOX APPROACH
CASE HISTORY [casuistic approach]

Medical indications Quality of life

Patient preference Contextual features

recommendations

MEDICAL INDICATIONS
1. What is patients medical problem ? diagnosis?

prognosis? 2. Is problem acute? chronic? critical? emergent? reversible? 3. What are goals of treatment? 4. What are probabilities of success? 5. What are plans in case of therapeutic failure? In sum, how can this patient be benefited by medical and nursing care, and how can harm be avoided?

Tell me what you are thinking?

PATIENT PREFERENCE
1. What has the patient expressed about preferences for treatment? 2. Has patient been informed of benefits and risks, understood, and given consent? 3. Is patient mentally capable and legally competent? What is evidence of incapacity? 4. Has patient expressed prior preferences, e.g., Advance Directives? 5. If incapacitated, who is appropriate surrogate? Is surrogate using appropriate standards? 6. Is patient unwilling or unable to co-operate with medical treatment? If so, why?

In sum, is patients right to choose being respected to extent possible in ethics and law ?

QUALITY OF LIFE
1. What are the prospects, with or without treatment, for a

return to patients normal life?

2. Are there biases that might prejudice providers evaluation of patients quality of life?

3. What physical, mental, and social deficits is patient likely to

experience if treatment succeeds? 4. Is patients present or future condition such that continued

life might be judged undesirable by them?

5. Any plan and rationale to forgo treatment? 6. What plans for comfort and palliative care?

CONTEXTUAL FEATURES
1. Are there family issues that might influence treatment decisions? 2. Are there provider (physicians and nurses) issues that might influence treatment decisions? 3. Are there financial and economic factors? 4. Are there religious, cultural factors? 5. Is there any justification to breach confidentiality? 6. Are there problems of allocation of resources? 7. What are legal implications of treatment decisions? 8. Is clinical research or teaching involved? 9. Any provider or institutional conflict of interest?

4-BOX APPROACH

A device for teaching and discussion User (health care providers + families) friendly vocabulary A practical review method to move a discussion of an ethical problem toward a resolution Begins with the factual features of a case. Principles and rules are referred to as they arise in the discussion of each box/topic. Moral rules and principles are best appreciated in the specific context of the actual circumstances of a case.

Facts + Principles Judgement

No escape from the exercise of judgement in circumstances of uncertainty BUT not just any judgement will be acceptable. No system of guidelines could reasonably anticipate the full range of conflicts to provide mechanical solutions or definitive procedures for decision-making about moral problems in medicine. Experience and sound judgement are indispensable allies

CONFLICTS & DILEMMAS

Treatment : effective + humane & dignified Medical goals from the perspectives of doctors, are NOT necessary the only and most important goals of patients Judgements and decisions are frequently - value laden - role-dependent - influenced by self- and other interests

COMMON ETHICAL PROBLEMS IN HOSPITAL PRACTICE

Patients and/or families demand for everything be done regardless of medical futility Patients refusal of treatment / placement Familys insistent of withholding diagnosis Use of tube feeding in demented patients Issues related to informed consent Confidentiality issues Justice / Distribution issues

COMMON PRETENDERS OF ETHICAL PROBLEMS

Inappropriate medical indications Treatment options inadequately explored Communication problems Breakdown in therapeutic relationships due to bad outcomes Discharge problems Legal problems Assessment of decisional capacity of a patient Obtaining informed consent

CLINICAL ETHICS VERSUS RESEARCH ETHICS

CLINICAL ETHICS RELATIONSHIP PRIMARY OBJECTIVE NONMALEFICENCE INTERVENTION CONSENT Doctor-patient Fiduciary therapeutic effect to benefit patient RESEARCH ETHICS Researcher-patient competing and conflicting interests Generalisable knowledge to benefit society

Above all, do no harm. Risk of harm always exists risk-benefit ratio Proven or established treatments Implied and verbal consent applies except for high risk treatment Experimental treatment clinical equipoise Full informed consent process and document except for minimal risk research

The Belmont Report : Ethical Principles and Guidelines for the Protection of Human Subjects of Research [The National Commission for the Protection of Human Subjects
of Biomedical and Behavioral Research (April 18, 1979)] Nuremberg War Trials; Tuskegee Experiment

1. Respect for persons infromed consent 2. Benficence assessment of benefits and risks 3. Justice patient selection

ETHICS CONSULTATION SERVICE

Assists hospitals health care professionals in the analysis and resolution of ethical issues encountered in daily clinical practice. Clarifies complex issues Improves communication Offers options and/or specific recommendations Provides reassurance and guidance
Ultimately improves patient care

ETHICS CONSULTATION SERVICE

NOT to takeover the duties or rights of individual doctors to make decisions

NOT to interfere with treatment or management NOT to police the doctors

NOT to provide legal immunity / coverage

The practice of medicine in a thoughtful, ethical, compassionate and effective manner helps to make doctoring a satisfying, sustainable and enjoyable part of our lives.