Title: Medical ethics
1Medical ethics
- Dr Gary Heyburn
- Orthogeriatrician
- Royal Group of Hospitals
2(No Transcript)
3Aims
- Principles
- Human rights
- Case studies
- Rationing
- Research
4- How do we resolve ethical problems in medicine?
5Case 1
- 34 year old Jehovahs Witness is about to give
birth when she starts to bleed the blood loss
is life threatening. - Should we give blood?
6Case 2
- A 25 year old needs a Caesarian Section for the
safe delivery of her child. - However she has a phobia about needles and
refuses to agree to surgery - How should we proceed?
7Case 3
- A 35 year old man has waited 20 years for a
transplant. He requires dialysis 3 times per
week. He is contacted by a company in India which
says they can sell him a kidney. - Should he be able to buy a new kidney?
8Duties of a doctor
- make the care of your patient your first concern
- treat every patient politely and considerately
- respect patients' dignity and privacy
- listen to patients and respect their views
- give patients information in a way they can
understand - respect the rights of patients to be fully
involved in decisions about their care - keep your professional knowledge and skills up to
date - recognise the limits of your professional
competence - be honest and trustworthy
- respect and protect confidential information
- make sure that your personal beliefs do not
prejudice your patients' care - act quickly to protect patients from risk if you
have good reason to believe that you or a
colleague may not be fit to practise - avoid abusing your position as a doctor and
- work with colleagues in the ways that best serve
patients' interests.
The duties of a doctor registered with the
General Medical Council
9Ethical Framework
10Clinical Ethics Framework
- Confidentiality
- Autonomy
- benefits/best interests
- non maleficence
- Justice/equity
- Human rights
- Equality
- other considerations
11The Four Principles
- Autonomy
- Beneficence
- Non-maleficence
- Justice
Beauchamp and Childress Principles Biomedical
Ethics, OUP, 5th edition 2001
12Autonomy
- Respect for autonomy respecting the
decision-making capacities of autonomous persons
enabling individuals to make reasoned informed
choices.
13Beneficence
- this considers the balancing of benefits of
treatment against the risks and costs the
healthcare professional should act in a way that
benefits the patient
14Non maleficence
- avoiding the causation of harm the healthcare
professional should not harm the patient. All
treatment involves some harm, even if minimal,
but the harm should not be disproportionate to
the benefits of treatment.
15Justice
- distributing benefits, risks and costs fairly
the notion that patients in similar positions
should be treated in a similar manner.
16The Rights of Humans
- Article 2 Right to life
- Article 3 Prohibition of torture and inhuman
and degrading treatment - Article 4 Prohibition of slavery
17The Rights of Humans
- Article 5 Right to liberty
- Article 6 Right to a fair trial
- Article 7 No retrospective crimes
18The Rights of Humans
- Article 8 Right to respect for private and
family life, home and correspondence - Article 9 Freedom of thought, conscience and
religion - Article 10 Freedom of expression and right to
information
19The Rights of Humans
- Article 11 Freedom of assembly and association
- Article 12 Right to marry and found a family
- Article 14 Right not to be discriminated
against on the grounds of race,sex etc
20Equality Legislation
- Religion
- Political opinion
- Gender
- Ethnic origin
- Disability
- Age
- Marital status
- Dependants
- Sexual orientation
Equality Legislation Section 75 of The Northern
Ireland Act 1998
21Case
- 70 year old is admitted with a chest infection
- He has a background history of lung carcinoma
- The cancer has spread to his bones including his
ribs - He was given 3 months to live, 4 months ago
- The family want full resuscitation
22 23Survival
- If I have a cardiac arrest in hospital what are
my chances of leaving alive?
24(No Transcript)
25Advance statements
- Competent adult
- Voluntary
- Medical consequences of advance refusal explained
- Applicable to the circumstances that arise
26DNAR
- Consider a DNAR
- Where the patients condition indicates that CPR
is unlikely to be successful (BONE METS) - Where CPR is not in accord with the recorded
sustained wishes of a competent patient - Valid applicable advance directive
- Where successful CPR is likely to be followed by
a length and quality of life that would not be in
the best interests of the patient
Alert course
27DNAR
- Relatives cannot determine a patients best
interest, nor demand, give consent to or refuse
treatment on a patients behalf. Their role is to
reflect the patients views not take the decision
on behalf of the patient.
Alert course
28Good Practice in Decision-making
- You should always take the patient's wishes into
account. You must respect a competent patient's
decision to refuse CPR. You should usually comply
with patients' requests to provide CPR, although
there is no obligation to provide treatment that
you consider futile. The patient's decision must
be recorded appropriately and communicated
clearly to the health care team.
http//www.gmc-uk.org/guidance/current/library/wit
holding_lifeprolonging_guidance .aspCardiopulmona
ry_resuscitation
29 Back to Case
- 70 year old is admitted with a chest infection
- He has a background history of lung carcinoma
- The cancer has spread to his bones including his
ribs - He was given 3 months to live, 4 months ago
- The family want full resuscitation
30Capacity/Competence
- Capacity is treatment specific - it depends on
the treatment to be performed. - Capacity can fluctuate.
31- An adult is presumed to have capacity.
- An adult is a person 18 years and over.
- The 3 stage test can be used to assess capacity
323 stage test
- A patient has capacity to consent / refuse
medical treatment if he/she can - comprehend and retain treatment information
- believe it
- weigh it up to arrive at a choice
33Re C 1994 1 WLR 290
- Patient was an adult detained in Broadmoor mental
hospital. - He had gangrene in his left leg and the doctors
considered that amputation was necessary to save
his life. - He refused such treatment.
34- Although he was a paranoid schizophrenic his
mental illness did not render him automatically
incapable of making a decision about his medical
treatment. - Although C believed that he was a world-renown
doctor, the experts considered that he passed the
3-stage test therefore he had capacity to decide
about his medical treatment
35Children
- In law, children are those who are under 18 years
of age - The Family Reform Act 1969 provides that the
consent to treatment of a 16 or 17 year old is to
be treated like the consent of an adult. - This has no application to a refusal of medical
treatment
36Gillick competent
- This states that if a minor has sufficient
intelligence and understanding to enable him /
her to understand the treatment and implications
of treatment then he / she is 'Gillick competent'
and can consent to treatment - However a refusal of treatment may be treated
differently
Gillick v West Norfolk and Wisbech AHA 1986 AC
112).
37Children
- A child who is competent can consent to
treatment. However, a refusal of treatment may be
overridden by a parent or the Court where such a
refusal would be likely to result in the death or
permanent disability of the child. Then the
wishes of the child may be overridden to preserve
his or her long-term interests.
38Re M 1999 2 FLR 1097
- M was a competent 15 ½ year old who sustained
acute heart failure and required a heart
transplant. She stated that she did not want
someone else's heart and refused to give consent.
It was considered to be in her best interests to
have the transplant and (although she ultimately
consented to the operation) it is clear that
treatment would have been declared lawful despite
a refusal
39- The English courts protect strenuously the right
to be self-endangeringly eccentric - "The patient is entitled to reject the advice
for reasons which are rational, or irrational, or
for no reason.
Lord Templeman in Sidaway v Board of Governors
of Bethlem Royal Hospital 1985 1 AC 171
40Case 1
- 34 year old Jehovahs Witness is about to give
birth when she starts to bleed ? - Should we give blood?
41Case 2
- A 25 year old needs a Caesarian Section for the
safe delivery of her child. - However she has a phobia about needles and
refuses to agree to surgery - How should we proceed?
42Ralph Sandland
An Overview of the Law Relating to the Giving
of, and the Refusal to Give, Consent to Medical
Treatment
43Confidentiality
- Patients have a right to expect that
information about them will be held in confidence
by their doctors. Confidentiality is central to
trust between doctors and patients. Without
assurances about confidentiality, patients may be
reluctant to give doctors the information they
need in order to provide good care.
44Confidentiality
- A 66 year old is admitted with weight loss.
- Tests reveal the presence of cancer
- The family feel their father will give up and die
if told any bad news - They demand therefore that he is not told his
diagnosis under any circumstances - How do we proceed?
45Confidentiality
- A family doctor is told that one of his patients
is an epileptic who still drives despite regular
episodes of fitting - WHAT SHOULD HE DO?
46Organ Transplantation
- Over 5000 people in the UK are on the national
transplantation waiting list. - Over 1000 people died in the period from
1995-1999 while waiting for transplant of heart,
lung or liver. This figure does not include those
in need of renal transplant. - About 1600 kidney transplants are carried out
each year in the UK.
47Organ Transplantation
- Active kidney waiting list is over 4000, and
increasing. - In 1999, 16 of renal transplants were from
living donors. This proportion is increasing. The
majority of organs for transplant, however, is
from dead donors. - Of 24,023 deaths in intensive care in 1989-90,
3266 had a possible diagnosis of brain stem death
and may therefore have been suitable for
donation. Only 1232 (37.7) became donors
48Ways of increasing the number of donors
- Making direct appeals to the public
- Addressing public concerns
- Increasing the number of living donors
- Using non-heart beating donors
- Moving to a system of presumed consent
(opt-out). - Automatic availability
49- Mandated choice
- Required request
- Elective ventilation of patients in deep coma and
close to death with no possibility of recovering - Living kidney exchange
- Payment for organs
- Allowing conditional donations
50- The reasons why 2034 potential donors did not
become actual donors included - tests for brain stem death were not carried out
(39) - refusal by relatives (27)
- medical contraindication to donation (22)
- relatives not asked about donation (6).
51The legal definition of death
- Patient is pulseless, apnoeic, with fixed
pupils and no heart sounds - Organs must be perfused
- Donor would need to be on ventilator and have a
beating heart - Concept developed of brain stem death
52Brainstem death
- the patient is in deep coma with no spontaneous
respiration - that there is an absence of various possible
reversible causes for such coma (such as drug
intoxication, hypothermia or electrolyte
imbalance) - that all brainstem reflexes are absent
- Tests have to be carried out twice (typically 24
hours apart). - 2 doctors opinions
53Organ Transplantation
- The Human Tissue Act
- The Human Tissue Act came into force on 1st
September 2006 - The Act regulates the use and storage of human
tissue, including organ transplantation - It replaces the the Human Tissue Act 1961, the
Anatomy Act 1984 and the Human Organ Transplants
Act 1989.
http//www.ethox.org.uk
54The Human Organ Transplants Act 1989
- This Act was passed hurriedly by Parliament in
response to a commercial trade in kidneys - No payment must be made for the organs
http//www.ethox.org.uk
55- Thus relatives have a power of veto if the person
did not express any wishes about the use of
organs after his death. Even where the person did
express a wish that an organ or organs be used
the advice of the Department of Health suggests
that relatives may be able to veto this - Staff need to consider the feelings of
relatives, who may be under great stress, so that
in practice any objections raised by relatives
usually take priority over donors wishes. - Department of Health, 1998.
http//www.ethox.org.uk
56Consent
- The Human Tissue Act places consent at the centre
of the system, both from the living and from or
on behalf of the deceased
57Hierarchy
- Step-parent
- Half sister or brother
- Friend of longstanding
- Spouse/partner
- Parent/child
- Sister/brother
- Grandparent/grandchild
- Niece or nephew
58Case 3
- A 35 year old man has waited 20 years for a
transplant. He requires dialysis 3 times per
week. He is contacted by a company in India which
says they can sell him a kidney. - Should he be able to buy a new kidney?
59Selling a kidney for transplantation
- In individual cases it may be entirely morally
justified - Respecting individuals' autonomy (both
donors/sellers and recipients), - Producing net benefit over harm for
donors/sellers and recipients, - Involving at least no transgression of rights
based justice
J Med Ethics 200329267-268
60Selling a kidney for transplantation
- enhancing distributive justice
- no transgression of legal justice (in countries
that have not banned it involving) BUT - none the less overall the likely dangers of
financial exploitation and of postoperative harm
to predominantly poor donors/sellers - the likely increased risks to recipients of HIV
and other infections - and the likely reduction in volunteer donors
61Conclusion
- will probably result in sufficient excess overall
of harm over benefit to conclude that a legal
ban would be justified
62Summary of the Law Relating to Medical Decisions
at the End of Life
- Active euthanasia (mercy killing) is illegal
- Passive euthanasia is not necessarily illegal
- Withdrawing treatment is legally equivalent to
withholding treatment - Intending relief of distress, but foreseeing
death, is normally legal - Assisting suicide is a criminal offence
- A competent patient who refuses life saving
treatment is not committing suicide
http//www.ethox.org.uk
63Self inflicted problems
- Should smokers be offered surgery such as cardiac
bypass surgery ? - Should HIV patients be treated?
- Should sports injuries be treated?
64Case
- A ten year old girl had non Hodgkin's lymphoma
with common acute lymphoblastic leukaemia. Her
father wanted the Health Authority to fund a
further course of chemotherapy and a bone marrow
transplant. - It refused on the grounds that the proposed
treatment was unproven and that the cost was
disproportionate to the likely benefit. - In the court of first instance Laws J. said that
where a life was at stake then a health authority
must 'do more than toll the bell of tight
resources' and must explain the priorities that
led them to decline to fund the treatment. He
referred to the fundamental right to life and
that the Health Authority should justify any
limitation on that right if it refused to fund
treatment. - However, the Court of Appeal did not invoke the
right to life. The court said that in reviewing
the decision of the Health Authority it must only
look at the lawfulness of its decision and not
the merits. - "Difficult and agonising judgments have to be
made as to how a limited budget is best allocated
to the maximum advantage of the maximum number of
patients. That is not a judgment which the court
can make."
65Difficult choices
- Should preference in treatment be given to
- Those who are young and have a longer expected
time of survival / good health with treatment? - Those who are parents with dependent children?
- Treating a greater number of patients rather than
fewer patients with a greater need? - Treatment that prolongs life or treatment that
improves the quality of life? - Established treatments rather than experimental
treatments?
66Rationing
- Medical criteria
- Age criteria
- Economic criteria
- Philosophical criteria
67Medical criteria
- Priority level 1 Procedures immediately
necessary to save lives in acute physical or
mental illness - Priority level 2 procedures required to avoid
longer-term harm to patients or groups of
patients where interventions are supported by
evidence- diagnosis and treatment of asthma or
diabetes
68- Priority level 3 procedures with documented
effects but where the consequences of not
treating are less serious slightly elevated
blood pressure - Priority level 4 services which are in demand
but where there is no physiological ill effect
from not treating- examples are IVF, repeated
ultrasound during pregnancy - Zero priority- special health services for top
athletes
69Economic criteria
- Cost-minimization analysis
- Cost-effectiveness analysis
- Cost-benefit analysis
- Cost-utility analysis
70Cost-minimization analysis
- When alternatives accomplish the same desired
outcome, the economic evaluation is essentially a
search for the least expensive alternative
71Cost-effectiveness analysis
- Compares the cost per unit of beneficial outcome
( ie cost of life saved, cost per year of life
gained)
72Cost-benefit analysis
- An analysis that measures both the costs and the
consequences of alternatives in terms of money
73Cost-utility analysis
- Instead of simply comparing how many life years
can be saved through various interventions, QALY
analysis weights in how much value or utility
people attach to a year in a particular status
complete freedom of pain- severe disability.Death
is 0, perfect health is 1 - The results of such a cost utility analysis are
expressed in terms of cost per QALY
74Measurement of benefits
75QALY
76Malek, M. 2001. Implementing QALYs
www.evidence-based-medicine.co.uk
77Philosophical criteria
- Aristotle, explaining his view of distributive
justice, says, in effect, that equals should be
treated equally, and unequals treated unequally
in proportion to the relevant inequalities. This
is known as Aristotle's "formal principle of
equality". - Rawls veil of ignorance
78Rawls veil of ignorance
- In trying to make decisions about allocation of
resources in the context of different needs, it
may be helpful to use the concept of the ' veil
of ignorance' put forward by John Rawls in his
Theory of Justice. Faced with a range of possible
societies (or possible methods of healthcare
resource allocation) you must decide which
society you would wish to live in given that you
would not know your position in that society,
whether you would be old or young, rich or poor
sick or healthy. Rawls would argue that a
rational person would choose the society (or to
allocate resources) so that the most
disadvantaged were as well off as they could be.
(Rawls J. A Theory of Justice, The Belknap Press,
1971, revised edition 1999).
79Research Ethics
- Nuremberg code first internationally agreed
ethical code concerning the conduct of clinical
trials - Largely superseded by Helsinki declaration (first
drawn up 1964 and revised several times since) - Medical research brings many benefits but these
benefits should not be bought at any price
80Declaration of Helsinki
- The design and performance of each experimental
procedure involving human subjects should be
clearly formulated in an experimental protocol
which should be transmitted for consideration,
comment and guidance to a specially appointed
committee independent of the investigator and the
sponsor. - The purpose of biomedical research involving
human subjects must be to improve diagnostic,
therapeutic and prophylactic procedures and the
understanding of the aetiology and pathogenesis
of disease. -
- Biomedical research involving human subjects must
conform to generally accepted scientific
principles and should be based on adequately
performed laboratory and animal experimentation
and on a thorough knowledge of the scientific
literature
http//www.ethox.org.uk
81Research Principles
- Knowledge the proposed research should be likely
to produce an increase in knowledge directly or
indirectly relevant to patient care - Necessity it should be necessary for the
research to be carried out with the subjects
proposed rather than with some less vulnerable
group
KWM Fulford
82Research Principles
- Benefits the potential benefits arising from the
research should outweigh any inherent risk of
harm - Consent research subjects should give valid (ie
free and informed) consent to their participation
Parker M and Dickenson D. The Cambridge Medical
Ethics Workbook, case studies, commentaries and
activities. Cambridge University Press 2001
83 Ethical Checklist in Medical Research
- Respect for autonomy
- Consent
- Competent
- Informed
- Voluntary
- Confidentiality
- Patient contact details
- Information from medical records
- Research data and results
- Risk of harm to participants
- Physical
- Psychological
- Therapeutic/non therapeutic research
- Value and quality of the research
- Are the aims worthwhile?
- Is the methodology appropriate to the aims?
- Are the outcomes clinically significant?
- Are the outcomes patient centred?
- Justice
84Patients who are not competent to give consent
for research
May be eligible if
- The risk of harm is very low, probably lower than
the risk that is acceptable in the case of
competent participants - that the research aims cannot be achieved by
other means - that the research is of considerable value, and
- that a relevant person (usually a close relative)
gives valid consent.
85REFERENCES
- Extensive use has been made of the following
resources - UK Clinical Ethics Network http//www.ethics-netw
ork.org.uk/index.htm - The Ethox centre http//www.ethox.org.uk/education
/teach/seminars.htm - Parker M and Dickenson D. The Cambridge Medical
Ethics Workbook, - case studies, commentaries and activities.
Cambridge University Press 2001