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Medical ethics

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Title: Medical ethics


1
Medical ethics
  • Dr Gary Heyburn
  • Orthogeriatrician
  • Royal Group of Hospitals

2
(No Transcript)
3
Aims
  • Principles
  • Human rights
  • Case studies
  • Rationing
  • Research

4
  • How do we resolve ethical problems in medicine?

5
Case 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?

6
Case 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?

7
Case 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?

8
Duties 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
9
Ethical Framework
10
Clinical Ethics Framework
  • Confidentiality
  • Autonomy
  • benefits/best interests
  • non maleficence
  • Justice/equity
  • Human rights
  • Equality
  • other considerations

11
The Four Principles
  • Autonomy
  • Beneficence
  • Non-maleficence
  • Justice

Beauchamp and Childress Principles Biomedical
Ethics, OUP, 5th edition 2001
12
Autonomy
  • Respect for autonomy respecting the
    decision-making capacities of autonomous persons
    enabling individuals to make reasoned informed
    choices.

13
Beneficence
  • 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

14
Non 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.

15
Justice
  • distributing benefits, risks and costs fairly
    the notion that patients in similar positions
    should be treated in a similar manner.

16
The Rights of Humans
  • Article 2 Right to life
  • Article 3 Prohibition of torture and inhuman
    and degrading treatment
  • Article 4 Prohibition of slavery

17
The Rights of Humans
  • Article 5 Right to liberty
  • Article 6 Right to a fair trial
  • Article 7 No retrospective crimes

18
The 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

19
The 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

20
Equality Legislation
  • Religion
  • Political opinion
  • Gender
  • Ethnic origin
  • Disability
  • Age
  • Marital status
  • Dependants
  • Sexual orientation

Equality Legislation Section 75 of The Northern
Ireland Act 1998
21
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

22
  • How do we proceed?

23
Survival
  • If I have a cardiac arrest in hospital what are
    my chances of leaving alive?

24
(No Transcript)
25
Advance statements
  • Competent adult
  • Voluntary
  • Medical consequences of advance refusal explained
  • Applicable to the circumstances that arise

26
DNAR
  • 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
27
DNAR
  • 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
28
Good 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

30
Capacity/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

32
3 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

33
Re 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

35
Children
  • 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

36
Gillick 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).
37
Children
  • 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.

38
Re 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
40
Case 1
  • 34 year old Jehovahs Witness is about to give
    birth when she starts to bleed ?
  • Should we give blood?

41
Case 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?

42
Ralph Sandland
An Overview of the Law Relating to the Giving
of, and the Refusal to Give, Consent to Medical
Treatment
43
Confidentiality
  • 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.

44
Confidentiality
  • 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?

45
Confidentiality
  • 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?

46
Organ 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.

47
Organ 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

48
Ways 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).

51
The 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

52
Brainstem 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

53
Organ 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
54
The 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
56
Consent
  • The Human Tissue Act places consent at the centre
    of the system, both from the living and from or
    on behalf of the deceased

57
Hierarchy
  • Step-parent
  • Half sister or brother
  • Friend of longstanding
  • Spouse/partner
  • Parent/child
  • Sister/brother
  • Grandparent/grandchild
  • Niece or nephew

58
Case 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?

59
Selling 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
60
Selling 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

61
Conclusion
  • will probably result in sufficient excess overall
    of harm over benefit to conclude that a legal
    ban would be justified

62
Summary 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
63
Self inflicted problems
  • Should smokers be offered surgery such as cardiac
    bypass surgery ?
  • Should HIV patients be treated?
  • Should sports injuries be treated?

64
Case
  • 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."

65
Difficult 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?

66
Rationing
  • Medical criteria
  • Age criteria
  • Economic criteria
  • Philosophical criteria

67
Medical 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

69
Economic criteria
  • Cost-minimization analysis
  • Cost-effectiveness analysis
  • Cost-benefit analysis
  • Cost-utility analysis

70
Cost-minimization analysis
  • When alternatives accomplish the same desired
    outcome, the economic evaluation is essentially a
    search for the least expensive alternative

71
Cost-effectiveness analysis
  • Compares the cost per unit of beneficial outcome
    ( ie cost of life saved, cost per year of life
    gained)

72
Cost-benefit analysis
  • An analysis that measures both the costs and the
    consequences of alternatives in terms of money

73
Cost-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

74
Measurement of benefits
75
QALY
76
Malek, M. 2001. Implementing QALYs
www.evidence-based-medicine.co.uk
77
Philosophical 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

78
Rawls 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).
79
Research 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

80
Declaration 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
81
Research 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
82
Research 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

84
Patients 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.

85
REFERENCES
  • 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
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