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Ethics for medical student

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Introduction to Medical Ethics

Publicada em: Saúde e medicina
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  • very nice presentation
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Ethics for medical student

  1. 1. Introduction to Medical Ethics Dr Md. Yunus Additional Professor & Co-ordinator of Medical Education Unit, NEIGRIHMS, Shillong
  2. 2. 2
  3. 3. Disclaimer “I’m not an ethicist but I do ethics”
  4. 4. • Nowadays, conflicts of interests between the government & medical institutions, between medical institutions and medical personnel, between physicians and patients are getting more and more serious and complex. Why Ethics Become Important?
  5. 5. • High technologies not only brought us hopes of cure but have also created a heavy economic burden. • The ethical dilemmas of high technology medicine-brain death, organ transplantation, and concerns about quality of life-have become increasingly prominent.
  6. 6. Ethics are not … • Ethics is not the same as feelings • Ethics is not religion • Ethics is not following the law • Ethics is not following culturally accepted norms • Ethics is not science
  7. 7. Ethics are … • Moral Principles • What is good and bad • What is right and wrong • Based on value system • Ethical norms are not universal – depends on the sub culture of the society
  8. 8. Ethics are … Ethics refers to standards of behavior that tell us how human beings ought to act in the many situations in which they find themselves as friends, parents, children, citizens, businesspeople, teachers, professionals, and so on.
  9. 9. Historically • Medical ethics may be traced to guidelines on the duty of physicians such as the Hippocratic oath
  10. 10. What is Ethics? • Ethics are standards of conduct (or social norms) that prescribe behavior. • Ethics as a field of study is a normative discipline whose main goals are prescriptive and evaluative rather than descriptive and explanatory. • So Ethicists are different from social scientists. • Ethicists (or moral philosophers) study standards of conduct.
  11. 11. Four basic Principles of Medical Ethics • Autonomy • Beneficence • Non maleficience • Justice
  12. 12. Autonomy ►Paramount ►Being self-governing ►Able to exercise free will in making a personal decision ►A right to withhold consent ►Applicable to anyone who has capacity
  13. 13. Beneficence ►Literally being charitable or doing good ►Performing care so as to maximise patient wellbeing ►Exercising clinical judgement ►Going beyond the minimum standards required
  14. 14. Beneficence • The practitioner should act in “the best interest” of the patient - the procedure be provided with the intent of doing good to the patient
  15. 15. • This needs health care provider to, -Develop and maintain skills & knowledge by continually updating training - Consider individual circumstances of all patients
  16. 16. Non maleficence • “Above all, do no harm,“ – Make sure that the procedure does not harm the patient or others in society
  17. 17. Non-malificence ►Doing no harm ►Avoidance of putting a person at risk of avoidable harm ►A 1st step towards beneficence ►Defined under the Hippocratic oath
  18. 18. Medical malpractice • An act or omission by a health care provider that deviates from accepted standards of practice in the medical community which causes injury to the patient.
  19. 19. Justice ►No single definition ►Usually distributive justice when applied to medical ethics ►Fairness ►Equity ►Method of righting wrongs
  20. 20. Justice • The distribution of scarce health resources, and the decision of who gets what treatment “fairness and equality” • The burdens and benefits of new or experimental treatments must be distributed equally among all groups in society
  21. 21. Limitations ►Very simplistic ►Autonomy trumps the other principles ►Role of justice ►No coherent approach to resolving conflicting principles
  22. 22. Other factors ►Patient expectations ►Family expectations ►Genuine uncertainty ►Wishes of patient ►Wishes of family ►Cultural values ►Religious values ►Preferences of professionals ►Power balance within the healthcare team ►Trust policies ►Financial issues ►Legal issues
  23. 23. To distinguish between Ethics and Policy • Political standards focus on the conduct of groups or social institutions, whereas ethical and moral standards focus on the conduct of individuals. • Political standards take a macro-perspective on human affairs; ethical and moral standards adopt a micro-perspective. • However, the distinction between ethics and politics is not absolute since many actions, institutions, and situations can be evaluated from an ethical or political point of view.
  24. 24. Professional Ethics • Professional ethics are standards of conduct that apply to people who occupy a professional occupation or role. • A person who enters a profession acquires ethical obligations because society trusts them to provide valuable goods and services that cannot be provided unless their conduct conforms to certain standards. • Professionals who fail to live up to their ethical obligations betray this trust. • Professional ethics studied by ethicists include medical ethics.
  25. 25. Medical ethics • The expressions “professional ethics” and “medical ethics” were coined by Thomas Percival. • Medical ethics is a special kind of ethics only as it relates to a particular realm of facts and concerns and not because it embodies or appeals to some special moral principles or methodology.
  26. 26. Bioethics • Bioethics could be defined as the study of ethical issues and decision-making associated with the use of living organisms • Bioethics includes both medical ethics and environmental ethics. • Bioethics is learning how to balance different benefits, risks and duties.
  27. 27. Clinical ethics Clinical ethics is a practical discipline that provides a structured approach for identifying ,analyzing, and resolving ethical issues in clinical medicine.
  28. 28. • Clinical medical ethics is a practical & applied discipline that aims to improve patient care and patient outcomes by focusing on reaching a right and good decision in individual cases. • It focuses on the doctor-patient relationship and takes account of the ethical and legal issues that patients, doctors, and hospitals must address to reach good decisions for individual patients.
  29. 29. • Clinical ethics emphasizes that in practicing good clinical medicine, physicians must combine scientific and technical abilities with ethical concerns for the personal values of the patients who seek their help.
  30. 30. The content of clinical ethics includes • specific issues such as truth-telling, informed consent, end of life care, palliative care, allocation of clinical resources, and the ethics of medical research. • the study of the doctor-patient relationship, including such issues as honesty, competence, integrity, and respect for persons.
  31. 31. Ethical Issues in Modern Healthcare In modern healthcare and research, value conflicts arise where often there appears to be no clear consensus as to the “Right thing to do.” These conflicts present problems requiring moral decisions, and necessitates a choice between two or more alternatives. Examples: • Should a parent have a right to refuse immunizations for his or her child? • Does public safety supersede an individual’s right?
  32. 32. Ethical Questions, Cont. • Should children with serious birth defects be kept alive? • Should a woman be allowed an abortion for any reason? • Should terrorists be tortured to gain information possibly saving hundreds of lives? • Should health care workers be required to receive small pox vaccination? • Who should get the finite number of organs for transplantation?
  33. 33. Ethical Theories: Ideas and Actions • Deontology (duty) • Consequentialism (actions) • Virtue Ethics/Intuition (morals and values) Beliefs • Rights Ethics (individuality and the American culture)
  34. 34. Two questions when faced with a dilemma: • Behavior: What should I do? • Motivation: Why should I do it?
  35. 35. What Are Ethical Principles, and How Do They Help With Decision Making?
  36. 36. Ethical Principles • Autonomy/Freedom • Veracity • Privacy/Confidentiality • Beneficence/Nonmaleficence • Fidelity • Justice
  37. 37. Veracity • The duty to tell the truth. Truth-telling, honesty.
  38. 38. Privacy/Confidentiality • Respecting privileged knowledge • Respecting the “self” of others.
  39. 39. Fidelity • Strict observance of promises or duties. • This principle, as well as other principles, should be honored by both provider and client.
  40. 40. Ethical Communication • How to explore positive communication techniques which can be used in obtaining consent for treatments (Feature Benefit Check)!
  41. 41. Ethics Committees • Decision making in health care often involves more than just medical facts of the case • Ethical principles and values will be the determining factor in which course of action to take. • Many health care facilities have established Ethics committees.
  42. 42. Ethics Committees • Found in most health care facility’s • Usually Ten to Twelve members • Multidisciplinary members – A representative from the Board of dirctor – The Administrator – A physician – An area clergy – A Social Worker – A Judge – An Ethic ist (Usually a philosophy or Sociology professor) – Lay persons from the community
  43. 43. Functions of the Committee • Education – To committee members themselves – Continuing education and inservice to facility’s staff – To the community
  44. 44. Functions continued • Development and review of laws, standards of care, institutional policies and guidelines – About withdrawing and withholding nutrition and hydration – Do Not Resuscitate – Utilization of facility’s/communities resources
  45. 45. Functions continued • Case Consultation with: – Family members – Patients – Health care providers – Staff
  46. 46. Case Consultation May: – Provides information about ethical principles relevant to the case under discussion – Help clarify what options are open – Provide information about relevant policies of the facility – Make a recommendation that is advisory in nature
  47. 47. Changing Scope of Ethics Committees • Committees are expanding their scope of their activity to include organizational ethics, considering questions regarding: – Finances – Administration – Organization – Human Resource
  48. 48. Informed Consent Origins of the Informed Consent Doctrine • Right to be free from nonconsensual interference with one’s person • Morally wrong to force one to act against his or her will • Serves six functions – Protect individual autonomy – Protect patient status as human being – Encourage physicians to carefully consider decisions – Avoid fraud or duress – Foster rational decision-making by patients – Increase public involvement in medicine
  49. 49. Informed Consent Legal framework for Informed Consent • Historically was based on “Battery Theory” – Unwanted touching – Not operative today in almost all jurisdictions – May be operative if there is no consent at all (i.e. operating on the wrong knee) • Negligence: Operative in virtually all jurisdictions – Prima facie case based on: • Duty to disclose information • Failure to disclose (unless statutory exception met) • If information had been disclosed, patient would not have consented to procedure • Injury and damages
  50. 50. Informed Consent Duty to disclose standards • Professional Standard – Physician has disclosed information that a reasonable or prudent doctor would have disclosed under similar circumstances • Patient-need standard – What a reasonable person would want to know; information that would be material to a patient • States with statutes usually adopt the “Professional Standard” • Case law is split 50-50 on which standard to follow
  51. 51. Informed Consent What must be disclosed • The condition or diagnosis • Nature and purpose of treatment • Risk of treatment • Treatment alternatives which includes: – Things that are already known – Things that everybody should know – Option of no treatment – All alternatives do not have to be disclosed
  52. 52. Informed Consent Exceptions to the General Rule of Disclosure • Patient is unconscious or otherwise incapable of consenting (Emergency treatment) – Harm from failure to treat is imminent – Outweighs any harm threatened by proposed treatment • Therapeutic Privilege – Risk disclosure poses such a threat of detriment to a patient as to become unfeasible or contraindicated from a medical point of view – Does not accept the paternalistic notion that the physician may remain silent because divulgence might prompt the patient to forego therapy the doctor believes the patient must receive
  53. 53. Informed Consent Causation Issues • Disclosure of information would have caused the patient to refuse to undergo the treatment – Subjective: The patient states that if s/he had known, s/he would have refused the intervention. This standard is impossible to prove because anyone could say they would have refused if they had known something they claim was not disclosed. – Objective: One must prove that a reasonable patient would not have agreed to the intervention if s/he had known. • Most states have adopted the objective standard
  54. 54. World Medical Association Declaration of Geneva • I SOLEMNLY PLEDGE to consecrate my life to the service of humanity; • I WILL GIVE to my teachers the respect and gratitude that is their due; • I WILL PRACTISE my profession with conscience and dignity; • THE HEALTH OF MY PATIENT will be my first consideration; • I WILL RESPECT the secrets that are confided in me, even after the patient has died; • I WILL MAINTAIN by all the means in my power, the honour and the noble traditions of the medical profession; • MY COLLEAGUES will be my sisters and brothers; • I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient; • I WILL MAINTAIN the utmost respect for human life; • I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat; • I MAKE THESE PROMISES solemnly, freely and upon my
  55. 55. MEDICAL ETHICS CREATE BETTER PHYSICIANS 55 Medical Ethics VirtuesGood of the patient Excellent physician Self understood goodBiological-medical good
  56. 56. GOOD PRACTICE YOU WILL FLOURISH • Basic template for professions: • identify distinguishing characteristic • Rank virtues for particular profession • Define professional excellence 56 Ethics Values Virtues Flourishing life
  57. 57. • WHAT IS YOUR CHOICE MAKES DIFFERENCE ??? • Medicine is about : “Can we?” • Ethics is about: “Should we?” 57
  58. 58. Created by Dr Md. Yunus for Learning & Development of Post Graduate Medical Student Email: drmdyunus@hotmail.com Web: www.neigrihms.nic.in

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