EthicsST3 Teaching

10/10/12

Ruth Gooch

Aims and Objectives

Aims:

To be aware that every single consultation has an ethical component

To be familiar with different ethical frameworks

To consider how ethics affects our daily practice and relationships with patients

Objectives:

To think about a “non-medical” ethical case

To discuss ethical issues that you have encountered recently

Apply different ethical frameworks

To learn more about what trust and autonomy are

Group debate of some commonly encountered clinical ethical issues

Overview

• Introduction

• Types of ethics

• Trust and Autonomy

• Cake break

• Debate

• Summary

• Questions

Get into small groups please......

Discuss a recent case with an ethical dimension...

Regarding the case you’ve discussed:

1) What goals or outcomes do I want to strive for?

2) What duties do I owe to myself and to others?

3) What kind of person do I want to be?

Ethical frameworks

• “Medical”

• Utilitarianism

• Deontological / Duty based

• Virtue based

Medical Ethics

• Justice

• Autonomy

• Beneficence

• Non-malificence

Utilitarianism

• 1) What goals or outcomes do I want to strive for?

• Making decisions and taking actions that benefit people by maximizing “good” and minimizing “bad.”

• Outcomes, results or goals are the focus—not the action taken to achieve them.

• Not “what is best for me” rather “what is the greatest good for the greatest number”

Utilitarianism

Duty based / deontological ethics

• 2) What duties do I owe to myself and to others?

• German philosopher Immanuel Kant (1724–1804). • Kant believed that there are higher principles that are good in

every time, every culture, and every situation.

• When faced with an ethical dilemma, he believes we should ask ourselves: “To whom do I owe a duty and what duty do I owe them?”

Duty based / deontological ethics

• Universal applicability. We should not act one way in some situations or with some people and another way in others. Our actions should be consistent across the board.

• Respectful of others. In Kant’s view, the fact that human beings can reason gives us greater value than anything else. Never treat people as a means to an end, even if you believe the ends are positive.

Duty based / deontological ethics

Virtue

3) What kind of person do I want to be?

Virtue ethics make us decide what actions we should take based on the kind of person we want to be.

This framework dates back to the Greek philosopher Aristotle (384/3–322 B.C.).

He believed that we can achieve happiness—or the “good life”—by developing virtue.

“Clinical Virtue”

• The virtue of being a son or daughter enables you to act differently toward your parents than a stranger. Do you act differently towards your favourite patients?

Resources

• http://nefe.danielsfund.org/ethics/introduction.html

• GMC Good Medical Practice

• MDU / MPS

Summary

• All medical consultations have an ethical component

• Ultimately you must abide by the law, by guidance from our medical authorities (GMC, the RCGP etc)

What is Trust???

Why do patients trust their doctor?

• Competence will inspire confidence

• Compassion will inspire hope

• Someone you can trust to care

Models of doctor-patient relationship

• Consumerist model of care…. “boutique medicine”

• The health professional as a means

• Problems if divergence

• Contractual model

• Rigid and legalistic

• Based on mistrust

• “Doctor-centred” paternalistic

• Emphasis on beneficence

• Public health model

• Consequentialistic framework, target driven

• Mutuality models

• Linking the act of the profession with the fact of the illness

• Virtue/ narrative based model

• Thinking with stories, author of his own life

• Affirming the existence of the author as a human being

What reinforces or erodes trust?

• Evidence suggests listening to the narrative and working with it promotes trust

• Related to ; Quality of GP-patient relationship

• Low trust is associated with ;

– Less satisfaction

– Less adherence to advice

– Less symptom improvement

• Breaking bad news• Deception ,your face says

something else…

The Death of Ivan Ilyich

• And the pretence made him wretched : it tormented him that they refused to admit what they knew and he knew to be a fact, but persisted in lying to him concerning his terrible condition, and wanting him and forcing him to be party to the lie. Deceit, the deceit enacted on him up to the very eve of his death……. Tolstoy

Autonomy

• Ms A 35 year old lady with downs syndrome, severe menorrhagia not controlled by medical rx. Gynae recommends a hysterectomy . Ms A and her mother come to see you. She doesn't want an operation mum thinks it is a good idea….

• Mr B 56 year old executive with DM raised chol smoking 25/ day, states not taking statin and enjoys smoking too much to stop….

• Who has autonomy when to respect it ad when is paternalistic care appropriate?

• Ms C is pregnant for the 5th time, 40 years old, having had STOP x 2,and complications with last delivery. She is insisting on a home delivery and has asked to see her practice records……

• Mrs D has type 1 DM while waiting for an appt at the diabetic clinic she feels dizzy .GP diagnoses hypoglycaemia and gives IM glucagon…..

• Mrs E has breast cancer has had surgery and radioT, oncology has recommended chemo. Mrs E tells her GP she doesn’t want to be involved in this decision and wants to leave it to the doctors….

• Mrs G is former teacher in her early 50s has MND and is terminally ill with resp failure. Her GP has looked after her for many years and is disturbed when she refuses to take more antibiotics…..

Autonomy

• Fundamental principal to act in the best interest of the patient, balancing with autonomy and paternalistic approach.

• Gillons definition

• The capacity or ability of the autonomous person to make independent decisions and act on those decisions

• The freedom to act autonomously, although limits must be posed when it acts on the autonomy of others

• Our role as clinicians is to help patients develop and exercise their autonomy to see the consultation as a partnership between the doctor and patient with a mutual respect for each other’s autonomy.

• Shared universe of expectations, histories, memories,

• Shared normal morality

Good Medical Practice Framework

• 4 Domains

• Domain 1..Knowledge skills and performance

• Domain 2..Safety and Quality

• Domain 3..Communication , partnership and teamwork

• Domain 4..Maintaining trust

Domain 4 Maintaining trustAttributes Examples of principles and values from Good Medical

Practice

4.1 Shows respect for patients

Implement + comply with systems to protect pt confidentialityBe polite considerate,honest + respect patients dignity+privacyTreat each patient fairly and as an individual.If you undertake research, respect the rights of participating patients.

4.2 Treat patients + colleagues fairly +without discrimination

Be honest+ objective when appraising or assessing colleagues and when writing references.Respond promptly and fully to complaintsProvide care on the basis of needs and the likely effect of treatment

4.3 Act with honesty and integrity

Ensure adequate indemnity or insurance cover for your practiceBe honest in financial and commercial dealingsEnsure published information about services is factual and verifiableBe honest in any formal statement or report, whether written or oral, making clear the limits of your knowledge or competence.Inform patients about any fees or charges before starting treatmentIf undertaking research, obtain ethical approval+honestly report results.

Trust Good Medical Practice Framework 4 Domains Domain 1..Knowledge skills and performance Domain 2..Safety and Quality Domain 3..Communication , partnership and teamwork Domain 4..Maintaining trust Domain 4..Maintaining trust Attributes Examples of principles and values from Good Medical

Practice 4.1 Shows respect for patients

Implement and comply with systems to protect patient confidentiality Be polite considerate and honest and respect patients dignity and privacy Treat each patient fairly and as an individual. If you undertake research, respect the rights of participating patients.

4.2 Treat patients and colleages fairly and without discrimination

Be honest and objective when appraising or assessing colleagues and when writing references. Respond promptly and fully to complaints Provide care on the basis of the patient’s needs and the likely effect of treatment

4.3 Act with honesty and integrity

Ensure you have adequate indemnity or insurance cover for your practice Be honest in financial and commercial dealings Ensure any published information about your services is factual and verifiable Be honest in any formal statement or report, whether written or oral, making clear the limits of your knowledge or competence. Inform patients about any fees or charges before starting treatment If you undertake research, obtain appropriate ethical approval and honestly report results.

Debate Time!

Circumcision in babies for cultural/religious reasons is acceptable.

• A person should be able to choose for someone else to help end their life.

• The maximum gestation for which an abortion can be performed should be lowered from 24 weeks to 20 weeks

The end

• Ethics is everywhere!

• Remember there are more frameworks than just the “medical” ethical approach

• You will be assess on your ethical decision making in the CSA......so consider it in your daily practice!