Medical ethics

Dr D Grace MD. FFARCSI. Dip.ICM.

Dept of Anaesthesia & Critical Care Medicine

Altnagelvin Area Hospital

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Aims

Consider medical ethics & clinical practice

Outline and define ethical principles

Outline practicalities & challenging issues arising in medical practice

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Ethics

A branch of moral philosophy & the theoretical study of practical morality

Medical ethics - value judgements applied in a professional context

Ordinary morality

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Principles of medical ethics

Autonomy

Beneficence

Non-maleficence

Justice, equity, utility

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Autonomy

The capacity to think, decide and act freely and independently on the basis of such thought & decision

Linked to autonomy are issues pertaining to:

Consent

Competence

Advance directives

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Consent - principles

“Every adult has an inviolable right to determine what is done to his or her body” Lord Donaldson

Required for examination, treatment, care

Verbal, written, implied, presumed

Given voluntarily

Informed / valid if the quality & clarity of information given is adequate and appropriate

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Competence

> 16 years competence presumed unless evidence to the contrary

Adults may be competent to make some decisions but not competent to make others

Mental disorder / impairment does not of itself imply incompetence

Implies that one can understand, retain, evaluate and choose freely

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Advanced statements

Autonomy (expression of)

Facilitate communication

A useful guide to wishes

Facilitate a good death

Uptake limited

Impact limited

Potential for disagreement

Wording crucial

Circumstances unanticipated

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Beneficence / non-maleficence

The promotion of what is best for the patient - do good

Objective professional assessment v autonomous choice by patient - paternalism v autonomy

Non-maleficence - do no harm

Sanctity of life - quality > duration

Futility - inappropriate provision of life-prolonging therapies when there is no expectation of survival

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Justice

Healthcare resources are finite

One strives for fair distribution

Futility is very costly

Funds are rationed / treatment options are restricted

Advocates and rationers - medical profession, patient groups, government

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Utility

The maximizing of outcomes / preferences

Tension exists between utility & equality

Concentrate resources?

Utility implies making service & provision choices

Requires measurement and research

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Challenging scenarios

Right to treatment

Ordinary v extraordinary measures

Futility & treatment limitation

End of life issues and care

Commissions and omissions

Do not attempt resuscitation

Death & organ donation

Research

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Should all patients be treated?

Natural claim to care / natural duty & professional duty

Statutory “right” to care (consultation, advice, treatment)

Right to be received, respected, heard, advised, treated appropriately if available

Responsibility for the treatment chosen rests with the clinician

When consulted Courts authorize but do not order care

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Ordinary / extraordinary treatment

Treatments with a reasonable probability of benefit with minimal burden

Actions may involve pain + distress

Proportionate v disproportionate measures

Duty to provide proportionate care

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End of life (E.O.L.) considerations in ICU

ICU aims to restore patients to well-being or to a functional existence

Medical intervention may prolong life / postpone death

E.O.L. issues including symptom palliation arise

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Futility + withdrawal

Balance likelihood of survival to discharge against risks & burdens of therapy

Institute/continue/escalate/limit/withdraw treatment - all ethically equivalent

Communication is paramount

Ensure dignity, rights, comfort, wishes (of patient or proxy)

G.M.C., B.M.A., professional bodies provide guidelines & standards

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Omissions, commissions & double

effectInability to benefit

Withholding & withdrawing differ from killing

Intent v foresight / double effect:

palliation & cardiorespiratory depression - relieve burden + allow to die

Physician-assisted suicide / active euthanasia – illegal

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D.N.A.R. / P.N.D.(do not attempt resuscitation – permit natural death)

Cardiorespiratory arrest may -> cardiopulmonary resuscitation (C.P.R.)

C.P.R. success is circumstance-dependent

Consent (for C.P.R.) is invariably assumed when unknown

Communication re E.O.L. care absolutely essential

Patient’s wishes & preferences determined

Multi-disciplinary input to decision invaluable

Treatment status / wishes recorded + reviewed

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Death and B.S.D. (brain stem death)

Death = the irreversible loss of the capacity to breathe and the capacity for consciousness - occurs when the brain stem ceases to function

Brain stem - the critical part of the critical organ

Traditional cardiorespiratory death v B.S.D.

Brain stem or “beating heart” death

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Organ donationDemand rising, supply falling

Beating-heart (B.S.D.) & non-beating heart

Life-saving & life-enhancing

Requires consent/assent – patient or N.O.K. (next of kin)

Advance statement - register as potential donor - http://www.organdonation.nhs.uk

Presumed consent / opt out largely irrelevant as N.O.K.’s wishes actually paramount

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Medical researchAn imperative – today’s research is tomorrow’s medicine

Requires funding & regulation

Potential conflict b/n public & personal interests?

Nuremberg code (1946)

Declaration of Helsinki (1964/2000) – concern for the interests of the subject must prevail over the interest of science & society.

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Research guidelines

Respect autonomy of potential participants thus rigorous consenting: (i) research (ii) not contrary to subject’s interests (iii) outcome unpredictable (iv) freedom to withdraw

Risk of harm - quantifiable, identifiable? Ideally risk < minimal!

Research of quality and of value

Justice

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Summary

Ethical concepts, definitions & context outlined

Autonomy, beneficence & non-maleficence, equity justice & utility - the pillars of medical ethics

Consent + associated difficulties considered

Futility, commission, omission & double effect discussed

Special circumstances – D.N.A.R. - P.N.D. / death & organ donation

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