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Medical Ethics By Shauna O’Sullivan Outline • Background • Definition of Medical Ethics • Ethical Guideline • Principles of Medical Ethics Background • Medical professionals increasingly find themselves confronted with moral questions and ethical dilemmas • Need to reflect on the moral dimension led to a number of international ethical codes and guidelines Background • Documents present a set of basic principles for medical ethics that are deemed universally valid by interested bodies • Many countries have established their own national medical ruling bodies to govern ethical issues that arise within their medical communities Overview of Medical Ethics • Medical profession has maintained simple medical ethics standards for more than 4,000 years – Hippocratic Oath, Prayer of Moses Maimonides, Bible, Holy Koran, as well as cultures, traditions and social mortality have shaped ethical standards • Majority of these documents focus on “avoiding harm to patients” Definition of Medical Ethics • A system of moral principles that apply values and judgments to the practice of medicine • “Ethics is the moral reasoning of actions” – Morality refers to social norms that distinguish between right and wrong in human conduct • Ethics refers to a professional moral conduct – Moral actions based on professional character and ethical principles in each profession Medical Ethics • Medical professionals must confront ethical dilemmas on a consistent basis • Ethical dilemmas are not rare phenomena and thus merit special attention Medical Ethics • Do the best for the patient and place the patient’s interests before the interests of the physician • Purpose is to protect and defend human dignity and patient’s rights • It is not about avoiding harm; rather, it is a set of norms, values and principles Ethical Guidelines • International guidelines such as the Declaration of Geneva (1948) proclaim that medical care must not violate any universally applicable standards • Help medical and professional professionals around the world to: – Recognize ethical dilemmas in medical and health care – Provide general rules and principles to guide decision making processes during these dilemmas Ethical Guidelines • Ethics is culturally defined • Applied ethics involves cultures and traditions – Relies on academia to inform the profession of ethical theories and principles • International guidelines acknowledge the need to account for cultural values and traditions Why is it important to adhere to ethical standards in medical care? • Promotes the aim of medical care: to alleviate suffering • Built on communication between medical providers and patient’s or patient’s families • Helps build support for medical care Ethical Principles • In the realm of health care, it is difficult to hold rules or principles that are absolute – Even thought they are not absolute they serve as powerful action guides in clinical medicine • For medical practice to be considered “ethical” – It must respect all 4 of these principles: autonomy, nonmaleficence, beneficence and justice Autonomy • The right of patients to make decisions about their medical care without their health care provider trying to influence the decision • Patient autonomy does allow for health care providers to educate the patient but does not allow the health care provider to make the decision for the patient Autonomy • Respect for autonomy is one of the fundamental guidelines of medical ethics • Autonomy in medicine is not simply allowing patients to make their own decisions • Physicians have an obligation to create the conditions necessary for autonomous choice in others Autonomy • For a physician, respect for autonomy includes respecting an individual’s right to self-determination as well as creating the conditions necessary for autonomous choice • This principle is the basis of “informed consent” Informed Consent • Informed consent is more than simply getting a patient to sign a written consent form • Process of communication between a patient and physician that results in the patient’s agreement to undergo a specific medical intervention Informed Consent • Communication process must involve: – Patient's diagnosis, if known; – Nature and purpose of a proposed treatment – Risks and benefits of a proposed treatment – Alternatives to the treatment – Risks and benefits of the alternative treatment – Risks and benefits of not receiving treatment Autonomy • Includes confidentiality, seeking consent for medical treatment and procedures, disclosing information about their medical condition to patients, and maintaining privacy • Illustrative case: Jehovah’s Witnesses have a belief that it is wrong to accept a blood transfusion – What happens if a blood transfusion is needed to save a person’s life? Non-maleficence • “Do no harm ” • Physicians must refrain from providing ineffective treatments or acting with malice toward patients • This principle is difficult as many beneficial therapies also have serious risks – The pertinent ethical issue is whether the benefits outweigh the burdens Non-maleficence • Considered negligence if one imposes a careless or unreasonable risk of harm to another • Providing a proper standard of care – Avoids or minimizes the risk of harm is supported by moral convictions but laws of society as well Non-maleficence • This principle affirms the need for medical competence – It is clear that medical mistakes occur – This principle articulates a fundamental commitment on the part of medical professionals to protect their patients from harm Non-maleficence • Illustrative case: How to best treat a pregnant women with newly diagnosed uterine cancer – A single action may have 2 effects, one that is considered good and the other bad (Principle of double effect) – What do you think about this case? What is right and what is wrong? Beneficence • Duty of the health care provider to be of benefit to the patient – Take positive steps to prevent and to remove harm from the patient • These duties are viewed as self-evident and viewed as the proper goals of medicine • These goals are applied to both the patient, and to the good of society as a whole – Vaccinations for disease prevention example Beneficence • Illustrative case: One clear example exists in health care where principle of beneficence is given priority over the principle of respect of autonomy • Example is in the Emergency Room: Patient is incapacitated by the grave nature of accident or illness – We presume that the reasonable person would want to be treated aggressively and we rush to provide beneficent intervention Autonomy vs. Beneficence • Often the most common and difficult ethical issues to navigate arise when the patient’s autonomous decision conflicts with the physician’s beneficent duty – Should a patient who has had heart bypass surgery continue to smoke? – What would you do if a patient with pneumonia refuses antibiotics? Justice • Justice in health care is usually defined as a form of fairness, or as Aristotle once said, "giving to each that which is his due“ • Deals with issues of treating patients equally • Physicians should treat similarly situated patients similarly and allocate resources justly Justice • If you had ten patients and only enough medicine to save five, who would you give the medication to first? Summary • Medical professionals increasingly find themselves confronted with moral questions and ethical dilemmas • Ethics refers to a professional moral conduct • For medical practice to be considered “ethical” – It must respect all 4 of these principles: autonomy, non- maleficence, beneficence and justice Any Questions? References • www.ama-assn.org (AMA code of ethics) • http://depts.washington.edu (Ethics in Medicine) • Gillon R. Medical Ethics: four principles plus attention to scope. BMJ. 1994 Jul 16; 309(6948):184-8.