Download ETHICS IN GENERAL PRACTICE - South Bristol GP trainers workshop

ETHICS IN GENERAL
PRACTICE
Bristol Trainers –Saunton Sands
Thursday 13th March 2008
Dr. Bill Foster
Aims for this session…..
 To discuss the relevance of teaching ethics
to GPs in training (and to our daily work)
 To consider some principles and theories
 To provide a practical framework
(Illustrated by two scenarios)
 To apply this to some ethical scenarios
 To consider how we teach ethics to GP
trainees.
PLAN FOR THE SESSION
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Some questions from me
An interactive presentation (slides on handout)
Two ethical dilemmas (applying theory)
More examples (split into smaller groups)
BREAK
Teaching rehearsal – working in trios with your
ethical dilemmas
 What have we leant?
 LUNCH
Some questions for you…….
 What teaching have you had on medical
ethics?
 How is medical ethics relevant to your work
as a GP?
 Is medical ethics the special preserve of
doctors?
 Will the advance of scientific medicine
reduce the need for ethical debate?
Why bother? What problems?
 No clear solutions provided
 A mish-mash of conflicting opinions
 Increases complexity, excessive choice
 It all takes time
 Decisions can be delayed
 What’s wrong with pragmatism anyway?
(We all use our experience, intuition and
common sense)
Why learn about ethics?
 ESSENTIAL IN DIFFICULT CASES
Almost all consultations have an ethical dimension
 SENSITIVITY
More sensitive to individual situations and more
self-critical. This helps to balance EBM.
Paternalism replaced by partnership
Greater range of options considered
 RISK REDUCTION
– Reducing risk of complaint and litigation
 HELPS PASS THE nMRCGP EXAM!!
What is meant by Ethics
 “The philosophical study of the moral value
of human conduct and the rules and
principles that ought to govern it …a code
of behaviour considered correct especially
that of a particular group, profession or
individual”
Collins English Dictionary 1994
How does it relate to philosophy?
 Philosophy
 - is the study of beliefs and ideas. It deals
with theories
 Ethics (moral philosophy) is a branch of
philosophy with practical application.
 Ethical and moral refer to behaviour –
good and bad, right and wrong
 An attempt to make judgements objectively
SORTING RIGHT FROM WRONG
MORAL THEORIES ……...
 VIRTUE….Individuals with intrinsic good
character follow their conscience (Aristotle)
 DUTIES….obligations we owe to each other
based on respect for others. Morality depends on
intention (Kant)
 UTLITY…. Right / wrong judged only by the
consequence. The greatest good for the greatest
number (John Stuart Mill)
 RIGHTS….A more recent theory. What a citizen
can expect to be provided.Stated in law.
Illustration of the theories…..
 VIRTUE….
A Doctor’s decisions are
strongly influenced by an intuitive sense of
moral right. If we follow this we feel
virtuous and our self respect is enhanced.
If others see us in this light we attract
support and respect.
 What if the doctor’s religious belief
prohibits any referral of a woman seeking
abortion?
More illustration of theory…
 UTILITY theory fits well with resource allocation,
Use of Q.U.A.L.Y.s shows funding for CABG best
targeted at non-smokers. NICE decides on new
treatments for cancer
 But if we consider DUTIES….(obligations we
owe to each other based on respect for others)
…….what of our duty of care to the smoker who
wants a CABG? Kant’s categorical imperative
says that individual’s treatment is just as important
as that of a non-smoker.
Whose rights take precedence?
 Our concept of respect for the rights of
others often means that the particular
patient we are dealing with in a consultation
has paramount rights, e.g. patients have a
right to confidential consultations.
 But what about our concerns for the safety
of others when an elderly patient with
reduced vision is desperate to drive to
maintain an independent existence?
Some principles to guide you…
 Four irreducible principles that govern all decision
making in clinical practice
(Beauchamp and Childress 1994, USA, Ethicists)
(Gillon 1994, UK GP)
 Autonomy
 Beneficence
 Non-maleficence
 Justice
AUTONOMY
 The capacity of people to make their own
decisions
 To be fully autonomous you might need to
have all the information and feel free and
un-coerced
BENEFICENCE
 This encourages the GP focus on what he
feels is “acting in the patient’s best interest”
 This may not necessarily coincide with
what the patient wants
NON-MALEFICENCE
 “Primum non nocere”
 Firstly do no harm
 Gross harm….. Shipman
 Subtle harm…. Side effect of drugs given
for self-limiting conditions
(eg NSAIDS, SSRIs)
JUSTICE
 Nothing to do with legal retributive justice
 Is population based
 This refers to distributive justice
 Helps authorities and organisations to
allocate resources fairly according to need
Three helpful friends….
 REALISM…. About what can be changed,
and who can change it
 COMPLEXITY… Try shifting the focus
and the view point
 SHARING…Responsibility with the
patient, relatives, friends, other
professionals
“It would be too much for her…”
 Mrs Lyons is 82, frail but still looking after her
dementing husband. She has an iron deficiency
anaemia and you refer her for investigation.
Colonoscopy and USS show inoperable Ca colon
with mets. The specialist tells her daughter, Carol,
but has arranged for the patient to see you for
results. Carol sees you. She is insistent that you
should not tell her mother she has cancer as, “It
would be too much for her to bear”
 What do you do?
Drinking on duty….
Janet had a stroke and is housebound
Daughter, Liz, lives with her and is her carer
You are the family GP and are called to see her when
she has become chesty again
Liz seems relieved that it is you. She tells you that
last week she called out a GP from the OOH
service. He was rude to her and hasty and rough in
his examination of Janet. He also smelt of alcohol.
This GP is a partner in a neighbouring practice.He
is well respected.
Do you take any action? If so, what do you do
In summary……
 Life , and GP, are full of ethical dilemmas
 4 moral theories
– Virtue / Duty / Utility / Rights
 4 principles to guide you
Autonomy/Beneficence/Non-maleficence/Justice
 3 helpful friends
– Realism / Complexity / Sharing
 You can apply these to any problem
Time to take a breather….
Split Into small groups
More dilemmas
Elect a spokesperson to
present the group’s
discussion of one case
Meet back in the main
room at ……..
Further reading suggestions
“Ethics in General Practice – a practical handbook
for personal development” by Ann Orme-Smith and
John Spicer: Radcliffe Medical Press Ltd, 2001
“Medical Ethics Today”
The BMA’s handbook of ethics and law, 2nd Ed.
BMA Ethics Dept . An excellent resource for the
practice library and includes a CD-Rom. Available
www.bmjbooks.com
“Patient-centred Ethics and Communication at the End
of Life” by David Jeffrey: Radcliffe Publishing, 2006
Idea to consolidating your learning
 Before your next appraisal……. Something
for the Toolkit!
 Apply your new knowledge and skills by
identifying an ethical dilemma from your
own practice and by production of a written
discussion of the dilemma and arguments
for the best resolution.
 One side of A4, briefly describe the
dilemma, and give your analysis.