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Consent and truth telling
Harm and a potential abortion
You receive a prescription for a pregnant patient. The drug prescribed could harm the
unborn child but you know that the patient has been schedules for a medical
termination. You are 99.9% sure that the patient will have the termination but feel a
moral responsibility not to dispense the drug in case the patient changes her mind.
Should you dispense the drug?
TUTOR NOTES
Duty of care to mother and unborn child
Dilemma: Respecting woman’s autonomy and desire to protect foetus
Some possible areas for discussion include:
Consent
Duties
Woman’s rights
Best interests
Notion of when personhood begins
Fetal rights
Potential conflicts of interest
Doctrine of double effect
Public policy issues
Covert medication
Veracity
Ethical aspects
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Protect rights and interests of patients
Relationship between healthcare professional and patient
Status of fetus; whether fetus is a ‘person’ entitled to the same rights as other
persons
Conflict between woman’s rights (including right to control own body) and the
rights of the fetus, and the rights of others (including healthcare professionals)
Truthfulness – whether to inform patient of risks
Respect for bodily integrity
Doctrine of double effect
Balancing interests:
o nature and extent of risk
o strength and weakness of causal link between what is proposed and risk
to fetus
o timeframe
o gestational age and viability of fetus
o how significant is denial of choice/delay in exercising choice
o to what extent do interests coincide
Principles
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Respect for autonomy
 Veracity - truthfulness
 Faithfulness – faithful to patient’s best interests
Non-maleficience duty to patient to ensure no harm is done
Beneficience - act to benefit patient
Justice
Deontology: assumes unchanging and absolute principles
Consequentialism: no strict principles, moral codes, or duties to determine conduct in any
particular situation; assumes that good and harm can be quantified; consider consequences
for those involved ( Note: if termination then fetus not considered; if no termination then
consider net results for all involved, including the fetus)
Virtues: integrity, honesty, veracity, courage, fortitude, respect for others, compassion,
fairness, self-control, prudence, etc.
Professional aspects
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Professional duties
Professional guidance
GMC; BMA; RPSGB; NHS/DoH
care not to undermine trust and confidence
vulnerability of patient
issues of conscientious objection
risk-benefit analysis
o risk to woman of not administering drug
o risk to fetus of administering
risk management
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ensure procedures are transparent and reasonable
ensure consent process is robust
implement comprehensive risk management
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alternative therapies
Legal aspects
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criminal/civil liability
negligence: duty, breach, causation
(Law concerning abortion)
consent
o material/significant risks
o candour
o age and level of competence of patient
o duty to inform of options
English law – unborn child is not a ‘person’ in law; fetus has no rights
until birth and strictly does not merit legal protection
civil law rights (duties owed) held only after an infant is born viable –
‘born alive rule’
protection of fetus under criminal law from intentional harm
Congenital Disabilities (Civil Liability) Act 1976 (as amended), which
gives a child a right of action for damage caused in utero against
everyone except its mother (with the exception of motor accidents, for
which the mother is insured)
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applicable only where child capable of being born alive
provides cause of action to child born disabled as a result of
negligence of another prior to the birth of that child
arises if defendant would have been liable to one or both parents in
respect of the events causing disability
o can occur before conception, during pregnancy or during childbirth
o risk if pregnancy not terminated and child born
Summary points
Telling the truth – demonstrates respect for person; enables informed decisions
(self-determination); social contract; establishes trust and confidence
No legal personality in the fetus until it is born alive: fetus neither a person nor
an adjunct of the mother
Competent adult has right to self-determination: patient autonomy paramount
Pharmacist expected to use skill and judgement regarding appropriateness of
drugs in given circumstances
ETHICAL DECISION-MAKING
Is the question an ethical one?
Legal and professional issues but the also ethical issues: Avoiding harm, Doing good,
Confidentiality, Truth telling, Faithfulness
Step 1 – Gather relevant information
Step 2 – Identify type of ethical problem
 rights and best interests of patient
 withholding information
Step 3 – Analyse problem
 principles of autonomy, non-maleficence; beneficence; faithfulness; veracity
Step 4 – explore options/solutions
 deontological approach – weighing of conflicting principles/conflict of duties –
which course of action best respects duties and rights?
 utilitarian approach – consider all potential consequences (to all parties involved)
– what benefits and harms will each course of action produce and which will lead
to best overall consequences?
 virtues approach – which course of action develops moral virtues?
 alternative courses of action, e.g.
tell woman of risks ↪ autonomy (any constraints infringe woman’s autonomy)
↪woman has a moral right to chose what to do ↪ fully informed consent
supply and do not tell woman ↪ fetus has no status until birth? ↪ lack of veracity ↪
paternalism ↪ infringement of woman’s autonomy and rights (and ‘rights’ of fetus?) ↪
lack of informed consent? ↪ best interests; vulnerable patient? ↪ consequence if no
termination ↪ risk of harm to faith and trust in healthcare professional(s) if becomes
aware↪ risk of physical/psychological harm
delay/do not supply until post-termination ↪ morally wrong to act in ways that
might harm the fetus even if such behaviour is not subject to legal restraint ↪ principle
of prevention of harm to others ↪ paternalism/infringe autonomy ↪ limits of
conscience ↪ imposing own values ↪ risk of physical harm ↪ acceptable alternative
treatment (beneficence/non-maleficience)
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N.B. frequently, there are no definitive right answers, only answers that are more
or less reasonable, more or less defensible: two people may come to an opposite
decision using the same information - it depends on how important each
consideration is to each person and also the degree to which an individual takes a
“deontologist“ or a “consequentialist” approach.
Step 5 – make decision
Step 6 – assess and reflect
Discussion review/links
Pharmacist responsibilities and accountability
Consent to medical treatment
Principles of clinical negligence
Drug induced injury and informed consent
Thalidomide
Risk management
Covert medication