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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 o o o o o o o o 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 o o o o 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 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 o o ensure procedures are transparent and reasonable ensure consent process is robust implement comprehensive risk management o alternative therapies Legal aspects 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) o o o 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) 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