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Transcript
What is medical ethics?
A-Ethics (Gr) ethikos , adjuctive, noun, ethos, having to do with character
A- Devided to :
1- Practical ethics:
o Applications of ethical standards in practice
2- Theorotical ethics :
A ttemps to understand the underlying basis, assumptions and implication of
ethical systems
B- Medical ethics is concerned with the ethical obligations of doctors to:
1- Patients
2- Collegues
3- Society
C- Medical professionalism in the new millennium: a physicion charter lays down three
fundamental principles as asset of definitive professional responsibilities
1- Principle of primary patient welfare:
a- Serving the interests of the patient.
b- Altruism contributes to the trust that is central to the physician – patient
relationship
2- Principle of patient autonomy:
a- Respecting autonomy
b- Empower patients to make informed decisions about their treatment.
c- Patient’s decision about their care must be paramount.
3- Principles of social justice:
a- Fair distribution of health care resoures
b- Elimination of discrimination in health care
1- The need for medical ethics
a- No doctor can avoid having to make difficult ethical decisions
e.g. – how to ventilate a patient in ITU
- End stage chronic disease
- C.P.R & terminal cancer
- Confedentiality & Sexually transmitted diseases
b- While the “how” of medical practice is a matter of sience and technology, the “why”
is a matter of medical ethics.
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2- Why we need to understand medical ethics?
A- Difficult ethical dilemmas are now common place
B- Clinical decision are increasingly questioned by patients, relatives and the coart (e.g.
CPR) withdrawal of treatment (Especially fluids), ITU care
C- “How – to –treat” issues are a matter of medical ethics
D- Medical ethics is based on moral philosophy.
E- There is a rational behind medical ethics , just as there is behind medical practice.
F- Medical ethics is not defined by medical law, except for the legal positivist.
G- Not everything that is unethical is illegal e.g. advertising.
The charter also propose asset of specific professional responsibilities:
-
Professional competence
Honesty with patients
Patients confidentiality
Maintaining appropriate relations with patients
Improving quality of care
Improving access to care
Just distribution of finite resources
Commitment to scientific knowledge
Maintaining trust by managing conflicts of intrest
Commitment to professional responsibilities
3-The ethical basis of medical practice:A- Ethics & reason:
1- To begin our understanding of ethics we might begin with the following assertion
a- Human beings are moral agents and can determine their actions throught
reflection and choice
b- Justice demands that moral actions are:
• Equitable
• Impartial
• Principled
c- Moral decisions should treat all equally and be open to national scrutiny
B- No account of medical ethics should be complete without consideration of the Hippocrate
Oath:Formed ethical basis of medical practice over two thousand years.
Did not arise from any specific religious perspective
Adoped subsequenthy by Islamic, jewish and Christian faiths
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4-Virtue ethics:
Development of character traits that will enable us to become the sort of person who
will make right decision:Divided to:Moral
Intellectual
Virtues
Moral virtues included
Courage
Friendship
Temperance
Patience
Truthfullness
Intellectual virtues included
Wisdom
Right judgment
Prudence
ETHICAL THEORY:
TWO FUNDAMENTAL THEORIES
1- Consequentialism (utilitarianism)
-Consequences of each action to be addressed
- The most favourable consequence is one where there is the least human
suffering and the most happiness
2- Duty –based ethics (deontological):This theory dictates that we are duty –bound to certain actions in our medical practice
irrespective of consequence. For instance it is important to always be honest with our
patient’s. in contrast a utilitarian may argue that it is better to lie to terminally ill patient about
their prognosis if the truth is likely to add to their suffering
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Basic principles of medical ethics:1- Autonomy = self rule respect Patients wishes
Patient’s decisions Even if they are wrong
2- Beneficence:- doing good promotes the doctor to act in the patient’s best interest
3- Non- Malfeasance :- Maleficence
To do no harm, even if we are unable to do good
4- Justice: - To treat all patient’s equally and thus to give medical resources equally.
Your patients won’t care how much you know, but they will know how much you care.
Part of caring for people as a doctor is behaving in a way which is both ethically and legally
acceptable.
Qualities of a good doctor:1234-
Good communicater.
Clinically competent and aware of their own limitations
An improver of other people’s health and facilitator of access to healthcare
A teacher of patients, families other doctors and medical students, other health
professionals and themselves too as lifelong learner.
5- Good listener and able to explain clearly.
6- Empathetic and sympathetic
7- Patient, tolerant and non discriminatory
8- Genuine and kind
9- No judgmental
10- Fair and trustworthy
11- Not to advertise their services
12- Not to get drunk on duty
(THE HIPPOCRATIC TRACTION)
1- The best known code of medical ethics is the time – honoured Hippocratic Oath
2- It served to differentiat the practice of medicine from quackety and whichcraft
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1-The doctor- patient relation from a Hippocratic perspective
Based on trust:
abcd-
Patient is the most vulnerable member of the society
Doctor makes the diagnosis
Doctor provide the appropriate treatment
The relationship regards as one of partnership rather than paternalism
2-The purpose of medicine – to benift the sick:
1- It is an axiomatic that the purpose of medicine is to benefit the sick
2- The merits of a particular treatment for a given patient are a matter of professional
judgment , the intrinsic worth of the patient is unquestioned
3- Hence, while doctors may make clinical judgment on the benefits of treatment,
they are rather qualified more entitled to make value judgment regarding the
moral worth of the individual
4- Recognition of the intrinsic value of the individual requires respect for all human
life and the prohibition of deliberate killing
3-Refrain from the harm
a- It is the patient who is being treated not simply the disease
“First we must consider the nature of man in general and each of individual and the
charecteristics of each disease”
(Hippocrates epidemic)
b- The doctor must weigh the risks and benefits of treatment and advise what
therapy is indicated, avoiding that which would be inappropriate or unduly
burdensome:
“Practice two things in your dealings with disease; either help or do not harm the
patient”
(Hippocrates epidemic)
c- Indeed some patients are better off without treatment
“It is better not to treat those who have internal cancers since, if treated, they may
die quickly; but if not treated they last a longer time”
(Hippocrates aphorism)
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4-Trust & integrity: The trust between doctor and patient requires confidentiality and the
integrity of the physician
5-FEES:
a- Hippocrates exhorted physicians to consider the patients mean in fixing fees
b- Doctors should be prepared to treat some patients for nothing
c- The advice in his Decorum was that (it is better to reproach patients you have
saved than to extort mony from those in danger of dying)
6-The Hippocratic Oath as a model of medical ethics:
a-The Hippocratic Oath is a duty- based code
b- It predates Christianity &Islam
c-It is compatable with Islam, Christianity and Judaism
d- What is particularly absence is any reference to personal patient autonomy and
informed consent
e- The Hippocratic Oath and tradition has formed the basis of medical practice for
well over two thousand years.
MEDICAL ETHICS AND RELIGION
1- Ethical decision – making has a religious significance , and ethics is indistinguishable from
morality
2- Clinicians must be aware of the religious sensitivities of their patients and how their
believes affect their approach to illness and treatment decisions.
3- A patient’s decision to accept or refuse treatment will include consideration beyond the
merely clinical e.g. a mother might decide to forgo chemotherapy for cancer during
pregnancy in order to protect the foetus.
The Hippocratic Oath
According to my ability and judgement I will in every particular keep this oath covenant. To
regard him who teaches this art equally with my parents. To share my substance with him,
and, if need be, to relieve his necessities and to regard his offspring eqally with my brethren
and to teach them this art, if they should wish to learn it, without fee or stipulation. To impart
knowledge by percept and by lecture and by every other mode of instruction to my sons, to
the sons of my teacher and to pupils who are bound by stipulation and by oath according to
the law of medicine but to no other. I will use that regimen which according to my ability shall
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be for the welfare of the sick and I will refrain from that whom may be baneful or injurious, if
any should ask me a drug to produce death, I will not give it. Nor will I suggest or counsel
such. In like manner I will not give a women a pessary to produce abortion. With purity and
holiness will I watch closely my life and my art. I will not cut for stone but give way to those
are practitioners in this work. Into whatever house I shall enter there I shall go for the benefit
of the sick, abstaining from every voluntary act of justice and corruption and from any act of
seduction of man or women, slave or free.
Whatever in the life of men I shall see or hear in my practice , or without my practice, which
should not be made public, I will hold silence thereon, believing such things not be spoken
while I keep this oath inviolate and unbroken may it be granted me to enjoy my life and my
art, forever honoured by men. But should I by transgression violate it. Let the reverse be my
lot.
(Hippocrates 460 -377 B.C.)
AUTONOMY:
-
Fundamental
Human being of adult years
Sound mind
Freedom to choose one’s own form of health care
The patient have right to refuse undesired therapy
Choose their participation in experimentation
Patients have the autonomy of free will
Doctors are trained to act in the best interested of their patients, but the patients right
to act against his own best
COMPETENCE AND CAPACITY TO MAKE DECISIONS:
A- Definitions:- Competence is a legal term only the coart can determine that the patient is
incompetence
B- Minors:
a- Patient under age 18 years
b- parents or guardian can give consent
c- Neighbors, aunts, uncles and grandparents cannot give consent.
d- This rule does not cover life threatening or serious emergencies
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C- Partial Emancipation
Exceptions for the parental notification in minor: (15-18 years)
abcd-
areas of prenatal care
contraception
sexually transmitted disease;
HIV substance abuse
D- Emancipated minor (16-17 y) (Freed for the need to have parental consent)
1- Not living with his parents, has a job, and is self- supporting financially
2- The minor no longer is dependent upon parental consent for their action
3- Serious conditions requires court order for the consent to be fully valied:a- Organ donation
b- Surgery
b- Abortion
E- Limitations on parental right of refusal for minors:- Parents cannot refuse life saving treatment for their child based on religious belief
- Parents cannot refuse therapy for: children.
+Even if they are brain damaged
+ Cerebral palsy
+ Down- syndrome and trache -bronchial fistulae
PSYCHIATRIC PATIENTS:
A- Lakes capacity:
-Suicidal a tempt
- Those who are not able to decide their financial decisions
B- Capacity to refuse procedures in an otherwise mentally disabled patient
-Retain the right to refuse medical procedures
- Schizophrenia, mental retardations & Autism
INFORMED CONSENT:
A- All points must be described
4- Risks and benefits
5- Understandable language
6- Full information regarding alternative treatments
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B- All major adverse effects must be described
C- Consent is required for each specific procedure
1- Rt. & Left
2- Appendicis & Ca. Colon
D- Beneficence is not sufficient to eliminatate the need for consent e.g. cancer cases on
nasal turbinate during endoscopy.
E- Decisions made when competent are valid when capacity is lost
1- The patient’s last known wishes documented in writing following verbally
expressed wishes is perfectly valid
2- Oral consent is valid if proved
F- The person performing the procedure should obtain consent:Telephone consent is valid
G- All forms of verbal communication, oral advance directive,
and telephone consent are more difficult to prove if
contested. However they are equally valid.
The real questions about telephone consent are:a- Is the person you are speaking to really the surrogate?
b- Does the person know the patient’s Wishes?
c- Did you get the oral/ telephone consent witnessed by another person so that
the person giving consent cannot later deny having given consent?
H- PREGNANT WOMEN CAN REFUSE THERAPY.
a- The prevailing consensus is that a fetus is not a person until birth
b- The mother can refuse a lifesaving. Transfusion & caesarian section to
remove the child even if this will put the life of the fetus at risk.
c- For any question concerning reproductive rights, decisions are based entirely
on maternal wishes
d- The father has no legal right to make an informed consent for any pregnancy
related issues because the question concerns the body of the mother.
e- Only the mother can sign informed consent for any procedure or treatment
during pregnancy
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