Transcript medical ethics in 21st century general practice

Medical ethics
in 21st century
General Practice
Scope of session
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Raise awareness of ethical and legal
dimensions of clinical decision making
Practise skills in ethical analysis and its
application to clinical situations (especially
in GP context)
Provide overview of key areas of English
law relating to clinical practice
Your experience of an ethical
dilemma
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Write down the story
What made it an ethical dilemma? (not just a
situation where you didn’t know what to do)
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What was most important to you about the
decision you had to make? (e g getting it right,
protecting yourself, avoiding conflict)
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What did you base your decision on? (e g
guidelines, law, advice (who from?), your moral values or
just feeling it was the right thing to do)
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What was the most difficult thing about it?
(e g not having enough information, upsetting other
people, or the responsibility you had)
How do people make ethical
decisions? - 4 moral theories
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Virtue (Aristotle) - good people make good
decisions
Duty (Kant) - there is a supreme moral law
which means
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Do not treat anyone in a way you would not want
to be treated yourself (universalisability)
People have intrinsic worth - no one should be
treated as a means to an end
Utility (Bentham, Mill) - the greatest
happiness of the greatest number
Rights - legal vs moral rights; rights vs
obligations
The 4 ethical principles
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Approach should be applicable by anyone,
whatever their personal philosophy, religion etc
The principles:
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Beneficence
Non maleficence
Respect for autonomy
Justice (fairness, respect for rights, respect for
morally acceptable laws)
Need to reflect on their scope of application whom do we apply them to?
NB they may conflict with each other
A framework for analysing ethical dilemmas, not
a formula for solving them
2 interesting points from the
Curriculum Statement
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Respect for patient autonomy requires a
holistic approach - to help them make choices,
doctor must explore what’s important to them
overall, not just share clinical information
Contextual aspects - how do the values and
beliefs prevalent in the local culture impact on
patient care?
Some areas raising ethical
considerations
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Professional duties
Confidentiality
Consent
Reproductive issues
End of life issues
Mental health
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Children
Screening
Rationing (resource
allocation)
Genetics
Research
Legal aspects of consent
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Form of consent (implied or explicit)
Treatment without consent could lead to
charge of battery (criminal or civil law) or
negligence (civil law)
How much information should we give?
Who can give legally valid consent?
Who has capacity to consent?
To have capacity to consent,
patient must be able to
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understand in simple language what the medical
treatment is, its purpose and why it is being
proposed
understand its principal benefits, risks and
alternatives
understand in broad terms what will be the
consequences of not receiving the proposed
treatment
retain the information for long enough to use it
and weigh it in the balance in order to arrive at a
decision
Who is ‘competent’ (has
capacity to consent)?
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People over 16 presumed to be competent
unless there is evidence to the contrary
Under 16s are only considered competent if they
have sufficient intelligence and understanding to
understand fully what is proposed
Parent can consent on behalf of anyone under
18 who lacks capacity
If someone over 18 lacks competence, no one
can consent on their behalf - decision to be
made by medical team ‘in the best interests of
the patient’; consulting relatives considered
good practice to help medical team make
decision
Power of Attorney
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Enduring Power of Attorney (pre 2007) only
applied to financial affairs
Lasting Power of Attorney (since Mental
Capacity Act 2005, implemented 2007) - 2 kinds
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Property and Affairs LPA (like Enduring Power of
Attorney pre 2007)
Personal Welfare LPA which can specifically include
health decisions. Attorney’s decision could override
Advance Directive made prior to the POA being
registered
Advanced directives
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Advanced directive specifies how you want to
be treated if circumstances arise when you
don’t have capacity to make decisions
Now considered binding in Common Law and
under the Mental Capacity Act 2005
Not valid if
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Unsigned
Doubt re authenticity (e g not witnessed)
Concern it was written under duress
Concern about mental state at time of signing
Advisable to discuss with family before writing
No use if clinical team don’t know it exists
Confidentiality
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All personal info given to a health
professional must be treated confidentially
except in particular circumstances
This includes friends and relatives
Duty of confidentiality continues after
death
Most breaches of confidentiality are
inadvertent
Exceptions to confidentiality
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Patient’s consent
Need to know
Statutory duty (eg DVLC)
Instruction from Judge (in Court or via a warrant
under Police and Criminal Evidence Act
Wider public interest
Child Protection
Access to information
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Data Protection Act 1984 (computer records)
Access to Health Records Act 1991(manual
records)
Access to Medical Records Act 1988 (medical
reports)
Data Protection Act 2000 (access to all records)
Safeguards against having to disclose harmful
or third party information
Other important legal areas
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Mental Health Act
Reproductive Issues
End of Life Issues
Human Rights Act
When you have an ethical
dilemma, consider
Talking to colleagues
 Getting advice from your defence
organisation
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Further info
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RCGP curriculum statement refs
GMC website
BMA website
Ethics in General Practice - a practical
handbook for personal development Anne Orme-Smith and John Spicer.
Radcliffe Medical Press 2001
Scenarios on VTS website