11.medical ethics and challenges in clinical practice

7/31/2019 11.Medical Ethics and Challenges in Clinical Practice

1/30

Medical Ethics andChallenges in Clinical

PracticeDjoko Wahono Soeatmadji
http://rds.yahoo.com/_ylt=A9G_bHMmrL1IvI4AbaeJzbkF;_ylu=X3oDMTBxdmQzaHJiBHBvcwM5BHNlYwNzcgR2dGlkA0kwODdfMTA5/SIG=1gk49jk48/EXP=1220476326/**http%3A//images.search.yahoo.com/images/view%3Fback=http%253A%252F%252Fimages.search.yahoo.com%252Fsearch%252Fimages%253Fei%253DUTF-8%2526p%253Dphysician%2526fp_ip%253DID%2526fr2%253Dtab-web%2526fr%253Dyfp-t-501%26w=600%26h=401%26imgurl=www.kyma.org%252Fimages%252Fphysician_xray.jpg%26rurl=http%253A%252F%252Fwww.professorsearch.com%252Flaw%252Fphysician%26size=44.7kB%26name=physician_xray.jpg%26p=physician%26type=JPG%26oid=03c845c865d81dc2%26no=9%26tt=373,642%26sigr=11cen8128%26sigi=1164cd4jb%26sigb=133va9q8chttp://rds.yahoo.com/_ylt=A9G_bHMmrL1IvI4Aa6eJzbkF;_ylu=X3oDMTBxZGFxZ2diBHBvcwM4BHNlYwNzcgR2dGlkA0kwODdfMTA5/SIG=1lc169q2j/EXP=1220476326/**http%3A//images.search.yahoo.com/images/view%3Fback=http%253A%252F%252Fimages.search.yahoo.com%252Fsearch%252Fimages%253Fei%253DUTF-8%2526p%253Dphysician%2526fp_ip%253DID%2526fr2%253Dtab-web%2526fr%253Dyfp-t-501%26w=375%26h=500%26imgurl=static.flickr.com%252F83%252F236534735_5f13887830.jpg%26rurl=http%253A%252F%252Fwww.flickr.com%252Fphotos%252Fthatotherguy%252F236534735%252F%26size=101.6kB%26name=Stethoscope%26p=physician%26type=JPG%26oid=ee052f7ac8bee312%26fusr=That%2BOther%2BGuy%26tit=Stethoscope%26hurl=http%253A%252F%252Fwww.flickr.com%252Fphotos%252Fthatotherguy%252F%26no=8%26tt=373,642%26sigr=11k0fosge%26sigi=11dcv8puc%26sigb=133va9q8c%26sigh=11a1hpvdb


2/30

The Doctor for the 21 st Century Promote health, prevent and treat disease, and

rehabilitate the disable in a compassionate, ethical way (within resources constrain) Providers of primary care Communicators

Critical thinkers Motivated life-long learners Information specialist Citizen of the World Practitionars of applied economics, sociology,

anthropology, epidemiology and behaviouralmedicine

Health team managers Advocate for communities


3/30

Patients are entitled to gooddoctors..

Patients must be able to trustdoctors with their lives and

wellbeing..


4/30

Good Doctors

Good doctors make the care of theirpatients their first concern: they are

competent, keep their knowledge andskills up to date, establish and maintaingood relationships with patients and

colleagues, are honest andtrustworthy, and act with integrity.


5/30

Physicians frequently confront ethical issues inclinical practice that perplexing, time-consuming , and emotionally draining .

Experience, common sense, and simply being a

good person do not guarantee that physicianscan identify or resolve ethical dilemmas.

Knowledge about common ethical dilemmas is

also essential


6/30

Historical Background

The Hipocratic Oath Ischaq bin Ali Rahawi

Maimonides (Jewis thinkers) Thomas Aquinas (Roman Catholic scholastic) Thomas Percival (Medical juris prudence) The American Medical Association (1847)


7/30

Six of the values that commonly apply tomedical ethics discussions are

Autonomy (The patient has the right to refuse or choose theirtreatment ( Voluntas aegroti suprema lex )

Beneficence (A practitioner should act in the best interest of the patient ( Salus aegroti suprema lex )

Non-malificence ("first, do no harm" ( primum non nocere ) Justice (Concerns the distribution of scarce health resources,and the decision of who gets what treatment (fairness andequality)

Dignity (The patient (and the person treating the patient)

have the right to dignity) Thruthfulness and honesty (The concept of informed consenthas increased in importance since the historical events of theDoctorss Trial of the Nurembergs and Tuskegee SyohillisStudy


8/30

The principle of autonomyrecognizes the rights of individuals

to self determination

A patient's competency for making life-

and-death decisions at the end of life ?

Autonomy


9/30

The term beneficence refers toactions that promote the wellbeingof others.

One of the core values of healthcare ethics (James Childress and

Tom Bauchamp, 1978)

Beneficence


10/30

The guidance of beneficence requires physiciansto act for the patients benefit.. The interest of the patient should prevail overphysicians self -interest or the interest of 3 rd

parties (e.g. hospitals or insurers)..

...These obligation contrast sharply with

bussiness relationship


11/30

Enthusiastic practitioners are prone to

using treatments that they believe willdo good, without first having evaluatedthem adequately to ensure they do no

(or only acceptable levels of) harm.Much harm has been done to patients

as a result

Non-Maleficence(Primum non nocere)

(first, do no harm)


12/30

He or she should not prescribemedications (or otherwise treat thepatient) unless s/he knows that the

treatment is unlikely to be harmful; orat the very least, that patient understands the risks and benefits , and

that the likely benefits outweigh thelikely risks


13/30

In practice, however, manytreatments carry some risk of harm..

The principle of non-maleficence isnot absolute, and must be balancedagainst the principle of beneficence

(doing good)


14/30

"Non-maleficence" is defined by itscultural context

Violation of non-maleficence is thesubject of medical malpractice

litigation. Regulations thereof differ,over time, per nation


15/30

Double effectSome interventions undertaken by physicians

can create a positive outcome whileunintentionally doing foreseeable harm. The

combination of these two circumstances isknown as the "double effect".

Use of morphine in dying patient can ease the pain andsuffering of the patient, while simultaneouslyhastening the demise of the patient through

suppression of the respiratory system


16/30

Conflicts between autonomy andbeneficence/non-maleficence

Examples include when a patientdoes not want a treatment becauseof, for example, religious or cultural

views


17/30

Different societies settle the conflict in a widerange of manners. Western medicine generallydefers to the wishes of a mentally competent

patient to make his own decisions, even incases where the medical team believes that heis not acting in his own best interests. However,many other societies prioritize beneficence over

autonomy


18/30

In the case of euthanasia the patient, orrelatives of a patient, may want to endthe life of the patient. Also, the patient

may want an unnecessary treatment, ascan be the case in hypochondria . A doctormay want to prefer Autonomy because

refusal to please the patient's will wouldharm the doctor-patient relationship


19/30

The role of surrogate medicaldecision makers is an extension of

the principle of autonomy


20/30

Fundamental Elements For DisclosureTo Patients

Diagnosis and prognosis Nature of proposed intervention Reseonable alternative intervention Risk associated with each alternative intervention Benefits associated with each alternative

intervention Probable outcomes of each alternative intervention


21/30

A person must be fully-informed aboutand understand the potential benefitsand risks of their choice of treatment

An uninformed person is at risk of mistakenly making a choice not reflective

of his or her values or wishes


22/30

If the patient is incapacitated,laws around the world designatedifferent processes for obtaining

informed consent, typically byhaving a person appointed by

the patient or their next kin make decisions for them.


23/30

The value of informed consent is

closely related to the values of autonomy and truth telling


24/30

Legal protections prevent physicians fromrevealing their discussions with patients,

even under oath in court.

Numerous exceptions to the rules have

been carved out over the years (gun-shotwounds; impaired drivers; sexually

transmitted diseases ???)

Confidentiality(Patient-physician privilege)


25/30

A correlate to informed consent is

the concept of informed refusal


26/30


27/30

Health is a political issue Health is a basic humanentitlement, to which all should have

equal access and equal right


28/30

Justice forbids discrimination inhealth care (education ?) based on

race, religion, or gender andsupports a moral right to health care,with access based on medical need

rather than ability to pay.


29/30

Most illness has its origins insocial condition

health is a political issue and those enjoying care do notwant to share it ..

Both in the underdeveloped and thedeveloped world the medicalcontribution is largely inappropriateto health need and does not copewith helath problems of the vastmajority

gap between health care andmedical care has become evenwider


30/30

Professional Responsibility Violations (ingeneral)

Conflicts of interest Mishandling of client Disclosure of confidential information

11.medical ethics and challenges in clinical practice

Documents