Ethics in Family

Medicine

Nita ArisantiDepartment of Public Health

Learning objectivesO Describe the principles of medical

ethicsO Understand the implementation of

medical ethics in family medicine casesO Describe the ethical issues in several

cases:O Confidentiality O ConsentO Non-compliant patient

O Ethics is an understanding of the nature of conflicts arising from moral imperatives and how best we may deal with them

O Ethics does NOT decide what is morally right or wrong; rather it considers how we should act best in the light of our duties and obligations as moral agents.

Medical EthicsO Medical ethics is the discipline of

evaluating the merits, risks, and social concerns of activities in the field of medicine.

THE PRINCIPLES IN MEDICAL ETHICS

O The Principle of Non-MaleficenceO The Principle of BeneficenceO The Principle of AutonomyO The Principle of VeracityO The Principle of Confidentiality(or

Fidelity)O The Principle of Social Responsibility

and Justice

The Principle of Non-Maleficence

The Principle of Non-Maleficence

O first do no harmO sanctity of lifeO calculated risk or risk benefit

The Principle of Beneficence

The Principle of Beneficence

O do only that which benefits the patient

O patient’s welfare as the first consideration

O care consideration competence

The Principle of Autonomy

The Principle of Autonomy

O right to information and self determination

O free and informed consentO free will and accord - intentional

participation in treatmentO respect and dignity maintained

The Principle of Veracity

The Principle of Veracity

O Truth tellingO Obligation to full and honest

disclosure

The Principle of Confidentiality

The Principle of Confidentiality

O Based on loyalty and trustO Maintain the confidentiality of all

personal, medical and treatment information

O Information to be revealed with consent and for the benefit of the patient

O Except when ethically and legally required

O Disclosure should not be beyond what is required

The Principle of Justice and Social Responsibility

The Principle of Justice and Social Responsibility

O Actions are consistent, accountable and transparent

O not to discriminate on age, sex, religion, race, position or rank

O greater good of societyO respect of the LawO equity and distribution of burden &

benefits

Components of Medical Ethics

O The Physician -- Patient RelationshipO The Physician -- Physician

RelationshipO The relationship of the Physician to

the System of HealthcareO The Relationship of the Physician to Society

THE MEDICAL ECOSYSTEM- Enlarging Circle of Influence

DOCTOR PATIENT

Disease DiagnosisHealth Promotion

Disease Prevention

Therapy

Medical Insurance Managed Care

Hospital

Laboratories

Pharmaceutical Industry

Patients’ Family, Culture, Religion

Patients’ Work, Employer

Other Doctors

Paramedics

Clinic Management

Public Health

Medical Research

Medical Students

CME, CPD

Doctor’s Employer

Doctor’s Family

Doctor’s Employee

Practice Management

MDO

Medical Council

The LAWGovernment Bodies

Medical Charities

Patient Organisation

Alternative Medicine

Press, Media

National Community

International Community

Natural Disasters

Political Upheaval, War

Special problems in primary care setting

Confidentiality

OThe principle of medical confidentiality-that doctors must keep their patients' secrets-is one of the most venerable moral obligations of medical ethics.

OThe Hippocratic Oath enjoins: "Whatever, in connection with my professional practice, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret."

What is "medical confidentiality"?

Essentially medical confidentiality is the respecting of other people's secrets

Confidentiality is important as a way to encourage patients to be frank

Opeople's better health, welfare, the general good, and overall happiness are more likely to be attained if doctors are fully informed by their patients, and this is more likely if doctors undertake not to disclose their patients' secrets.

Case O Patient requests a statement

certifying that he or she is fit to return to work

O Insurance company requests for a patient’s condition

O Teenage patient seeking abortion and contraceptive advice

O Demented elderly patient

The General Medical Council (GMC)’s lists the following legitimate exceptions:

(a) when the patient "or his legal adviser" gives written and valid consent;

(b) when other doctors or other health care professionals are participating in the patient's care;

c) when the doctor believes that a close relative or friend should know about the patient's health but it is medically undesirable to seek the patient's consent;

(d) exceptionally when the doctor believes that disclosure to a third party other than a relative would be in the "best interests of the patient" & when the patient has rejected "every reasonable effort to persuade";

(e) when there are statutory requirements to disclose information;

(f) when a judge or equivalent legal authority directs a doctor to disclose confidential medical information;

(g) (rarely) when the public interest overrides the duty of confidentiality "such as for example investigation by the police of a grave or very serious crime"; and

(h) for the purposes of medical research approved by a "recognised ethical committee."

In general, patient confidentiality can be breached

for three broad reasonsOavoiding harm to others

Obenefiting the patientOpublic health reporting

Consent

OThe principle’s basic mandate is that a physician must obtain the free and informed consent of a patient or of the surrogate before medical treatment is provided

Exceptions…Exceptions to the General Rule of Disclosure• Patient is unconscious or otherwise incapable of consenting

(Emergency treatment)– Harm from failure to treat is imminent– Outweighs any harm threatened by proposed treatment

• Therapeutic Privilege– Risk disclosure poses such a threat of detriment to a patient

as to become unfeasible or contraindicated from a medical point of view

– Does not accept the paternalistic notion that the physician may remain silent because divulgence might prompt the patient to forego therapy the doctor believes the patient must receive

The information includes

i. The nature of the patient’s condition

ii. Purpose of the treatmentiii. The potential benefitiv. The foreseeable risks and

discomfortv. The available alternativesvi. Cost

Informed consent for Incompetent adults:

OObtain from surrogate

Case: what, however should one do when patient’s mental capacities are impaired but present to some degree?

OInformed consent for children

OChildren Unable to Participate in decision making: From new-born period to early childhood. Parents are viewed as their surrogate decision makers

A Hypothetical CaseMrs. HO 83 year old Hispanic femaleO Alert and orientedO Terminal advanced COPDO Family agrees to hospice care for patient provided:

O Patient not be told she is dying and on hospiceO Hospice staff remove name badges when visitingO Hospice staff not tell patient why they have come to see her

Question: O Does this violate the concept of informed consent?

A Hypothetical CaseO During the initial visit by hospice staff:

O Patient is given hospice papers and signs them without reading them

O Patient is told by family to sign papers without reading them, which she does

O Family member signs papers for patient without the patient even knowing this was done

Question: O Which of these scenarios, if any, violate the concept of

informed consent?

The non compliant patient

O Patient choose not to comply with the physician’s recommendations

Case O Consider a patient who refuses to

stay in the hospital

O Patient does not fill the prescription that the doctor writes

The non compliant patient

O Patient choose not to comply with the physician’s recommendations

O Mutually acceptable alternative treatments are often available

Evaluation of noncompliance

cause Clinical responseProblem in communication

Patient should be reinformed about the need for treatment

Failure to trust Address question of mistrust; involved other health professionals who may be trust

Psychological factors

Treat anxiety…

Value conflict Respect patient wishes