Medical Ethics and Law

Introduction

Dr Gordon Linklater

Medical Ethics and Law system

2013 am pm

Mon 17th Ethics Introduction Medicolegal part 1

Tue 18th Community course Moral theories/ reasoning

Wed 19th Beginning of life

Thu 20th Anatomy Debate: abortion

Fri 21st Research/ human rights/ resource allocation

Mon 24th End of life Mental health/ complaints

Tue 25th Children Debate: assisted suicide

Wed 26th Medicolegal part 2

Thu 27st Social media

Fri 28nd Assessment

Morality and Ethics

Two traditions:1. Duties, “right” & “wrong” actions, absolute

values

2. Look at benefits and harms to individual and society; look at the consequences.

Two traditions:

1. Duties, “right” & “wrong” actions, absolute values

DEONTOLOGY

2. Look at benefits and harms to individual and society; look at the consequences.

UTILITARIANISM (a type of consequentialism)

Hippocratic tradition

• “as to diseases, make a habit of two things – to help and not to harm.”

• “I will never give a poison to anyone to cause death, not even if asked.”

Hippocratic tradition

• “into whatever houses I enter, I will enter to help the sick, and I will abstain from all intentional injustice and harm, especially from abusing the bodies of man or woman, bond or free.”

Kant

• Immanuel Kant (1724 – 1804)

– Categorical Imperative • Act only in such a way

that you would be happy for it to become an universal law

– Treat people as ends in themselves, never just means

Religion

• e.g. the ‘sanctity’ of human life

http://www.gmc-uk.org/guidance/good_medical_practice.asp

Doctors are powerful

• We get to look at you naked

• We can cut you open

• We might tell you that you are going to die

• We can decide what is in your best interests

Doctors are trusted

• Trust to tell the truth%– Doctor 92– Teacher 88– Professor 80– Judge 80

– Journalist 22– Politician 13

MORI poll 2009

Deontology

• Good points– Gives you some certainty

• Duty not to kill

– Defines behaviours• Duty of care

Deontology

• Bad points

Consequentialism

• The moral worth of an action is determined by its outcome

Utilitarianism

• Jeremy Bentham (1748 – 1832)

• The greatest good for the greatest number (maximising pleasure/ happiness and minimising pain/ unhappiness)

Utilitarianism

• Classic– Judges the consequences of a particular act

• Rule– Judges the consequences of particular rules

• Preference– Maximising choice rather than pleasure

Utilitarianism

• Good points– Flexible

• Can adapt to the particular circumstances of a decision

– Avoids need for a belief system

– Measurable• Do you want a nice doctor or an effective doctor?

Utilitarianism

• Bad points

Ethics and clinical decisions

• Duties

• 4 Principles

• Ethics grid

Duties

• Having watched a caesarean section whilst on my medical elective in Kwa-Zulu Natal I thought, ‘that looks fun – I’ll have a go on the next patient’

• A young woman comes to your surgery very distressed. She tells you she had unprotected intercourse last night whilst drunk. She does not want to get pregnant. She asks if there is anything that can be done…

4 Principles

• Respect for Autonomy

• Non-maleficence

• Beneficence

• Justice

4 Principles

• Respect for Autonomy– Promote the right to self determination

• Non-maleficence

• Beneficence

• Justice

4 Principles

• Respect for Autonomy

• Non-maleficence– The avoidance of harm

• Beneficence

• Justice

4 Principles

• Respect for Autonomy

• Non-maleficence

• Beneficence– To do good

• Justice

4 Principles

• Respect for Autonomy

• Non-maleficence

• Beneficence

• Justice– Fairness/ equality– Individual vs population

Which chemotherapy?

• Mr Jones has non small cell lung cancer

Chance of benefit %

Chance of death %

Cost £

Chemo A 10 2 1 000

Chemo B 50 33 1 500

Chemo C 60 10 100 000

• Autonomy Chemo C• Non-maleficence Chemo A• Beneficence Chemo C• Justice Chemo B

Chance of benefit %

Chance of death %

Cost £

Chemo A 10 2 1 000Chemo B 50 33 1 500Chemo C 60 10 100 000

• Justice– you cannot use chemo C

• Non-maleficence– you must not use chemo B

• Beneficence– chemo A is better than nothing

• Autonomy– Patient can chose either chemo A or nothing

Chance of benefit %

Chance of death %

Cost £

Chemo A 10 2 1 000Chemo B 50 33 1 500Chemo C 60 10 100 000

• Should we use data from medical ‘research’ carried out in the concentration camps of Nazi Germany?

– Specifically research into the effects of hypothermia on the human body

A synthesis of ethics and the current UK law

• Duty of care, right to life, sanctity of life– If in doubt, doctors have a duty of care to save life and preserve function– Euthanasia and physician assisted suicide are illegal– Doctors must not intend to hasten death, but may in certain

circumstances administer treatment that will hasten death (Doctrine of Double Effect)

– Not keeping alive versus killing (usually not considered equivalent)

• Autonomy, justice– Patient autonomy allows the refusal of any treatment, even if refusing

the treatment will result in their certain death– Patients cannot demand a treatment that a doctor does not consider

indicated (but they can get a second opinion)• Also remember that healthcare is rationed. Treatment may be indicated but

not affordable– Family members cannot make medical decisions for patients (unless

they have been legally appointed proxy decision maker)