Introduction to Clinical Ethics

Introduction to Clinical Introduction to Clinical EthicsEthics

Ben Faneye, OP, DHCEBen Faneye, OP, DHCE

West African Bioethics West African Bioethics Training ProgramTraining Program

Historical BackgroundHistorical Background

• Evolution of clinical ethics, attributed Evolution of clinical ethics, attributed to certain needs:to certain needs:– Need for bedside teaching of ethics – Need for bedside teaching of ethics –

William Osler’s medical teaching traditionWilliam Osler’s medical teaching tradition– Need for a method of ethical enquiry most Need for a method of ethical enquiry most

suitable to individual clinical settingssuitable to individual clinical settings– Need to create a bridge btw academic Need to create a bridge btw academic

world of bioethics & the world of clinicians world of bioethics & the world of clinicians and pts.and pts.

Clinical Ethics: Its ContentClinical Ethics: Its Content

• Concerned with restoring and Concerned with restoring and strengthening bonds between strengthening bonds between professionals, patients and families. This professionals, patients and families. This is contrary to the conflicting principles of is contrary to the conflicting principles of bioethics.bioethics.

• Uses cases and relies on the clinician-Uses cases and relies on the clinician-patient relationship/encounter in patient relationship/encounter in contributing to research on ethical contributing to research on ethical issues.issues.

Clinical Ethics: Its Content Clinical Ethics: Its Content

• Focuses on issues of concern to Focuses on issues of concern to clinicians, patients & the general societyclinicians, patients & the general society

• Issues stemming out of real life Issues stemming out of real life encountersencounters

• Uses its empirical findings to encourage Uses its empirical findings to encourage reform practices among clinicians, which reform practices among clinicians, which helps establish the 2-world relationship.helps establish the 2-world relationship.

Clinical Ethics: ServicesClinical Ethics: Services

• To provide clinical ethics education To provide clinical ethics education to clinicians, patients, surrogates and to clinicians, patients, surrogates and the larger communitythe larger community

• Policy studies and recommendations Policy studies and recommendations for institutional guidelines on ethical for institutional guidelines on ethical issues in pt. care. issues in pt. care.

Clinical Ethics: ServicesClinical Ethics: Services

• Providing a process for case Providing a process for case consultation at the bedside or the consultation at the bedside or the conference roomconference room

• Researching ethical problems and Researching ethical problems and initiating prevention plans for such initiating prevention plans for such problems often encountered.problems often encountered.

Clinical Ethics: Its PracticeClinical Ethics: Its Practice

• Ethical Obligations: Basis for praxisEthical Obligations: Basis for praxis– Stem from the concept of duty, which is Stem from the concept of duty, which is

the necessity of action done out of the necessity of action done out of respect for the law.respect for the law.

– Connotes what one is bound to do in Connotes what one is bound to do in situations arising from patient care.situations arising from patient care.

– A recognition of one’s duty in upholding A recognition of one’s duty in upholding another’s rights (pt’s rights).another’s rights (pt’s rights).

Ethical Obligations In Ethical Obligations In CasesCases

• Respecting Privacy & ConfidentialityRespecting Privacy & Confidentiality

– Right to privacy:Right to privacy:

which is a person’s claim to those things which is a person’s claim to those things that define one as such, e.g., thoughts, that define one as such, e.g., thoughts, feelings, aspirations, information, feelings, aspirations, information, physical body.physical body.


– Privacy rights: Its typesPrivacy rights: Its types•Negative right is right to non-interference or Negative right is right to non-interference or

to be left alone, e.g., right to bodily integrity. to be left alone, e.g., right to bodily integrity. It is a right that restricts others.It is a right that restricts others.

•Positive right is a person’s prerogative to Positive right is a person’s prerogative to control access to and distribution of control access to and distribution of information about the self, e.g., patient’s information about the self, e.g., patient’s control over treatment. This ordinarily control over treatment. This ordinarily requires the active participation of others.requires the active participation of others.


• Confidentiality: Corresponding dutyConfidentiality: Corresponding duty– Mechanism by which a person’s right is Mechanism by which a person’s right is

recognized and respectedrecognized and respected– Based on a fiduciary relationship, some Based on a fiduciary relationship, some

sort of promise, whereby a clinician sort of promise, whereby a clinician recognizes one’s recognizes one’s dutyduty to safeguard a to safeguard a patient’s rightspatient’s rights

– Basis for intimacy between persons, Basis for intimacy between persons, clinicians and patients and familiesclinicians and patients and families


• Confidentiality: Why?Confidentiality: Why?– Public knowledge of health records can Public knowledge of health records can

cause discrimination and cause discrimination and embarrassmentembarrassment

– Required by law and professional code, Required by law and professional code, a breach of which can lead to a breach of which can lead to disciplinary and legal action against an disciplinary and legal action against an organization and employeeorganization and employee


• Confidentiality: What is covered?Confidentiality: What is covered?– Personal information that can identify a Personal information that can identify a

ptpt– Treatment informationTreatment information– Details about illness and/or diagnosisDetails about illness and/or diagnosis– Medical RecordMedical Record– Conversation btw clinician and pt and/or Conversation btw clinician and pt and/or

family.family.

Ethical Obligations In Ethical Obligations In CasesCases• Confidentiality: Basis of dutyConfidentiality: Basis of duty

– Hippocratic Oath – “And whatever I shall Hippocratic Oath – “And whatever I shall see or hear . . . I will never divulge, see or hear . . . I will never divulge, holding such things to be holy secrets.”holding such things to be holy secrets.”

– T. Percival in his T. Percival in his Code for Medical Ethics Code for Medical Ethics ((later adopted bylater adopted by AMA AMA in 1847)states: in 1847)states: “Patients should be interrogated “Patients should be interrogated concerning their complaint in a tone of concerning their complaint in a tone of voice which cannot be overheard.”voice which cannot be overheard.”


• Confidentiality: Basis of dutyConfidentiality: Basis of duty

– International Council of Nurses’ Code – International Council of Nurses’ Code – “the nurse holds in confidence personal “the nurse holds in confidence personal information and uses judgment in information and uses judgment in sharing this information.”sharing this information.”


• Respect for Patients’ Decision-Making Respect for Patients’ Decision-Making CapacityCapacity

– Duty towards pts stems out of Duty towards pts stems out of pt’s right of autonomy

– Autonomy is a person’s right to Autonomy is a person’s right to determine what happens to, or is done determine what happens to, or is done to the self (paternalism, an issue).to the self (paternalism, an issue).

Ethical Obligations In Ethical Obligations In CasesCases• Respect for Patients’ Decision-Making Respect for Patients’ Decision-Making

CapacityCapacity– Corresponding to this right is clinician’s duty Corresponding to this right is clinician’s duty

to ascertain and enable the pt in exercising to ascertain and enable the pt in exercising autonomy right (duty to inform). autonomy right (duty to inform).

– A determination of pt’s capacity considers:A determination of pt’s capacity considers:• Individual abilities of pt, e.g., sound mind or notIndividual abilities of pt, e.g., sound mind or not• Importance of the decision at handImportance of the decision at hand•Consequence likely to follow from decisionConsequence likely to follow from decision


• Respect for Patients’ Decision Making Respect for Patients’ Decision Making CapacityCapacity

– Where pt is deemed incapable, there are Where pt is deemed incapable, there are standards in place for surrogate decision standards in place for surrogate decision makers.makers.

Ethical Obligations In Ethical Obligations In CasesCases• Standards for Surrogate decision-makersStandards for Surrogate decision-makers::

– Substituted Judgment: decision made based Substituted Judgment: decision made based on the known & perceived wishes of the pt. on the known & perceived wishes of the pt.

– Best Interest: decision made based on what a Best Interest: decision made based on what a reasonable person would do. Risks & benefits reasonable person would do. Risks & benefits of treatment analyzed, with goal of of treatment analyzed, with goal of maximizing benefits and minimizing harms.maximizing benefits and minimizing harms.


• Decisional Capacity: What is it?Decisional Capacity: What is it?

– ““Ability to make a decision”Ability to make a decision”– Exercise of free power of choice (no Exercise of free power of choice (no

force)force)– Crucial aspect of Crucial aspect of voluntary consent consent– Focuses on giving or withholding Focuses on giving or withholding

consent for treatment.consent for treatment.

Ethical Obligations In Ethical Obligations In CasesCases• Respect for Decision Making Capacity: Respect for Decision Making Capacity:

Its ChallengesIts Challenges– Incapable pts giving consent does not Incapable pts giving consent does not

validate treatment by clinician (possibility validate treatment by clinician (possibility of self-harm)of self-harm)

– Clinician who withholds treatment from an Clinician who withholds treatment from an incapable pt who refuses treatment risks incapable pt who refuses treatment risks liability if other legally valid treatment liability if other legally valid treatment authorization steps are not sought.authorization steps are not sought.

Other Obligations In Clinical Other Obligations In Clinical CasesCases

• Communication:Communication:– Ability to listen to and understand the Ability to listen to and understand the

pt’s story & body languagept’s story & body language

• Truth-telling:Truth-telling:– Clinician’s professional integrity imposes Clinician’s professional integrity imposes

a negative duty not to lie, as well as a a negative duty not to lie, as well as a positive duty to tell the truth about what positive duty to tell the truth about what the pt has right to know.the pt has right to know.

Other Obligations In Clinical Other Obligations In Clinical CasesCases

• Disclosure:Disclosure:– Duty to provide information about care to Duty to provide information about care to

be given to the pt. Clinician determines be given to the pt. Clinician determines what information is too much/little. what information is too much/little.

– Therapeutic privilege, an exception to Therapeutic privilege, an exception to informed consentinformed consent

N.B.: These 3 obligations are derived from These 3 obligations are derived from the principle of respect for pt’s autonomy.the principle of respect for pt’s autonomy.

Clinical Ethics & Clinical Ethics & PrinciplesPrinciples

• Major bioethics principles provide Major bioethics principles provide basis for the ethical obligations in basis for the ethical obligations in clinical ethicsclinical ethics

• Practical orientation adopted by Practical orientation adopted by clinical ethics in light of the clinical ethics in light of the dynamism of interpersonal (clinician, dynamism of interpersonal (clinician, pt, family) relationships.pt, family) relationships.

Documents

Introduction to Clinical Ethics