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Medical ethics in 21st century
General Practice
Medical ethics in 21st century
General Practice
Scope of sessionScope of session
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
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
Your experience of an ethical dilemma
Write down the story What made it an ethical dilemma? (not just a situation
where you didn’t know what to do) What was most important to you about the
decision you had to make? (e g getting it right, protecting yourself, avoiding conflict)
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)
What was the most difficult thing about it? (e g not having enough information, upsetting other people, or the responsibility you had)
Write down the story What made it an ethical dilemma? (not just a situation
where you didn’t know what to do) What was most important to you about the
decision you had to make? (e g getting it right, protecting yourself, avoiding conflict)
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)
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 theoriesHow do people make ethical decisions? - 4 moral theories Virtue (Aristotle) - good people make good
decisions Duty (Kant) - there is a supreme moral law which
means 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
Virtue (Aristotle) - good people make good decisions
Duty (Kant) - there is a supreme moral law which means 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 principlesThe 4 ethical principles Approach should be applicable by anyone, whatever their
personal philosophy, religion etc The principles:
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
Approach should be applicable by anyone, whatever their personal philosophy, religion etc
The principles: 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
2 interesting points from the Curriculum Statement
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?
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
Some areas raising ethical considerations
Professional duties Confidentiality Consent Reproductive issues End of life issues Mental health
Professional duties Confidentiality Consent Reproductive issues End of life issues Mental health
Children Screening Rationing (resource
allocation) Genetics Research
Children Screening Rationing (resource
allocation) Genetics Research
Legal aspects of consentLegal aspects of consent
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?
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
To have capacity to consent, patient must be able to
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
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)?
Who is ‘competent’ (has capacity to consent)?
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
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 AttorneyPower of Attorney
Enduring Power of Attorney (pre 2007) only applied to financial affairs
Lasting Power of Attorney (since Mental Capacity Act 2005, implemented 2007) - 2 kinds 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
Enduring Power of Attorney (pre 2007) only applied to financial affairs
Lasting Power of Attorney (since Mental Capacity Act 2005, implemented 2007) - 2 kinds 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 directivesAdvanced directives 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 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
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 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
ConfidentialityConfidentiality
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
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 confidentialityExceptions to confidentiality
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
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 informationAccess to information
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
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 areasOther important legal areas
Mental Health Act Reproductive Issues End of Life Issues Human Rights Act
Mental Health Act Reproductive Issues End of Life Issues Human Rights Act
When you have an ethical dilemma, consider
When you have an ethical dilemma, consider
Talking to colleagues Getting advice from your defence
organisation
Talking to colleagues Getting advice from your defence
organisation
Further infoFurther info
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
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