ETHICAL ROUNDS:

PRINCIPLES AND PRACTICE

SIVALINGAM NALLIAH
PROFESSOR
OBSTETRICS & GYNAECOLOGY
INTERNATIONAL MEDICAL UNIVERSITY
THEORIES AND
PRACTICE
Theories
UTILITARIANI
SM
Right
consequences
DEONTOLOG
Y
Right principles
APPLIED
ETHICS
Rights and
duties
Virtue theory
Autonomy
Self determination
Protection
Non-maleficence
Beneficence
Equity
Justice
Fairness
Respect
UTILITARIANISM
DEONTOLOGY
APPLIED ETHICS
VIRTUE THEORY

www.newscorpse.com
MEDICAL EDUCATION 2010; 44: 11171147
http://www.medscape.com/features/slideshow/public/ethic
s2012#1 n=24000 physicians
WHY DO WE NEED ETHICIAL ROUNDS?
Dr Conrad Murray
Charged with Manslaughter
-Michael Jackson
09-02-2010
California
Clinics with no patience
2010/02/08 NST
Annie Freeda Cruez
KUALA LUMPUR: A total of 457 medical establishments
nationwide failed to comply with the Private Healthcare
Facilities and Services Act 1998 and remained
unregistered with the Health Ministry.
GREED, VALUES AND
PROFESSIONALISM
GREED LEADING TO INCREASING HEALTH COSTS (NST 23
RD
MAR 2006)
NEED TO INSTILL MORAL AND HUMANISTIC VALUES AND ASPECTS IN
MEDICAL CURRICULUM
INCREASING ADVERSE COMMENTS
BRIDGET MENZES
(COLUMN WRITER IN SERENDIPITY -NST 14
TH
JUNE 2003)
ROGUES IN WHITE COAT
SUSPENSION OF 100 DOCTORS BY THE FOREIGN WORKERS MEDICAL
EXAMINATION MONITORING AGENCY (FOMEMA)

IF DOCTORS ARE DEEMED TO BE JOINING THE ROGUES GALLERY IN DROVES, HOW DO
WE KEEP SOCIETYS FAITH IN THIS RESPECTED PROFESSION?

ROCKYS BRU
AHIRUDIN ATTAN
SUNDAY PEOPLE 13TH NOV. 2005
ROGUES IN WHITE COAT
NOTHING WILL PROMOTE THE INTEGRITY OF THE PROFESSION WHICH , OF
LATE , HAS ALREADY BEEN HIT BY THE UNBECOMING BEHAVIOUR OF SOME
OF ITS PRACTITIONERS GREEDY GPS SELLING MEDICAL CHITS TO LAZY
WORKERS FOR A FEW RINGGIT, YOUNG DOCTORS TURNING THEIR BACKS
ON THE COUNTRY..
ROCKYS BRU
AHIRUDIN ATTAN
SUNDAY PEOPLE NOV 13, 2005
ETHICAL DILEMMA
DECISION TO GIVE CHEMOTHERAPY
TO PATIENTS WITH ADVANCED
METASTATIC SOLID TUMORS SHOULD
CONSIDER PATIENTS
PERFORMANCE STATUS
ONLY GIVEN TO THOSE WHO CAN
ATTEND CLINIC UNAIDED!
BRODY H NEJM
www.nejm.org/doi/full/10.1056/nejmp0911423
FRAGMENTATION
SUBSPECIALIZATION
MEDICAL TECHNOLOGY
MANAGED CARE
PATERNALISM
DEFENSIVE MEDICINE
TERMINAL ILLNESS
MEDICAL INSURANCE

ETHICAL DILEMMA
COLONY STIMULATING FACTORS
(CSM) SHOULD BE AVOIDED OR USED
IN LOW DOSE AS NO IMPROVED
SURVIVAL IS SEEN
PATIENTS WITH PROGRESSIVE
CANCER SHOULD BE SWITCHED TO
PALLIATIVE CARE AS CHANCE OF
SUCCESS IS MINIMAL
Self determination
Consent to progress
Distributive justice
Smith T & Hillner
Need for overhaul of cancer treatment
Massey Cancer Centre NEJM ;364;2060
VALUE OF ETHICAL ROUNDS
OPPORTUNITY FOR ETHICAL
DISCOURSE
EXPLORE OWN PERSONAL SETS OF
VALUES
BALANCE THIS WITH PROFESSIONAL
SET OF VALUES
CONSIDER MORAL FABRIC OF BOTH
INSTITUTE AND COMMUNITY
(SOCIETY)
HELP DISCUSS DIFFICULT TOPICS
AND ADDRESS HIDDEN CONFLICTS
RESOLVING INTERNAL CONFLICTS
USING ETHICS DECISION MODELS
CORRECTLY ADDRESS ETHICAL
DILEMMAS
THE BIGGER PICTURE
ETHICAL PRINCIPLES GOVERN
PRACTICE
CONSIDER NATURE OF PRACTICE AND
PROFESSIONAL PRACTICE ( VALUE OF PRACTICE
GUIDELINES-EBM)
OBLIGATIONS OF INDIVIDUALS (VALUE BASED
PRACTICE)
TO PATIENT ( AS PRIORITY?)
COMMUNITY AND SOCIETY
THE LIVERPOOL CARE PATHWAY
www.cdc.gov.
TRUST
PHYSICIAN-PATIENT RELATIONSHIP
LEGAL CONCEPT
PHYSICIAN-PATIENT RELATIONSHIP ARE
IN A FIDUCIARY RELATIONSHIP
INCORPORATES SPECIAL OBLIGATIONS
OF TRUST AND CONFIDENTIALITY
THE THERAPEUTIC ALLIANCE
PATIENT IS MY PRIORITY


THE RELATIONSHIP IS NOW
EGALITARIAN AND
PATERNALISTIC
TRUST ME BECAUSE I KNOW WHAT IS
BEST FOR YOU!
TRUST ME , BECAUSE I HAVE
SHOWN THAT YOU CAN TRUST ME
PRACTICE GUIDELINES COULD
CONFLICT WITH THESE NEW
DEVELOPMENTS IN CLINICAL
CARE
IN INDICATED CASES
ETHICS AND FUTILITY IN
MEDICINE
American Medical Association:
The right of the patient to choose
does not imply the right to demand care beyond
appropriate options based on medical judgment and
accepted standards of care . . .
(Council on Judicial Affairs, 1992).
Hence there is no professional or moral
obligation to offer or provide treatment that is
determined to be futile according to the
standard
OPPONENTS OF MEDICAL FUTILITY
IT IS ABOUT POWER
WHO KNOWS BEST?
ENHANCING THE AUTHORITY OF THE
MEDICAL PRACTITIONER, PLAYING A
DOMINANT ROLE IN DECISION MAKING
FUTILITY
(SUSAN RUBIN)
Evaluative futility
(based on evaluative
judgment)
Treatment is not appropriate
and not worth it
Factual Futility
(based on fact judgment)
Treatment is ineffective ,
does not work
RESOLVING THE DILEMMA
Shared Decision Making
Doctor-
Patient
Relationship
Physician
Authority
Patient and
Surrogates
Views
A WORKING MODEL
(VEATCH R, 2005)
Physician
should refuse
this
Demanded treatment, physiologically futile

Evaluate against
existing health
delivery system
Competing for scarce resources
Social Dialogue
Treatment likely to achieve patients goals though
physician feels it is valueless

THE WAY FORWARD
There is a need to REGULATE medical futility
due to escalating health costs and scarce
resources
Factors to consider are medical facts,
normative values, socio-economic status
Consider societal interest and opinions of
patient and family
DIALOGUE TO BE ESTABLISHED
Patient
Autonomy
Doctors
Paternalism
DIALOGUE TO BE ESTABLISHED
GOOD CLINICAL PRACTICE
EVIDENCE BASED PRACTICE
PRACTICE GUIDELINES
EXPERT OPINION
HOSPITAL PROTOCOL
VALUE BASED PRACTICE
ETHICAL ISSUES ARISE WHEN THERE
ARE CONFLICTS OF VALUES OR
SOMETIMES AIMS
GOOD CLINICAL PRACTICE
EVIDENCE BASED PRACTICE
PRACTICE GUIDELINES
EXPERT OPINION
HOSPITAL PROTOCOL
VALUE BASED PRACTICE
ETHICAL ISSUES ARISE WHEN THERE
ARE CONFLICTS OF VALUES OR
SOMETIMES AIMS
http://www.medcrunch.net/w
EXPERTS
TARGETED ETHICS ROUNDS
ETHICS GRAND ROUNDS FOR
EDUCATION AND INTERACTION
RESOURCE CENTER
NEW EMPLOYEE ORIENTATION

Ethics committee and ethical ward round.
ARE THEY MANDATED IN YOUR INSTITUTE?.
THEORIES AND
PRINCIPLES
EXPERTS
TARGETED ETHICS
ROUNDS
ETHICS GRAND ROUNDS
FOR EDUCATION AND
INTERACTION
RESOURCE CENTER
NEW EMPLOYEE
ORIENTATION
THE ETHICS COMMITTEE

REFERENCE
Nelson, L.J. and Nelson, R.M. 1992. Ethics and the Provision of
Futile, Harmful, or Burdensome Treatment
to Children, Critical Care Medicine, Vol. 20, pp. 427-433
Rubin, S. 1998. When Doctors Say No: The Battleground of
Medical Futility, Indiana University Press.
Doctor 2008 wordpress