MEDICAL ETHICS

DR. BUYINZA NICHOLAS

Bpharm, MPharm
Ethics definition
The word ‘ETHICS’ is derived from the Greek word ‘ETHOS’ meaning
“custom or practice”, a characteristic manner of acting, a more or less
constant mode of behavior in the deliberate actions of men.
More technically, ethics is defined as that science which studies the
morality of human acts through the medium of Natural reason.
It is the science, which is a directive of moral acts of man’s will
according to basic rational principles. In short, ethics teaches us how
to judge accurately the moral goodness or badness of any human
action.
 Origin
Ethics derives its origin from religion, culture and law in relation to
culture
It is about what practices should be accepted and why?
It involves the use of rational reasoning to arrive at a decision
It is a functional component of every profession
Its application varies from profession to profession
 patient

The term “Patient” means “the person who is suffering”.

Some other terms have been used such as “Client”. This term
originates from Latin “Client”, which originates from Latin “Cliens”
signifying “person under protection or patronage of a superior”. In
health professions, therefore, use of the term client, with such
connotations, would be unfortunate.
 Types of ethics
Normative ethics; An inquiry into which general moral norms for the
guidance and evaluation of conduct should we accept and why?

Non-normative ethics; Descriptive ethics is factual investigation of

moral conduct and beliefs (anthropology, sociology, psychology and
historians)
Meta-ethics involves analysis of the language, concepts and methods of
reasoning in ethics
 Morality
Morality is the effort to guide one’s behavior by reason – that is to do
what there are the best reasons for doing – while giving equal weight
to the interests of each individual who will be affected by ones actions.

Morality refers to norms about right and wrong human conduct that
are so widely shared that they form a stable (although usually
incomplete) social consensus
It includes moral ideals that individuals and groups voluntarily accept
Morality cont
In understanding moral life, we explore the values and preferences of
the different individuals
This appreciation of our individual differences enables us to
accommodate and tolerate the different beliefs and practices that may
not be applicable in our societies
If we respect other people’s choices, we are respecting others’ rights
Basic ethical principles
1. Our practice must be in accord with techne (Skilled form of
knowledge) or art whose aim is to confer substantial benefit on
suffering human beings. This techne is governed by an ethic that is
committed to restoring and repairing, as far as possible, the form and
function of a human being. Any health care provider should be able,
with sincerity and integrity, to assure patients that the care they will
receive is at least as good as that defined by the accepted standards of
contemporary medical practice.
Basic ethical principles cont
2. We must always treat patients as persons not people, involving
them in those significant decisions about their care that will affect their
lives and well-being. Thus, our conception of substantial benefit is and
should remain patient oriented.
3. We must safeguard the continuity and standards of medicine and
other health care professions, taking care to ensure that what is done
and taught is consistent with an ongoing enterprise in service of the
people
Basic ethical principles cont
4. We must practice health care in the light of the patients’ needs
without being influenced or prejudiced by factors that have nothing to
do with their illness. Thus, we must act with justice and impartiality;
ensuring that our care is given in a spirit of compassion and a desire to
benefit the patients rather than being distorted by any other motive or
interest.
Basic ethical principles
Respect of autonomy: is to acknowledge that person’s right to hold
views, to make choices and to take actions based on personal values
and beliefs.
Hence autonomy as a fundamental right is used to justify rights of
privacy, confidentiality, refusal to participate in research, informed
consent, and fair treatment.
Hence right to self determination for all individuals
Additional protection for individuals with diminished capacity
 Informed consent
Before undertaking any procedure, a doctor must obtain the patient’s
consent.
The healthcare professional, who fails or ignores to obtain consent, exposes
himself/herself to claims of medical malpractice or violation of the patient’s
civil rights. The doctor’s duty to obtain consent arises from the patient’s
right to self-determination. Every adult human being, who is sound in mind,
has a right to determine what shall be done with or to his/her own body.
Thus, a doctor who administers management modality without the patient’s
consent would be deemed to have committed an assault for which he/she is
liable in damages
In medical emergencies, however, consent is generally implied. Thus, a
health care professional is deemed legally authorized to treat a patient in an
emergency situation without having received the patient’s explicit consent.
Informed consent cont
The concept of informed consent
The concept of “informed” consent implies that consent is ineffective
unless the doctor has fully disclosed, the risks involved in giving a
particular treatment and alternative management modalities and how
their effectiveness and risks compare to the one being proposed,
before consent is given by the patient.
Consequently, the doctrine of “informed consent” is meant to enable
the patient and not the doctor to be the one who makes the final
decision.
Reasons for failure to give consent
• Religious beliefs that forbid a certain type of procedure e.g. Jehovah’s
witnesses refusing to be transfused with blood or blood products.
• Fear e.g. of discomfort or disfigurement or even death e.g. a patient
refusing limb amputation, radical mastectomy or ileostomy.
• Viewing the proposed treatment modality as constituting an artificial
prolongation of life without hope for recovery. This includes
terminally – ill patients for whom it is suggested that they be put on
life support equipment e.g. respirator, or should have a palliative
surgical operation.
Basic ethical principles
Confidentiality
The provision of medical care always involves an invasion of privacy by
gaining access to the patient’s body and to a wide range of personal
information about the patient. This is necessary in order to make an
adequate diagnosis and to prescribe appropriate treatment.
This privileged access, however, is justified only because it brings the
patient benefits. It is only obtained with the patients consent (except
in emergency situations).
Confidentiality cont
This information is usually contained in medical records that are the property
of either the individual practitioner or a Health Board. It should normally be
used only for those purposes agreed between the practitioners and the
patient (i.e. authorized by the patient).
Any other use of the information represents a breach of contract and trust
that made the patient willing to consult the practitioner in the first place.
There are circumstances in which maintaining absolute confidentiality may
be difficult. For example when active harm to others is likely to be caused.
The problem here is defining “active harm”.
Another example is where a court of Law orders that the information must
be provided. Here the practitioners must operate within the legal
constraints of privacy legislation. Thus, whatever the circumstances, breach
of privacy must have clear ethical justification
Confidentiality cont
Confidentiality and the Law:
Many countries recognize the right of Medical personnel to withhold in civil
courts such confidential information as is acquired through professional
conduct with the patient i.e. on the grounds of medical privilege.

The common law of England, on which laws of the countries in the East
African region are based, does not have these provisions i.e. no medical
privilege is allowed in court.

In Kenya Ministry of Health Code of professional conduct and Discipline it

states. “Every Medical Practitioner or Dentist shall respect his patient’s
confidence, and shall hold secret to himself all that he may learn in
confidence from his patient or anyone acting on behalf of a patient...”
Confidentiality cont
Exceptions to the general rule of confidentiality:
Most countries accept that absolute secrecy is impracticable. They
allow certain exceptions including:
1. The patient or his/her legal advisor may consent to the disclosure,
preferably in writing; e.g. when a patient makes a claim for re-
imbursement of medical expenses from an insurance company or when
claiming damages from another person or insurance company as after
a road traffic accident – the medical report may be seen by “the over
side”.
Exceptions to the general rule of confidentiality

2. Statutory duty e.g. those rules and regulations requiring the

healthcare professionals to notify the relevant authority regarding
Infectious diseases, Occupational diseases, Births and deaths
3. In a court of law the court may insist and if the healthcare
professional refuses, he/she may be held in contempt of the court.
4. Sharing information with colleagues, Relatives (never without
consent), Research (never without consent).
Exceptions to the general rule of confidentiality
5. Medical Education (patient’s name should not be revealed)
6.Public interest especially in maintenance of law and order.
7.Professions supplementary to medicine – paramedics, including:
Chiropodists, Dieticians, Lab technicians (now called Medical Scientific
Officers), Occupational Therapists; orthopists, Physical Therapists,
Radiographers, Remedial Gymnasts.
General approach to confidentiality problems
In the final analysis the doctor has to make his/her decision according
to his conscience.
“Conscience may be defined as a dictate of man’s practical reason
deciding that a particular act is morally right or wrong”. We all have
different consciences in that what may appear as a problem to one
person may not appear so to another.
Specific confidentiality problems
Epilepsy and driving
A problem arises if the doctor knows the patient is continuing to drive
in spite of having seizures.
Collaboration with the police
A problem arises if the police are unwilling to allow the doctor to
approach his patient (being suspected of criminal activity) to ask for
his/her consent for him/her to submit a report about him to the police.
Refusal to submit the report may constitute obstruction to police work.
Specific confidentiality problems cont
The drunken driver
The healthcare professional required to examine such a subject should
provide the correct findings.
Suicide (attempted)
Regarded as an illegal act in some countries
Regarded as a cry for help in medical circles
Doctor usually not obliged to report the case to police.
 Special relationships

Special relationships
Husband and wife e.g. if one is diagnosed as having HIV but does not
want the spouse told
Also if a couple decides on divorce proceedings and medical reports are
requested for.
Employer and employee e.g. when employer requests (and even pays
for) a medical examination of a prospective employee. If after the
examination the patient objects to the doctor’s submission of the
report to prospective employer – doctor may give the report to the
patient and tell him/her to do what he/she wants to do with it.
Basic ethical principles cont
Beneficence – “doing good to others”. This is similar to the religious
virtue of compassion and helping others. This comes to the fore in
efforts to distinguish therapeutic from non-therapeutic research on
human participants. Beneficence can be seen both as a principle and
a virtue for physicians. Self-sacrifice is part of medicine. Beneficence
may sometime come into conflict with autonomy e.g. whether or not
to treat a psychiatric patient against his/her will. Balancing the two in
such cases may be difficult.
Basic ethical principles cont
• Non-malficience – “not harming others”. This implis that if a
practitioner is not technically competent to do something, he/she
should not do it. Taken further, medical students should not harm
patients by practicing on them (unless the patients consent). This
principle prohibits corruption, incompetence and dangerous, non-
therapeutic research. Harm can also be done by unsolicited
intrusions (help, advice or even concern).
Basic ethical principles cont
Justice, Is a group of norms for distributing benefits, risks, and costs
fairly. It can be interpreted as fair, equitable, and appropriate treatment
in light of what is due or owed to persons.

Hence the need for fairness to participation in research and access to

results of research

Injustice involves a wrongful act or omission that denies people

benefits to which they have a right without good reason or distributes
burdens unfairly
Application of ethics
• Used in perspective to develop professional codes
• Ethical principles are universal but their application varies from place
to place and time to time, used to develop ethical code of conduct