Ethics in Medical Practice

Medical workers face clinical issues with ethical

components almost on daily basis.
Some core questions on medical ethics for clinicians:
 Did you recognise the ethical issues?
 Did you know how to handle them, what to do?
 Is there an organised framework for such cases?
 How did you relate ethical issues with patients and
families?
 Were you comfortable and confident with your decision?
Recognition of ethical issues and their resolution can:
 improve patient care
 improve research practice
 improve institutional arrangements.
 Medical Ethics/Bioethics - Definition

Bioethics is as old as medicine itself. For instance,

medical codes of practice such as the Hippocratic Oath
has provisions regarding ethical considerations in medical
practice. Bioethics refers to ;
 Considerations of issues relating to the underlisted
aspects of medical practice:
 Moral
 Legal
 Political
 Clinical
 Social
 Medical Ethics: Definition

• Medical ethics refers to the moral principles that

underlay the judgement medical workers make daily
at work on the bid to provide the best principled care
for each patient and /or each clinical situation.
• Ethical consideration in health care involves doing the
right thing while achieving the best outcome for the
patients.
• The complexity involved in making principled and
morally sound choices in medical practice is alleviated
through the application of the ethical principles of
autonomy, beneficence, non-maleficence and
justice, termed the pillars of medical ethics
 The Four Pillars of Medical Ethics
• Autonomy: refers to the respect accorded to the
patient and their right to make their own decisions.
This principle is based on the assumption that an
informed, competent adult patient has the right to
make choices for themselves.
• The exception to this principle is usually on the
ground that the patient is unfit to make
autonomous decision for self.in such cases, the
patient is considered mentally incapable of
making right decisions for themselves, such as in
relation to children, mental health patients,
dementia, etc.
 Autonomy
• For a patient to make an autonomous decision, the
clinician should:
• explain fully the patient’s medical condition, their
options for treatment and the advantages and
disadvantages of those treatments
• Identify the ability of the patient to retain the
provided information
• Evaluate their options and arrive at a decision –
patients’ autonomy is not absolute
Informed consent must be obtained from the
mentally stable, adult patient
 Beneficence
• The principle of beneficence implies that the health
worker must do the ‘best good’ for their patients in
every situation. To apply this principle, the health
worker must consider:
• The best option to resolve the patient’s medical
problem
• The compatibility of the option with the patient’s
individual circumstances and expectations of
treatment
• Beneficence considers not only what is medically
good for the patient but also what is acceptable for
the patient as a human being.
 Non-Maleficence: ‘do no harm’
• This principle of ‘do no harm intentionally’
underpins almost every aspect of the medical
practice as a treatment intended to do good can
unintentionally cause harm. It helps clinicians
make difficult medical decisions.
• When considered alongside the pillars of
beneficence and autonomy, and when to do
nothing will cause harm, the clinician needs to
explain the possible positive and negative
effects of a proposed treatment.
•
• To prevent harm to patients, clinicians must
consider the associated risks with
intervention or non-intervention and must
decide whether:
• They possess the required skills and
knowledge to perform the needed action
• They treat the patient with dignity and
respect
• There are other factors that put the patient at
risk – resources, staff -
 Non-Maleficence Vs Beneficence

• In Non-Maleficence, treatments that cause

more harm than good are not considered while
in Beneficence, every valid treatment option is
considered and then ranked in order of
preference.
• Beneficence is usually in response to a specific
situation, such as determining the best treatment
for a patient, Non-Maleficence is a constant in
practice. For instance, a doctor has a duty to
provide medical attention to a patient anywhere
 Justice

• The pillar of justice implies that every medical

intervention must be legal and respect the human
rights of individuals
• Based on this principle, treatments must be
allocated fairly and justly based on legislation even
in the midst of dire distance between demand and
supply.
• Justice indicates that no one should be unfairly
disadvantaged in access to healthcare.
• The clinician could consider the following
questions in an attempt to apply this principle:
• Is the intervention/treatment option legal?
• Does the planned intervention unfairly contradict
someone’s human rights?
• Is one group prioritised over another? Will the
prioritisation of the said group be justified in terms
of overall net benefit to society or agreed moral
conventions?
Answers to these questions will help the clinician to
make justified choices
 Why Study Medical Ethics?

 Every role played by the clinician in the provision

of healthcare services involves complex situations
that require ethical reflections.
 Knowledge of medical ethics enables the
development of the awareness and skills required in
analysing norms that affect clinical and research
practices.
• The integration of ethical knowledge into medical
practice facilitates the ability to make rational and
defendable decisions.
 Ethical Concepts
 The relationship between a doctor and the
individual patient form the professional and ethical
aspect of health management.
 This relationship revolves round giving and the use
of information – sharing information between the
patients who provide information about their
conditions and the doctors who use the provided
information to provide management plans.
 The concepts of consents, confidentiality and
truth telling relate to how information is used by
the doctors and their clients, and determine the
ethical outcome of doctor-patient relationships
 Consents
• Beauchamp and Faden (2004, 1279) define consent as the
‘autonomous authorization of a medical intervention … by
individual patients.’
This implies that a patient has the right of choice to make
decisions about their medical care based on the information
provided by the doctor throughout the process of healthcare
management.
• Consent is not relegated to acceptance of proffered
management plan but also to alternative treatments and to
refusal of treatments.
• Consent may be explicit or implicit, explicit can be given
orally or in writing, implicit is indicated by a patient’s
behavior. Explicit consent is more preferable for most
procedures.
 Consent

• Consent is based on the ethical principles of

autonomy and respect for persons.
• Autonomy involves the right of the patients to
make free decisions about their healthcare.
• Respect for persons requires that health workers
provide opportunities that allow patients control
over their lives and defer from providing
unwelcome interventions.
• Consent comprises of three components: disclosure,
capacity/competence and voluntariness
 Components of Consent
 Disclosure: the process during which the patient is
provided with information about a proposed medical
intervention – investigation or treatment -, and allowed
the rights to make own decisions. Disclosure includes
information about inherent risks, alternatives and
consequences of the proposed treatments or tests.
 Benefits of disclosure include: defense on the part of
the physician in a law proceeding, exchange of
information, establishment of trust, cooperation of
patient in proposed treatment options, and patient’s
empowerment.
 Disclosure is based on the ethical principles of
autonomy and beneficence.
 Capacity/Competence
Capacity/Competence - the patients’ ability to understand the
information provided by clinicians and the consequences of
their decisions.
 Described as the ‘gateway’ to the exercise of autonomy (self
rule) (Gunn, 1994).
 Cases arise where a patient refuses treatment considered
important by the doctor – a tension between respect for
autonomy and beneficence. Autonomy usually takes
precedence in such cases.
 Though every clinician should be trained to assess capacity
there are situations that psychologists or psychiatrists, those
with specialist skills are required to conduct the assessment.
 Documentation of the capacity assessment is essential for
clinical and legal purposes.
 Voluntariness

Voluntariness refers to patients right to make decisions

about their health and their personal information without
undue influence.
 Factors affecting voluntariness
 Internal factors arising from the patient’s health
conditions.
 External factors – involve the ability of others to exert
control over a patient by force (the use of physical
restraints or sedation to enable treatment), coercion
(the use of explicit or implicit threats to ensure
treatment) or manipulation (the deliberate omission
or distortion of information to compel a certain
decision or accept a treatment).
 Rather than using these external factors, the doctor
should try to persuade the patient (appeal to the
patient’s reason). The patient is still free to choose.
 Tension exists between autonomy and paternalism
(a doctor’s need to act in the patient’s best interest
based on training and expertise), hence –
• Clinicians should be mindful of the thin line between
persuasion and coercion – the duty to provide
adequate information to support a patient’s free
choice in contrast with allowing a patient’s
actions/decisions to be considerably controlled by
others
• Voluntariness is a legal requirement of valid consent.
 Obstacles to informed consent
Fully informed consent is rarely achieved in practice due to:
Linguistic and cultural differences
Diagnostic uncertainties
Complexity of medical information
Overworked medical workers
Psychological barriers to rational decision making
However, obtaining informed consent is a priority in the
healthcare relationship.
Exceptions to informed consent
voluntary giving over of decision making capacity to the doctor
or a third party
when disclosure of information would cause harm to the patient
–therapeutic privilege-.
 Truth Telling
-defined as the practice and attitude of being open and
straightforward with patients about health conditions and
treatments.
 Works on the premise that truth is better than deception.
 Hindrances to Truth Telling
 The concept of ‘protective deception’ where the doctor feels
the patient may not handle the whole truth and decides to select
what to tell.
 Some cultures and families consider it cruel due to the
‘supposed’ effects it will have on patients.
 Quite difficult in practice due to uncertainty in medical
diagnosis and the patient’s response. (Verify your patient’s
readiness/willingness
 Ignorance is not an option that many patients desire.
 Confidentiality

Confidentiality operates on the expectation that the information

provided during clinical relationships are not to be disclosed by
a health professional to a third party, without permission -
Hippocratic Oath and ethical codes of practice -.
Confidentiality is premised on trust and openness.
Breach of Confidentiality
It is argued that confidentiality is not absolute and may at times
be legally permissible to be breached -
If there is a risk of serious harm to patient or others
Sharing information among the healthcare team for a better
management of the case.
 Pregnant women and children

Unlike other medical conditions where a patient’s

autonomy is paramount, dealing with pregnant women
and children require a consideration of –
• The risks to the woman as opposed to the potential
benefit to the foetus.
• A child’s medical needs against the interests
(spiritual, economic, psychological) of the family.
• These considerations determine the course of action
to be taken.
 Pregnancy: Ethical Considerations
An ethical dilemma ensues when a physician is torn
between the obligation to respect a patient’s autonomy and
the safety of the foetus due to a pregnant woman’s
engagement in behaviour(s) that could harm her foetus.
 Some ethical issues in pregnancy
 The principle of reproductive freedom – gives the
woman the rights to make reproductive choices -.
Objection to this principle is that the foetus has as much
right (equal right) as the woman.
 Another group advocates reproductive rights with some
restrictions, arguing that the foetus has a right not to be
harmed once the woman choses to continue her
pregnancy.
 Ethical Issues in Pregnancy
• There is the view that the foetus does not have any legal
rights until born alive and detached from the mother - ‘All
human beings are born free and equal in dignity and rights’
(The Universal Declaration of Human Rights, UN, 1994) -.
• Equally, the Convention on the Elimination of All Forms of
Discrimination Against Women (UN, 1979) declares that all
women ‘have the same rights to decide freely and
responsibly on the number and spacing of their children and
to have access to the information, education and means to
enable them to exercise these rights.’
• The practice is usually different from these promulgations
because of socio-cultural demands. The competent woman,
however, has the right to make decisions for herself and her
foetus.
 Involving Children in Decision Making
• Traditionally, children have been excluded from medical
decision making since they were considered non-
autonomous.
 Involvement of children in decision making
 Ethical involvement of children in decision making has
identified two significant changes:
 The recognition that children from infants to teens differ
in their level of capacity for decision making allowed the
creation of three categories of children by the American
Academy of Paediatrics (1995) –
 Those lacking decisional capacity
 Those with developing decisional capacity
 Those with developed decisional capacity
Difficulties arising from the standards for measuring
children’s capacity enabled the change that suggests -
• respectful involvement of the child is dependent on
 the decisional needs and abilities of the child
 the communication abilities of the child –may not be
competent to make decision but comprehends like
an adult-.
A family-centered ethic is considered the best model
as it involves the family context of the child.
 Family-centered Approach: Challenges

Challenges:
Disagreement between the patient and family places the
physician in a dilemma.
However, the best interest and involvement of the child
(depending on the child’s capacity) is primary.
Disagreement between the parents and the healthcare team
with respect to the child’s best interest.
Parents usually have their child’s best interest. However,
Situations may arise when parents are too distressed to make
the most appropriate decisions for the child.
The child’s interest should be the basis for every decision
 Child Abuse and Neglect

• Child abuse refers to actions by a parent/caregiver

that results in serious harm to the child.
• There are interpersonal and cultural variations to
what constitutes child abuse. Intention and harm
are the underlying terms. However,
• Every well-intended cultural practice that causes
serious harm is an abuse. E.g. clitoridectomy.
• Child abuse is mostly not reported due to a lot of
conflicting issues including that reporting does not,
at times, benefit the child.
 Not Reporting Abuse: Conditions

Child abuse is prevalent and should be reported

when noticed unless when there is -
• A genuine belief that reporting will cause more
harm to the child
• Confidence that the child is not at risk for
subsequent injury
• Other law abiding alternatives could cause harm
• Conviction that one’s stand can be defended
publicly
 Religious and Cultural Views on Ethics

 Moral values of clinicians and their patients often

raise ethical dilemmas.
 While many clinicians ascribe to secular values that
emphasise autonomy and social utility
 Their patients ascribe to cultural and religious values
that centralise obedience to a deity and the
responsibilities of a family to its members.
 These differences need to be negotiated based on
policies set up by individual nation’s health sector
and/or on individual case and situation.
 This section only highlights, generally, the need for
clinicians to be aware of these differences
• Most patients’ ideas about ailments, treatments, death
and every other health related issue are based on their
cultural beliefs with religion at the core.
• Yet, in a culture or a religion, there are individual
differences.
• Information about each patient’s religious/cultural
beliefs, especially in relation to their issues are
extremely important.
• Of note is that a patient might be misinformed or
misconceive their religious/cultural beliefs or the
medical system. The clinicians need to be aware of the
belief and cultural practices in their community of
service.
 Conclusion
• Ethics is at the moral center of the clinician’s work,
and helps direct the clinician on steps to take during
clinical emergencies and needs.
• There is no ‘one size fits all’ framework for
handling clinical problems, especially the ones that
require ethical considerations. The context of each
medical case determines how to address each case.
• Medical ethics far exceeds these notes and branches
into every aspect of medical practice. A clinician’s
recognition of the ethical issues in their practice will
enhance their practice.
 References

American academy of Pediatrics. 1995. Informed consent, parental

permission and assent in pediatrics practice. Pediatrics, 95, 314-17.
American Medical Association. 1995. AMA Code of Ethics: Policy
Statement on Confidentiality. Washington DC: AMA.
Beauchamp, T.L and Faden, R.R. 2004. Informed consent: Meaning and
elements of informed consent. In Ency of Bioethics, vol. 3. New York:
Macmillan.
Council of Europe. 1997. Conventions on Human rights and Biomedicine.
Brussels: Council of Europe. Available at:
http://conventions.coe.int/Treaty/EN/WhatYou
Gunn, M. 1994. The meaning of incapacity. Med Law. Rev, 2, pp8-29.
Medical ethics explained. 2002. Available at:
https://www.themedicportal.com/medical-ethics-explained-autonomy/.
Accessed 05 Jan. 2019.
Singer, P.A and Viens, A.M. 2008. The Cambridge Textbook of Bioethics.
Cambridge: Cambridge University Press.