Medical Ethics and

Professional Practice
Yr. III and IV
DR MARTIN M. NSUBUGA
SENIOR LECTURER
 Presentation Outline
•Course Outline
•Recap of the earlier Ethics Course
oPrinciples of Medical Ethics
 Respect for Autonomy
 Non-maleficence
 Beneficence
 Justice
oConfidentiality
•References

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 Course outline
•Incompetent and vulnerable patients
•Truth telling and withholding of information; Quality of life. End of life
issues including withholding life sustaining treatment; Euthanasia;
physician assisted suicide
•Resource allocation
•Cross-cultural issues that affect health, ethics and human rights; Spiritual
issues that affect health, ethics and human rights. Religion culture and
Medicine
•Futility and difficult patient Organ donation and transplant.

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 Course outline(cont’d)
•Ethical dilemmas: in HIV treatment and control; refusal of treatment
•Research Ethics
•Inter-professional relationships; rights of patients and health
professionals
•Hippocratic Oath
•Qualities of Ethical Professionals (i.e. doctors, nurses, radiographers)
Roles and Responsibilities of Medical Councils and Associations

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 Course outline(cont’d)
•Basic concepts of Health and Human Rights; linkages between health
and human rights; International Bill of rights/categories of rights i.e.
economic, social cultural rights, civil and political rights; sexual and
reproductive rights.
•Right to health in national, regional and international law.
Application of the Human Rights framework to public health policies
and programs; Monitoring, implementation and violation of health
rights (national, regional and global mechanisms)

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 Course outline(cont’d)
•Role of health professionals in protecting and promoting human
rights;
•Gender based violence as a health and human rights issue

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 References
•Beauchamp, Tom., and James F. Childress. Principles of Biomedical
Ethics. 6th Ed. New York: Oxford University Press

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 Principles of Biomedical Ethics
•Respect for Autonomy:
• Is to acknowledge others’ right to hold views, to make choices and
take actions based on their personal values and beliefs.
• Respect involves respectful action and not merely a respectful
attitude.
• Every person has an unconditional worth and everyone is an
individual.

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 Principles of Biomedical Ethics(cont’d)
•Respect for Autonomy:
oNegative obligation: Autonomous actions should not be subjected to
controlling constraints by others although there maybe valid exceptions.

oPositive obligation: respectful treatment in disclosing information and

actions that foster autonomous decision making – options must be
made available.

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 Principles of Biomedical Ethics(cont’d)
•Respect for Autonomy:
oIt helps justify many other moral rules:
Tell the truth.
Respect the privacy of others.
Protect confidential information.
Obtain consent for interventions with patients.
When asked, help others make important decisions.

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 Principles of Biomedical Ethics
•Respect for Autonomy:
oCompeting moral considerations can override respect for autonomy:
If choices endanger public health

Potentially harm innocent others

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 Principles of Biomedical Ethics
•The meaning and justification of Informed Consent
oPhysicians have the obligation to obtain informed consent from
patients prior to a substantial intervention
oEssentially to protect autonomous choice and not to prevent harm

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 Principles of Biomedical Ethics:
•Informed Consent:
•Definition: One gives an informed consent to an intervention if one is
competent to act, receives a thorough disclosure, acts voluntarily,
and consents to the intervention.

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 Principles of BM Ethics (cont’d)
•Informed Consent:
oAn informed consent is an individual’s autonomous authorisation of a
medical intervention.
oThe patient does not simply express agreement or comply with a
proposal.
oHe or she must authorise something through an act of informed and
voluntary consent

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 Principles of BM Ethics (cont’d)
•Informed Consent:
oInformed consent occurs if and only if a patient, with substantial
understanding and in the absence of substantial control by others,
intentionally authorises a professional to do something quite specific.

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 Principles of BM Ethics
•Informed consent:
oInformed consent (IC) may also conform to the social rules of consent –
one therefore has to obtain legally or institutionally valid consent from
patients before proceeding with diagnostic or therapeutic procedures.
oLatter still stems from autonomous choice but obviates the need to
meet a very high standard

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 Principles of BM Ethics (cont’d)
•Informed consent:
oComponents of IC:
Competence – to understand and to decide
Disclosure – of material information
Understanding – of the disclosed information and the recommended plan
Voluntariness – in deciding; not coerced
Consent – decides in favour of a proposed plan and authorises the carrying out of
the given plan

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 Principles of BM Ethics
•Nonmaleficence
oAn obligation not to inflict harm on others

oPrimum non nocere: ‘Above all (or first) do no harm’.

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 Principles of BM Ethics
•Nonmaleficence:
•Hippocratic oath clearly expresses an obligation of nonmaleficence
and an obligation of beneficence: “I will use treatment to help the
sick according to my ability and judgment, but I will never use it to
injure or wrong them.”

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 Principles of Biomedical Ethics
Nonmaleficence and Beneficence are distinct entities of equal
importance – the obligation to help others is distinct from the
obligation not to harm others.

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 Principles of BM Ethics
•Principles of Nonmaleficence and Beneficence
oNonmaleficence:
1 One ought not to inflict evil or harm.
oBeneficence
1. One ought to prevent evil or harm.
2. One ought to remove evil of harm.
3. One ought to do or promote good.

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 Principles of BM Ethics
•Beneficence:
oWe need to treat persons autonomously and refrain from harming
them, we also need to contribute to their welfare.
oWe need to take positive steps to help the patient
oBeneficence – all forms of action intended to benefit others

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 Principles of BM Ethics:
•Beneficence:
oMoral rules of obligation:
 Protect and defend the rights of others.
 Prevent harm from occurring to others.
 Remove conditions that will cause harm to others.
 Help persons with disabilities.
 Rescue persons in danger

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Medical Ethics and Professionalism
•We follow from here tomorrow.

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Medical Ethics and
Professional Practice
Yr. III and IV
DR MARTIN M. NSUBUGA
SENIOR LECTURER
 Presentation Outline
•Final recap of Principles of BM Ethics
oJustice
•Incompetent and vulnerable groups
•Truth Telling and Withholding of Information

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 Principles of Biomedical Ethics
•Justice
oJustice – fair, equitable, and appropriate treatment in light of what one
is due or owed to persons.
oStandards of justice are needed whenever persons are due benefits or
burdens because of their particular properties or circumstances
oA holder of a valid claim based in justice has a right, and therefore is
due something.
oAn injustice involves a wrongful act or omission that denies people
resources or protections to which they have a right.

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 Principles of Biomedical Ethics
•Justice:
oDistributive justice – fair, equitable, and appropriate distribution
determined by justified norms that structure the terms of social
cooperation.
oScope include policies that allot diverse benefits and burdens such as
property, resources, taxation, privileges, and opportunities.

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 Principles of Biomedical Ethics
•Justice:
oOne principle of Justice is the principle of need; which declares that
social resources including healthcare should be distributed according to
need
oHealth is a fundamental need – people will be harmed or affected in a
fundamental way if any such need is not fulfilled.

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 Principles of Biomedical Ethics (cont’d)
•Privacy stems from the Principle of Respect for Autonomy:
oPrivacy – an agent’s control over access to himself/herself.
oFour forms of privacy –
Informational - information
Physical – personal space
Proprietary privacy - property interests
Relational privacy – family and close human relations

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 Principles of Biomedical Ethics (cont’d)
•Confidentiality – We surrender some of our privacy when we grant
others access to our personal information or our bodies, but we
usually maintain some control over information generated about us
in diagnostic and therapeutic contexts and in research.
Confidentiality is a branch of Informational privacy.

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 Principles of BM Ethics (cont’d)
•Confidentiality: cont’d
•It prevents redisclosure of information originally disclosed within a
confidential relationship i.e. a relationship in which the confider has
a reasonable and legitimate expectation that the confidant will not
further disclose the information without the confider’s authorization.

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 Principles of Biomedical Ethics (cont’d)
•Privacy and confidentiality – an infringement of a person’s right to
confidentiality occurs only if the person (or institution) to whom the
information was disclosed in confidence fails to protect the
information or deliberately discloses it to someone without first-
party consent.

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 Principles of Biomedical Ethics (cont’d)
Why confidentiality:
◦ To enable the patient disclose as much information to the doctor
as possible to allow the latter offer the best possible treatment
◦ Autonomy and the right to control one’s privacy

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 Principles of Biomedical Ethics (cont’d)
•Privacy and confidentiality – on the other hand a person who
without authorisation, enters a hospital record room or computer
database violates rights of privacy, although he or she may also
obtain confidential information.
•There is need to ensure patient’s confidential information is
protected to the utmost and is discussed only in a professional
clinical context

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 Incompetent and vulnerable groups
•Competence: If one can understand a therapeutic or research
procedure, deliberate regarding its major risks and benefits, and
make a decision in light of this deliberation.
•In the absence of the above capacities, then the individual’s
competence to decide, consent, or refuse is questionable.
•Inabilities required to ascertain incompetence:
i. Inability to express or communicate a preference or choice
ii. Inability to understand one’s situation and its consequences
iii. Inability to understand relevant information

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 Incompetent and vulnerable
groups(cont’d)
•Inabilities:
iv. Inability to give a reason
v. Inability to give a rational reason
vi. Inability to give risk/benefit-related reasons
vii. Inability to reach a reasonable decision
Besides mental and psychological capacity other criteria are also used to
ascertain competence i.e. pragmatic criteria e.g. efficiency, feasibility and
social acceptability.
• Criteria like age – experience, maturity, responsibility and welfare.

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 Incompetent and vulnerable
groups(cont’d)
•Surrogate decision making: Authorised to make decisions for
doubtfully autonomous or nonautonomous patients.
•If a patient is not competent (incompetent) to choose or to refuse
treatment, a hospital, a physician, or a family member may justifiably
exercise a decision –making role or go before a court or other
authority to resolve the issues before implementing a decision.

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 Incompetent and vulnerable
groups(cont’d)
•Surrogate decision making is based on:
i. Substituted judgement standard – what would the patient want in
the circumstances?
ii. Pure autonomy standard – patient’s previous wishes – advance
directives?
iii. Best Interests standard – risks and benefits?

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 Incompetent and vulnerable
groups(cont’d)
•Advance directives: rooted in respect for autonomy and in
nonmaleficence.
oA person while competent either writes a directive for health
professionals or selects a surrogate to make decisions about life-
sustaining treatments during periods of incompetence.
oTwo types of advance directives:
i. Living wills stipulating patients wishes in specific circumstances regarding
medicalprocedures
ii. Durable power of attorney – power continues in effect even when the signer
becomes incompetent

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 Incompetent and vulnerable
groups(cont’d)
•Advance directives – shortfalls:
oDifficulty making decisions and specifying guidelines that adequately
anticipate the full range of medical situations that might occur.
oFew people compose these documents
oDesignated decision maker may be unavailable, incompetent, have a
conflict of interest
oPatient preferences may change without them remembering to alter the
AD
oThe health professional hands are tied in situations where patients
interests may be compromised

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 Incompetent and vulnerable
groups(cont’d)
•In the absence of an AD, who makes the decision: A third
party/parties who are:
oAble to make reasoned arguments
oHave adequate knowledge and information
oAre emotionally stable
oCommitted to the incompetent patient’s interests – free of Conflict Of
Interests and any controlling influence

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 Incompetent and vulnerable
groups(cont’d)
•Classes of decision makers:
oFamily: First choice – they know the patient and are close to him/her
and know the patient’s wishes. Family can however be imprecise! They
can make bad decisions and can have a COI. Health worker should be
wary of family member limitations – ignorant, acting in bad faith or
have a COI.
oHealth Care professionals: Advise family especially in case of imminent
death. In case conflicts with family decision should seek recourse to
Court or Hospital Ethics committee.

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 Incompetent and vulnerable
groups(cont’d)
•Institutional Ethics Committee: These resolve disagreements,
generate reasoned options and help parties adhere to institutional
guidelines and governmental regulations.
•Judicial system: Last recourse.Especially when there is no family or
family is taking a bed decision and won’t listen to advice.

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 Incompetent and vulnerable
groups(cont’d)
•Vulnerable persons –incapable of protecting their interests because
of sickness, debilitation ,mental illness, immaturity, or cognitive
impairment.
•VPs:
o Unprotected by rights (often)
oExposed to potentially harmful circumstances
oUnable to make decisions
oImpoverished

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 Incompetent and vulnerable
groups(cont’d)
•Issue of vulnerable persons arises in research – they are susceptible
to intimidation, manipulation, coercion or exploitation.
•Humans who lack certain capacities should not be used in
biomedical research that is risky and does not offer them a prospect
for direct benefit.
•These groups need to be treated with sympathy and avoid many
wrongs that were done in the past.

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 Truth Telling and Withholding of
Information
•Truth telling (veracity): refers to comprehensive, accurate, and
objective transmission of information, as well as to the way the
professional fosters the patient’s or subject’s understanding.
•Linked to respect of autonomy
•Based on respect owed to others

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 Truth Telling and Withholding of
Information(cont’d)
•Obligations of fidelity, promise keeping and contract. The patient has
a right to truthful information regarding diagnosis, prognosis,
procedures etc… Professional is also entitled to truthful information
from patients.
•Relationship between healthcare professional and patients depends
on trust and adherence to rules of veracity fosters trust.

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 Truth Telling and Withholding of
Information(cont’d)
•Veracity is however not absolute, careful management of information
including limited disclosure, nondisclosure, deception and even lying
is occasionally justified when veracity conflicts with other obligations.
•Arguments for non-disclosure of bad news:
i. Benevolent deception: ‘What you don’t know can’t hurt and may help
you’. Beneficence and nonmaleficence. Not everyone agrees. This
could threaten trust! There is room for staged disclosure and cautious
language about prognosis. We readily share information about
diagnosis and therapeutic options.

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 Truth Telling and Withholding of
Information(cont’d)
•Arguments for nondisclosure of bad news:
i. Benevolent deception(cont’d): For prognosis, professional norms
incorporate the therapeutic value of hope for patients, and virtues of
compassion, gentleness, and sensitivity taking precedence over
veracity. ‘Bad news’ can be disclosed over time – particularly if you
have the time!
ii. The health care professional cannot know the ‘whole truth’. ‘You can
never tell what will happen next’. Disclosure of the whole truth
about something complex may be a difficult ideal to reach.

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 Truth Telling and Withholding of
Information(cont’d)
•Arguments for non-disclosure of bad news:
iii. Many patients are unable to understand and appreciate the
implications of the information provided. Communication can be
complex, especially if the patient has limited capacity to understand.
iv. Sometimes the very sick and the dying do not want to know the
truth about their condition. Not everybody agrees.

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•We continue from here tomorrow.

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