Ethics in

Family
Medicine

L/O/G/O Nita Arisanti

Department of Public Health
Learning objectives
• Describe the principles of medical ethics
• Understand the implementation of medical
ethics in family medicine cases
• Describe the ethical issues in several
cases:
– Confidentiality
– Consent
– Non-compliant patient
 BAD

WRONG

GOOD

RIGHT

• Ethics is an understanding
VS .
of the nature
of conflicts arising from moral imperatives
and howGOODbest
#1
we may deal GOOD
with#2 them

• Ethics does NOT decide what is morally

right or wrong; rather it considers how we
should act best in the light of our duties
and obligations as moral agents.
Medical Ethics
• Medical ethics is the discipline of
evaluating the merits, risks, and social
concerns of activities in the field of
medicine.
THE PRINCIPLES IN MEDICAL
ETHICS 6
• The Principle of Non-Maleficence
• The Principle of Beneficence
• The Principle of Autonomy
• The Principle of Veracity(accuracy)
• The Principle of Confidentiality(or Fidelity)
• The Principle of Social Responsibility and
Justice
The Principle of Non-Maleficence

• first do no harm
• sanctity (holiness) of life
• calculated risk or risk benefit
The Principle of Beneficence
• do only that which benefits the patient
• patient’s welfare as the first consideration
• care consideration competence
The Principle of Autonomy
• right to information and self
determination
• free and informed consent
• free will and accord - intentional
participation in treatment
• respect and dignity maintained
The Principle of Veracity

• Truth telling
• Obligation to full and honest disclosure
The Principle of Confidentiality

• Based on loyalty and trust

• Maintain the confidentiality of all personal,
medical and treatment information
• Information to be revealed with consent
and for the benefit of the patient
• Except when ethically and legally
required
• Disclosure should not be beyond what is
required
The Principle of Justice and
Social Responsibility
• Actions are consistent, accountable and
transparent
• not to discriminate on age, sex, religion,
race, position or rank
• greater good of society
• respect of the Law
• equity and distribution of burden & benefits
Components of Medical Ethics

• The Physician -- Patient Relationship

• The Physician -- Physician Relationship
• The relationship of the Physician to the
System of Healthcare
• The Relationship of the
Physician to Society
 Medical Medical Political
Students Researc Upheaval, War
h
CME,
CPD Natural Disasters
Medical
Managed Care
Doctor’s Insurance
Employer Other Doctors International
Hospital Community

Doctor’s Paramedics
Health Promotion Disease Diagnosis National Community
Employee
Laboratories
Clinic DOCTOR PATIENT
Managemen Press, Media
Doctor’s t Pharmaceutical
Family Disease Therapy
Industry
Prevention
Public Health Alternative
Practice Medicine
Management Patients’ Work, Employer
Patients’ Family,
Culture, Religion
Patient
MDO Organisation

Medical Council Medical

Charitie
Governmen s
The LAW t Bodies

THE MEDICAL ECOSYSTEM

- Enlarging Circle of Influence
SPECIAL PROBLEMS IN
PRIMARY CARE
SETTING
 Confidentiality

• The principle of medical

confidentiality-that doctors must keep
their patients' secrets-is one of the
most venerable moral obligations of
medical ethics.
• The Hippocratic Oath enjoins: "Whatever,
in connection with my professional
practice, or not in connection with it, I see
or hear, in the life of men, which ought not
to be spoken of abroad, I will not divulge,
as reckoning that all such should be kept
secret."
What is "medical
confidentiality"?

Essentially medical confidentiality

is the respecting of other people's
secrets

Confidentiality is important as a
way to encourage patients to be
frank(HONEST)
• people's better health, welfare, the
general good, and overall happiness
are more likely to be attained if
doctors are fully informed by their
patients, and this is more likely if
doctors undertake not to disclose
their patients' secrets.
Case
• Patient requests a statement certifying that
he or she is fit to return to work
• Insurance company requests for a
patient’s condition
• Teenage patient seeking abortion and
contraceptive advice
• Demented elderly patient
The General Medical Council (GMC)’s lists the
following legitimate exceptions:

(a) when the patient "or his legal adviser"

gives written and valid consent;
(b) when other doctors or other health
care professionals are participating in
the patient's care;
c) when the doctor believes that a close relative
or friend should know about the patient's
health but it is medically undesirable to seek the
patient's consent;

(d) exceptionally when the doctor believes that

disclosure to a third party other than a
relative would be in the "best interests of the
patient" & when the patient has rejected "every
reasonable effort to persuade";
(e) when there are statutory (CRIMINAL
OFFENSE)Arequirements to disclose
information;

(f) when a judge or equivalent legal

authority directs a doctor to disclose
confidential medical information;
(g) (rarely) when the public interest
overrides the duty of confidentiality
"such as for example investigation by the
police of a grave or very serious crime";
and

(h) for the purposes of medical research

approved by a "recognised ethical
committee."
In general, patient confidentiality can
be breached for three broad reasons

– avoiding harm to others

– benefiting the patient
– public health reporting
 Consent

• The principle’s basic mandate is that

a physician must obtain the free and
informed consent of a patient or of the
surrogate before medical treatment is
provided
Exceptions…

Exceptions to the General Rule of Disclosure

• Patient is unconscious or otherwise incapable of consenting
(Emergency treatment)
– Harm from failure to treat is imminent
– Outweighs any harm threatened by proposed treatment

• Therapeutic Privilege
– Risk disclosure poses such a threat of detriment to a patient
as to become unfeasible or contraindicated from a medical
point of view
– Does not accept the paternalistic notion that the physician may
remain silent because divulgence might prompt the patient to
forego therapy the doctor believes the patient must receive
The information includes 6

i. The nature of the patient’s condition

ii.Purpose of the treatment
iii.The potential benefit
iv.The foreseeable risks and discomfort
v.The available alternatives
vi.Cost
Informed consent for Incompetent
adults:
• Obtain from surrogate

Case: what, however should one do

when patient’s mental capacities are
impaired but present to some
degree?
• Informed consent for children

• Children Unable to Participate in

decision making: From new-born
period to early childhood. Parents
are viewed as their surrogate
decision makers
A Hypothetical Case
Mrs. H
• 83 year old Hispanic female
• Alert and oriented
• Terminal advanced COPD
• Family agrees to hospice care for patient provided:
– Patient not be told she is dying and on hospice
– Hospice staff remove name badges when visiting
– Hospice staff not tell patient why they have come to see her
Question:
• Does this violate the concept of informed consent?
A Hypothetical Case
• During the initial visit by hospice staff:
– Patient is given hospice papers and signs them without reading
them
– Patient is told by family to sign papers without reading them,
which she does
– Family member signs papers for patient without the patient even
knowing this was done
Question:
• Which of these scenarios, if any, violate the concept of informed
consent?
The non compliant patient
• Patient choose not to comply with the
physician’s recommendations
Case
• Consider a patient who refuses to stay in
the hospital

• Patient does not fill the prescription that

the doctor writes
The non compliant patient
• Patient choose not to comply with the
physician’s recommendations

• Mutually acceptable alternative treatments

are often available
Evaluation of noncompliance

cause Clinical response

Problem in Patient should be reinformed
communication about the need for treatment
Failure to trust Address question of mistrust;
involved other health
professionals who may be trust
Psychological factors Treat anxiety…
Value conflict Respect patient wishes