Welcome to

FunMed
Medical Ethics Part 2
Dr Leila Saeed
Year 2 clinical lecturer CBME
7th November 2023
Before we get started
• You do not need to be an expert in law or medical ethics to
be able to make logical decisions

• Today will be a continuation of the previous session. We will

be discussing one or more ways of approaching medical
ethic decisions – but as growing minds, you will find your
own way

• We will discuss the principles NOT specifics

3
Needs to be interactive...

4
Hand in hand with respecting each other's
views

5
What have we covered so far: 24th Oct 2023

• What is medical ethics?

• Why is it important to learn about medical ethics?
• Some examples to put it into context
• How it affects you as a student
• The application of medical ethics
- CoRE- Values Compass

6
What we will cover in this session
• Looking at the 4 GMC pillars in more detail
• Application of medical ethics into your placements
• Responsibilities as a student/doctor
- Professionalism
- Social media
• Additional:
- Capacity (intro)
- Confidentiality
- Consent
7
GMC 4 principles
of ethics

8
What is the definition of
'autonomy'?
Autonomy
The law:
• Definition: respect for the patient's right to self-determination
An adult patient...who suffers from no
• 'No one else can make a decision on behalf of an adult who has capacity' mental capacity has an absolute right
to choose whether to consent to
https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/decision-making-and-consent/circumstances-that-affect-the-decision-making-process-continued-1 medical treatment...This right of
choice is not limited to decisions
• You can help in decision making I.e. Explain risks and benefits which others might regard as
sensible. It exists notwithstanding
• Related to 'consent' and 'capacity' that the reasons for making the
decision are rational, irrational,
• Why it is important? unknown or even non-existent.
- Most talked about concept Lord Donaldson. Re T (Adult) 4 II ER
- Should be sought before any procedures/investigations or treatment 649

- Highlighted more – when patients refuse life sustaining treatment

• Three conditions:
1) Relevant capacity* (will discuss later)
2) Enough information
3) Without any external constraints (voluntarily)

10
Think about coercion..

• Not so easy to detect

• Relatives making decisions regarding treatment – may be trying to help
• Husband making decision regarding TOP- trying to be supportive

If not clear – speak to patient alone, be inquisitive, speak to others

11
Ethical dilemma – No wrong or right answer

A patient with anorexia with capacity – should they be force fed

in hospital ?

Just something to think about...

12
Give some examples of where
autonomy is important as a
patient?

13
What is the definition of
'Beneficence'?
Beneficence – the duty to 'do good’
• All medical professionals have the moral duty to do good that they believe is for the best interest of
the patient
- If only it was that simple...

• There may be more than one option for the patient and therefore ranking from best to worse is
more realistic
- Many things to consider:
• Patient's perspective
• Resources
• Pros Vs Cons
• Why is it important?
- We should always aim to do what is best for our patients
- What is 'best' for one person is not always the best for someone else... think holistically

15
 Give some examples of where
beneficence may be difficult as a
doctor?

16
What is the definition of 'Non-
Maleficence'?
Non-Maleficence – the duty to 'not do bad'

• Do no harm
• Again, not as simple as it sounds
• In doing what we feel may be good – it may be harmful I.e., an
operation, giving a medication, avoiding drugs (due to concerns of side
effects)
• It may a balance between good vs harm

18
• A 15-year-old girl asking for contraception – do we give it to
her?
• You are on the underground and see a person fall and hit
their head – do you intervene?
• A relative asking for medical advice

19
What is the definition of
'Justice'?
Justice – to treat all people equally and equitably

• This can be applied both individually

• Or to a population
• When thinking about population level healthcare priorities – NICE need to
consider:
- 1) cost effectiveness, a level of beneficence
- 2) nondiscrimination
- 3) priority to worse off
• Policy makers/ NICE

21
 Can you think of an example of
where justice is difficult in medicine?

22
Examples – clinical scenarios

• A patient asking for a bunion operation (IFR)

• Not discussing contraception with a patient due to cultural
differences
• Avoiding the use of a translator for a patient
• Poorly resourced areas I.e. immunisations, education ,
screening

23
Professionalism

24
What do we mean by professionalism in
the context of being a medical student?

25
Before we get started...

• The next few slides are to help you understand the idea of
'professionalism' and our responsibilities
• The aim is nurturing the idea of what it means
• It is about producing a professional identity
• If you have any concerns or worries – please discuss with your
tutors/academic team
• This is not fear mongering – but an open/ honest discussion

26
What is professionalism?

• 'The competence or skill expected of a professional'

(Oxford English Dictionary, 2016)

• A member of a profession- from the latin profiteri, to avow or profess; for

example, many doctors profess the Hippocratic oath when they qualify

• 'A reflective practitioner who acts ethically' (Hilton and Slotnick, 2005)

27
One definition that summarises it all
Cruess et al., 2004
"an occupation whose core element is work based upon the mastery of a complex body of knowledge and
skills. It is a vocation in which knowledge of some department of science or learning or the practice of an
art founded upon it is used in the service of others. Its members are governed by codes of ethics and
profess a commitment to competence, integrity and morality, altruism and the promotion of the common
good within their domain" (McKimm et al, page 59)

• Cruess goes on to talk about 'social contract' between the professional and society
• Professionals do have autonomy and self-regulation, but at the same time accountable to those they
serve
• Is it about how we should behave?

28
Professionalism continued..
• There are many definitions
• Conceptualised in many ways + should be integrated throughout your medical school curriculum
• Important aspect of the medical curricula
- Formal and informal
- Formal teaching --> communication skills, ethics, teamwork, leadership
- Informal--> selfcare, awareness of self in society, cultural awareness
• GMC:

GMC 2009 states:

'The principles of professional practice set
out in Good Medical Practice must form
the basis of medical education'

https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice

29
Why is professionalism important in medicine?

• Aim is to think about qualities, attitudes and values that are fundamental to the practice of
medicine
• This starts at medical school (or before) and continue throughout your careers as doctors
• Patients trust doctors
• Best patient care
• Knowledge and skill is up to date
• Role models – It is the responsibility of us to act as role models to each other and those
around us
- This includes clinicians and academic members you will be shadowing
- What we do/say/act reflects our 'professional values'

30
Rank the following in order of
Less serious ---> more serious. 1 minute. Be ready to
justify your answers....

1) Missing a clinic and not notifying the tutor

2) Asking a friend to sign into a lecture for you whilst you are hung over at home
3) Laughing behind a fellow students back about a question they got wrong
4) Being rude to a patient as they did not want to be examined
5) Being disruptive in class

31
Social media

• We cannot talk about professionalism without thinking about social media

• Be mindful of what you say
• Be mindful of comments
• Be mindful of the image you are giving
• Protect yourself and patients
• Confidentiality

• What does your profile picture look like?

32
#Medbikini

33
Your thoughts....

Facebook post:
'Had such a rough day on ward round today, Dr X was so harsh to me – Argh 3 more years of this :('

Befriending a patient who is interested in a charity you have put together

Instagram post:
A meme about patients being poor historians...

34
Social media

• Guidelines on GMC
https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/doctors-use-of-soci
al-media

• Guidelines on BMA
https://www.bma.org.uk/media/1851/bma-ethics-guidance-on-social-media-2018.pdf

35
You are in a very privileged
position – do not abuse it

36
Capacity – just an intro

37
Capacity

• Definition: Being able to make your own

decisions
• It is our duty – to check if patient has the
capacity to make decision
• It is decision and time specific
• Here we will refer to it as 'mental capacity'
• Ethical dilemma – when one lacks capacity
• We must start with the presumption that every
https://www.gmc-uk.org/ethical-guidance/ethical-hub/mental-
adult patient has the capacity to make decisions capacity
about their care.

38
Consent

39
Consent
• Definition: Signals informed agreement about a
procedure/treatment
• Links into autonomy
• Required by law
• Will be discussing those adults with capacity
• Trust between patient + HCP
• As a medical student, you will not always be solely
responsible for seeking consent
• May include: asking to speak to a patient, taking bloods,
examining, sitting in with GP/hospital clinician

40
What the law says:

"A doctor who operates without the consent of his patient, save in cases of emergency or mental disability,
is guilty of the civil wrong of trespass to the person; he is also guilty of the criminal offence of assault"

Lord Scarman. Sidway v Board of Governors of the Bethlem Royal Hospital Governors. [1985] AC 871

What are your thoughts on this? Over to Menti

Ref: https://www.bma.org.uk/advice-and-support/ethics/medical-students/ethics-toolkit-for-medical-students/adults-with-capacity-and-consent

41
Valid consent

• Patients requires to have mental capacity

• Consent needs to be voluntary
• Requires sufficient information to make the decision

Caveats – some emergencies where consent is difficult to gain or treatment under mental health act

Competent patients can refuse treatment

42
Consent

Explicit Implied

• Orally • Signalled by behaviour I.e., putting arm out to

have bloods
• Written

43
Where do you think we need consent?

• Taking blood conscious patient

• Taking blood unconscious patient
• Lifesaving operation – patient alert
• Examining someone's leg ulcer whilst on a ward round – cons asks you to
• Talking to a patient in a GP surgery
• Sharing information with another agency I.e., physiotherapy ref

44
Where do you think we need consent?

• Taking blood conscious patient - yes

• Taking blood unconscious patient - impossible
• Lifesaving operation – patient alert - yes
• Examining someone's leg ulcer whilst on a ward round – cons asks you to – yes, even if cons examined
• Talking to a patient in a GP surgery – yes
• Sharing information with another agency I.e., physiotherapy ref – yes

45
Confidentiality

46
 Confidentiality
"A duty of confidence arises when confidential information comes to
the knowledge of a person…in circumstances where he has notice,
or is held to have agreed, that the information is confidential…"

Lord Goff. Campbell v MGN Limited [2004] UKHL 2 2

47
Confidentiality
• The duty of confidentiality extends to you as a student
- You have access to sensitive information
- Privileged position
• Importance:
- Central to trust between patient and doctor
- Confidential unless a real reason to break this
- Maintain integrity of profession
• Relevance to student i.e., discussing patients outside of work
• What information is confidential?
- All identifiable information (whatever format)
• Clinical information
• Clinics attended/HCP involved
• Pictures/scans/results

48
Confidentiality is an important legal
and ethical duty BUT is not absolute

GMC

49
Corridor conversations

• Interesting cases that you want to discuss

• Fellow students/ other doctors
• Be aware!
• Food for thought - those who hear may not be directly involved but upset

50
Breaking confidentiality – when can we disclose?

The duty of confidentiality is not absolute

Confidential information can be disclosed where:
• the patient has the capacity to consent and consents to the disclosure
• it is required by statute, such as in relation to certain communicable
diseases
• it is required by a court order, or
• it is justified in the public interest

51
References

• Taken from McKimm, J et al (2017) Reference Medical Education at a Glance, Wiley

• BMA
• GMC website
• https://xerte.cardiff.ac.uk/play_4275
• The medic portal https://www.themedicportal.com/application-guide/medical-school-interview/medical-
ethics/

52
Thank you