Medical ethics

Medical ethics started with Hippocrates and his oath to 'do no harm. Today the term covers a range of issues in health care and other related fields, especially the study of moral values as they apply to medicine. In many cases, moral values can be in conflict, and ethical crises can result. Medical ethics shares many principles with other areas of healthcare ethics, such as nursing ethics. A particularly controversial area of medical ethics is that of so-called reproductive ethics.

In the 'hospital context' these include the relationship of patient and doctor, the need to obtain 'informed' consent before undertaking treatment, and related to this, the degree to which the doctor can depart from the truth when it appears in the patient's interest to do so; the allocation of healthcare resources; euthanasia and withholding of treatment (perhaps from the new born, perhaps from the very old) ; confidentiality of medical information and so on. In a research context they may include the limits of acceptability of experiments on animals - or on humans; the use of genetic information (particularly in relation to choices affecting families) ; the relationship of private profit to pubic health. The term 'bioethics' is often used interchangeably.

The idea behind medical ethics is that there is a particular kind of moral expertise that belongs not in the area of medicine but in philosophy, and hat either philosophers can be asked to express their opinions on medical matters, or medical people can be given training as philosophers. In practice, this leads to the dominance in the field of two narrow interpretations of ethics: the utilitarian calculations, epitomised by such things as the QALYs system for allocating resources (where the number of Quality Assessed Life Years for patients is counted up and compared under various treatment options, so for example a hip transplant programme may be 'better' than an expensive hear operation); and a residual notion of 'rights' in which certain treatments, (for example, being treated for a rare disease) are funded anyway, whatever the potential costs, par t of a sense of a fundamental 'right to life'. These approaches are often described as 'Kantian'.

Writers about medical ethics have suggested many methods to help resolve conflicts involving medical ethics. Sometimes, no good solution to a dilemma in medical ethics exists, and occasionally, the values of the medical community (i.e., the hospital and its staff) conflict with the values of the individual patient, family, or larger non-medical community.

DECLARATION OF GENEVA (Adopted by the General Assembly of the World Medical Association, September 1948 [2] At the time of being admitted as a member of the medical profession: I solemnly pledge to consecrate my life to the service of humanity; I will give to my teachers the respect and gratitude that is their due; I will practise my profession with conscience and dignity; The health of my patient will be my first consideration; I will respect the secrets that are confided in me, even after the patient has died; I will maintain by all the means in my power, the honour and the noble traditions of the medical profession; My colleagues will be my sisters and brothers; I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient; I will maintain the utmost respect for human life; I will not use my medical knowledge to violate human rights and civil liberties, even under threat; I make these promises solemnly, freely and upon my honour.

Values in medical ethics

A Case Method To Assist Clinical Ethics Decision Making (Modified from American College of Physicians Ethics Manual) 1. Define the ethics problem as an "ought" or "should" question. (e.g." "Should we withhold a respirator for this unconscious man with AIDS, as his partner requests, or use it, as his parents request?") 2. List relevant facts and uncertainties. Include facts about the patient and caregivers (such as emotional state, cultural background, and legal standing). Include physiologic facts and significant medical uncertainties (such as expected outcomes with and without treatment), and the benefits and harms of treatment options. 3. Identify a decision maker. If the patient is competent, the decision maker is the patient. If the patient is incompetent, identify a proxy decision maker (e.g., as specified by court appointment, state law, a durable power of attorney for health care, living will, or the next of kin.) 4. Give understandable, relevant, desired information to the decision maker and dispel misconceptions. 5. Solicit values of the patient that are relevant to the question. These include the patient's values about life; relation to community and health care institutions; goals for health care and conditions that would change goals; and preferences about health care or proxy decision makers. 6. Identify health professional values, including health goals (such as prolonging life and alleviating pain), values that pertain to patient–physician communication (such as truth telling and confidentiality), and some values that extend outside of the patient–physician relationship (such as promotion of public health, and respect for the law). 7. Propose and critique solutions, including options for treatment and alternative providers. 8. Identify and remove or address constraints on solutions (such as unavailability of services, laws, or legal myths).

Six values that often apply to medical ethics discussions include:

• Beneficence - a practitioner should act in the best interest of the patient. (Salus aegroti suprema lex.)

• Non-maleficence - "first, do no harm" (primum non nocere).

• Autonomy - the patient has the right to refuse or choose their treatment. (Voluntas aegroti suprema lex.)

• Justice - concerns the distribution of scarce health resources, and the decision of who gets what treatment.

• Dignity - the patient (and the person treating the patient) have the right to dignity.

• Truthfulness and honesty

These values do not give answers as to how to handle a particular situation, but they can provide a useful framework for understanding conflicts. There are often conflicts in ethical values between the patient and family, and the medical care providers, and these can lead to ethical dilemmas. Conflicts can also arise between health care providers, or among family members. For example, the principles of autonomy and beneficence clash when patients refuse life-saving blood transfusion, and truth-telling was not strongly emphasized before the HIV era.

In the United Kingdom, the General Medical Council provides guidance in the form of its 'Good Medical Practice' statement.

Informed consent

Informed Consent usually refers to the idea that someone who is not adequately informed about the full implications of a decision about his or her treatment is at risk of mistakenly making a choice not reflective of his or her ethical values. It does not specifically mean the process of obtaining consent, nor the legal requirements for decision-making capacity. Patients can choose to make their own medical decisions, or can delegate this authority to someone else. Sometimes, the patient may be incapacitated, in which case U.S. State law designates a process for obtaining informed consent. In some American States, family members have differing levels of precedence over one another in making medical decisions for the patient, while other States recognize all family members equally in making medical decisions.

The value of informed consent is closely related to the values of autonomy and truth telling. American culture places a high value on these principles, finding justification in the U.S. Constitution and Declaration of Independence. The concept of informed consent has increased in importance since the Nuremberg trials and the Tuskegee Syphilis Study

Confidentiality

"Confidentiality is a fundamental tenet of medical care. It is a matter of respecting the privacy of patients, encouraging them to seek medical care and discuss their problems candidly, and preventing discrimination on the basis of their medical conditions." American College of Physicians, Ethics Manual, Fourth Edition

"A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law." AMA Principles of Medical Ethics

Confidentiality applies especially to conversations between doctors and patients, and is commonly known as "patient-physician privilege". Legal protections prevent physicians from revealing their discussions with patients, even under oath in court. Confidentiality is mandated in the USA by HIPAA laws, specifically the Privacy Rule. Confidentiality is challenged in cases such as the diagnosis of a sexually transmitted disease in a patient who refuses to reveal the diagnosis to a spouse, or in the termination of a pregnancy in an underage patient, without the knowledge of the patient's parents. Many States in the USA have laws governing parental notification in underage abortion[3]

Beneficence

The principle of beneficence expresses the duty of health care providers to be of a benefit to the patient, as well as to take active steps to prevent and to remove harm from the patient.

Bedside rationing

Bedside rationing is defined as when the following conditions exist regarding the physician's actions:

1. "withhold, withdraw, or fail to recommend a service that, in the physician's best clinical judgment, is in the patient's best medical interests"
2. "act primarily to promote the financial interests of someone other than the patient (including an organization, society at large, and the physician himself or herself)"
3. "have control over the use of the beneficial service"

The physician's role in rationing is debated; however, even among proponents of the physician's role there is an emphasis that the physician should not make a rationing decision in isoloation.

Justice

Justice in health care is usually defined as a form of fairness,and in medicine it means that when access to health care is limited, then some fair way of allocating those scarce resources must be found. It is generally accepted that persons who are equals should qualify for equal treatment; for example, Medicare is available to all persons over the age of 65 years. This category of persons is equal with respect to their age, but says nothing about need or other factors about the persons in this category. One of the most controversial issues in modern health care is "who has the right to health care?" Most generally, as a society, do we want to provide some minimum level of health care for all citizens, regardless of ability to pay? More particularly, if scarce resources mean that only some people can be treated, how should they be chosen?

Non-maleficence

The concept of non-maleficence is embodied by the phrase, "first, do no harm," (in Latin, primum non nocere). Physicians must not prescribe medications they know to be harmful. American physicians interpret this to exclude the practice of euthanasia, but not all concur. For example, Dr Jack Kevorkian was convicted of second-degree homicide in Michigan in 1998 after demonstrating active euthanasia on the TV news show 60 Minutes.[4] Dr Kekorvian, who claims that he participated in at least 130 assisted suicides, was released in January 2007 after eight years in prison.

Non-maleficence is a legally definable concept. Violation of non-maleficence is the subject of medical malpractice litigation.

Double effect

Some interventions undertaken by physicians can have a beneficial outcome while also potentially doing harm, a combination known as the "double effect." One example is the use of morphine in the dying patient: morphine can ease the pain and suffering of the patient, while simultaneously hastening the patient's demise by suppressing the respiratory drive.

The concept was first formulated, in a more general ethical context, by Thomas Aquinas.

Importance of communication

Many "ethical conflicts" can be traced back to a lack of communication. Communication breakdowns between patients and their healthcare team, between family members, or between members of the medical community, can all lead to disagreements and strong feelings. These breakdowns should be remedied, and many apparently insurmountable "ethical" problems can be solved with open communication.

Ethics committees

Often, simple communication is not enough to resolve a conflict, and a hospital ethics committee, comprised of heath care professionals, clergy, and lay people, must convene to decide a complex matter.

Cultural concerns

Cultural differences can create difficult medical ethics problems. Some cultures have spiritual or magical theories about the origins of disease, for example, and reconciling these beliefs with the tenets of Western medicine can be difficult.

Truth-telling

Some cultures do not place a great emphasis on informing the patient of the diagnosis, especially when cancer is the diagnosis. Even American culture did not emphasize truth-telling in a cancer case until the 1970's. In American medicine, the principle of informed consent takes precedence over other ethical values, and patients are usually at least asked whether they want to know the diagnosis.

Conflicts of interest

"A physician shall, while caring for a patient, regard responsibility to the patient as paramount." Article VIII of the AMA Principles of medical ethics

Physicians should not allow a conflict of interest to influence medical judgment. In some cases, conflicts are hard to avoid, and doctors have a responsibility to avoid entering such situations.

Futility

Advanced directives include living wills and durable powers of attorney for healthcare. Often, these directives document the "expressed wishes" of the patient, and this provides a framework to guide family members and health care professionals in decisionmaking when the patient is incapacitated. Undocumented expressed wishes can also help guide decisionmaking, in the absence of advanced directives. "Substituted judgement" is the concept that a family member can give consent for treatment if the patient is unable (or unwilling) to give consent himself. The key question for the decisionmaking surrogate is not, "What would you like to do," but "What do you think the patient would want in this situation." Courts in the USA have supported family's arbitrary definitions of futility to include simple biological survival, as in the case of "Baby K".

• Baby Doe Law Establishes state protection for a disabled child's right to life, ensuring that this right is protected even over the wishes of parents or guardians in cases where they want to withhold treatment.

External links

1. Lois Snyder for the American College of Physicians Ethics, Professionalism, and Human Rights Committee. (2011) American College of Physicians Ethics Manual: Sixth Edition