Medical Ethics: Values and Principles

Medical Ethics

• Medical ethics is a system of moral principles that are applicable to clinical medicine and scientific research.
• The values of medical ethics include autonomy, beneficence, non-maleficence, and justice.

Traditional Principles of Medical Ethics

• Autonomy: the right to decide, self-determination, free will, and accord.
• Beneficence: refers to actions that promote the well-being of others, means taking actions that serve the best interest of patients.
• Non-maleficence: the concept of "first do no harm", respect the sanctity of life, and calculate the risk-benefit ratio.
• Justice: a complex concept based on numerous fields, including morality, law, religion, and theology, and concerns fairness, peace, and genuine respect for people.

Need for Medical Ethics

• The present clinical environment is "patient-centered" and requires practicing doctors to cultivate a different mindset.
• The practice of medicine has changed, patients are better educated, and there is easy access to the internet.
• Higher standards of care, higher levels of investigations, and rising costs of hospitalization require effective and affordable treatment.

Importance of Ethics in Life

• Ethics in life is a system of principles that helps differentiate between right and wrong, good and bad.
• Ethics in life is a study of what is morally right and what is not, and provides practical guidance in daily life.

Principles in Medical Ethics

• The related principles of medical ethics include veracity, confidentiality, informed consent, and fiduciary.
• Veracity refers to truth telling, full and honest disclosure, and promotes a better patient-doctor relationship.
• Confidentiality is based on loyalty and trust, and maintains the confidentiality of all personal, medical, and treatment details.
• Informed consent is the process by which the attending physician discloses appropriate information to a competent patient to enable the patient to make a voluntary choice.
• Fiduciary refers to a person who has the power to act on behalf of another person, and acts in someone else's best interest.

The Principle of Autonomy

• Autonomy is the "personal rule of the self that is free from both controlling interferences by others and from personal limitations that prevent meaningful choice."
• Autonomous individuals act intentionally, with understanding, and without controlling influences.
• The principle of autonomy grants every competent adult the right to do what they want with their own healthcare.

The Value of Autonomy

• Autonomy is rooted in society's respect for an individual and their ability to make decisions.
• The physician is encouraged to uphold patient autonomy, respect the patient as an individual, empower the patient to take control over their health problems, and encourage full participation in decision-making.
• The law says that an adult patient who suffers from no mental incapacity has an absolute right to choose whether to consent to medical treatment.### Reasonable Physician Standard vs. Reasonable Patient Standard
• The reasonable physician standard is often inadequate and inconsistent with informed consent as the focus is on the physician rather than the patient's needs.
• The reasonable patient standard focuses on what the average patient needs to know to be an informed participant in the decision.

Subjective Standard

• The subjective standard considers what a particular patient in their unique circumstances and conditions needs to know to make an informed decision.
• This approach is difficult to follow and requires the physician to know what the patient needs to know.

Physicians' Problem with Autonomy

• Physicians often struggle with patients making inferior choices, including wrong choices, and must balance respecting autonomy with doing what is best for the patient.
• The physician's role is to inform and educate, not to take over decision-making for the patient.

Patient's Best Interest Standard

• The best interest principle is used when making decisions on behalf of an incapacitated patient.
• The goal is to act in the patient's best interests, considering their previously expressed preferences and cultural, religious, or employment considerations.

Best Interests Principle

• The principle is used to decide what options are reasonable for a patient who lacks capacity for informed consent.
• Factors to consider include:
  • Clinically indicated treatments
  • Previously expressed preferences
  • Doctor's knowledge of the patient's background
  • Views of third parties with knowledge of the patient
  • Which option least restricts the patient's future choices

Autonomy and Confidentiality

• Respect for autonomy has been widely accepted and applied in clinical and research settings.
• Confidentiality is essential, with exceptions for explicit consent or legal requirements.

Conflict of Interest

• A conflict of interest arises when professional judgment or actions may be unduly influenced by secondary interests.

Case Studies

• Case 1: A pregnant woman refuses a life-saving procedure for her fetus; the court may intervene to protect the fetus.
• Case 2: A dementia patient's best interests must be assessed, considering the needs of her carer.

Medical Ethics

• Beneficence: action done for the benefit of others, with obligatory and ideal beneficence.
• Non-maleficence: "do no harm," with the goal of promoting the patient's welfare.
• Balancing beneficence and non-maleficence is essential in decision-making.

Paternalism and Therapeutic Privilege

• Paternalism can be justified if it prevents significant harm or obtains a benefit, with the least autonomy-restrictive alternative used.
• Therapeutic privilege allows withholding information if it may cause harm, but this is rarely justified.

Balancing Autonomy and Beneficence

• Physicians must respect patients' autonomous decisions while promoting their best interests.
• A patient's decision may conflict with the physician's beneficent duty.

The Ends of Medicine

• Beneficence is central to the goals and nature of medicine as a social practice.
• The category of medical benefits should not include items like fertility control, cosmetic surgery, or assisting in a merciful death.

Primum Non Nocere and the Doctrine of Double Effect

• "First, do no harm" is a corollary to beneficence.
• The doctrine of double effect allows for a morally good act with a bad side-effect, providing the bad effect is not intended.

Quality of Life and Proportionality

• Quality of life is a consideration in treatment decisions, but it does not justify withholding treatment from mentally retarded or severely disabled neonates.
• Proportionality demands that the probable benefits outweigh the infringed moral considerations.

Steps of Ethical Reasoning

• Identify and frame the moral conflict
• Identify relevant ethical principles and their specifications
• Gather all relevant information
• Weigh conflicting principles and their specifications
• Conclude and propose a solution### Confidentiality in Medical Fraternity
• Definition: Confidentiality refers to the assurance that a patient's personal information shared with a physician will be kept private and not disclosed to anyone else.
• Importance: Maintaining confidentiality enhances the patient-doctor relationship, encouraging patients to share information necessary for good medical care.

Principles of Confidentiality

• Protection of information: Ensure that patient information is adequately protected when stored, transmitted, received, or disposed of.
• Consent for disclosure: Obtain patient's expressed/written consent for disclosure, ensuring they understand what will be disclosed, the reasons for disclosure, and the likely consequences.
• Respecting patient rights: Respect patients' rights to be informed about how their information will be used and to have access to or copies of their health records.

Precautions

• Maintain confidentiality: Ensure that patient information is not discussed in public areas or left accessible to others.
• Technology: Take steps to ensure that patient confidentiality is maintained when using technology to communicate health information.

Duration of Confidentiality

• The duty of confidentiality continues even after the patient has stopped seeing or being treated by the doctor.
• The duty survives the patient's death.

Breach of Confidentiality

• Definition: Breach of confidentiality occurs when confidential information is disclosed to a third party without the patient's knowledge or consent.
• Exceptions: Disclosure is allowed if required by law, with the patient's consent, or in the public interest.

Disclosure of Patient Information

• When disclosure is allowed:
  • With patient consent.
  • Within a healthcare team treating the patient.
  • If the assessment is done by the employer or insurance company.
  • If the information is in the interest of others or to protect the public.
  • If the patient refuses consent but it is in the medical interest of the patient.
  • If it is to the court or required by the law.
• Disclosure requirements:
  • Use anonymized or coded information if possible.
  • Ensure the patient understands the potential disclosure and has not objected.
  • Keep disclosures to the necessary minimum.
  • Keep up to date with and observe relevant legal requirements.

Disclosures Required by Law

• Notification of infectious diseases: Disclosure is required to satisfy specific statutory requirements.