RCSI The Four Principles & Doctor-Patient Relationship PDF

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn THE FOUR PRINCIPLES AND THE DOCTOR- PATIENT RELATIONSHIP Professor David Smith Presented by Dr. Eman Alarayedh  IPCP Learnin...

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn THE FOUR PRINCIPLES AND THE DOCTOR- PATIENT RELATIONSHIP Professor David Smith Presented by Dr. Eman Alarayedh  IPCP Learning outcomes 1. Display high-quality communication with patients and demonstrate competence in conducting a structured history 2. Demonstrate basic competence in physical examination of cardiovascular, respiratory, gastrointestinal and neurological systems 3. Demonstrate professional behaviour towards patients and colleagues and engagement in ‘critical reflection’ to learn from experiences 4. Identify the challenges faced by patients living with a chronic disease and their families 5. Explain the ethical principles underpinning patient care and the doctor-patient relationship including recognition of issues arising for doctors practicing in multicultural environments 6. Demonstrate an understanding of the basic principles of evidence-based medicine (EBM) as applied to the clinical care of individual patients 7. Illustrate how patients access the healthcare system including recognition of the social and cultural influences on health 8. Recognise the basic principles of therapeutics and issues  CASE * When does the duty of care begin? Three night watchmen drank tea and shortly afterwards began vomiting and went to the casualty department of the local hospital. A nurse telephoned the casualty officer, Dr. Banerjee, who advised that the men should go home and call their own doctors. Dr. Banerjee himself felt tired and unwell and did not see the men. They all died from arsenic poisoning. It was subsequently discovered that the tea contained arsenic. Did Dr. Banerjee have a duty of care towards the men? *Barnett V Chelsea and Kensington Hospital Management Committee (1969), in BMA Medical Ethics Today (2012) pg. 30. Most trusted profession SURVEY 2017 MRBI Some 20th Century advances Stem Antibioti Antibioti Cell cs cs Research Cardiac Genetics Resusc- itation Organ Chlor- Intensive Trans- promazin Care plants e Units Life Immun- Expect- isation ancy Regen- Assisted Artificial Repro- Reprod- erative Limbs duction uction medicine What Changed? Medical / Scientific Advances Nuremberg Trials / NAZI Doctors Universal Human Rights Bioethic Scandals – Beecher and s Pappworth Information Highway Paternalism → Partnership Model Phrases from – Hippocratic oath, 5th Century bce “I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrong-doing…..” (Beneficence/Non-Maleficence) “Whatever houses I may visit, I will come for the benefit of the sick ,remaining free of all intentional injustice, of all mischief and in particular of sexual mischief and in particular of sexual relations with both female and male persons, …….” (Equal respect for all) “And, whatsoever I shall see or hear in the course of my profession….. If it be what should not be published abroad, I will never divulge, holding such things to be holy secrets” (Confidentiality) Doctor-Patient relationship Most unique of human relationships A relationship of EQUALS? What makes it different from other relationships? A power differential? What does power mean in this context? DOCTOR: competence, knowledge, skills PATIENT: impact of illness, drugs, pain, vulnerability Difference between Illness and Disease Doctor-Patient relationship PATERNALISM to COLLABORATION Old model based on doctor making decision on behalf of a competent patient without their consent Today, model is of a COLLABORATIVE process based on patient autonomy But culture & religious belief can influence decisions: where families or a senior member requests to treat/not treat, tell/don’t tell, God or Allah will intervene etc The doctor as patient Doctor-Patient relationship Types of Relationship PATER INFORM ative nalistic PATIENT INTERPRET COLLABORAT ive ive 12 PATERnalistic Model Physician promotes patient’s well being independently of patient’s current preferences & autonomy Wants best for patient without their involvement Example INFORMative Model Patient has fixed values, physician provides factual information (menu) & implements patient’s selected intervention Respects patient autonomy Physician informs patient Example: Cosmetic surgery for enhancement purposes INTERPRETive Model Patient values unclear, somewhat confused Physician elucidates, interprets as well as inform patient Physician supports patient autonomy through advise Example: Patient autonomy compromised through accident, condition, illness, medication Assisted Decision-Making (Capacity) Act, 2015 COLLABORATive Model Patient values open to discussion/development Physician persuading (nudging) patient of the best course of action in line with their developing values... but not imposing Supports developing self autonomy of patient Example: When a patient’s choice may be medically unproductive/futile Nudging 17 The art of Nudge Framing information which encourages individuals to make choices in their best interests, while maintaining their freedom Must be transparent, defensible and NOT coercive And patient can still refuse best option 18 NUDGING Has emerged from research in psychology, sociology and economics Humans have “bounded rationality”, means sometimes humans make decisions contrary to their best interests With “choice architecture” (designing decision-making contexts differently) humans can be nudged to make a particular decision, in medicine for their own benefit 19 Nudging & Health example Organ donation, variants of a message, most successful was: “would you accept an organ if you needed one, if so please help others” 20 Doctor patient relationship LISTENING How long before a doctor interrupts a patient? Conversations as important as prescriptions? Beckman & Frankel survey “The Effect of physician behaviour on the collection of data”, Ann. Internal Medicine, 1984. Nirmal Joshi, Doctor, Shut Up and Listen, The New York Times, 4 Jan 2015 22 The Four Principles  PRINCIPLES OF BIOMEDICAL ETHICS (1979; 2013) Four principles govern clinical research & clinical medicine regarding human persons: 1) Respect for Autonomy 2) Nonmaleficence 3) Beneficence 4) Justice  FOUR PRINCIPLES* govern a doctor’s obligations to patients Beneficence Respect for Autonomy Nonmaleficence Justice *Beauchamp & Childress, Principles of Biomedical Ethics (1979; 7th ed. 2013  RESPECT FOR AUTONOMY DOCTOR’S OBLIGATIONS PATIENT’S RIGHTS The obligation to maintain patient The right to have one’s medical confidentiality. information kept confidential. The obligation to presume the The right to self-determination capacity of the patient to consent/refuse treatment, OR if through choice and action i.e. to indications to the contrary, to make an autonomous choice. assess incapacity. The right to receive all the The obligation to provide all information necessary for necessary information for informed consent. decision-making. The obligation to get consent / The right to consent/refuse refusal prior to treatment. examination, procedures etc.  BENEFICENCE v PATERNALISM BENEFICENCE PATERNALISM The intentional overriding of a The ethical obligation to patient’s preferences by: Manipulation of information act for the benefit Nondisclosure of information patients. Deception Lying Coercion and justifying this action by: Reference to the patient’s best interests; Preventing harm to the patient; Mitigating harm to the patient.  THE PRINCIPLE OF NONMALEFICENCE “Do no harm” DUE CARE ABSENCE OF DUE CARE Taking sufficient and NEGLIGENCE – appropriate care to intentional or avoid causing harm, as unintentional. the circumstances demand of a reasonable PROFESSIONAL and prudent person. MALPRACTICE – not following professional standards of due care.  DISTRIBUTIVE JUSTICE TYPES OF ALLOCATION Partitioning the comprehensive social budget Allocating within the health budget Allocating within the health care budget Allocating scarce treatment for patients  my Be on o ne t fic r Au en f o ce pect Res STRENGTHS OF THE FOUR PRINCIPLES Culturally neutral. Universal appeal – give us a common moral language. Enable us to avoid moral imperialism & moral relativism. WEAKNESSES OF THE FOUR PRINCIPLES CLAIMS & NAMES: They are only a collection of names and don’t fulfil the claims they make. CRUDE, NOT COMPLEX: (i) They fail to capture the complexity of real life. (ii) They make ethical debate boring. WESTERN PRINCIPLES: The primacy of ‘respect for autonomy’ indicates a lack of respect for community values & cultural autonomy. What would you do? An 8 yr old girl has just had an elective tonsillectomy. No complications, girl is awake and feeling well. Her parents insist she stay in hospital for observation. The surgeon says there is no medical justification to extend the hospital stay. 33 What would you do? A. Immediately discharge her home B. Offer to send her home with a home nursing visit later in the evening C. Observe for a few more hours in the post surgery unit, then discharge her home D. Admit the girl for overnight observation 34 What would you do? A patient demands to have a CT scan of her spine to evaluate her lower back pain. In your clinical judgement, the pain is due to a muscle spasm: therefore a CT scan is unnecessary. Do you: A. Order the scan so that the patient will not file a malpractice law suit B. Order the scan but tell the pat that as it is not medically indicated, insurance will not pay for it C. Do not order the scan but refer the pat to another physician for a second opinion 35  “Perhaps the most basic skill of the physician is the ability to have comfort with uncertainty, to recognise with humility the uncertainty inherent in all situations, to be open to the ever-present possibility of the surprising , the mysterious, and even the holy, and to meet people there” Rachel Naomi Remen (Cancer specialist) 36 Modern version of Hippocrates’ Oath I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism, (do no harm, non- maleficience) I will remember that there is ART to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug. I will not be ashamed to say “I don’t know” I will respect the privacy of my patients ( confidentiality) I will remember that I do not treat a fever, or chart or a cancerous growth, but a sick human being, (beneficience) Ethics assessment in IPCP As part of your Portfolio, you will need to reflect on a patient encounter at the start of Semester 2, in which you considered an ethical principle (Portfolio 2.a.) Examples of ethical principles you can include are: – Consent – Confidentiality – Autonomy – Beneficence – Non-maleficence – Justice References Are Doctors Altruistic? J Med Ethics, Glannon & Ross, 2001 Autonomy in Medical Ethics after O’ Neill, GM Stirrat, R Gill, 2005 Rational Non-interventional Paternalism: why doctors ought to make value judgments of what is best for their patients. Julian Savulescu J Med Ethics, 1995 Towards a Practical Definition of Professional Behaviour, Wendy Rogers, Angela Ballantyne, J Med Ethics 2010 Nudging behaviours in healthcare: insights from behavioural economics, by Benjamin G Voyer (2015) in the British Journal of Healthcare Management Nudge in the clinical consultation- an acceptable form of medical paternalism? Ajay Aggarwal, Joanna Davies, Richard Sullivan in BMC Medical ethics 2014 Nudging in Public Health - an ethical framework from Advisory Committee on Bioethics, 2015 References Nirmal Joshi, Doctor, Shut Up and Listen, The New York Times, 4 Jan 2015 Mary T Shannon, Please Hear What I’m Not Saying: The Art of Listening in the Clinical Encounter, The Permanente Journal, 2011, Spring 15 (2): e114-e117 Stephen Westerby, Fragile Lives, 2017, Harper Collins Assisted Decision Making (Capacity) Act 2015 41