Ethics in Family Practice PDF

Dr. Mosleh A.Ismail MD Family Medicine  Patient's problem A male patient aged 61 years old known to your practice, he turned up to your center for periodic check up. You requested some basic investigations and the results revealed : FBS 200mg/dl 2HPP 350 mg/dl A...

Dr. Mosleh A.Ismail MD Family Medicine  Patient's problem A male patient aged 61 years old known to your practice, he turned up to your center for periodic check up. You requested some basic investigations and the results revealed : FBS 200mg/dl 2HPP 350 mg/dl After breaking such new to the patient, you initiated a new file on his request to be followed up in your Family Practice center. The patient whispered you: Doctor, Please, treat my disease and file as top secret. How do you behave ? Ethical Dilemma After breaking a bad news to one of the patient known to your practice who has got HCV infection, the patient request you as his family physician that his HCV status not be disclosed to her spouse. You as FP may have to make the difficult choice between maintaining the patient's confidentiality and the obligation to prevent harm to the spouse?????? How do you behave??  Ethical Dilemma A male patient aged 61 years old known to your practice, he turned up to your center for periodic check up that is required in his work for renewal. He is working as a driver. While you are preparing a medical certificate to be given to him, he whispered you: Doctor, as you know I am the breadwinner of the family and kindly do not mention that I have HTN. This may be followed by no renewal. How do you behave ?  Outline of Presentation Why Medical Ethics? What do you mean by Medical Ethics? Definition Principles Classification Who is concerned with Medical Ethics? How do you practice Ethics in in daily family practice  ?Why Medical Ethics Evolution of ME Medical ethics and codes are very old and paralleled the medical practice. Moral requirement is a part of the universe and like the law of gravity. Certain norms (tradition-value) like: love, justice, honor beneficence, do no harm and others. These norms are inherited along the history of the mankind through the religion, the philosophical theories or social workers.  ?Why Medical Ethics In the seventies of the 20th century (modern-post-modern medicine), medical practice has became more complex. Over this period there has been a corresponding increase in related legal problems resulting in complicated physician-patient relationship (Examples:-(Organ donation and transplantation; euthanasia; illegal abortion; medical certificate; stem cell research; human  Why Medical Ethics? Evolution of ME Introduction of the new medical technology like mechanical ventilation. Emergence of the new techniques in the medical field such as organ transplantation, and genetic (cloning). Social concerns regarding the possibility of human abuse in medical research (patient right).  ?? What do you mean Ethics is discipline (process) that examines and attempts to resolve the moral problems “Bio”: means life “Ethics”: means the development of principles, rules that give standards of good and bad, right and wrong. Morality refer to social conventions about right and wrong conduct that are so widely shared. These conventions are accepted by majority of people in stable society ?? What do you mean Who is concerned with Medical Ethics?  Roles of Medical syndicate  License to practice medicine  Register for qualified persons  Removal of Registration  Restoration of Registration  Medical council  If disgraceful conduct  erase (omit) name from register  Disciplinary committee   convict practitioner in misconduct (court)  ?Why Medical Ethics Evolution of ME Modern ethics It was dominated by the development of : 1- Theories 2- Rules/Codes of conduct  Declaration of Geneva (1948)  Conferences of the Medical World Association (1949) Principles.3  The concept of 4 Principles was developed in USA (1968)  ?Why Medical Professional Codes/Rules of.2 Ethics Conduct The declaration of Geneva (1948 ):The declaration of Geneva is a sort of updated version of Hippocratic Oath (1948)  Services of humanity/patient  Respect patient secretes.  Prevent consideration of religion, nationality, politics, social standing from intervening between duty and patient.  Respect laws of humanity.  ?Why Medical Ethics Professional Codes/Rules of. Conduc The world medical association’s international code of medical ethics was adopted(1949) :  Adherence to declaration of Geneva  Honest with patient and colleges  High professional standards.  Clinical decision.  Exposure to colleagues.  Why Medical Ethics? In spite of these codes and rules, unethical medical practices have occurred? ?Why Such codes and rules are inadequate or Ignoring important issues in reality ,So There was a wide gap between universal theories and real life ethical dilemma in medicine  ?Why Medical Eth In attempt to narrow this gap and to make ethical theories more applicable to clinical dilemmas. The concept of four principles was developed since 1968 in United.State  3. Principles of Medical Ethics 1. Beneficence (to do good ) 2. Non-maleficence (do no harm–risk and probability). 3. Justice( to be fair) fair treatment – rights based, legal and distributive justice. 4. Respect autonomy (wishes/rights/free decision) Informed consent Truth-telling Respect for confidentiality  Principles of Medical Ethics 1. Beneficence  Beneficence is refers to doing good  It is the duty of physician to do good for the patient, by curing disease and promote health  It is the duty of physician to do good, prevent and remove harm from the community at large (e.g.. Conducting applied research..  (ongoing education and training- empowerment).  Principles of Medical Ethics 2.Non-maleficence  Non-maleficence means doing no harm  It is the duty of physician to avoid inflicting physical and emotional harm on the patient or increasing the risk of such harm  Such harm can occur due to :-  Negligence (patient humanity-aseptic techniques-prescribing-operation)  Lack of medical competence  Principles of Medical Ethic Justice.3 This principle deals with the fair treatment of patients and resources distribution  Principles of Medical Ethics 4. Respect for autonomy  It means Self-Rule.  It refer to the right of every individual to make his or her decisions (free decision).  In health care this would entail allowing the patient to make the final decision regarding her or his treatment, after having been given all the necessary information. Informed consent  It includes:- Truth-telling Respect for confidentiality  Principles of Medical Ethics Respect of autonomy.4 Informed consent Before subjecting a patient to any investigation or treatment we need to obtain his agreement The patient is competent to consent and that the consent is voluntary. Patient also should be given all information related to procedure or treatment in language that is easily  Principles of Medical Ethics Respect of autonomy.4 Informed consent The risk and benefit of intervention must be clear. Recommendation of treating physician is also important. It is important to ensure that information given has been correctly understood. The patient will make decision and either authorize the intervention or refuse it  Principles of Medical Ethics 4. Respect for autonomy Informed consent Elements Description of the condition Description of the proposed treatment Benefits of treatment Risk of the treatment Alternatives therapies  Principles of Medical Ethics Forms (types) of consent Express Consent Implied Consent (oral-written) Any operation/ interventions/ examinations/investigations/ to the patient is considered an assault except in an emergency  Principles of Medical Ethics 4. Respect for autonomy When consent is invalid /illegal It includes unlawful operation: illegal abortion/artificial insemination/ unnecessary operation It is taken by fraud or misrepresentation of operation being a life saving measure-while it is not It is given by a minor or insane (mentally)  Principles of Medical Ethics 4. Respect for autonomy Confidentiality Confidence (secrecy) between physician and patient arise from the feeling that any thing found on examination, investigation will remain secrete All med. personals involved in med. practice are not allowed to disclose the professional secrete (E.g. nurse, pharmacist, technician and med. students) Publication of patient name or photograph in scientific journals is considered a  Principles of Medical Ethic 4. Respect for autonomy Disclosure of Confidentiality 1-On request of the patient himself 2-For the sake of the patient In a case of mental disease –-minor-imminent danger 3-For the sake of the public - Notification of infectious diseases as typhoid, cholera. - Serious crime. (e.g. by treating deep wound originating in a serious assault) or rape.  Principles of Medical Ethic Respect for autonomy.4 Disclosure of Confidentiality 4-For the sake of the physician In a case of if he accused of malpractice, he may explain to the court the nature of the disease and the procedure he adopted. 5-In case of expert witness (physician is called by the court as an medico legal expert for examination of a person e.g. prisoner 6-To other doctor (opinion) sharing his/her opinion of that patient (it is assumed that patient has given implied Ethical Dilemma Challenging FP , The End of life issue and brain death (terminally ill patient& euthanasia) The Organ Transplant The Moral Issues in Abortion &Adoption The Moral Issues in BIO-Technical Reproduction Genetic manipulation Prenatal screening & Termination of pregnancy Child Abuse &disciplines The Ethical Questions about HIV/AIDS patients Medical certificate  Ethical Dilemma Challenging FP Q.1. Is CPR (Cardio Pulmonary Resuscitation) part of the mandate to maintain life? Q.2. Is it OK to withdraw the life support system for example: ( A Ventilator for a patient who has no cerebral function and is in a vegetative state)? Q.3.When a terminally ill patient and their families reject medical treatment saying that "it is God's will", what should a physician do? Q. 4. What is the definition of "dead" when do you say it is OK to turn the machine off when the patient is dead? Is brain death and brain stem death the same thing? Ethical Dilemma Challenging FP Q. 5. If a person is in a vegetative state on artificial life support but he is not brain dead but his survival chances are minimal, are physicians' allowed to turn off the machine at this point? Q.6. Should cancer patients' requiring heavy pain medication take the medication or be in pain patiently and remember God.? Q.7. Should a patient with terminal cancer or parents of a newborn with a congenital defect with a poor chance to survive seek the most invasive and most expensive treatment and do whatever that can be done to save lives or submit to God's will and accept death? Q.8. Is organ donation permitted? Q.9. Is receiving organs for transplantation from an animal source permitted and especially if the animal is a pig?  Ethical Dilemma Challenging FP Q.10. Is it necessary to have the permission from the donor or a relative to receive the organ? Q.11. What is position on fetal tissue transplant? Q.12. How come contraception is allowed and abortion is not? Q.13. If the fetus is diagnosed with a genetic disease such as Down's Syndrome, can the mother have an abortion? Q.14. Would you allow an abortion for pregnancy resulting from rape? Q.15. Is cloning permissible or not? Q.16. If a doctor who is apposed to abortion and euthanasia is asked by his patient's relatives to perform such procedures which is also acceptable in the States, should he refuse because of his personal convictions? Q.17. Do Medical Ethics slow down medical research and progress?  Golden Rule , 1. Maintenance of Life 2. Maintenance the intellect 3. Preservation of honour and integrity 4. Protection of the property 5. Protection of an individual's freedom of belief 6. Actions are judged by intension 7. Neither harm nor reciprocating harm 8. Don't jeopardize yourself 9. Love for your brother what you love for yourself 10. Love is the core of ethical values Conclusion  Medical Ethics is discipline (process) that examines and attempts to resolve the moral problems.  Medical practice in modern has became more complex. In spite of the rules, codes, principle unethical medical practice has occurred!!!!!!.  Ethics is part of daily Family Practice, So FP needs to have high ethical standards in daily practice not only in special circumstances.  Preservation of human life (honor & integrity) is central concern to all the religions.