MEDICAL PRO PDF

Introduction and Overview of Professionalism Dr Ahmed A Elsheshai ILOs Understand the term “medical professionalism” and identify it’s connotation. Learn about the scope of the subject and different concepts involved in the professional character of a physician. Receive an overview of th...

Introduction and Overview of Professionalism Dr Ahmed A Elsheshai ILOs Understand the term “medical professionalism” and identify it’s connotation. Learn about the scope of the subject and different concepts involved in the professional character of a physician. Receive an overview of the course including general outlines, year 1 lectures, and assessment plan. What is “Professionalism”? “The collection of basic competencies expected of a professional.” What is “competency”?  Sk ill E xperi ence Kno wled ge Competency Who decides what competencies?  Medical schools Syndicates Certification authorities Regulatory boards Employers Clients If you needed a doctor, what competencies would you like him to have? “Aspiring toward altruism, accountability, excellence, duty, service, honor, integrity, and respect for others.” American Board of Internal Medicine Medicine’s social contract with society Society's expectations Medicine's expectations of medicine of society Trust Au to nomy The services of the healer S elf -re gulation Assured competence A health care system that is Altruistic service value-driven and adequately Morality and integrity GMP f unde d Accountability Participation in public policy Transparency Shared responsibility for Objective advice health Promotion of the public good A monopoly Both non-financial and financial rewards Reality vs appearance? Information I nfodem ic Public sentiment A dvoca c y What is the scope of this subject? Scope of the course Good Medical Medical Ethics Practice Communication Quality S kil ls Sources https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for- doctors/good-medical-practice Attributes of a Physician Dr Ahmed Elsheshai MD, MRCPsych LOs 1 2 3 4 Differentiate Identify items List attributes Describe an between trait, belonging to belonging to a example for competency, each of the good doctor. each attribute. and attribute. three domains. Variation in medical practice What are your expectations? What is a good fit for you?  Optimism Communication Organization Meticulous Cur iosity Com pas si on Collaboration Confide nce Humility A collection of Persistence Passion Mentorship attributes Courage Humanity Optimism Hopefulness and confidence about the future or the success of something. “Optimism is the faith that leads to achievement. Nothing is done without hope & confidence.” Communication skills The imparting or exchanging of information by speaking, writing, or using some other medium Good decisions can turn into disasters when communicated poorly Organization skills Organizational skills are a set of techniques used by an individual to facilitate the efficiency of future-oriented learning, problem-solving, and task completion. For every minute spent organizing, an hour is earned. Meticulous Showing great attention to detail; very careful and pre ci se. Meticulous planning will enable everything a man does to appear spontaneous Curiosity A strong desire to know or learn something. Curiosity is one of the most permanent and certain characteristics of aintellect. vigorous Curiosity is the origin of knowledge; experience is the origin of wisdom. Collaboration The action of working with someone to produce s om et hi ng Collaboration – the ultimate intertwining of skill, passion, and knowledge – is what concocts the most shatter- proof forms of change- mak ing Persistance Continuing in an opinion or course of action in spite of difficulty or opposition. Persistence guarantees that results are inevitable Compassion Sympathetic concern for the sufferings or misfortunes of o th ers. Use what seems like poison as medicine. Use your personal suffering as the path to compassion for all beings. Confidence A feeling of trust in one's abilities, qualities, and jud ge me nt. A man cannot be comfortable without his own approval Humility The quality of having a modest or low view of one's i mp ort ance. Humility is not thinking less of yourself but thinking of yourself less. Passion Strong and barely controllable emotion. Skills are cheap, passion is priceless Mentorship The guidance provided by a mentor, especially an experienced person. In learning you will teach and in teaching you will learn. Courage The ability to do something that frightens one. Courage is grace under press ure Humanity The quality or state of being human. Believing in what sets humanity apart and makes humans special. The good physician treats the disease; the great physician treats the patient who has the disease.  Definitions of Trait Attribute Take home Competence Don’t rush yourself, take your time and find the message right fir for you in the vast world of medicine. Build your character around your passion in this wonderful career. Medical Career Pathway Dr Ahmed Elsheshai MD MRCPsych  IOs Compare degrees and qualifications Assess career opportunities Match career choices with personal preferences and circumstance Plan a career in medicine  Under- Early Speciali- graduate career zation Medical Higher education Administrative Primary Medical Re s earc h Degree and PGY Academic Teaching Employment Clinical Administrative  Primary Medical Degree M BBCh Validity in other countries Corresponding qualification USMLE PLAB ECFMG Post graduate medical degrees Diploma Master of Science Medical Doctorate Fe ll owshi p Duration 1 –2 years 3 –5 years 5 –7 years 4 –5 years Theme Cli nical Acade mic Acade mic Cli nical P rer eq u isi te Bachelor’s Bachelor’s Master’s Bachelor’s Expe rie nce Sometimes required No requirement No requirement Essential element Research None Th es is Th es is Critical appraisal Specialist promotion + 2 years experience Immediately NA I mme d iately Consultant promotion N/A + 8 years experience + 3 years experience -2 years from other req Egyptian fellowship Arab board Issuing authority Un ive rsi ty Royal College  Quality management CPHQ BHQE ASQ Six-Sigma Post graduate Healthcare administration supporting degrees Clinical governance Corporate governance People management Infection control  Senior House House officer ‫ﺗﻴﺎز‬ ( ‫) ام‬ Officer (SHO/‫ﻃﺒﻴﺐ‬ Re s id ent ‫)ﺗﻜﻠﻴﻒ‬ Technical Registrar/Qualified resident‫ﻣﻘﻴﻢ‬ ( ‫ﻃﺒﻴﺐ‬ Assistant specialist Specialist ‫ﻣﺆﻫﻞ‬/‫)ﻣﺴﺠﻞ‬ promotion Consultant III Consultant II Consultant I  House officer Transition from student to professional Mostly an observer-ship Minimal responsibilities Duties assigned by resident Ass essmen t Portfolio  Number of changes in rules of SHOs in past 10 years Hired by MOHP Distributed according to need Preventive/clinical medicine Senior house officer Relation to family medicine and Egyptian fellowship Duration 2 –5 years End by starting residency  Residency Residency is a job Offered by different medical institutes each specifying their own requirements for the job University hospitals MOHP hospitals Undergraduate GPA Private hospitals Undergraduate and SHO portfolio Graduating university (PMD) Armed forces hospitals Undergraduate grade in specialty Police hospitals Age/time since graduation Petroleum hospitals Interview Foreign (matching program, NHS…etc) Recommendations  A residency is the most important time in the career of a clinical doctor Specialty choice Initial training Qualification coincide with this period Maximum mentorship Choice of residencies Seniors working at the institute Facilities in the institute Rate of patients Mentorship and educational activities Training program and logbook/portfolio of a senior resi d ent  A residency is the most important time in the career of a clinical doctor Specialty choice Initial training Qualification coincide with this period Maximum mentorship Choice of residencies Seniors working at the institute Facilities in the institute Rate of patients Mentorship and educational activities Training program and logbook/portfolio of a senior resi d ent  A doctor that has finished specialty training First level of autonomous doctors Primary tasks are delivery of clinical care CME and CPD activities (attending conferences, Specialist presenting papers & cases) Also expected to Lead teams Share in management responsibilities Share in educational and training activities  Experts in the field The highest responsibility in the unit and/or hospital Clinical care mostly involved complex cases and supervision (e.g. rounds) Primary role Consultant Supervision of the clinical pathway and quality of care Training and education CME & CPD planning and execution within and outside their organization  Ped iatr ics Anesthesiology d is ease Internal N e uro lo gy med ic in e Radiology Ophthalmology Physical Uro lo gy med ic in e Dermatology OBGYN Clinical Oncology Neurosurgery Emergency Psyc hi atry s pe cialt ies med ic in e Plastic surgery Family Nephrology med ic in e ENT Ga stroen tero l o Cardiology gy Geriatric Orthopedics Infectious Surgery  American Association of Medical Colleges lists more than 135 medical specialties and subspecialties Medical Most of them require a separate residency that may range from 4 – 8 specialties years Some subspecialties require an extension of an original residency. E.g. child psychiatry, epileptology, allergy, neonatology. HO/SHO Registrar Specialist  ‫اﻟﻠﻬﺎﻟﻠﻬﺎﻟﻠﻬﺎﻟﻠﻪ‬ If everything goes to plan ( ‫ )إن ﺷﺎء‬you should be applying for specialist jobs in 203 5. Write your CV as you would like to apply it to hospitals and recruiters then. Assignments Create a LinkedIn profile. Browse through LinkedIn profiles of some doctors you know to get inspiration about your own career. Doctor-Patient Dr Ahmed Elsheshai MD MRCPsych Relationship Aconsensual relationship in which the patient knowingly seeks the physician’s assistance and in which the physician knowingly accepts the person as a patient.  Health values Matter in qu esti on Patient values Fundamentals of DPR Communication E mp athy Trust Informed consent Professional boundaries  Paternal Deliberative 4 Models of DPR Informative Interpretive  An The radical intervention will allow “international him to return to field in 1 year therefore missing a whole seasons footballer” with his team. who makes The alternative will allow him to around return to the field in 3 months, but he has to take intensive $500K/week, physiotherapy and in around 3 years sustains a knee he probably will need knee injury. replacement. Paternalistic model (Authoritarian) Physicians use their skills to determine the diagnosis, required investigations, and best treatment. Then they will present the patient with selected information that will encourage the patients to consent to the doctors opinion. This model assumes that the criteria for decision making is shared between patient and physician. i.e. no personal issues or choices.  Physician act as guardian At the extreme, the physician only informs the patient when the intervention will be initiated. Usually only advocated in emergency situations and where patients are incapacitated (e.g. disoriented or severely psychotic patients). Deliberative model (Authoritative) Physicians recommend the course they see best and discuss with the patient why this course should be taken. The physician here should stick ONLY to health related values. i.e. values that affect or are affected by the patient’s disease or treatment. The patient feels empowered and safe in choosing a path that adheres to their health as well as life values.  Physicians act as “teachers” At the extreme, Physicians may engage with patients in “deliberation” of all available courses of action. E.g. Jehovah’s witnesses refuse blood transfusions, Muslims refuse wine as sleep aid, vegans may insist on a special diet, and someone may just value their temporary well-being over an extended life of sickness in refusing chemotherapy. Informative model (Consumer) The physician informs the patient of his/her disease state, the nature of possible therapeautic and diagnostic interventions, the nature and probability of risks and benefits associated with each intervention, and any uncertainties of knowledge. The patient selects the medical intervention he/she wants and the physician then proceeds to execute them.  Physicians act as information vendors or technical expert. At the extreme, patients could come to know all medical information relevant to their disease and available interventions that best relaize their values. Especially valuable in chronic conditions requiring continuous care such as DM and RA, also in elective and aesthetic procedures. Interpretive model (Advocate) Here the physician tries to clarify the patient’s values, describe available intervention options in light of patient’s values, and help patients decide the best option that fits their values  Physician act as counselor At the extreme, the physician will form a full picture of the patient’s life as a narrative whole and from this specify the patient’s values and what is best done to help. Exampleswhere this model is especially effective include lifestyle medicine, dietary medicine, sport medicine, and addiction medicine.  Paternalistic Deliberative Informative Interpretive Patient values Only concern is health, Open to development Defined fixed and Require clarification and shared by physician & and revision known to the patient. a greement patient Physician’s Patient well-being Persuading the patient Provide factual Clarify patient’s obligation independent of their of the best path… i nfo rmati on … personal values… p refe r ne ce and implement their and implement and implement their choice. patient’s choice. choice. Autonomy Assenting to objective Developed through Control over medical Developed through health values understanding of health care understanding of own values values Physician role Guardian Teacher or friend Technical expert Counselor or advisor  Physicians who communicate well and treat patients with chronic illnesses fairly improve the patient’s ability to manage their disease independently with adherence to the advice of Impact of DPR doctors. For example, patients monitor their blood pressure and adhere to medical regimens as per the advice of the doctor to manage health disorders such as hypertension and diabetes.  An The radical intervention will allow “international him to return to field in 1 year therefore missing a whole seasons footballer” with his team. who makes The alternative will allow him to around return to the field in 3 months, but he has to take intensive $500K/week, physiotherapy and in around 3 years sustains a knee he probably will need knee injury. replacement.  Who would act in a paternalistic model? Who would act as a deliberative physician? Brain-storm Who would assume the informative model? Who may be the Interpretive doctor in this situation? Insurance Team doctor doctor Salah’s Private friend doctor Thank you Maintaining professional boundaries Dr Ahmed Elsheshai MSs MD MRCPsych Psychi a t ris t  Contrast professional and personal areas of a LOs doctor’s life. Relate to the patient’s view of their doctor’s role and the possibility of misinterpreting these roles. Identify situations where doctors are obligated to take special steps to maintain professional bo un dary. Judge when and how it would be appropriate to be involved in a personal relation with a patient. Remember cardinal rules pertaining to ethics of developing personal relations with patients. Reflect on possible detrimental outcomes of neglecting boundary setting.  Positive Healer (‫)ﻣﻌﺎﻟﺞ‬ Patients’ Saviour(‫)ﻣﻨﻘﺬ‬ views of Angel of mercy‫اﻟﺮﺣﻤﺔ‬ ( ‫)ﻣﻼﻻك‬ Wise person (‫)ﺣﻜﻴﻢ‬ doctors Negative Butcher ( ‫) ﺟﺰار‬ Greedy (‫)ﺟﺸﻊ و ﻃﻤﺎع‬ Money-grabber‫اﻟﻔﻠﻮس‬ ( ‫)ﻛﻞ ﻫﻤﻪ‬ Fraud (‫)ﻧﺼﺎب‬ Which view do you want your patient to have of you? How much do you really “KNOW” a professional?  Keep it professional Treating Time and space boundaries relatives & Financial boundaries Patient autonomy friends Avoid high-risk situations Encourage second opinion Involve a colleague You will ALWAYS run into thatrelative again The worst kind of bad reference is that of someone close to you personally  Tests professional boundaries Developing Time Space friendships Autonomy Finances with Heightened expectations patients  “Sexual or romantic relationships with former Entering a patients are unethical if the physician uses or exploits trust, knowledge, emotions, or romantic influence derived from the previous professional relationship, or if a romantic relation with relationship would otherwise foreseeably harm the individual.” a patient American Medical Association “You must not use your professional position to pursue a sexual or improper emotional relationship with a patient or someone close to them.” General Medical Council  NEVER enter a romantic relation with a current patient. Current If the patient pursues a romantic relation with you: Politely and considerately re-establish the patient professional boundary If not possible then terminate relation with the patient according to guidance You must not use professional relationship to pursue romantic relations with someone close to the patient You must not end the professional relation with a patient solely to pursue a romantic relationship with them  Personal relationships with former patients may Former also be inappropriate depending on factors such as: patients The length of time since the professional relationship ended The nature of the previous professional relationship Whether the patient was particularly vulnerable at the time of the professional relationship, and whether they are still vulnerable Whether you will be caring for other members of the patient’s family.  It is not possible to specify a length of time after Timing which it would be acceptable to begin a relationship with a former patient. However, the more recently a professional relationship with a patient ended, the less likely it is that beginning a personal relationship with that patient would be app ro pri ate. The duration of the professional relationship may also be relevant. For example, a relationship with a former patient you treated over a number of years is more likely to be inappropriate than a relationship with a patient with whom you had a single consultation.  Some patients may be more vulnerable than others, the more Patient vulnerable someone is, the more likely it is that having a relationship with them would be an abuse of power and your position as a doctor. vulnerability Pursuing a relationship with a former patient is more likely to be (or be seen to be) an abuse of your position if you are a psychiatrist or a paediatrician. Whatever your specialty, you must not pursue a personal relationship with a former patient who is still vulnerable. If the former patient was vulnerable at the time that you treated them, but is no longer vulnerable, you should be satisfied that: The patient’s decisions and actions are not influenced by the previous relationship between you. You are not (and could not be seen to be) abusing your professional position. Trust is the foundation of the doctor- patient partnership. Patients should be able to trust that their doctor will behave professionally towards them.  A gynecologist who performed routine examination for breast cancer in the emergency ward at the middle of the night every few days. A pediatrician who had the habit of calling single mothers of chronically ill children to check on his patients. A psychiatrist who convinced teenage troubled girls that their problems were caused by their parents, forcing them to sever relations with their families. Thereafter offering to host them at his house until they found shelter. A dentist who anesthetised his patients and then molested them and took illicit photographs of them. A dermatologist who gave frequent follow-up appointments to her patient who was always accompanied by her handsome son.  A terminally ill patient’s daughter who developed an infatuation with the treating intensivist for “supporting her during hard times”. A businessman visiting his “wise and well educated” cardiologist to ask advise on his son’s career choices. A woman meeting her friend’s husband (the paediatrician) at a restaurant at lunchtime, noticing he is alone, sits down to ask him a “few questions” about her son’s sport career. A surgeon’s colleague asks his “friend” to write a fake report to help his son postpone exams because he hasn’t studied. Stand your ground, be a doctor Conflict of interest  Service Standard BIAS Education Process  Any personal benefit to physicians has the potential to put their primary interest (patient welfare) at odds with their secondary interest (financial profit)  Pha rm a Gifts Fees for promotion Sponsorship Trials Private institutions Sources Nepotism Self-referral Incentives Personal Gifts from patients Recommending non-healthcare services Pharmaceutical industry Pharmaceutical marketing ≈ 60 Bn dollars spent on pharmaceutical marketing in the USA in 2004 20 Bn for clinic visits 2 Bn for meetings 237,000 meetings where physicians were speakers 134,000 meetings where sales reps were speakers Chances that audience will prescribe the drug or use the service is twice more likely with physician speakers than sales rep speakers It is now a standard in all scientific events that a speaker should declare any source of conflict before starting his talk. Participation in clinical trials Phase III trials Responsibility lies with Participating physicians Third party oversight Regulators Publishers (e.g. conferences and journals) Stringent Loos e Critical appraisal Sponsorship Conferences and scientific Non-essential meetings Presence of alternatives Affiliations (APA, EPA, WPA, WFSBP, ASA, CINP) Later trends Universities (ANC, ASUIP) On-demand subscriptions Regulatory bodies (GSMH) Bursaries Online meetings Affiliation membership Subsidization for LMICs Su bs c rip ti on s Access to sources Gifts Stationery and office supplies Drug samples Meals Personal Birthday gifts Personal celebration Direct payment Private institutions Self referral “Physicians have been conflicted about their dual roles as professionals and businessmen for millennia, but this dilemma has sharpened in recent years as income from the practice of medicine has faltered” Kassirer, 2001, p. 159 Self referral Physician income decline (?) Primary interest vs secondary interest Disclosure (?) You should tell the patient if you stand to profit from the service you are prescribing or recommending Regulation (?) You are forbidden from referring patients to services where you stand to make profit other than your known and agreed upon fees. Watchdogs (?) Public registers for hospital/company owners and stakeholders Incentives Target payments to general practitioners can be used to enhance public awareness and preventative measures such as immunizing children and screening for cervical cancer. The other side is pressuring patients to participate Incentives to reduce cost must guard against withholding legitimate i nter ve nt io ns Consider this: in an insurance-based healthcare systems, radiologists performing ultrasound imaging will make double the money if the request was for separate “ultrasound abdomen” AND “ultrasound pelvis” than a single “ultrasound for the abdomen and pelvis”. Nepotism Nepotism is an advantage, privilege, or position that is granted to relatives in an occupation or field. Personal Gifts and donations You must not encourage patients to give, lend or bequeath money or gifts that will directly or indirectly benefit you. You may accept unsolicited gifts from patients or their relatives provided: This does not affect, or appear to affect, the way you prescribe for, advise, treat, refer, or commission services for patients You have not used your influence to pressurize or persuade patients or their relatives to offer you gifts. However, if you receive a gift or bequest from a patient or their relative, you should consider the potential damage this could cause to your patients’ trust in you and the public’s trust in the profession. You should refuse gifts where they could be perceived as an abuse of trust. You must not put pressure on patients or their families to make donations to other people or organizations. Recommending services outside healthcare E.g. Insurance company, personal trainer, attornies…etc You should make it absolutely clear that this is a personal recommendation and is not being done in your capacity as a physician In order to maintain trust you should NOT accept fees for referring patients to such services in your medical capacity. Take-home message  Conflicts of interest are not always avoidable. Trust may be damaged if your interests affect, or are seen to affect, your professional judgement. Use your professional judgement to identify when conflicts of interest arise Avoid conflicts of interest wherever possible If you are in doubt about whether there is a conflict of interest, act as though there is. Get advice about the implications of any potential conflict of interest Make sure that the conflict does not affect your decisions about patient care.  Declare any conflict to anyone affected, formally and as early as possible, in line with the policies of your employer or the organization contracting your services You must be honest and open in any financial arrangements with patients. If you charge fees, you must: Tell patients about your fees, if possible before seeking their consent to treatment Tell patients if any part of the fee goes to another healthcare professional. You must not exploit patients’ vulnerability or lack of medical knowledge Thank you Overview and Development of Medical Ethics Dr Ahmed A Elsheshai IOs Define the four main pillars of clinical ethics Differentiate between conventional ethics and clinical ethics Argue ethical decisions according to clinical ethical reasoning Solve hypothetical ethical dilemmas using principles of bioethics What is Medical Ethics? Dr Ahmed A Elsheshai, MD MRCPsych Psychiatry Consultant  Moral ph ilo sophy Bioethics Clinical ethics The story of medical ethics Medical Papyri The Egyptian physician made a prognosis before undertaking treatment. If the prognosis was favorable, the physician's comment was "an ailment that I shall treat"; if it was uncertain, "an ailment that I shall combat"; and if the prognosis was unfavorable, "an ailment not to be treated. (Left) Plates vi & vii of the Edwin Smith Papyrus at the Rare Book Room,New York Academy of Medicine. Hippocratic oath I swear by Apollo Healer, by Asclepius, by Hygieia, by Panacea, and by all the gods and goddesses, making them my witnesses, that I will carry out, according to my ability and judgment, this oath and this indenture. To hold my teacher in this art equal to my own parents; to make him partner in my livelihood; when he is in need of money to share mine with him; to consider his family as my own brothers, and to teach them this art, if they want to learn it, without fee or indenture; to impart precept, oral instruction, and all other instruction to my own sons, the sons of my teacher, and to indentured pupils who have taken the Healer’s oath, but to nobody else. I will use those dietary regimens which will benefit my patients according to my greatest ability and judgment, and I will do no harm or injustice to them. Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course. Similarly I will not give to a woman a pessary to cause abortion. I will keep pure and holy both my life and my art. I will not use the knife, not even, verily, on sufferers from stone, but I will give place to such as are craftsmen therein. Into whatsoever houses I enter, I will enter to help the sick, and I will abstain from all intentional wrong-doing and harm, especially from abusing the bodies of man or woman, bond or free. And whatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets. Now if I carry out this oath, and break it not, may I gain for ever reputation among all men for my life and for my art; but if I break it and forswear myself, may the opposite befall me. Thomas Percival The four pillars of medical ethics Autonomy Be n efi ce n ce Non-Maleficence Justice Consider the following case: A 52 year old man collapses in the street complaining of severe acute pain in his right abdomen. A surgeon happens to be passing and examines the man. Suspecting that he is on the brink of rupturing his appendix (a potentially life threatening condition), the surgeon decides the best course of action is to remove the appendix immediately, using his trusty pocket knife. Pause the video and debate the actions of the surgeon for a minute. how do the surgeon’s actions benefit the patient? And how do they harm him? Do you believe the surgeon took the best course of action? Beneficence “I will use treatment to benefit the sick according to my ability and judgement, but never with a view to injury and wrongdoing” Hippocrates It is the duty to try and bring about those improvements in physical or psychological health that medicine can a chi eve. E.g. giving the most effective antibiotics for an infection. Non malificence “First do no harm” Going about medical activities in ways that prevent further injury or reduce its ri sk. E.g. giving the antibiotic with the least side effects and least cost. 12 In the previous example: The surgeon’s action may save the patient’s life. According to the concept of beneficence, the surgeon is justified to take this line of action On the other hand, The environment is unlikely to be sterile, as is the pocket knife, so risk of infection is very high. There are no other medical staff or surgical equipment available, therefore chances that the operation will succeed are very narrow. The surgeon may have experience in performing appendectomy before, but definitely never on a street. Therefore experience is decontextualized and inappropriate. The weighing of these two points show that unless there is no hospital around for many miles, the actions of the surgeon are highly disproportionate. 13 Consider the following case: Ali is a patient suffering from repeated attacks of angina (mini-heart attacks). He is admitted to the hospital for followup, investigation, observation, and emergency intervention. Although there is an order for medication to treat his heart condition, Ali refuses these medications daily. On one visit, his family members notice that he is not taking his medications and demand that you hide them in his mashed potatoes. Pause the lecture and think about the best course of action. What if you refuse to trick him into taking the drugs and subsequently he deteriorates or even worse, suffers a major heart attack and dies? Autonomy Requires that the patient have autonomy of thought, intention, and action when making decisions regarding health care procedures. Therefore, the decision-making process must be free of coercion or coaxing. For a patient to make a fully informed decision, she/he must understand all risks and benefits of the procedure and the likelihood ofsuccess.  Respect for autonomy is a two-way street The autonomy of a physician to act only on their best judgement about how to benefit the patient medically should be respected Therefore, respect for the patient autonomy does not imply that the patient has the right to demand inappropriate treatment or that the physician must accede to any and every request of a patient if it conflicts with the physician’s best judgement. 16 Justice The idea that the burdens and benefits of treatments must be distributed equally among all groups insociety. Requires that procedures uphold the spirit of existing laws and are fair to all players involved. The health care provider must consider four main areas when evaluating justice: fair distribution of scarce resources competing needs rights and obligations potential conflicts with established le gislat ion 17 Consider the following case: Patients suspected of having cancer are prioritised within the NHS, with the maximum waiting time for referral being two weeks (as opposed to 18 weeks for non-urgent referrals). Patients diagnosed with cancer are entitled to a range of treatments including radio- and chemotherapy. These treatments are expensive and treat a small, but significant proportion of patients.  It could be argued that prioritising cancer patients means you’re limiting the ability of other patients to access healthcare. A counter-argument might be that by referring these patients to specialist oncology centres, you’re actually freeing up other se r vic es. Then again, spending on a smaller group of public peoplemoney onbudget is taking radio- and awaychemotherapy from less expensive treatments that would benefit a greater number of A counter-argument would be that early treatment increases people –rates survival for example, insulin and actually for diabetic reduces patients. the cost of cancer treatment Making an ethical decision Doctor Hospital Court Clinical Ethics Ar bit ration discussion consultation If patient, Patient, Clinical relative, or Doctor, & all Ethics doctor are still concerned (CEC) Committee unconvinced Mediation & parties reach conflict resolution action a consensus on a single course of Clinical Ethics Committee (CEC) Meet involved Decision Medical p art ies Weighing ma kin g How decisions are Non-medical Doctors collected info vs Single decision implemented ethical principles Lessons learned Nurses and laws Or Patient Alternatives Collect Family Ethical Follow-up i nfor mati on analysis “CASES” approach to ethics consultation Clarify the consultation request Assemble the relevant information Synthesize the information Explain the synthesis Support the consultation process Clarify Characterize the type of consultation request Obtain preliminary information from the requester Establish realistic expectations about the consultation process Formulate the ethics question Characterize the type of consultation request Ethical issue Legal questions Medical questions Request for psychologic support General patient care complaints Allegations of misconduct Active clinical case answer questions about ethics topics in health care interpret policy relating to ethics in health care review documents from a health care ethics perspective provide ethical analysis on organizational ethics questions provide ethical analysis on questions that are hypothetical or historical Obtain preliminary information from the requester Requester’s contact information and title Urgency of request Brief description of the case and the ethical concern as the requester understands them Requester’s role vis-à-vis the case (e.g., attending physician, family member, administrator) Steps already taken to resolve the ethical concern Type of assistance desired (e.g., forum for discussion, conflict resolution, policy interpretation) Establish realistic expectations about the consultation process Time frame or nature of the response. Ethics consultants don’t take over decision making in the case. Consultants do not automatically “rubber-stamp” the position of requester or the health care team. Consultants should take time to explain how their role as an ethics consultant differs from other technical roles they play in the o rga ni zat io n. Formulate the ethics question Given uncertainty or conflict about values, what decisions or actions are ethically justifiable? Given uncertainty or conflict about values, is it ethically justifiable to decision or action? Example A surrogate for a patient who lacks decision-making capacity asks that mechanical ventilation be stopped. The health care team wishes to continue providing this treatment because they believe the patient might recover the ability to breathe on his own. They ask the ethics consultation service whether they should discontinue mechanical ventilation. Given the conflict between the surrogate’s right to make health care decisions on behalf of the patient and the health care providers’ obligation to act in the best interests of the patient, what decisions or or actions are ethically justifiable? Given the conflict between the surrogate’s right to make health care decisions on behalf of the patient and the health care providers’ obligation to act in the best interests of the patient, is it ethically justifiable to withdraw mechanical ventilation? Assemble Consider the types of information needed Identify the appropriate sources of information Gather information systematically from each source Summarize the case and the ethics question Consider the types of information needed The “Four Boxes” model Medical Indication Patient preference Consider each medical condition and its proposed Address the following: treatment. Ask the following questions: What does the patient want? Dos it fulfil a medical goal? Does the patient have the capacity to decide? With what likelihood? if not, who will decide for the patient? If not, is the treatment futile? Do the patient’s wishes reflect a process that is informed? Understood? Voluntary? Quality of life Contextual features Patient’s quality of life in the patient’s terms Social, legal, economic, and institutional What is the patient’s subjective acceptance of likely circumstances in the case that can quality of life? Influence the decision What are the views of the care providers about the Be influenced by the decision, e.g. inability to pay quality of life? for treatment, inadequate social support. Is quality of life less than minimal? Identify the appropriate sources of information Pat ie nt Health record Staff Family members and friends Gather information systematically from each source Collect sufficient information Verify the accuracy of information Distinguish facts from value judgements Handle interactions professionally  “This patient is an old patient. He is over 70. He has a terrible hepatomegaly. He has got a very nasty hepatocarcinoma. I think giving him a liver transplant is a mere waste of resources.” “This is a 73-year-old patient, with an enlarged liver of 12 cm below the right costal margin, which is tender on examination. He thought he could be considered a candidate for liver transplant.” Summarize the case and the ethics question Communicate information Highlight the conflict Review the case Synthesize Determine whether a formal meeting is needed Engage in ethical analysis Identify the ethically appropriate decision maker Facilitate moral deliberation about ethically justifiable options Determine whether a formal meeting is needed Lack of confidence by a party that their interests or views have not been accurately represented Parties are having trouble understanding one another’s point of view There are many different parties involved. Help effective communication Keep process professional Engage in ethical analysis Principalism Autonomy, Beneficence, Non-maleficence, Justice Others: Casuistry approach Feminist ethics Deductivist (moral rules) approach Narrative ethics Identify the ethically appropriate decision maker STEP ONE: CAPACITY ASSESSMENT May be the answer to the whole ethical dilemma without going into d eta il s Surrogates (like patients) cannot decide on unconventional or inappropriate methods of treatment. In this case, the HEALTHCARE PROFESSIONAL is the decision maker. Facilitate moral deliberation about ethically justifiable options Explain Communicate the synthesis to key participants Provide additional resources Document the consultation in the health record Document the consultation in consultation service records Communicate the synthesis to key participants Provide additional resources Document the consultation in the health record information about the person requesting the consult, sources and summary of the relevant information, including: including: medical facts name and role in the case patient’s preferences and interests date and time of the request other parties’ preferences and interests requester’s description of the circumstances, including his or information about patient’s decision-making capacity her ethical Concern(s), and steps they have already taken to resolve them information about patient’s advance directive, if applicable information about authorized surrogate, if applicable information about the patient, including: ethics knowledge including relevant VA policy, professional patient’s name codes and guidelines, published literature, precedent cases, etc. location and clinical service caring for the patient description of any formal meetings held patient’s attending physician ummary of ethical analysis name(s) of consultant(s) working on the case clear statement of the ethics question identification of the ethically appropriate decision maker(s) options considered, and whether they were deemed ethically justifiable explanation of whether consensus was reached recommendations and action plan(s) Document the consultation in consultation service records communications among consultants consultants’ observations about the consultation process, such as comments on the power dynamics during meetings or discussions logistical details, such as documentation of actions taken to support the consultation process scheduled appointments overall (See Step 5, “Support the Consultation Process.”) notes and references relating to the sources of ethics knowledge Support Follow up with participants Evaluate the consultation Adjust the consultation process Identify underlying systems issues Follow up with participants Evaluate the consultation Adjust the consultation process Identify underlying systems issues Clarify Assess Synthesize Explain Supp ort Type of Types of Determine Communicate Follow up consultation information formal the synthesis with requ est needed meeting to key participants Preliminary Appropriate Ethical participants Evaluate the information sources of analysis Provide consultation from the information Identify the additional Adjust the Gather ethically resources consultation requester Realistic information appropriate process expectations systematically decision the Document Identify about the Summarize maker consultation underlying process the case and in the health systems Moral Ethics the ethics deliberation record issues question question about Document ethically the justifiable consultation o pt io ns in consultation service records Thank you  An eight year old boy had a third relapse of leukaemia, which was treated without success. The child was discharged in acceptable general health. The parents understood that any further active treatment represented a high risk and would most probably deprive the child of a good life during the time when he could live normally. After a while, however, the parents again contacted the hospital to discuss further treatment because their relatives and neighbours had read on the internet about the child’s condition and alternative types of treatment.  A one year old boy had an unknown genetic syndrome, with no psychomotor development since birth. He had problems swallowing, was dependent on constant oxygen supplement and had frequent lung infections, which required respiratory treatment. The ethical dilemma identified was a conflict between the physicians who regarded treatment as only prolonging the child’s suffering and the parents who wanted the active treatment to be continued. The discussion in the CEC revealed that some nurses had told the parents “never to give up their child”. The nurses’ comments had made the parents suspect the physicians were not acting in the best interest of the child. The parents chose to believe only the comments which suggested hope of recovery.  A 26 year old, 28 weeks pregnant woman underwent ultrasound examinations. The physician who performed the final examination informed the woman that the fetus had a lethal brain malformation. Birth was then induced prematurely not only in accordance with the mother’s wishes, but also because it was considered to give the child a better prognosis. After birth, the child’s condition improved much more positively than anticipated. The woman, however, strongly expressed that she wanted treatment to be withheld. The physician thought this was unethical. He felt he had a duty to save the life of the child. All the people involved experienced great difficulty in communicating with the mother. You are a general practitioner and a mother comes into your office with her child who is complaining of flu-like symptoms. Upon entering the room, you ask the boy to remove his shirt and you notice a pattern of very distinct bruises on the boy's torso. You ask the mother where the bruises came from, and she tells you that they are from a procedure she performed on him known as "cao gio," which is also known as "coining." The procedure involves rubbing warm oils or gels on a Critical thinking Dr Ahmed Elsheshai MD, MRCPsych Learning outcomes Design a logic argument to support a premise/formulate a hypothesis. Contrast critical versus conventional reasoning in different situations. Define the concepts of bias and logic fallacies. Identify common biases and logic fallacies in an argument. Use socraticquestioning method to navigate arguments. Defend own argument against criticism and bias. Do violent movies cause violence? What is critical thinking? The objective analysis and evaluation of an issue in order to form a judgement. Thinking spontaneously vs thinking rationally How does celebrity behavior affect the public taste? Round earth? Flat earth? Global warming, is it real? Is it related to mankind? How? Why did I get a bad score? Why is the treatment not working? The only true wisdom is knowing that you know nothing S ocra tes  Socratic questioning “The disciplined practice of thoughtful questioning enables the scholar to examine ideas and be able to determine the validity of those ideas" John Dewey Use of the term ‘critical thinking’ to describe an educational goal More commonly called it ‘reflective thinking’. Which he defined as: “Active, persistent and careful consideration of any belief or supposed form of knowledge in the light of the grounds that support it, and the further conclusions to which it tends.” (Dewey1910: 6; 1933: 9)  Here, O king, is a branch of learning that will make the people of Egypt wiser and improve their memories. My discovery provides a recipe for memory and wisdom. But the king answered … If men learn this, it will implant forgetfulness in their souls.They will cease to exercise memory because they rely on that which is written, calling things to remembrance no longer from within themselves, but by means of external marks. Stages of critical thinking Brainstorming Fo r mu l atio n Using one suggestion Reasoning Implementing the after another to so lu ti on Looking into a problem initiate and guide Deciding on which from all sides and further observation hypothesis is best gaining various and collection of data suited for solving the perspectives pr ob lem Suggestion Hypothesis Testing Components of the process Noticing a difficulty Defining the problem Dividing the problem into sub-problems Formulating a variety of possible solutions Gathering information Judging the credibility of information Drawing conclusions from information Determining what evidence is relevant Systematic observation or experiment Accepting a solution that the evidence adequately supports  Observing Identifying and Deciding Inferring analyzing a rgu ments Judging Critical Thinking Consulting Skills Imagining Knowledge Experi- Wondering Feeling menting Rational fallacies and bias A systematic error of thinking. An error that is a result of a wrong understanding of the situation based on one’s attitudes and thoughts and not for example on lack of knowledge, negligence, or mal-intention Rational fallacies and bias Availability Actor-observer Anchoring Attentional heuristic False Functional Confirmation Halo effect consenseus fixedness Misinformation Dunning-Kruger Op t imi sm Self serving effect effect Actor-observer bias Self serving bias Anchoring Apophenia Availability heuristic False consensus Halo & horn effects Application Thank you  MEDICAL PROFESSION MED131 Abstract An overview of what it means to be a professional, who is considered a medical professional, how to think critically, the foundations of medical ethics, and how to conduct oneself to the best interest of the patient and medical profession. Dr Ahmed Elsheshai, MD MRCPsych [email protected] Contents Introduction & overview of professionalism 2 Critical thinking 7 Attributes of a physician 9 Doctor-patient relationship 10 Maintaining a professional boundary 11 Overview of medical ethics 12 1 Introduction & Overview of Professionalism Part 1: What is professionalism The competences expected of a professional Competence = skill + knowledge + experience Thinking about your studies in medical school, reflect on how you are working to gain knowledge, skill, and experience to become a medical professional According to the American board of internal medicine, the competencies expected of a physician are: “Aspiring toward altruism, accountability, excellence, duty, service, honor, integrity, and respect for others.” Altruism (:)‫ اإليثار‬The only productive outcome of our work as physicians is improving patients’ quality of life. Therefore, this should be our prime target, and we should aim to achieve everything else only through the patient's benefit and never despite it. Accountability (‫)المساءلة‬: Whether before he makes them, while he makes them, or after he makes them, a physician should always be ready and willing to be held accountable for his decisions. A physician’s will and acceptance of accountability at all stages of decision making signifies that all his decisions have only the best interest of the patient at heart and the best available evidence on his mind. Excellence (‫)التميز‬: When have you ever heard of a patient settling for a mediocre doctor? In our time of weakness, we always seek the most excellent medical service we can have. It is essential that doctors provide a minimum level of excellence that assures that no matter where a patient might end up, they will have a satisfactory service provided to them. Duty (‫)الواجب‬: The medical profession is not one that is bound by the rules of working hours or fees for service. Instead, medical professionals should be motivated in the first place by their sense of duty and responsibility towards their patients. Service (‫)الخدمة‬: Medical professionals work in the service of their patients. All actions that a physician makes in his career should be geared towards this prime and only target. 2 Honour (‫)الشرف‬: A physician’s actions should always be honorable. Meaning that he/she should always be doing what he/she knows and believes to be the morally correct action. Integrity (‫)النزاهة‬: While “honour” means knowing and intending to do well, “integrity” means actually doing the honourable action, being honest about it, and having a clear, constant, and honourable direction for their actions. Respect for others (‫)احترام اآلخرين‬: The medical profession is a very busy one. While in other professions one may deal with only his client and maybe a few colleagues, physicians deal with so many stakeholders every single day. Patients, relatives, caregivers, colleagues, managers, seniors, and junior doctors just to name a few. In dealing with all these people, doctors should have respect for the diversity of their views, backgrounds, and intentions. Of course, and above all, respect for patients reign supreme. Part 2: The social contract The relation of the medical field with society is an especially complicated one. Doctors usually view treating patients and dealing with the hardships of a disease in a very practical way as their everyday job. Patients suffering from this disease regard this matter with more emotionality and sensitivity. To achieve a balance between these two contradicting views, a social contract was outlined to describe what society should expect from doctors and vice versa. Society’s expectations from medicine The service of a healer: society expects doctors to understand that the primary target for all their actions is healing patients. Assured competence: Either because it is too difficult or impractical, patients cannot test their doctors’ knowledge and skill before accepting their services. Therefore, it is the duty of the 3 medical community to assure that those working in this profession have the necessary and essential set of skills and knowledge to carry their jobs properly. Altruistic service: As mentioned earlier, doctors should only seek success through their patients’ well-being. A patient giving himself in to his doctor should trust that the doctor only has his best interest at heart. Morality and integrity: patients need to trust that doctors are acting according to the best-known standards and that what doctors do to them is the same as what would be done to the doctors if they were in their shoes. Accountability: Again, as patients’ do not usually have medical education, it is their right to be able to hold physicians accountable for their actions. This is not a thing that physicians should shy from, instead a physician should always be ready to defend his/her decisions and actions. Transparency: Physicians should be clear about all forces influencing their decisions. Whether there is a conflict of interest or whether there is something a patient may object to, it is not a physician’s right to hide anything from their patient. Objective advice: while many patients value their doctors’ personal opinions, it is imperative that physicians provide impartial and objective advise based of the best known evidence. Moreover, when expressing their opinion, physicians should point this out clearly, explaining the difference between evidence and choice. Promotion of the public good: finally, physicians are expected to not only promote their individual patient’s health, but also the public good of all society and the prevention of all disease and suffering. Medical profession’s expectations from society Trust: While it is a patient’s right to know and understand everything he is going through, it is not always practical to explain every little detail about their illness and treatment. Therefore, doctors need society to trust them that they are doing what is best for their patients. Autonomy: in practicing medicine, doctors need to have autonomy and not to be forced to take any actions they believe is not in the best interest of their patients. Self-regulation: The medical profession is a complicated one, where many professionals work together and where the slightest margin of error can prove fatal. Therefore, regulating this delicate workplace should be left to those carrying this responsibility and who best understand it. A health care system that is value-driven and adequately funded: imagine a patient who has a problem in the arteries of his lower limbs (a condition called ischemia), he cannot walk properly and has started using a wheelchair. Which is a more proper target to describe this patient’s need: to be able to walk freely again (value), or to perform an operation on his arteries (service)? 4 Sometimes just performing a service such as surgery, writing a prescription, or doing physiotherapy is not enough on its own to achieve the value that the patient needs. In a service- oriented healthcare system, patients provide fees and doctors provide service. However, in a value-based healthcare system, patients and doctors decide on a specific target value they want to achieve, then the doctors work with their teams and with the patient to achieve that target regardless of how many services will or will not be included. Both doctors and patients stand to have great benefit from having a value-based and well-funded healthcare system. Participation in public policy: A doctor’s role is not only sitting in their clinic with their patients, but in order to promote public good, doctors need to be involved in public policy. This also reflects on their work directly as poor policy will lead to more sick people which in turn will lead to more healthcare burden. A very recent and live example was the “stay home” campaign that took place during the early days of COVID-19 pandemic. Not staying home meant higher infection rate, which meant more patients at hospitals, leading to exhaustion of resources and higher risk to medical teams. Shared responsibility for health: health and healing is not the sole responsibility of doctors. Patients, relatives, caregivers, religious leaders, political figures, business owners, and the whole society share in the common responsibility of preserving and promoting health. A monopoly: in order to maintain the integrity of the medical profession, doctors need to make sure that all those who enter their profession are certified and qualified to practice medicine, and that all those who are not are prevented from claiming false healing effects. Both non-financial and financial rewards: as any professionals, doctors seek proper compensation for their efforts. According to maslow’s “hierarchy of needs” theory, one cannot have the best interest of others at heart if one’s own interests are not fulfilled. Part 3: Reality vs appearance It is not enough for physicians to only have the competencies or to fulfil the duties decreed by the social contract detailed above, but it is also essential that physicians make sure this is communicated clearly to society. This involves several challenges, among which are: Information abundance: information is all around us and patients may easily think they do not really need doctors (the internet has videos that describe how to perform operations for yourself at home). unless they understand the complexity of the medical profession and have trust in their doctors, this phenomenon will only become worse. Info-demic: Many doctors are opposed to patients seeking verification for their symptoms and treatments from other sources (most commonly the internet). The real problem is not that patients seek knowledge elsewhere but rather that this “knowledge” is usually nonsense that is either put on the internet by mistake (misinformation) or intentionally to promote a product or a certain view (disinformation). The way to fight this is by leaving patients with no need to look 5 further or at least encouraging and directing them on where to look and where to get their information. Public sentiment: The abundance of social media in people’s lives today means that the negative sentiment experienced by one person towards the medical field can be like a spark that can set the whole society on fire. It is important that doctors and medical professionals make sure this spark does not find a flammable environment to grow in by ensuring that, to the best of their abilities, the expectations of society detailed above are thoroughly met. A society that trusts their doctors as having integrity, transparency, altruism, accountability, and assured competence, is more likely to consider one of its members bad experience with a medical professional as an individual incident. Alternately, a society that believes that doctors are hiding information, acting in their own best interest, and having “flexibility” in their moral code, will probably interact with any individual complaint as a phenomenon. Advocacy: doctors need to advocate their own profession. Advocacy does not mean covering up mistakes or lying about shortcomings. Instead, advocacy means doing our best to defend our profession against slander and clarify its burdens and duties. 6 Critical thinking Definition The objective analysis and evaluation of an issue in order to form a judgement. History First used as a formal educational method by Socrates. His tool was “Socratic questions” which were a series of thoughtful questions posed against an argument to elaborate, examine, and determine the validity of said argument. In the 1930s, American philosopher John dewey formalized the term critical thinking in academia and for educational purposes by proposing the definition that critical thinking is “Active, persistent and careful consideration of any belief or supposed form of knowledge in the light of the grounds that support it, and the further conclusions to which it tends.” Dewey’s concept of critical thinking Dewey described the process of critical thinking as consisting of 5 stages: Brainstorming Formulation Using one suggestion Reasoning Implementing the after another to solution Looking into a initiate and guide Deciding on which problem from all further observation hypothesis is best sides and gaining and collection of data suited for solving the various perspectives problem Suggestion Hypothesis Testing He then went on to describe several components that are related loosely to these stages 1. Noticing a difficulty 2. Defining the problem 3. Dividing the problem into sub-problems 4. Formulating a variety of possible solutions 5. Gathering information 6. Judging the credibility of information 7. Drawing conclusions from information 8. Determining what evidence is relevant 9. Systematic observation or experiment 7 Accepting a solution that the evidence adequately supportsBeing a critical thinker requires various skills, among the most commonly cited such skills are Attentiveness Open-mindedness Habit of inquiry Willingness to suspend judgenent Self-confidence Trust in reason Courage Seeking the truth Rational fallacies and bias A systematic error of thinking. An error that is a result of a wrong understanding of the situation based on one’s attitudes and thoughts and not for example on lack of knowledge, negligence, or mal-intention. Actor observer bias: if I see someone bumped their car I immediately think “what did that person do wrong and why couldn’t he avoid this accident?”. If I bump my car I immediately think “what did the other person do wrong and why couldn’t HE avoid my car?” Self-serving bias: our failures are situational, but our successes are our responsibility Anchoring Apophenia Availability heuristic: I makes decisions based on the information available to me at the time. E.g. I want to book a flight → (brain remembers plane crashes) → I cancel trip False consensus: assuming everyone must share my same views Halo effect: one specific trait of a person is used to make an overall judgement of that person. 8 Attributes of a Physician Definitions Personality traits: genetically and developmentally determined features of the personality that are constant, stable, and very difficult to change. While they are very important in defining a person’s career, yet there may be a place for every type of personality in medicine. This is largely due to the very diverse nature of the medical profession. Famous theories describing personality traits are: Big five personality traits theory (OCEAN): o Openness to experience o Conscientiousness o Extraversion o Agreeableness o Neuroticism Myers Brigs Type Indicators o Extrovert-Introvert Try yourself at o Sensing-Intuition www.16personalities.com o Thinking-Feeling o Judging-Perceiving Attributes: Personal features that are amenable to learning and acquisition. Some of them are essential for the definition of a physician (competencies), while others can be considered bonus features. The presence of these bonus attributes makes for a better doctor, but their absence do not Attributes of a physician Optimism Compassion Communication Confidence Organization Humility Meticulous Passion Curiosity Mentorship Collaboration Courage Persistence Humanity 9 The Doctor-Patient Relationship (DPR) What is the nature of the relation between a doctor and his patient? A consensual relationship in which the patient knowingly seeks the physician’s assistance and in which the physician knowingly accepts the person as a patient. Key concept Health values Patient values Models of DPR Paternalistic Deliberative Informative Interpretive (Authoritarian) (Authoritative) Patient values Only concern is Open to Defined fixed and Require health, shared by development and known to the clarification and physician & revision patient. agreement patient Physician’s Patient well-being Persuading the Provide factual Clarify patient’s obligation independent of patient of the information… personal values… their preference best path… and implement and implement and implement patient’s choice. their choice. their choice. Autonomy Assenting to Developed Control over Developed objective health through medical care through values understanding of understanding of health values own values Physician role Guardian Friend/Teacher Technical expert Counselor or advisor Examples Doctors treating Most common Chronic disease, Nutritionists, incapacitated clinic model Elective Addiction patients procedures specialists (aesthetic procedures) 10 Maintaining a professional boundary Treating relatives and friends Keep it professional o Time and space boundaries o Financial boundaries o Patient autonomy Avoid high-risk situations Encourage second opinion Involve a colleague You will ALWAYS run into that relative again The worst kind of bad reference is that of someone close to you personally Developing friendship with friends Tests professional boundaries o Time o Space o Autonomy o Finances Heightened expectations Romantic relations with current patients NEVER enter a romantic relation with a current patient. If the patient pursues a romantic relation with you: o Politely and considerately re-establish the professional boundary o If not possible then terminate relation with the patient according to guidance You must not use professional relationship to pursue romantic relations with someone close to the patient You must not end the professional relation with a patient solely to pursue a romantic relationship with them Romantic relations with former patients Time since the professional relationship ended The nature of the previous professional relationship Level of vulnerability Whether you will be caring for other members of the patient’s family. 11 Overview & Development of Medical Ethics Part 1: definitions Moral philosophy: is a “branch of philosophy that involves systematizing, defending, and recommending concepts of right and wrong behavior”. It is debatable and there are always many sides to the argument of what is “right”. Bioethics: Bioethical questions often involve overlapping concerns from different fields of study including life sciences, biotechnology, public health, medicine, public policy, law, philosophy and religion. Bioethicists debate all factors concerned with different medical situations and decide on the Clinical Ethics: the set of rules that are outlined to help manage the delicate complexities of clinical situations. Moral philosophy Bioethics Clinical ethics An ongoing debate: Taking philosophy, medicine, public Rules to follow: view, and law into consideration: What is the meaning of it is not allowed to Life support should not be “death” and whether death discontinue life support to a disconnected to any patient of the brain is considered the brain-dead person. unless the heart stops to same as death of an function irrespective of his individual? brain activity. When is a fetus considered to A fetus is considered to have Abortion is prohibited after have a life of its own? After a life of its own after implantation (sparing fertilization? after implantation. However, a contraception). If there is implantation? after having a chance is given to examine severe deformity, abortion heartbeat? after making the the fetus for deformities and may be performed before 24 first voluntary action? severe congenital disease weeks. Afterwards it is before it reaches 24 weeks of prohibited unless pregnancy gestation. poses a risk to the mother. Is a person free to choose People have the right to Organ donation is allowed what to do with his organs? donate organs, but they do after making sure it will not not have the right to harm harm the donor’s health of themselves or end their or risk his/her life. anyone else’s lives. Is someone free to end their it is not the right of any It is completely prohibited to own life? Are doctors person to actively take any assist a person or a patient to allowed to help life even their own end their life regardless of people/patients end their any suffering or prognosis of lives? their condition. This, however, does not include refusing to seek treatment. 12 Part 2: History of medical ethics The first mention of ethical rules in medicine comes from the medical papyri of ancient Egypt such as the Edwin smith papyrus which mentions that resources should be saved to cases that can respond to treatment. Only in cases where resources are plenty that a doctor may perform palliative treatment to terminal cases. The first law concerning medical ethics was the Hippocratic oath which included many parts such as confidentiality, beneficence, non-maleficence, confidentiality, honoring teachers, and honorably representing the profession of medicine. The first detailing of the pillars of medical ethics that are universally central to almost all bio- ethical doctrines today was laid out by English physician Thomas Percival in his book “Medical Ethics” in 1794 AD Part 3: The four pillars of medical ethics Beneficence: everything a physician does should be aimed at the benefit of the patient Non-maleficence: the physician should not do anything that would harm his patient, unless the benefit of doing the procedure clearly outweighs the harm. Autonomy: a patient has the right to think freely of all the choices he has, to be free to favor any of the options without pressure, coercion, or deceit act in the way he choses to manage his case without being forced to any choice against their will Justice: The idea that the burdens and benefits of treatments must be distributed equally among all groups in society. Keeping in mind that exceptions can be made in order to: Have fair distribution of scarce resources e.g., ICU beds in COVID-19 pandemic Competing needs of certain populations e.g., pregnant women and the elderly Rights and obligations e.g., healthcare staff in the COVID-19 pandemic Potential conflicts with established legislation e.g., organ harvesting from brain-dead patients 13