Medical ethics.pdf

Medical Ethics By Reham Alaa Elkalla Medical ethics Objectives By the end of this lecture the student will be able to • Recognize the medical ethics • State the importance of medical ethics • Differentiate between code of ethics and conduct • Identify the Principals of medical ethics • Recogni...

Medical Ethics By Reham Alaa Elkalla Medical ethics Objectives By the end of this lecture the student will be able to • Recognize the medical ethics • State the importance of medical ethics • Differentiate between code of ethics and conduct • Identify the Principals of medical ethics • Recognize the main Characteristics of Professional Conduct • Conduct effective patient consultation WHAT IS: ETHICS ? • The word is derived form the Greek word “ethos” meaning “the set of moral principles” • Ethics are ways of understanding and examining the morals in life, or right and wrong human conduct. • Bioethics is a way of understanding and examining the moral aspects of biomedical practice and research Introduction • Ethics has been an integral part of medicine at least since the time of Hippocrates, the fifth century B.C.E. (before the Christian era) Greek physician who is regarded as a founder of medical ethics. • From Hippocrates came the concept of medicine as a profession, whereby physicians make a public promise that they will place the interests of their patients above their own interests. • There is a very close relationship between ethics and professionalism What is Medical Ethics? The application of moral principles and analysis to medical situations WHAT IS MEDICAL ETHICS? WHAT IS MEDICAL ETHICS? WHAT IS MEDICAL ETHICS? • Each of these case studies invites ethical reflection. They raise questions about physician BEHAVIOR and DECISION-MAKING NOT • Scientific or technical questions such as how to treat diabetes or how to perform a double bypass but questions about values, and responsibilities. Code of ethics and conduct Code of ethics ‫آداب المهنة‬ ❖These are guidelines derived from values and principals intended for the appropriate behavior while practicing various professional activities ❖They indicate the way a doctor is expected to behave Code of conduct ‫سلوكيات المهنة‬ ❖These are a set of rules and legislations that regulate the work of practitioners, ❖Violations of which impose consequent penalties i.e. they are kinds of LAW ❖These regulations indicate the way a doctor should behave. What is an Ethical Dilemma?  Occurs when there is conflict between two or more ethical principles, No correct decision exists and Ethical reasoning i.e., “what is the right thing to do?”  What is “medically” right vs. patient preference  What is best for patient vs. what is best for society Conflict  Law and morality e.g., religion-based Refusal of transfusion  Different decision makers ✓ Patient and proxy ✓ Patient and physician Ethical vs. Legal Obligations Medical ethics and the law are not the same, But they often help define each other Breach of ethical obligation may not necessarily mean breach of law Breach of ethical obligation may be used to prove medical malpractice or medical negligence WHY STUDY MEDICAL ETHICS? Importance of Medical Ethics 1.Increasing profile and press headlines 2.Increase in technology 3.Better informed society 4. Doctors in Management 5.Public inspection Principals of medical ethics Autonomy Beneficence Justice (Beauchamp & Childress, 1994 ) Non-maleficence 1- Autonomy • Self-rule (Greek city-states) • Autonomy is the ability to act in an independent manner. • Self-governance, liberty, rights, privacy, individual choice, freedom of the will, causing one’s behaviour, being one’s own person. • Patients hold views, make choices, and take actions based on personal values and beliefs, i.e. a person’s own choices are based on his/her evaluation of what is best for his/her life. • Respect of patients’ rights to have control over their own bodies and to make decisions about their medical treatment. Limits to autonomy • Patients with limited understanding, mental disability or severe mental illness • An unconscious or severely ill patient. • Patients who have addictions. • Children. • Social norms N.B For children & Unconscious Patients or those with Mental Disability Parents, Family members or legal guardians should act according to the “best interests standard” 2- Beneficence  Doing good; the principle of helping others by taking actions which promote the good of others.  Related to; Best interests: what makes a person’s life go well • Central to codes of professional ethics & Hippocratic Oath PROBLEMS WITH BENEFICENCE What do we mean by the good of the patient? Beneficence vs Paternalism Deciding what is clinically correct N.B Paternalism • The intentional overriding of one person’s known preferences or actions, by another person, where the person who overrides justifies the action by the goal of benefiting or avoiding harm to the person whose will is overriden. 3- Non-maleficence Doing no harm Avoidance of putting a person at risk of avoidable harm A 1st step towards beneficence Defined under the Hippocratic oath 4- Justice Distribution of scarce resources Distributive justice Respect for individual rights Rights based justice Respect for moral laws Legal justice Professionalim Professionalism Professionalism is a term which embodies numerous “Qualities” of physicians as public servants  It is a talent and implies services to others  It has a distinctive knowledge base which must be kept up to date.  It determines its own standards and sets its own examinations  It has a special relationship with those whom it serves i.e. patients.  It has particular ethical principles Professionalism ✓A commitment to the highest standards of excellence in: •The practice of medicine and • The generation and dissemination of knowledge. ✓ It has been described by The American Board of Internal Medicine as “Constituting those attitudes and behaviors that serve to maintain patient interest above physician Self-interest ” PROFESSIONALISM Professionalism aspires to 1. Unselfishness –Self-Sacrifice 2. Honor, and Integrity 3. Excellence in Duty 4. Respect for others 5. Accountability Main Characteristics of Professional Conduct (by the American Board of Internal Medicine) 1- Unselfishness–Self-Sacrifice • It is the essence of professionalism. • The best interest of the patients, NOT self-interest, is the rule. 2- Accountability: is required at many levels: • Individual patients, • Society • and the Profession 3- Excellence: entails the effort to exceed normal expectations and make a commitment to life-long learning. Main Characteristics of Professional Conduct (by the American Board of Internal Medicine) • 4- Duty: is the free acceptance of a commitment to service. • 5-Honor and Integrity: are the constant regard for the highest standards of behavior and refusal to violate one‟s personal and professional codes. • 6-Respect for others: • like patients and their families, • other physician and professional colleagues such as nurses, medical students, residents, subspecialty fellows. Patient consultation Defining consultation • A formalized interaction between doctor and patient in a setting, when the patient seeks the advice of his doctor. Elements of Effective Doctor -Patient Communication These elements can be summarized by the acronym GATHER Greet • G: Greet the patient warmly and politely. • Friendly, professional way • In an acceptable manner according to culturenorms considering his/her age, sex, etc Ask • A: Ask the patient about his name, the problem and him/herself. ❖Patients come with multiple concerns. ❖The first item mentioned may not be the most important. ❖Elicit problems by dynamic listening & probing questions. Elements of Effective Doctor -Patient Communication tell • T: Tell the patient what is going to happen. ❖Tell the patient everything about his/her case even if he/she does not ask ❖Respond to the patients' emotional questions Elements of Effective Doctor -Patient Communication Help • H: Help the patient make a decision. • Negotiate rather than ordering describing treatment Helping Patient to make a decision • “I would like….” • Describe the thing you want the patient to consider… • “because……….” • …and why you think the change will alleviate the problem • “What do you think?” • LISTEN to patient’s response, & respect choices, agree on what is reasonable. Elements of Effective Doctor -Patient Communication EXPLAIN • E: Explain procedures / examinations to the patient. Elements of Effective Doctor -Patient Communication RETURN • R: Ask the patient to Return if problems occur. What do we Need to Achieve in a Consultation ? You must be able to 1-Discover reasons for a patient’s attendance 2-Define the clinical problems. 3-Address the patient’s problems 4-Explain the problem to the patient 5-Make effective use of the consultation Doctors and Patients Agendas Main concerns of the doctor What are your symptoms? How long have you had the symptoms Did they start suddenly or come on gradually? How often do you experience the symptoms? How severe are the symptoms? Is there anything in particular that triggersthe symptoms –makes them worse/better? What is the diagnosis & best treatment Main concerns of the Patient What is wrong? What will happen? What can You do about it? What can I do about it? Will I get better? Am I receiving the best treatment? What are the possible side effects? Efficient Consultation  Acknowledge patient’s concerns and symptoms  Indicate commitment … ✓ To understand Patient’s concerns and symptoms ✓ To allocate time and resources to solve concerns  Encourage honest transfer of information that will provide a more comprehensive picture of patient’s concerns  Avoid open skepticism or disproving comments when discussing patient’s concerns Doctor-centered style of communication • Traditionally ❖The doctor has taken the dominant role in consultation ❖little attention to patient concerns and understanding of the patients’ suffering in the illness ❖Does not involve the patient in decisions about treatment Patient –centered style of communication ❖Patient know more about their illnesses ❖Involved in treatment decisions ❖Greater patient satisfaction& compliance with treatment An ideal patient –doctor consultation ❖The patient agenda figures highly. ❖The doctor does not start on his agenda till aftera while. ❖An ideal doctor lies in the middle, changing his behavior to adapt to needs of the patient and the situation. N.B The problem is –as shown by experience and research work – that doctors do not change their style. Phases of doctor-patient communication Phase1 Patient focus • Introduction • Present complaint • Other medical history • Family history • Social history Phase2 Doctor focus • Examination • Investigation Phase3 Mutual focus • • • • Management Discussion Follow-up Sign-off