Doctor-Patient Relationship Ethics PDF

CHAPTER TWO DOCTOR-PATIENT RELATIONSHIP ILOs: After working through this chapter, you should be able to: Recognize requirements of an effective doctor- patient relationship. Identify the situations for proper termination of doctor- patient relationship. Identify the essential elements of informed consent. Explain the justification for patient confidentiality and recognize legitimate exceptions to confidentiality. Recognize the principal ethical issues that occur at the beginning and end of life. General Principles: The doctors should be “honest and trustworthy”. They should “respect patient’s dignity”, and “treat every patient politely”. 9 The following principles apply to the doctor–patient relationship: Doctors owe special duties of care to their patients, but all interactions involving doctors and patients should be characterized by honesty, politeness, and respect on both sides. Doctors have the main duty to make the relationship work, but patients also have responsibilities to it. Establishing appropriate boundaries is essential. Effective communication requires both parties to listen as well as talk and to query anything that seems unclear. Requirements of an effective doctor-patient relationship The capacity for an effective relationship requires a deep appreciation for human behaviour and education in the techniques of talking and listening to people. To diagnose, manage and treat a person’s disorder, doctors must learn to listen. One of the supreme tasks of any medical training centre is to help doctors acquire the skills of active listening to what the patient says. When the educator has failed to emphasize, respect and convey the art and technique of active listening, he has failed to train doctors in establishing relationships with their patients and patient care is the inevitable loser. Doctor-patient relationship has traditionally been considered a contractual one, although the contract is usually implied by the actions of the parties in seeking and providing advice and care. When a person seeks the services of a doctor for the purposes of medical or surgical treatment, which person becomes a patient, and the additional relationship is established. In other words, a patient has consciously sought out a doctor who has affirmatively agreed to provide care. Even before the relationship was considered a contractual one, it was confidential. No distinction is made between information orally communicated to- and observations made by the doctor. It does not even expire at the death of the patient. A patient’s right to privacy and confidentiality is merely a moral, ethical, professional and a legal duty. The information disclosed to a doctor during the course of the relationship is confidential to the greatest degree. The doctor should not reveal confidential 10 communications or information without the consent of the patient unless required to do so by the law. The duties imposed by effective doctor patient relationship Doctors have to master communication skills which are important in the following areas in medical practice. 1. Physician Patient Communication 2. Breaking bad news 3. Truth Telling. 1. Physician Patient Communication: To Listen, Explain, Truth telling, Discuss options.  The key to receiving messages effectively is listening. Listening requires more than hearing words. It requires a desire to understand another human being, an attitude of respect and acceptance, and a willingness to open one's mind to try and see things from another's point of view.  Listening requires a high level of concentration and energy. True listening requires that we suspend judgment, evaluation, and approval to understand another is frame of reference, emotions, and attitudes.  When we listen effectively, we gain a greater understanding of the other person's perception. When we have a deeper understanding of another's perception, whether we agree with it or not, we hold the key to understanding that person's motivation, attitude, and behaviour. We have a deeper understanding of the problem and the potential paths for reaching agreement. 11 Listening skills The health care provider should know how to listen to be able to understand the problem that brings the clients to the clinic. Six Essential Techniques for Active Listening 1- Use silence appropriately: show respect by not interrupting during pauses made by the patient. Patient should not be interrupted, nor should they be rushed. 2- Clarify anything that you did not understand e.g., by asking the client '' what do you mean?''. 3- Paraphrasing what the patient just said in your own words. This helps the provider verify if what he/she has heard is correct. 4- Reflect on what the client has just said. Reflection is similar to paraphrasing but with adding an emotional tone to the message given by the client e.g. '' I can see that you are feeling guilty about having lost this pregnancy''. 5- Use proper non – verbal techniques to help the patient feel at ease and to show him that you are interested. R: Relax (avoid nervous movements). O: Be Open/ Flexible. L: Lean Forward Towards the patients. E: Maintain Eye Contact S: Show you are listening (head nodding,…). 6- Summarize: at the end of history taking summarize all what you have heard from the patient. Summarizing helps you group the issues and identify priority areas for intervention. Health care provider must establish a good relationship with the patient. This will help the provider gain the patient's trust and hence a 12 successful and effective relationship will be established between them. Elements helping good listening: Choosing private and comfortable place. Giving the client a chance to think. Observing her voice tone and body movements. Speaking in a moderate speed. Repeating what the client has said from time to time. Learning to be an effective listener is a difficult task for many people. However, the specific skills of effective listening behaviour can be learned. It is our ultimate goal to integrate these skills into a sensitive and unified way of listening. 2. Breaking bad news: What is difficult about giving bad news? There are personal, professional and social reasons why giving bad news to patients may be difficult. Why is it difficult to give bad news? The 'messenger' may feel responsible, and fears being blamed. Possible inhibition because of personal experience of loss. Reluctance to change the existing doctor-patient relationship. Fear of the patient’s emotional reaction. Uncertainty as to what may happen next and not having answers to some questions. The process of giving bad news ↓ 13 Give information ↓ Check the patients understanding of the information ↓ Identify the patient's main concerns ↓ Elicit the patient’s coping strategies, personal resources and give realistic hope There are some obvious things which should not be done: Not to give bad news at the end of physical examination while the patient is still undressed. Not to give bad news in corridors and over telephone. To whom should bad news be given? Who should give bad news? When should bad news be given? How to give bad news? Steps of How to Break Bad News A. The seven- step protocol to breaking bad news is as follows: 1. Getting started: (a) get the physical setting right; (b) ensure family support at the time of breaking the news; and (c) fire a warning shot. 2. Find out how much the patient already knows. 3. Find out how much the patient wants to know. 4. Decide on your objectives. 5. Share the information: (a) give the information in small chunks- start with the ''warning shot''; (b) use Arabic, Not ''medispeak''; (c) reinforce and clarify the information frequently; (d) listen for the patient's concerns; (e) blend your agenda with the patient's agenda; and (f) offer hope. 6. Respond to the patient's feelings. 7. Follow through with your planned objectives. 14 B. Remember your colleagues: Physicians as patients are just as vulnerable if not more vulnerable than patients who are not physicians and need our friendship, encouragement, help, and hope. C. Guidelines and suggestions: 1. Always leave the patient with realistic hope. 2. Realize that the patient will not absorb all the information on the first visit; schedule follow-up visits frequently. 3. Facilitate and coordinate the patient's care from this point on. 4. Remember the 5Cs of the family physician: continuous, comprehensive, compassionate, coordinated, and competent care. 5. Try to unlearn '' medispeak''. 3. Telling the truth: It is important to distinguish between "truth" and "truth telling". Health care professionals often conceal serious diagnoses from patients. Physician strategies commonly employed to minimize direct disclosure include using terminology that obscures the seriousness of a condition or communicating diagnostic and treatment information only to the patient's family members. The primary conflict has been between the concepts of paternalism (as applied to medical practice) and autonomy. Cultural factors strongly influence patients' reactions to serious illness and decisions about end-of-life care. In some cases, the truth might be far from beneficial and could also be harmful. Cultures that place a higher value on beneficence and non- maleficence relative to autonomy have a long tradition of family- centred health care decisions. In this collective decision process, relatives receive information about the patient's diagnosis and prognosis and make treatment choices, often without the patient's input. By paying attention to the patient's values, spirituality, and relationship dynamics, the family physician can elicit and follow cultural preferences. TERMINATION OF THE RELATIONSHIP Once the relationship is established, the obligation to treat the patient with proper care continues until it is terminated by either: - 15 1. Completion of the treatment by virtue of patient recovery. 2. Death of either the patient or doctor. 3. Dismissal of the doctor by the patient. 4. By mutual consents between the patient and the doctor. 5. The patient may terminate this relationship for any reason and at any time. The relationship may also be considered terminated once patient’s care has been properly and completely transferred to another doctor. A prudent doctor will carefully document the basis and circumstances of dismissal as protection against a later claim of abandonment by the patient. Abandonment is defined as the improper unilateral termination of the relationship. Acts of abandonment include: 1) A doctor expressed declaration that he will no longer care for the patient. 2) A doctor’s unqualified refusal to render further care without an expressed declaration of the abandonment of the patient’s care. 3) Leaving a patient during or immediately after surgery. 4) A doctor’s failure to keep a promise to attend a patient. 5) A doctor’s premature discharge of a patient from care or from the hospital. 6) A doctor’s failure to give proper discharge instructions. Proper withdrawal of the doctor is an absolute defence to abandonment. The patient should be notified to have enough time to find alternative care. When patients fail to follow a prescribed course of treatment, and have resulting problems, charge of abandonment will not prevail. THE INFORMED CONSENT Informed consent is one of the central concepts of present- day medical ethics. The right of patients to make decisions about their healthcare has been enshrined in legal and ethical statements throughout the world. The components of informed consent are voluntariness, competence, disclosure, understanding and consent. 16 a. Voluntariness In patients' care: Seeking medical consultation is the exact version of voluntariness. It implies consent to being examined. This consent is voluntary, based on the understanding that the doctor has to check the patient to find out what is wrong with him. This consent cannot be taken as blanket permission for subsequent intervention. In medical research: The participant's consent to participate must be free of any promises of benefits unlikely to result from participation, or threats about denial of service in case of refusal of participation. b. Competence: Competence refers to the ability of a person to make a rational decision after consideration of benefits, risks and outcomes of intervention and non- intervention. Consent is meaningless when the patient is incompetent to make decisions. The patient must be competent to give consent. If the patient is not competent due to mental status, disease, or emergency, a designated surrogate may provide consent if it is in the patient's best interest (as in infants and children, coma or mental incapacitation, severe stress). It is then necessary for the next- of- kin (according to traditions & cultures) to take on the role of a guardian and decide on behalf of the patient. In some cases, authority might be the guardian. Again, in certain emergency cases, consent may be waived due to the lack of a competent patient and a surrogate. Competence depends to a great extent on mental capacity which is the ability to receive, understand and recall information. It is the ability to count the consequences and make a decision. (The ability to weigh up information, compare, chooses). If we overrule a patient’s decision and take action, we could be open to a charge of assault. "Protecting the incompetent is a great ethical responsibility of doctors." c. Disclosure Disclosing to the patient relevant information about the benefits, costs and risks of the interventions and the possible outcome and agree to the proposed intervention or refuse it. Physicians should clarify the expected benefits to the patient and/or society, the potential of reasonably foreseeable side effects, risks, stresses, and discomforts and alternative plans of management. They should describe procedures in place to ensure the confidentiality or anonymity of the patient and the document should make it clear whom to contact in cases of need. 17 d. Understanding: The patient must understand what has been explained and must be given enough time to ask questions and have them answered by the physician as well as to have a second opinion. The informed consent document must be written in lay language, avoiding any technical terms. e. Consent: To sign an agreement accepting the decision and the consequences. All aspects of informed consent (extent of disclosure; comprehension by the patient of what is disclosed; the extent to which the consent is truly voluntary; and the competence to consent) are of utmost importance in the area of medical research. REFUSING TREATMENT In general, a health care provider must obtain a patient's informed consent prior to administering medical treatment. In case of an adult with sound mind, to violate the dignity of the person is considered unethical. If the patient is rational and understands the consequences of refusing the treatment, doctors must respect the decision. (It should be documented, better in the presence of witnesses). This means that the patient's right to autonomy is the primary ethical consideration (not the doctors desire to do well). However, in emergency situations saving life or preventing permanent injury is the primary concern of doctors even without voluntarily consent. For example, if a person is badly injured in a car accident and is unconscious when he/she arrives at the emergency department, the staff will treat him/her as though he/she consented to care. Both paternalism and autonomy are based on good intentions. Compromising the principle of beneficence result in a situation which poses an ethical dilemma for the doctor. Forms of medical consent: 1- Implied consent: Most of the medical practice conducted under the principle of "implied consent", where the very fact that a person has presented at doctor's clinic to be examined, or asks the doctor to visit him, implies that he is willing to undergo the basic clinical examination, but it does not extend to intimate examination such as vaginal and rectal examinations or to invasive examination such as venepuncture. These procedures necessitate express consent. 18 2- Express consent (oral or written) [Informed consent]: Where complex medical procedures are concerned, more specific permission (either, oral or written) must be obtained from the patient or his guardian (if a minor or insane) after explaining what is to be done and why in terms which the person can understand, this being called "express consent". Express consent may often be obtained in writing, but this is not a legal requirement, and a written consent is not more valid than verbal one. However, written consent is much easier to prove at a later date. Ideally, oral or written consent should be witnessed by another person (doctor's secretary or assistant, a nurse etc.), who should also sign any document. Written consent is necessary and should not omitted in surgical operations, invasive diagnostic procedures, termination of pregnancy, examination of persons in custody, at the request of the police. A written consent must be informative including the information necessary about the nature of the procedure and the expected side- effects or hazards. The consent is considered illegal or invalid when: 1- It includes unlawful operation: illegal abortion or artificial insemination heterologous or unnecessary operation. 2- It is taken by fraud or misrepresentation of the operation being a life-saving measure. While it is not. 3- It is given by a minor (under the age of 18), only the parents or legal guardian can give consent for a minor. 4- It is given by insane or incompetent patient. CONFIDENTIALITY It is a fundamental tenet of medical care. The expectation of confidentiality derives from the public oath which the physician has taken, and from the accepted code of professional ethics. Since the very early stages of this profession, the medical practice has to safeguard this value. The physician, Imhotep of ancient Egypt used to have his students take an oath not to disclose any secrets of their patients. Then came the Greek physician, Hippocrates, whose oath is still widely taken by graduates of most medical schools. This oath implies that all information, medical or non-medical, obtained by the physician through audible, visual or deductive means should be treated as secrets that must not be divulged being protected by professional confidentiality. It is a matter of respecting the privacy of 19 patients, encouraging them to seek medical care and discuss their problems openly. Trust between the patient and his physician is important in order to make accurate diagnoses and provide optimal treatment. The physician must have relevant information about the patient's illness or injury. This may require the discussion of sensitive information, which would be embarrassing or harmful if it were known to other persons. Conflict between confidentiality and interests of others: The doctor’s duty is to maintain confidentiality strictly, except in certain specified circumstances: (1) The patient or his legal adviser gives written consent. (2) Information is shared with other doctors, nurses or health professionals participating in caring for the patient. (3) Where on medical grounds it is undesirable to seek the patient's consent, information regarding the patient's health may sometimes be given in confidence to a close relative. (4) In exceptional circumstances may the doctor go ahead and impart that information without the patient's consent. (Domestic violence, child abuse, communicable diseases, suicidal tendency). (5) Information may be disclosed to comply with authority requirement, for example notification of an infectious disease. (6) Information may be disclosed where it is so ordered by a court. (7) Rarely, disclosure may be justified on the ground that it is in the public interest which, in certain circumstances such as, for example, investigation by the police of a grave or very serious crime, might override the doctor's duty to maintain his patient's confidence. (8) The doctor employed by an insurance company is not breaching confidentiality by passing on to the insurance company information about patient's health status. GIFTS FROM PATIENTS Small gifts from patients of nominal or modest value are acceptable on the part of the physician. This is provided that there is no expectation of a different form of therapy, or a higher level of care based on the gift. You can accept a cake on your birthday, or other tokens of esteem, but not if the patient expects an extra, or different prescription for something, in exchange for the gift. 20 The rules on gifts from patients are far less rigorous, precise, or clear than the rules on gifts from the pharmaceutical industry. There is an automatic presumption that gifts from industry always carry an influence toward a product, service, or prescribing practice. Gifts from industry are viewed differently because there can be no other intention behind them except in buy influence and alter behaviour. There is no such automatic presumption on the part of gifts received from patients. DOCTOR/PATIENT EXTRA PROFESSIONAL RELATION Extra professional relation between a physician and a patient is always inappropriate. At the very least, the physician and patient must mutually agree to end the formal professional relationship of a doctor and a patient. It is not clear how much time must elapse between the ending of the professional doctor/ patient relationship and the beginning of a personal relationship. The recommendation for psychiatrists is somewhat unique. The American Psychiatric Association guidelines specifically state that there can never be a personally intimate private relationship between doctor and patient even after the professional relationship has ended. In other words, a psychiatrist should not have private relationship even with former patients. These guidelines apply no matter who initiates the relationship. In other words, it is not more acceptable for a doctor and patient to have personal relations if the patient initiates this relationship rather than the physician. These guidelines also take no account of gender or sexual orientation. It is always ethically unacceptable to have a personal relationship between a psychiatrist and either a current or a former patient. It is ethically unacceptable for a physician of any kind to have a personal relationship with a current patient. BEGINNING-OF-LIFE ISSUES 21 Many of the most prominent issues in medical ethics relate to the beginning of human life. Here are the common items that have been the subject of extensive analysis by medical associations, ethicists and government advisory bodies, and in many countries, there are laws, regulations and policies dealing with them. STERILIZATION Both women and men have free access to sterilization. Consent is necessary from patient and husband/wife together with an official medical report saying that it is a mandatory intervention and there is a strict indication to it. ASSISTED REPRODUCTION For couples (and individuals) who cannot conceive naturally there are various techniques of assisted reproduction, such as artificial insemination and in-vitro fertilization and embryo transfer, widely available in major medical centres. Surrogate or Substitute gestation is prohibited by Egyptian laws. DONATION OF SPERM AND EGGS There is moral and religious prohibition to donate sperm and unfertilized eggs. PRENATAL GENETIC SCREENING Genetic tests are now available for determining whether an embryo or foetus is affected by certain genetic abnormalities and whether it is male or female. Depending on the findings, a decision can be made whether or not to proceed with pregnancy. Physicians need to determine when to offer such tests and how to explain the results to patients. 22 The Ethical Issues in genomic-based studies: 1. Confidentiality: It is of special concern as: Genetic information is commonly predictive of an individual’s risk of developing certain diseases in the future. It is typically not just about a particular individual who has been screened or tested, but also involves other family members of that individual. 2. Gender issues: In societies in which there is deep-seated bias and discrimination against women, genetic information can be withheld or used in ways deeply prejudicial to them. It is especially important to ensure that women are not subject to coercive pressure from within the family or community to pursue or not to pursue genetic testing. 3. Prejudice: Genetic information can be used to make generalizations about ethnic populations or societal groupings. 4. Guilt: A pre-symptomatic diagnosis may also cause the family to see a person as different in some way and to treat them differently. Also, some family members feel guilty if they have passed on a disease gene to their children, or, conversely, others feel guilty if they test negative for a disease gene that other family members have. 6. Eugenics: i.e., to improve the human race by encouraging the most genetically fit people to have more children and to prevent reproduction of people deemed unfit. We have to respect individuals’ human rights to reproductive freedom; intolerance of different views of a “good person,” life and society; and abuse of inequalities of power and unjustly sacrificing the rights and interests of individuals for a supposedly greater social good. 7. Stem-cell therapy: Stem-cells therapy is prohibited in Egypt. Stem-cell research, however, is allowed under clinical research law 214/2020. 23 There are four sources for the current human embryonic stem cells, which are: Excess gametes or blastocysts from in vitro fertilization, Fetal cells from the embryo in Natural or voluntary abortion, Blastosphere or single sex split blastocysts from somatic cell nuclear transfer technique, Reproductive cells from voluntary donations Theoretically, stem cell technology could be used to produce replaceable tissues or organs. Defective tissues/organs could be repaired using healthy cells. It would also be possible to genetically engineer stem cells to accomplish activities that they would not ordinarily be programmed to do. Part of this engineering could involve the delivery of chemotherapeutic agents for treatment of cancers and tumours. END-OF-LIFE ISSUES End-of-life issues range from attempts to prolong the lives of dying patients through highly experimental technologies, such as the 24 implantation of animal organs, to efforts to terminate life prematurely through euthanasia and medically assisted suicide. In between these extremes lie numerous issues regarding the initiation or withdrawing of potentially life-extending treatments, the care of terminally ill patients and the advisability and use of advance directives. Two issues deserve particular attention: euthanasia and assistance in suicide. EUTHANASIA Euthanasia means knowingly and intentionally performing an act that is clearly intended to end another person’s life and that includes the following elements: the subject is a competent, informed person with an incurable illness who has voluntarily asked for his or her life to be ended; the agent knows about the person’s condition and desire to die, and commits the act with the primary intention of ending the life of that person; and the act is undertaken with compassion and without personal gain. ASSISTANCE IN SUICIDE Assistance in suicide means knowingly and intentionally providing a person with the knowledge or means or both required to commit suicide, including counselling about lethal doses of drugs, prescribing such lethal doses or supplying the drugs. Euthanasia and assisted suicide are often regarded as morally equivalent, although there is a clear practical distinction, and in some jurisdictions a legal distinction, between them. Euthanasia and assisted suicide, according to these definitions, are to be distinguished from the withholding or withdrawal of inappropriate, futile or unwanted medical treatment or the provision of compassionate palliative care, even when these practices shorten life. Requests for euthanasia or assistance in suicide arise as a result of pain or suffering that is considered by the patient to be intolerable. They would rather die than continue to live in such circumstances. Furthermore, many patients consider that they have a right to die if they so choose, and even a right to assistance in dying. Physicians are regarded as the most appropriate instruments of death since 25 they have the medical knowledge and access to the appropriate drugs for ensuring a quick and painless death. Physicians are understandably reluctant to implement requests for euthanasia or assistance in suicide because these acts are illegal in most countries and are prohibited in most medical codes of ethics. WITH HOLDING AND WITHDRAWAL OF MEDICAL TREATMENT Every competent adult with the capacity to understand his own medical problems has the right to determine what treatments he does or does not wish to receive. There is no ethical or legal distinction between withholding and withdrawal of medical treatment. Case (1): A 60-year-old man with diabetes and hypertension develops renal insufficiency to the point of needing dialysis. He is equivocal about spending the rest of his life on dialysis, but he agrees to start. The patient is not depressed and is fully alert. Six months after starting dialysis, he comes to realize very clearly that he absolutely does not wish to continue. You have no doubt that the patient has full capacity to understand the implications of this decision. What should you do? Although there may be an emotional distinction between withholding dialysis and stopping it after it has started, there is no ethical distinction between the two. If I don't like to play basketball, there is no legal distinction between never starting to play basketball or playing a few games and then not doing it anymore. It is my right to stop. If I hire you to repair my house, but after a few days I decide that I don't like the work you are doing, I have the right to tell you to stop working on my house. You cannot say, "Sorry, once we start a job, we finish it whether the owner likes it or not." I have the right to refuse to allow you to work on my house and the right to tell you to stop after you started. The patient has the right to stop treatment. Case (2): An elderly man with chronic obstructive pulmonary disease (COPD) progresses to the point of needing mechanical ventilation on a chronic basis. He tells you, after long consideration, that he just does not want to live on a ventilator. 26 What should you tell him? You must honour his wishes. This patient is an adult with the capacity to understand his medical problems, so he has the right to choose whether or not he wishes to be on a ventilator. The wrong answers include getting a court order, treating him against his will, and asking the family for consent. Advanced Directives Definition An advance directive is the method by which a patient communicates his wishes for his health care in advance of becoming unable to make decisions for himself. The advance directive is a by- product of the success of medical therapies such as the mechanical ventilator that can keep a patient alive when in the past he would have died. Because of these therapies, doctors are now in the position of trying to determine what each patient wanted for himself in terms of his health care. The advance directive is part of the concept of autonomy. The advance directive tells the physician what the patient's wishes are so that the less accurate forms of decision making, such as substituted judgment or making a decision based on another person’s idea of the best interests of the patient, become avoidable. This concept is not yet applied to Egyptian healthcare. Health-Care Proxy The proxy is like a messenger. The patient writes the message- her wishes for her own health care-and the proxy delivers the message. You would not want your proxy to alter your wishes any more than you would want your mailman to rewrite your letters. The proxy is also like a waiter. The patient tells the waiter what kind of food he wants to eat (what kind of medicines and tests he wants). The proxy places the order in the kitchen. The proxy is not there to alter your expressed wishes. You would not want to order chicken and have the waiter tell the kitchen you want fish. Your waiter tries to understand what you want to eat. The waiter doesn't walk up and tell you, "You look weak and anaemic. You are having a rare steak tonight, which is what is best for you." Now the main difference is that this is a "restaurant" in which the customer is unconscious and can't tell you exactly what he wants. The proxy makes decisions based on two parameters: 27 1- The patient directly expressed healthcare wishes. 2- What the patient would have wanted if he/she had capacity Living Will A Living Will is a written form of advance directive that outlines the care that a patient would want for herself if she were to lose the ability to communicate or the capacity to understand he medical problem. The aetiology of the loss of decision-making capacity is irrelevant. A living will can range from being an extremely precise document outlining the exact types of care that a patient wants or does not want all the way to being a vague, useless document that makes nonspecific statements such as "no heroic care." The main problem with the living will is that most of the time it lacks precision because the patient does not explicitly state which tests and/or treatment modalities, she wants for herself. A document saying "no extraordinary care is virtually worthless what does "extraordinary care" mean? Does that mean a ventilator or chemotherapy, or dialysis, or blood tests, or all of them, or none of them? If the living Will is explicit in listing the precise names of the tests and treatments that the patient would like to receive (or not to receive), then it is useful. For instance, a living will that says "No intubations, no cardiopulmonary resuscitation, no dialysis, and no blood transfusions" is very useful and allows for easy following. Case (3): A 78-year-old woman is admitted with metastatic cancer leading to a change in mental status secondary to hypercalcemia. She has a living will in her record that states, “In the event that I become unable to speak for myself for any reason I wish to express my wish that I not be intubated or placed on a ventilator under any circumstances. I also do not wish to receive dialysis. Blood testing and antibiotics are acceptable.” What should you do? The living Will is most valid and usable when specific tests and treatments are outlined. In the case above, follow the direction of the living will and carry out the patient's wishes. A living will would overrule the wishes of the family because the living will communicate the patient's own wishes. As a matter of autonomy, the patient has clearly expressed wish always takes precedence over the wishes of 28 other decision makers, such as family members. The major issue with the use of a living will is that it is very difficult, in advance of the illness, to be certain which medical treatments and tests will be necessary. It is very difficult for a layperson to say, “I do not want an albumin infusion with my large volume paracentesis” or “A biopsy for diagnostic purposes by interventional radiology is acceptable, but do not want an open biopsy in the operating room” or "I agree to antibiotics, but not to amphotericin.” A health-care proxy allows for far greater flexibility. However, if a patient really does write out the specific names of the most common treatments and the parameters for their use, then the living will can be a very useful document. No Capacity and No Advance Directives Here is what is very clear about withholding and withdrawal of care decisions: An adult with capacity can decide to accept or refuse any therapy offered. An adult without capacity can be managed with a health-care proxy or a living Will, if the living Will is sufficiently clear and specific enough. Unfortunately, the vast majority of patients, even at older age and with life-threatening illnesses, do not have a formal advance directive. Decision making can be much more difficult in this circumstance. If the family is united and in agreement, then there is no difficulty with making decisions for the patient. The main issue again comes to demonstrating the best evidence of knowing the patient's wishes. Anyway, when a patient refuses treatment, search for the causes behind his/her refusal and evaluate the situation and try to counsel the patient or to solve the problem. However, after that if the patient insists on refusing the treatment, you have to honour his/her wishes and let him/her to sign an informed refusal of treatment. FUTILE CARE This concept refers to that the physician is not under an obligation to give treatment or perform tests that will not benefit the patient. This is true even if the patient or the family is demanding it. This concept is not applied in Egypt as the doctor should continue treatment till death is declared. 29 ORGAN AND TISSUE DONATION In Egypt organ and tissue donations are controlled by law number 5/2010 AUTONOMY OF THE DONOR Organ and tissue donation is a voluntary event entirely at the discretion of the live donor. The principle of autonomy is fully in play here. Case (4): A 35-year-old-man is dying of hepatic failure. His brother is fully HLA (Human Leukocytic Antigen) matched and a highly compatible donor. There are no other donors at this time and the patient will likely not survive long enough to find another donor. You are screening the brother for the donation, but he is not willing to undergo the surgery for the partial donation. What should you do? There is nothing you or anyone-including a court of law-can do to compel a person to donate an organ or tissue if he clearly chooses not to do so. The need of the recipient has no impact on mandating a donor to donate. This is true even if the donation is uncomplicated for the donor and the recipient will die without it. Safety of the donor (Do no harm) Thoroughly investigate the health condition of the donor before transplantation take place to assure safety of the donor. Justice: 30 Nonrelative cannot donate their organ to each other to assure non coercion of the donor except if there is no matched relative donor. PAYMENT FOR DONATIONS With the exception of renewable tissues such as sperm, unfertilized eggs, and blood, payment for organs is considered ethically unacceptable. However, in Egypt it is prohibited. People must not be indulged in the business of selling organs. The economic aspects of organ donation must be minimized so that the patients who need organs the most will get them, not that the wealthy get preferential treatment. It is, however, acceptable to cover the cost to the donor of donation. There is a difference between reimbursing the donor for the cost of donation creating a financial incentive for people to "sell" organs. ORGAN DONOR CARDS An organ donor card gives an indication of a patient's wishes for donation, and the potential donors can go to the Egyptian ministry of health and population to get their own donation card. DEFENSIVE MEDICINE Defining defensive medicine According to Office of Technology Assessment (OTA), it occurs when doctors order tests, procedures, or visits, or avoid high-risk 31 patients or procedures, primarily (but not necessarily solely) to reduce their exposure to malpractice liability. Types: Positive defensive medicine: When doctors do extra tests or procedures primarily to reduce malpractice liability. Negative defensive medicine: When doctors avoid certain patients or procedures to reduce malpractice liability. Under this definition, a medical practice is defensive even if it is done for other reasons (such as belief in a procedure effectiveness, desire to reduce medical uncertainty or financial incentives), provided that the primary motive is to avoid malpractice risk. Also, the motive need not be conscious. Over time some medical practices may become so ingrained in customary practice that doctors are unaware that liability concerns originally motivated their use. Doctors may stop performing certain tests or procedures if by doing so they can avoid the need for costly or hard to find malpractice insurance to cover these activities. The most frequently cited examples of negative defensive medicine are decisions by family practitioners and even some obstetrician gynaecologists to stop providing obstetric services. These decisions may result when malpractice insurance premiums vary depending on whether the doctor delivers babies. Most defensive medicine is not of zero benefit. Instead, fear of liability pushes doctors’ tolerance for medical uncertainty to low levels, where the expected benefits are very small, and the costs are high. Many doctors say they would order aggressive diagnostic procedures in cases where conservative management is considered medically acceptable by professional expert panels. Most doctors who practice in this manner would do so primarily because they believe such procedures are medically indicated, not primarily because of concerns about liability. It is impossible to accurately measure the overall level and national cost of defensive medicine. The best that can be done is to 32 develop a rough estimate of the upper limits of the extent of certain components of defensive medicine. Defensive medicine has a substantial influence on doctors’ behaviour in certain isolated clinical situations (e.g., Caesarean Sections and the management of head injuries in emergency rooms). Doctors are very conscious of the risk of being sued and tend to overestimate that risk. A large number of doctors believe that being sued will adversely affect their professional, financial and emotional status. The role of the malpractice system as a deterrent against too little or poor-quality care, one of its intended purposes, has not been carefully studied. Defensive medicine: good, bad or both OTA’s definition does not specify whether the defensive action is good or bad for the patient, it requires only that the doctor’s primary motivation to act is the desire to reduce the risk of liability. Thus, some defensive medical practices may be medically justified and appropriate while others are medically inappropriate. 33 CHAPTER THREE DOCTORS AND SOCIETY ILOs: After working through this chapter, you should be able to: Identify and deal with the ethical issues involved in allocating scarce medical resources. Recognize doctor's responsibilities for public and global health. RESOURCE ALLOCATION In every country in the world, including the richest ones, there is an already wide and steadily increasing gap between the needs and desires for healthcare services and the availability of resources to provide these services. The existence of this gap requires that the existing resources be rationed in some manner. The physician’s role in allocating resources is expressed in many national medical association codes of ethics and, as well, in the WMA Declaration on the Rights of the Patient, which states: “In circumstances where a choice must be made between potential patients for a particular treatment which is in limited supply, all such patients are entitled to a fair selection procedure for that treatment. That choice must be based on medical criteria and made without discrimination.” One way that physicians can exercise their responsibility for the allocation of resources is by avoiding wasteful and inefficient practices, even when patients request them. The overuse of antibiotics is just one example of a practice that is both wasteful and harmful. Many other common treatments have been shown in randomized clinical trials to be ineffective for the conditions for which they are used. Clinical practice guidelines are available for many medical conditions; they help to distinguish between effective and ineffective treatments. Physicians should familiarize themselves with these guidelines, both to conserve resources and to provide optimal treatment to their patients. A type of allocation decision that many physicians must make is the choice between two or more patients who are in need of a scarce 34 resource such as emergency staff attention, the one remaining intensive care bed, organs for transplantation, high-tech radiological tests and certain very expensive drugs. Physicians who exercise control over these resources must decide which patients will have access to them and which will not, knowing full well that those who are denied may suffer, and even die, as a result some physicians face an additional conflict in allocating resources, in that they play a role in formulating general policies that affect their own patients, among others. This conflict occurs in hospitals and other institutions where physicians hold administrative positions or serve on committees where policies are recommended or determined. Although many physicians attempt to detach themselves from their preoccupation with their own patients, others may try to use their position to advance the cause of their patients over others with greater needs. In dealing with these allocation issues, physicians must not only balance the principles of compassion and justice but, in doing so, must decide which approach to justice is preferable. There are several such approaches, including the following: LIBERTARIAN – resources should be distributed according to market principles (individual choice conditioned by ability and willingness to pay, with limited charity care for the destitute). UTILITARIAN– resources should be distributed according to the principle of maximum benefit for all. EGALITARIAN – resources should be distributed strictly according to need. RESTORATIVE – resources should be distributed so as to favour the historically disadvantaged. It is not applied in Egypt. Libertarian Approach The libertarian approach is based on the principle of individual autonomy and the right to self-determination. According to this approach, individuals have the right to make their own decisions about their health care, and resources should be allocated based on the ability to pay. In other words, those who can afford to pay for medical resources should have access to them, while those who cannot afford them should not. An example of this approach is a private health care system where individuals pay for their own 35 medical care. Utilitarian Approach The utilitarian approach is based on the principle of maximizing overall benefits and achieving the greatest good for the greatest number of people. According to this approach, resources should be allocated based on the potential to save the most lives or maximize life-years. An example of this approach is allocating resources to those who suffer the most or have the best chance of survival. Egalitarian Approach The egalitarian approach is based on the principle of equal distribution of resources regardless of one's attributes or characteristics. According to this approach, resources should be allocated based on a first-come, first-served basis or random selection. An example of this approach is a lottery system for allocating resources. Restorative Approach The restorative approach is based on the principle of correcting past injustices and restoring balance. According to this approach, resources should be allocated to those who have been historically disadvantaged or marginalized. An example of this approach is allocating resources to communities that have been disproportionately affected by a disease outbreak. It is important to note that these approaches are not mutually exclusive, and different approaches may be used in different situations. For example, during a pandemic, a utilitarian approach may be used to allocate resources to those with the best chance of survival, while an egalitarian approach may be used to allocate resources on a first-come, first-served basis. PUBLIC HEALTH The term ‘public health’, as understood here, refers both to the health of the public and also to the medical specialty that deals with health from a population perspective rather than on an individual basis. There is a great need for specialists in this field in every country to advice on and advocate for public policies that promote good health as well as to engage in activities to protect the public from communicable diseases and other health hazards. The practice of public health (sometimes called ‘public health medicine’ or ‘community medicine’) relies heavily for its scientific basis on epidemiology, which is the study of the distribution and 36 determinants of health and disease in populations. Indeed, some physicians go on to take extra academic training and become medical epidemiologists. However, all physicians need to be aware of the social and environmental determinants that influence the health status of their individual patients. As the WMA Statement on Health Promotion notes: “Medical practitioners and their professional associations have an ethical duty and professional responsibility to act in the best interests of their patients at all times and to integrate this responsibility with a broader concern for and involvement in promoting and assuring the health of the public.” Public health measures such as vaccination campaigns and emergency responses to outbreaks of contagious diseases are important factors in the health of individuals but social factors such as housing, nutrition and employment are equally, if not more, significant. Physicians are seldom able to treat the social causes of their individual patients’ illnesses, although they should refer the patients to whatever social services are available. However, they can contribute, even if indirectly, to long-term solutions to these problems by participating in public health and health education activities, monitoring and reporting environmental hazards, identifying and publicizing adverse health effects from social problems such as abuse and violence, and advocating for improvements in public health services. Sometimes, though, the interests of public health may conflict with those of individual patients, for example, when a vaccination that carries a risk of an adverse reaction will prevent an individual from transmitting a disease but not from contracting it, or when notification is required for certain contagious diseases, for cases of child or elder abuse, or for conditions that may render certain activities, such as driving a car or piloting an aircraft, dangerous to the individual and to others. In general, physicians should attempt to find ways to minimize any harm that individual patients might suffer as a result of meeting public health requirements. For example, when reporting is required, the patient’s confidentiality should be protected to the greatest extent possible while fulfilling the legal requirements. A different type of conflict between the interests of individual patients and those of society arises when physicians are asked to assist patients to receive benefits to which they are not entitled, for example, insurance payments or sick leave. Physicians have been vested with the authority to certify that patients have the appropriate 37 medical condition that would qualify them for such benefits. Although some physicians are unwilling to deny requests from patients for certificates that do not apply in their circumstances, they should rather help their patients find other means of support that do not require unethical behaviour. ADVERTISING IN MEDICINE The aim of advertising is to promote the well-being of patients (as a guide & education), and to help physicians. Paid TV interviews, magazine advertising, commercials and flyers and internet advertising for the purpose of encouraging the use of the physician services are the most popular. Still, physician's reputation is of central importance to acquire new patients and to be named for referral by colleagues and to be recommended by old patients. In advertising and marketing, medical services to the public, high ethical standards are a priority. Honesty is the best policy in advertising, avoiding misleading information about magic treatments, deception and fraud claims about inappropriate promises. Fraud and deception regarding experience, competence, and the quality of the physician are both unethical and illegal. As equally as important is not to omit any related or necessary information if it happened not to be in one's best interest. (Limited effect, side effects…). The ultimate goal is truth and not objectivity. This is of utmost importance in fields like plastic surgery, oncology & complementary medicine. Physicians should work to communicate information to the public in a readily comprehensible manner. Advertisements using pictures of attractive individuals or models may also be deceptive if the advertisement falsely implies that the viewer also can be as attractive if the advertised services are obtained. Photographs taken of individuals before and after a procedure using different lighting, poses, or altered images can also be very misleading to the public. Anything mentioning your name even paid for you by pharmaceutical companies or otherwise is ultimately your responsibility. Of great concern is the recent rash of products being promoted and sold in the market that are not approved by the ministry of health. Next to this is the unfinalized incomplete results of new remedies for chronic yet untreatable diseases. While ethical principles governing the relationship between physicians and their patients have been examined since the 38 beginning of medicine, interest in the rules of professional conduct has intensified dramatically in recent years. All of the fore mentioned influences not only raise questions about ethical practice, but also patient safety. Around the corner cosmetics factories products have resulted in adverse events and even death. CHILD ABUSE Physicians are mandatory reporters of child abuse. This means that the physician has a duty to report child abuse even if they feel uncomfortable doing so. There is no discretion on whether or not to report abuse. In addition, even suspected child abuse must be reported. The reporting to child protective services should happen immediately so that, there can be an urgent intervention to prevent further abuse. Case (1): A 20-year-old woman brings her seven-year-old son into the emergency department for a broken arm. The child has been to the emergency department twice before for various injuries. The mother lives with her boyfriend who is not the child's father. You have no direct proof that abuse has occurred, and the mother simply states that the child is accident prone. When you ask her whether her domestic partner may be injuring the child, she becomes very angry and vigorously denies it. What should you do? Report suspected child abuse cases no matter what the family says. The child abuse laws are very specific in terms of protecting the mandatory reporter against liability. Even if there is no abuse found, the suspected abuser has no standing to file suit against you as long as you make the report in good faith. In other words, as long as you are sincerely and honestly making the report there is no liability on your end. Although physicians are mandatory reporters, anyone who has a good reason to suspect child abuse can make a report as long as the same criteria are operating. You must have a reason to suspect the abuse and there must be no element of trying to harm or embarrass the family. 39 ELDER ABUSE The same criteria described for child abuse generally apply to elder abuse. Instead of child protective services, there are adult protective services. Reports made in good faith done without liability to the reporter. The circumstances with elder abuse are less than with child abuse, because the elderly person is often a still- competent adult who object to the report of the abuse on the basis that they are afraid of repercussions home or the loss of the home. Nevertheless, you must report elder abuse, breaching the confidentiality of the patient and family is permissible in the interest of protecting a vulnerable person. The other reason that elder abuse reporting is less clear is that there is no uniform standard for it all over the world. The vast majority of regions, however, have a reporting similar to that for reporting child abuse. TORTURE Physicians cannot participate in torture at any level. The knowledge of torture must be reported and opposed as you would report and oppose elder abuse, child abuse, or an impaired driver. You may treat those injured by torture once the victims have been removed from an environment where torture may occur; you cannot treat injuries to allow patients to become well enough to withstand more torture. SPOUSAL ABUSE The ethics and legalities surrounding spousal abuse are somewhat different from those for child abuse and elder abuse. In Egypt, the physicians, according to articles 25 and 26 of the law of criminal procedure together with article 33 of the Egyptian profession ethics (238/ 2003), they have to report any suspected crimes to the police (considered legal duty of the physician) The survivor can postpone the legal process on her request but the doctor should fulfil his/her legal duty by mandatory notification to police. 40 GUNSHOT WOUNDS Reporting of gunshot wounds is mandatory (legal duty of the doctor) but from a different perspective than the other forms of reporting. The mandatory reporting of gunshot wounds is based on pursuing a criminal investigation of the person doing the shooting. Report a gunshot wound even if the victim objects. The societal need for safety supersedes the privacy of the patient in the case of gunshots. GIFTS AND INDUSTRY FUNDING Gifts from industry are to be limited in both type and by numerical monetary value. The presumption is that all gifts from industry are an indirect attempt to obtain influence from physicians in terms of their prescribing patterns. Modest gifts are acceptable only if they are medical or educational in nature. In other words, you can receive books or medical equipment, but you cannot just get a check for cash. 41 CHAPTER FOUR DOCTORS AND COLLEAGUES ILOs: After working through this chapter, you should be able to: Describe how physicians should behave towards one another. Justify reporting unethical behaviour of colleagues. Identify the main ethical principles relating to cooperation with others in the care of the patients. RELATIONSHIPS WITH PHYSICIAN COLLEAGUES, TEACHERS AND STUDENTS As members of the medical profession, physicians have traditionally been expected to treat each other more as family members than as strangers or even as friends. The WMA Declaration of Geneva includes the pledge, “My colleagues will be my sisters and brothers.” The interpretation of this requirement has varied from country to country and over time. For example, where fee- for-service was the principal or only form of remuneration for physicians, there was a strong tradition of ‘professional courtesy’ whereby physicians did not charge their colleagues for medical treatment. This practice has declined in countries where third-party reimbursement is available. Besides the positive requirements to treat one’s colleagues respectfully and to work cooperatively to maximize patient care, the WMA International Code of Medical Ethics contains two restrictions on physicians’ relationships with one another: (1) Paying or receiving any fee or any other consideration solely to procure the referral of a patient; and (2) Stealing patients from colleagues. In the Hippocratic tradition of medical ethics, physicians owe special respect to their teachers. The Declaration of Geneva puts it this way: “I will give to my teachers the respect and gratitude which is 42 their due.” Although present-day medical education involves multiple student-teacher interactions rather than the one-on-one relationship of former times, it is still dependent on the good will and dedication of practicing physicians, who often receive no remuneration for their teaching activities. Medical students and other medical trainees owe a debt of gratitude to their teachers, without whom medical education would be reduced to self-instruction. For their part, teachers have an obligation to treat their students respectfully and to serve as good role models in dealing with patients. The so-called ‘hidden curriculum’ of medical education, i.e., the standards of behaviour exhibited by practicing physicians, is much more influential than the explicit curriculum of medical ethics, and if there is a conflict between the requirements of ethics and the attitudes and behaviour of their teachers, medical students are more likely to follow their teachers’ example. Teachers have a particular obligation not to require students to engage in unethical practices. Examples of such practices that have been reported in medical journals include medical students obtaining patient consent for medical treatment in situations where a fully qualified health professional should do this, performing pelvic examinations on anaesthetized or newly dead patients without consent, and performing unsupervised procedures that, although minor (e.g., I-V insertion), are considered by some students to be beyond their competence. Given the unequal power balance between students and teachers and the consequent reluctance of students to question or refuse such orders, teachers need to ensure that they are not requiring students to act unethically. REPORTING UNSAFE OR UNETHICAL PRACTICES Medicine has traditionally taken pride in its status as a self- regulating profession. In return for the privileges accorded to it by society and the trust given to its members by their patients, the medical profession has established high standards of behaviour for its members and disciplinary procedures to investigate accusations of misbehaviour and, if necessary, to punish the wrongdoers. This system of self- regulation has often failed, and in recent years steps have been taken to make the profession more accountable, for example, by appointing lay members to regulatory authorities. The main requirement for self-regulation, however, is wholehearted support by physicians for its principles and their 43 willingness to recognize and deal with unsafe and unethical practices. This obligation to report incompetence, impairment or misconduct of one’s colleagues is emphasized in codes of medical ethics. For example, the WMA International Code of Medical Ethics states that “A physician shall... strive to expose those physicians deficient in character or competence, or who engage in fraud or deception.” The application of this principle is seldom easy, however. On the one hand, a physician may be tempted to attack the reputation of a colleague for unworthy personal motives, such as jealousy, or in retaliation for a perceived insult by the colleague. A physician may also be reluctant to report a colleague’s misbehaviour because of friendship or sympathy. The consequences of such reporting can be very detrimental to the one who reports, including almost certain hostility on the part of the accused and possibly other colleagues as well. Despite these drawbacks to reporting wrongdoing, it is a professional duty of physicians. Not only are they responsible for maintaining the good reputation of the profession, but they are often the only ones who recognize incompetence, impairment or misconduct. However, reporting colleagues to the disciplinary authority should normally be a last resort after other alternatives have been tried and found wanting. The first step might be to approach the colleague and say that you consider his or her behaviour unsafe or unethical. If the matter can be resolved at that level, there may be no need to go farther. If not, the next step might be to discuss the matter with your and/or the offender’s supervisor and leave the decision about further action to that person. If this tactic is not practical or does not succeed, then it may be necessary to take the final step of informing the disciplinary authority. COOPERATION Medicine is at the same time a highly individualistic and a highly cooperative profession. On the one hand, physicians are quite possessive of ‘their’ patients. It is claimed, with good reason, that the individual physician-patient relationship is the best means of attaining the knowledge of the patient and continuity of care that are optimal for the prevention and treatment of illness. The retention of 44 patients also benefits the physician, at least financially. At the same time, as described above, medicine is highly complex and specialized, thus requiring close cooperation among practitioners with different but complementary knowledge and skills. This tension between individualism and cooperation has been a recurrent theme in medical ethics. The weakening of medical paternalism has been accompanied by the disappearance of the belief that physicians ‘own’ their patients. The traditional right of patients to ask for a second opinion has been expanded to include access to other healthcare providers who may be better able to meet their needs. However, physicians are not to profit from this cooperation by fee-splitting. These restrictions on the physician’s ‘ownership’ of patients need to be counter balanced by other measures that are intended to safeguard the primacy of the patient- physician relationship. For example, a patient who is being treated by more than one physician, which is usually the case in a hospital, should, wherever possible, have one physician coordinating the care who can keep the patient informed about his or her overall progress and help the patient make decisions. Whereas relationships among physicians are governed by generally well-formulated and understood rules, relationships between physicians and other healthcare professionals are in a state of flux and there is considerable disagreement about what their respective roles should be. Many nurses, pharmacists, physiotherapists and other professionals consider themselves to be more competent in their areas of patient care than are physicians and see no reason why they should not be treated as equals to physicians. They favour a team approach to patient care in which the views of all caregivers are given equal consideration, and they consider themselves accountable to the patient, not to the physician. Many physicians, on the other hand, feel that even if the team approach is adopted, there has to be one person in charge, and physicians are best suited for that role given their education and experience. Although some physicians may resist challenges to their traditional, almost absolute, authority, it seems certain that their role will change in response to claims by both patients and other healthcare providers for greater participation in medical decision- making. Physicians will have to be able to justify their recommendations 45 to others and persuade them to accept these recommendations. In addition to these communication skills, physicians will need to be able to resolve conflicts that arise among the different participants in the care of the patient. A particular challenge to cooperation in the best interests of patients' results from their recourse to traditional or alternative health providers. These individuals are consulted by a large proportion of the population in Africa and Asia and increasingly so in Europe and the Americas. Although some would consider the two approaches as complementary, in many situations they may be in conflict. Since at least some of the traditional and alternative interventions have therapeutic effects and are sought out by patients, physicians should explore ways of cooperation with their practitioners. How this can be done will vary from one country to another and from one type of practitioner to another. In all such interactions the well-being of patients should be the primary consideration. 46 CHAPTER FIVE FRAMEWORK FOR SOLVING ETHICAL DILEMMAS (RIGHT VS. RIGHT) ILOs: After working through this chapter, you should be able to: Evaluate Ethical problems. Choose the best practice in a clinical setting. An ethical dilemma is a situation that often involves an apparent conflict between moral principles, in which to obey one would result in overriding another. There is no one best for all situations. Ethical issues not uncommonly force us into grey areas where smart isn’t necessarily good. Science cannot resolve moral conflicts, but it can help to frame the debates more accurately about those conflicts. Steps to solve ethical problems: 1. Gather the facts. (Good ethics starts with the correct facts) a) What are the medical facts in this case? b) What is the nature of the conflict? c) What courses of action are available? d) Which individuals are involved in the decision-making process? e) Who will be affected by the outcome of the decision? f) What is the patient (or family) preferences? 2. What constraints limit the choice of action? o The law. o Personal values & religion. o Medical knowledge and skill. o Professional contracts and codes of practice (duty). o The rights of the individual(s) involved. Notice that: Not all topics will be relevant for the analysis of every clinical case. More often, the dilemma will be centred to one or two of these issues. The four principles provide a clear way of attempting 47 to shift physicians towards a more balanced attitude (autonomy, Beneficence, Nonmaleficence and Justice). Young practitioners who approach ethical issues with an attitude which reflects predominantly one of the four principles: (beneficence) Perhaps they have a bias towards paternalism. 3. Examine each potential action: a) Which ethical principles support this course of action? b) Which ethical principles appear to be violated by this course of action? c) What are the possible consequences of this course of action? 4. Discuss the alternatives: Does one choice emerge as the best option? If a widely held principle is being challenged Consider seeking help from colleagues, legal advisers and ethical expert. 5. Make a choice but be aware of the limits of confidence. 6. Record the justification for the selection. In reality, ethical problems (like other real-life clinical problems) are untidy, slippery and not usually susceptible to neat solutions. An important practical skill is learning to act under conditions of uncertainty. Beware that Factors Influencing Decisions Are: o Context the circumstances surrounding the issue, social influences. o Values, which are derived from personal beliefs. o Rules, which are sometimes derived from external sources such as institutions or ethical theories. o Person's motives, the consequences of the action. Clinical Ethics: From Ethical Theory to Clinical Practice The main questions when trying to resolve a moral issue are: a) Which actions are in the patient's best interest? b) Which action develops moral virtues? 48 c) Which actions violate others’ rights? d) Which action treats everyone the same, and does not show favouritism or discrimination? e) Which Ethical Principals promoted or violated in each decision. 49 ETHICAL PROBLEMS It is necessary to be able to reach a decision based in knowledge and moral justification. The following cases are not meant to be model consultations but show attendant physicians how to do their best to study and solve an ethical conflict. Use the previous guidelines repeatedly to master the process then you will be able to handle every case separately & differently. Keep the discussion centred on the ethical aspects of the problem. Case (1). 86 years old lady presenting with her first attack of epilepsy. The investigations proved a brain tumour (meningioma 1cm). The neurosurgeon advised brain surgery. Her elderly son is a doctor and was asking an ethical decision advice as he wants to omit her the troubles of surgery at her age and at the same time, he needs to do what is in her best interest. What is your opinion? Review of the Medical Facts.  Facts: slowly progressive lesion- not life threatening – she is likely to be kept on antiepileptic drugs for life after surgery.  Facts: the hazards of the operation at her age.  Facts: is she competent?  Facts: her family preferences.  Facts: The pressure from the surgeon. Options: Operate or not. Sequel: she might be left hemiplegic- in any situation she will need help and continuous attention. Identification of ethical dilemma(s) Patient (or family) preferences (autonomy) against the doctor's code of duty. Is it a futile treatment? What are the patients’ best interest? Ethical Principals promoted or violated in the decision. o Rights (autonomy) o Duty (respect her best interest) here is a conflict between family view & treating surgeon point of view. 50 o Consequences (end) o Virtue (surgeon: Help, Duty & Responsibility.) o Virtue (Family: Do no harm, keep her in peace and at the same time offer her the best chance for cure). Choices: Effect of the proposed courses of action in the overall well-being of the patient (patient’s best interest). Legal and socio- cultural context. (Codes: duty, help, beneficence). Case (2): A 64-year male patient with Colon Cancer, which has recurred after surgery. The patient has been in relatively good health until a few days ago, when he presented anuria, confusion, nausea and pruritus. An obstructive uropathy due to recurrent cancer was diagnosed. The patient is stuporous at this moment, as is incoherent. His physician believes that uraemia is a relatively painless form of dying, and therefore recommends not doing any corrective surgery. The wife of the patient insists in surgery, as he was not on any pain whatsoever, and was doing relatively well. 1. What should he do next? Follow the standards of practice and resuscitate the patient. 2. Does the principle of patient autonomy apply here? No. Autonomy is not a priority in emergency situations. 3. Can the physician perform a treatment against the consent of the patient? In this situation yes. Yes, because the patient is unable to give consent and the situation is life threatening. 4. What is the responsibility of the ER physician in this matter? Physicians main concern in emergency situations is to save patients life. If he does anything else, he will find himself in court and will lose. 51 GLOSSARY Key words in medical ethics: o Active euthanasia: Requires that a person, other than the patient, such as the health care worker, perform an action that brings about death. o Advanced directives: allow patients to make decisions about their own health care in advance in case a situation arises in which the patient is no longer able to make health care decisions or provide informed consent. The patients documented wishes specifying what interventions would or would not want he or she become terminally ill, comatose, injured in an accident or after his death (organ donation) o Altruism: An emphasis on doing good for others rather than in self-interest. o Assault: A threat of touching another person without his or her consent. o Authority: The power to enforce laws, exact obedience, command, determine, or judge. One that is invested with this power, especially a government or body of government officials. o Autonomy: Self-control. o Beneficence: Doing and promoting good. o Bioethics: A field that looks at how people make choices regarding right and wrong action in disciplines related to biology, health, research, nursing, medicine, bioengineering, and other related fields. o Capacity: "Capacity" refers to the patient's ability to understand information relevant to a treatment decision and to appreciate its reasonably foreseeable consequences. o Communication: The transmission of ideas o Confidentiality: Patients’ information is kept private. No third party is allowed to know. o Context: The sum of all the factors that influence the meaning of a particular use of language without being a part of the use of language in question. 52 o Do Not Resuscitate order (DNR): Indicate when patients do not want CPR if their heart stops beating or they quit breathing; health care workers will try to resuscitate any patient who doesn't have a DNR order; patients who are not likely to benefit from CPR, such as patients with advanced cancers, may choose to have a DNR order. o Ethics: That branch of philosophy that studies how and why people make decisions regarding what is right and what is wrong. It is the science of conduct. o Euthanasia: Comes from two Greek roots which translate literally to "a good death, or merciful death ―. Euthanasia is the intentional killing through a painless method to end suffering and requires that another person (such as a loved one or a health care worker) actively participate in bringing about death; euthanasia may be active or passive and voluntary, nonvoluntary, or involuntary. o Fraud: Misrepresentation of self or action that may cause harm to a person or property. o Futility: The goal of medical intervention is not expected to preserve life, restore health, or relieve suffering. o Gender: A person’s gender refers to that individual’s affiliation with either male or female social roles. Gender differs from sex in the same way that ethnicity differs from race: gender is a sociological concept, while sex is a biological one. o Gold standard: A method, procedure or measurement that is widely accepted as being the best available. o Guideline: A systematically developed statement designed to assist clinician and patient decisions about appropriate health care for specific clinical circumstances. Guidelines should be based on evidence, combined with local knowledge to ensure that they are appropriate for local conditions. o Impartiality: In ethics, an impartial standpoint is one which treats everyone as equal. For many philosophers, impartiality is an essential component of the moral point of view. o Informed consent: obtained by medical providers prior to administering treatment or participation in medical research; the patient should understand the condition that is being treated, the available treatment options, and the risks and benefits of each treatment option. 53 o Justice: Defined by different philosophers in different ways: fairness, opportunity, equal share, social merit. o Medical Ethics: Examining right and wrong behaviour within the field of medicine. o Morality: A complete worldview that includes what is right and what is wrong. o Nonmaleficence: To do no harm. To not act when action would cause harm because of ignorance, unsuitable environment, scientifically not valid. o Paternalism: Making decisions and choices for another person. Sometimes the person is unable to make those choices. Other times the person is simply not told or consulted. o Patient's Bill of Rights: a document that explains the rights and responsibilities of patients at a health care facility. o Quality of life: Quality of life is a descriptive term that refers to an individual's emotional, social, and physical well-being, and their ability to function in the ordinary tasks of living. o Testamentary capacity: Refers to the capacity to make a will. A valid will can be written by a person who knows what he is doing, knows what he owns, and knows who will benefit from the will and his relationship to those persons. o Uncertainty: An event or outcome that is not certain but may or may not happen is uncertain. When the uncertainty is quantified on the basis of empirical observations, it is called risk. o Utility: In economic and decision analysis, the desirability of an outcome, usually expressed as being between zero and one (e.g., death typically has a utility value of zero and a full healthy life has a value of one). o Utilitarianism: A theory which sees an action as moral and ethical when such an action produces the greatest good for the greatest numbers. o Value: A quality held to be desirable, important, or of worth. 54 APPENDIX A THE HIPPOCRATIC OATH The methods and details of medical practice change with the passage of time and the advance of knowledge. Many fundamental principles of professional behaviour have, however, remained unaltered throughout the recorded history of medicine. The Hippocratic Oath was probably written in the fifth century BC and was intended to be affirmed by each doctor on entry to the medical profession. In translation (this by Francis Adams, London, 1849) it reads as follows. 55 I swear by Apollo the physician, and Aesculapius and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation – to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this Art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none other. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to anyone if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion. With purity and with holiness I will pass my life and practice my Art. I will not cut persons labouring under the stone but will leave this to be done by men who are practitioners of this work. Into whatever houses I enter, I will go into them for the benefit of the sick and will abstain from every voluntary act of mischief and corruption; and, further, from the seduction of females, or males, of freemen or slaves. Whatever, in connection with my professional practice, not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret. While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the Art, respected by all men, in all times. But should I trespass and violate this Oath, may the reverse be my lot. 56 APPENDIX B DECLARATION OF GENEVA Adopted by the 2nd General Assembly of the World Medical Association, Geneva, Switzerland, September 1948 and amended by the 22nd World Medical Assembly, Sydney, Australia, August 1968 and the 35th World Medical Assembly, Venice, Italy, October 1983 and the 46th WMA General Assembly, Stockholm, Sweden, September 1994. AT THE TIME OF BEING ADMITTED AS A MEMBER OF THE MEDICAL PROFESSION: I SOLEMNLY PLEDGE myself to consecrate my life to the service of humanity; I WILL GIVE to my teachers the respect and gratitude which is their due; I WILL PRACTISE my profession with conscience and dignity; THE HEALTH OF MY PATIENT will be my first consideration; I WILL RESPECT the secrets which are confided in me, even after the patient has died; I WILL MAINTAIN by all the means in my power, the honour and the noble traditions of the medical profession; MY COLLEAGUES will be my sisters and brothers; I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, or social standing to intervene between my duty and my patient; I WILL MAINTAIN the utmost respect for human life from its beginning even under threat and I will not use my medical knowledge contrary to the laws of humanity; I MAKE THESE PROMISES solemnly, freely and upon my honour. 57 APPENDIX C WORLD MEDICAL ASSOCIATION Resolution on the Inclusion of Medical Ethics and Human Rights in the Curriculum of Medical Schools World-Wide (Adopted by the 51st World Medical Assembly, Tel Aviv, Israel, October 1999) 1. Whereas Medical Ethics and Human Rights form an integral part of the work and culture of the medical profession, and 2. Whereas Medical Ethics and Human Rights form an integral part of the history, structure and objectives of the World Medical Association, 3. It is hereby resolved that the WMA strongly recommend to Medical Schools world-wide that the teaching of Medical Ethics and Human Rights are included as an obligatory course in their curricula. WORLD FEDERATION FOR MEDICAL EDUCATION (WFME): Global Standards for Quality Improvement – Basic Medical Education (www.sund.ku.dk/wfme/Activities/Translations%20of%20St andard%20Documents/WFME%20Standard.pdf) These standards, which all medical schools are expected to meet, include the following references to medical ethics: 1.4 Educational Outcome The medical school must define the competencies (including knowledge and understanding of medical ethics) that students should exhibit on graduation in relation to their subsequent training and future roles in the health system. 4.4 Educational Programme – Medical Ethics The medical school must identify and incorporate in the curriculum the contributions of medical ethics that enable effective communication, clinical decision-making and ethical practices. 4.5 Educational Programme – Clinical Sciences and Skills Clinical skills include history taking, communication and team leadership skills. Participation in patient care would include 58 teamwork with other health professions. 4.4 Educational Resources – Research The interaction between research and education activities should encourage and prepare students to engage in medical research and development. 59 REFRENCES 1. Beauchamp TL, Childress JF: Principles of Biomedical Ethics, 2d ed. New York: Oxford University Press, 1983. 2. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 4th ed. New York: Oxford University Press, 1994. 3. Abdul Rahman C. Amine, M.D. and Ahmed Elkadi, M.D. Islamic Code Of Medical Professional Ethics. 4. Iserson KV, Sanders AB, Mathieu D (Editors) Ethics In Emergency Medicine, Second Edition 5. J Med Ethics 2001; 27:192-197, Truth-telling and patient diagnoses. 6. Riffat Hassan, Department of Religious Studies University of Louisville, Louisville, Kentucky "Gender Equality and Justice in Islam. 7. Robert J Sullivan, Lawrence W Menapace, and Royce M White. Truth-telling and patient diagnoses. J Med Ethics 2001; 27: 192- 197. doi:10.1136/jme.27.3.192 8. World Medical Association Medical Ethics Manual, 2005. 9. English,V.; Romano-Critchley, G. ; Sheather, J. and Sommerville A. ed.; Medical Ethics Today, The BMA’s handbook of ethics and law Second edition, MPG Books, Bodmin, Cornwall; 2004. 10. Medical ethics practice by Mossalam, A.; 2006.Russell and R.L. Burch (1959) The Principles of Humane Experimental Technique. http://www.nc3rs.org.uk/ 11. Principles for allocation of scarce medical interventions. Lancet. 2009; 373: 423-431 12. World health report. World Health Organization, Geneva; 2006 13. Medicine prices, availability, and affordability in 36 developing and middle-income countries: a secondary analysis. Lancet. 2009; 373: 240-249. 14.Prendergast, M. (2009). Who Should Receive Life Support During a Public Health Emergency? Using Ethical Principles to Improve Allocation Decisions. Journal of Emergency Medicine, 37(2), 247. 15.Kim, S. Y., Kwakkenbos, L., May, A., Nicholl, J., & Young-Afat, 60 D. (2017). The ethics of ‘Trials within Cohorts’ (TwiCs): 2nd international symposium. Health Services Research Unit, Aalborg University, Aalborg, Denmark. 16.Bolton, K. D. (2012). Ethical musing about the allocation of scarce resources, renal transplants and commercialisation. SA Orthopaedic Journal, 11(3), 74-78. 17.Persad, G., Wertheimer, A., & Emanuel, E. J. (2009). Principles for allocation of scarce medical interventions. The Lancet, 373(9661), 423-431. 18.Holm, S. (2017). Distributive Justice as a Means of Combating Systemic Racism in Healthcare. 19.Persad, G., Wertheimer, A., & Emanuel, E. J. (2009). Principles for allocation of scarce medical interventions. The Lancet, 373(9661), 423-431. 20.Kim, S. Y., Kwakkenbos, L., May, A., Nicholl, J., & Young-Afat, D. (2017). The ethics of ‘Trials within Cohorts’ (TwiCs): 2nd international symposium. Health Services Research Unit, Aalborg University, Aalborg, Denmark. 21.Emanuel, E. J., Persad, G., Upshur, R., Thome, B., Parker, M., Glickman, A.,... & Phillips, J. P. (2020). Fair allocation of scarce medical resources in the time of Covid-19. New England Journal of Medicine, 382(21), 2049-2055. 22.Emanuel, E. J., Persad, G., Upshur, R., Thome, B., Parker, M., Glickman, A.,... & Phillips, J. P. (2020). Fair allocation of scarce medical resources in the time of Covid-19. New England Journal of Medicine, 382(21), 2049-2055. 61 62

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