Introduction to Medical Ethics

1. Introduction to Medical Ethics
Dr Md. Yunus
Additional Professor
&
Co-ordinator of Medical Education Unit,
NEIGRIHMS, Shillong

2. 2

3. Disclaimer
“I’m not an ethicist but I do ethics”

4. • Nowadays, conflicts of interests between
the government & medical institutions,
between medical institutions and medical
personnel, between physicians and
patients are getting more and more
serious and complex.
Why Ethics Become Important?

5. • High technologies not only brought
us hopes of cure but have also
created a heavy economic burden.
• The ethical dilemmas of high
technology medicine-brain death,
organ transplantation, and concerns
about quality of life-have become
increasingly prominent.

6. Ethics are not …
• Ethics is not the same as feelings
• Ethics is not religion
• Ethics is not following the law
• Ethics is not following culturally
accepted norms
• Ethics is not science

7. Ethics are …
• Moral Principles
• What is good and bad
• What is right and wrong
• Based on value system
• Ethical norms are not
universal – depends on the sub
culture of the society

8. Ethics are …
Ethics refers to standards of behavior
that tell us how human beings ought
to act in the many situations in
which they find themselves
as friends, parents, children, citizens,
businesspeople, teachers,
professionals, and so on.

9. Historically
• Medical ethics may be traced to
guidelines on the duty of physicians
such as the Hippocratic oath

10. What is Ethics?
• Ethics are standards of conduct (or social
norms) that prescribe behavior.
• Ethics as a field of study is a normative
discipline whose main goals are prescriptive
and evaluative rather than descriptive and
explanatory.
• So Ethicists are different from social
scientists.
• Ethicists (or moral philosophers) study
standards of conduct.

11. Four basic Principles of
Medical Ethics
• Autonomy
• Beneficence
• Non maleficience
• Justice

12. Autonomy
►Paramount
►Being self-governing
►Able to exercise free will in
making a personal decision
►A right to withhold consent
►Applicable to anyone who has
capacity

13. Beneficence
►Literally being charitable or doing
good
►Performing care so as to maximise
patient wellbeing
►Exercising clinical judgement
►Going beyond the minimum
standards required

14. Beneficence
• The practitioner should
act in “the best interest”
of the patient - the
procedure be provided
with the intent of doing
good to the patient

15. • This needs health care
provider to,
-Develop and maintain skills
& knowledge by continually
updating training
- Consider individual
circumstances of all patients

16. Non maleficence
• “Above all, do no
harm,“ – Make sure that
the procedure does not
harm the patient or
others in society

17. Non-malificence
►Doing no harm
►Avoidance of putting a person at
risk of avoidable harm
►A 1st step towards beneficence
►Defined under the Hippocratic
oath

18. Medical malpractice
• An act or omission by a
health care provider
that deviates from
accepted standards of
practice in the medical
community which
causes injury to the
patient.

19. Justice
►No single definition
►Usually distributive justice
when applied to medical ethics
►Fairness
►Equity
►Method of righting wrongs

20. Justice
• The distribution of scarce health
resources, and the decision of who
gets what treatment “fairness and
equality”
• The burdens and benefits of new or
experimental treatments must be
distributed equally among all groups
in society

21. Limitations
►Very simplistic
►Autonomy trumps the other
principles
►Role of justice
►No coherent approach to resolving
conflicting principles

22. Other factors
►Patient expectations
►Family expectations
►Genuine uncertainty
►Wishes of patient
►Wishes of family
►Cultural values
►Religious values
►Preferences of
professionals
►Power balance within the
healthcare team
►Trust policies
►Financial issues
►Legal issues

23. To distinguish between Ethics and Policy
• Political standards focus on the conduct of groups
or social institutions, whereas ethical and moral
standards focus on the conduct of individuals.
• Political standards take a macro-perspective on
human affairs; ethical and moral standards adopt a
micro-perspective.
• However, the distinction between ethics and
politics is not absolute since many actions,
institutions, and situations can be evaluated from
an ethical or political point of view.

24. Professional Ethics
• Professional ethics are standards of conduct that apply
to people who occupy a professional occupation or role.
• A person who enters a profession acquires ethical
obligations because society trusts them to provide valuable
goods and services that cannot be provided unless their
conduct conforms to certain standards.
• Professionals who fail to live up to their ethical obligations
betray this trust.
• Professional ethics studied by ethicists include medical
ethics.

25. Medical ethics
• The expressions “professional ethics” and
“medical ethics” were coined by Thomas
Percival.
• Medical ethics is a special kind of ethics
only as it relates to a particular realm of
facts and concerns and not because it
embodies or appeals to some special moral
principles or methodology.

26. Bioethics
• Bioethics could be defined as the study
of ethical issues and decision-making
associated with the use of living
organisms
• Bioethics includes both medical ethics
and environmental ethics.
• Bioethics is learning how to balance
different benefits, risks and duties.

27. Clinical ethics
Clinical ethics is a
practical discipline that
provides a structured
approach for
identifying ,analyzing, and
resolving ethical issues in
clinical medicine.

28. • Clinical medical ethics is a practical &
applied discipline that aims to improve
patient care and patient outcomes by
focusing on reaching a right and good
decision in individual cases.
• It focuses on the doctor-patient relationship
and takes account of the ethical and legal
issues that patients, doctors, and hospitals
must address to reach good decisions for
individual patients.

29. • Clinical ethics emphasizes that in
practicing good clinical medicine,
physicians must combine scientific
and technical abilities with ethical
concerns for the personal values of
the patients who seek their help.

30. The content of clinical
ethics includes
• specific issues such as truth-telling, informed
consent, end of life care, palliative care,
allocation of clinical resources, and the ethics
of medical research.
• the study of the doctor-patient relationship,
including such issues as honesty, competence,
integrity, and respect for persons.

31. Ethical Issues in
Modern Healthcare
In modern healthcare and research, value conflicts arise
where often there appears to be no clear consensus as to
the “Right thing to do.” These conflicts present
problems requiring moral decisions, and
necessitates a choice between two or more
alternatives.
Examples:
• Should a parent have a right to refuse immunizations for
his or her child?
• Does public safety supersede an individual’s right?

32. Ethical Questions, Cont.
• Should children with serious birth defects be kept
alive?
• Should a woman be allowed an abortion for any
reason?
• Should terrorists be tortured to gain information
possibly saving hundreds of lives?
• Should health care workers be required to receive
small pox vaccination?
• Who should get the finite number of organs for
transplantation?

33. Ethical Theories:
Ideas and Actions
• Deontology (duty)
• Consequentialism (actions)
• Virtue Ethics/Intuition (morals
and values)
Beliefs
• Rights Ethics (individuality and
the American culture)

34. Two questions when faced
with a dilemma:
• Behavior: What should I do?
• Motivation: Why should I do it?

35. What Are Ethical Principles,
and How Do They Help
With Decision Making?

36. Ethical Principles
• Autonomy/Freedom
• Veracity
• Privacy/Confidentiality
• Beneficence/Nonmaleficence
• Fidelity
• Justice

37. Veracity
• The duty to tell the truth.
Truth-telling, honesty.

38. Privacy/Confidentiality
• Respecting privileged knowledge
• Respecting the “self” of others.

39. Fidelity
• Strict observance of promises or
duties.
• This principle, as well as other
principles, should be honored by
both provider and client.

40. Ethical Communication
• How to explore positive
communication techniques which
can be used in obtaining consent
for treatments (Feature Benefit
Check)!

41. Ethics Committees
• Decision making in health care often
involves more than just medical
facts of the case
• Ethical principles and values will be
the determining factor in which
course of action to take.
• Many health care facilities have
established Ethics committees.

42. Ethics Committees
• Found in most health care facility’s
• Usually Ten to Twelve members
• Multidisciplinary members
– A representative from the Board of dirctor
– The Administrator
– A physician
– An area clergy
– A Social Worker
– A Judge
– An Ethic ist (Usually a philosophy or
Sociology professor)
– Lay persons from the community

43. Functions of the Committee
• Education
– To committee members themselves
– Continuing education and inservice to
facility’s staff
– To the community

44. Functions continued
• Development and review of laws,
standards of care, institutional
policies and guidelines
– About withdrawing and withholding
nutrition and hydration
– Do Not Resuscitate
– Utilization of facility’s/communities
resources

45. Functions continued
• Case Consultation with:
– Family members
– Patients
– Health care providers
– Staff

46. Case Consultation May:
– Provides information about ethical
principles relevant to the case under
discussion
– Help clarify what options are open
– Provide information about relevant
policies of the facility
– Make a recommendation that is
advisory in nature

47. Changing Scope of Ethics
Committees
• Committees are expanding their scope
of their activity to include
organizational ethics, considering
questions regarding:
– Finances
– Administration
– Organization
– Human Resource

48. Informed Consent
Origins of the Informed Consent Doctrine
• Right to be free from nonconsensual interference with
one’s person
• Morally wrong to force one to act against his or her will
• Serves six functions
– Protect individual autonomy
– Protect patient status as human being
– Encourage physicians to carefully consider decisions
– Avoid fraud or duress
– Foster rational decision-making by patients
– Increase public involvement in medicine

49. Informed Consent
Legal framework for Informed Consent
• Historically was based on “Battery Theory”
– Unwanted touching
– Not operative today in almost all jurisdictions
– May be operative if there is no consent at all (i.e.
operating on the wrong knee)
• Negligence: Operative in virtually all
jurisdictions
– Prima facie case based on:
• Duty to disclose information
• Failure to disclose (unless statutory exception
met)
• If information had been disclosed, patient
would not have consented to procedure
• Injury and damages

50. Informed Consent
Duty to disclose standards
• Professional Standard
– Physician has disclosed information that a
reasonable or prudent doctor would have
disclosed under similar circumstances
• Patient-need standard
– What a reasonable person would want to know;
information that would be material to a patient
• States with statutes usually adopt the
“Professional Standard”
• Case law is split 50-50 on which standard to
follow

51. Informed Consent
What must be disclosed
• The condition or diagnosis
• Nature and purpose of treatment
• Risk of treatment
• Treatment alternatives which includes:
– Things that are already known
– Things that everybody should know
– Option of no treatment
– All alternatives do not have to be
disclosed

52. Informed Consent
Exceptions to the General Rule of Disclosure
• Patient is unconscious or otherwise incapable of
consenting (Emergency treatment)
– Harm from failure to treat is imminent
– Outweighs any harm threatened by proposed
treatment
• Therapeutic Privilege
– Risk disclosure poses such a threat of detriment to a
patient as to become unfeasible or contraindicated
from a medical point of view
– Does not accept the paternalistic notion that the
physician may remain silent because divulgence
might prompt the patient to forego therapy the doctor
believes the patient must receive

53. Informed Consent
Causation Issues
• Disclosure of information would have caused the
patient to refuse to undergo the treatment
– Subjective: The patient states that if s/he had known,
s/he would have refused the intervention. This
standard is impossible to prove because anyone could
say they would have refused if they had known
something they claim was not disclosed.
– Objective: One must prove that a reasonable patient
would not have agreed to the intervention if s/he had
known.
• Most states have adopted the objective standard

54. World Medical Association
Declaration of Geneva
• I SOLEMNLY PLEDGE to consecrate my life to the service of humanity;
• I WILL GIVE to my teachers the respect and gratitude that 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 that 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, social standing or any
other factor to intervene between my duty and my patient;
• I WILL MAINTAIN the utmost respect for human life;
• I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even
under threat;
• I MAKE THESE PROMISES solemnly, freely and upon my

55. MEDICAL ETHICS CREATE
BETTER PHYSICIANS
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Medical Ethics
VirtuesGood of the patient Excellent physician
Self understood goodBiological-medical good

56. GOOD PRACTICE YOU WILL
FLOURISH
• Basic template for professions:
• identify distinguishing characteristic
• Rank virtues for particular profession
• Define professional excellence
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Ethics
Values Virtues Flourishing life

57. • WHAT IS YOUR CHOICE
MAKES DIFFERENCE ???
• Medicine is about : “Can we?”
• Ethics is about: “Should we?”
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58. Created by Dr Md. Yunus
for Learning & Development of Post
Graduate Medical Student
Email: drmdyunus@hotmail.com
Web: www.neigrihms.nic.in