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Ministry of Ethics


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Ministry of Ethics

  1. 1. Contact Details: Mark Baxter Email: Unfortunately, our video content was too large to upload to the internet, so I have included a screenshot of each video along with a youtube link and case notes to accompany each video. Introduction to our Project
  2. 2. Example Topic 1: Organ Donation Case Notes: LEARNING OBJECTIVES o The significance andlimitsof respectforpatientautonomy o Proxyconsent o Bestinterestsof patientswholackcapacity o Local,national andinternational prioritizationinrelationtoclinical decisions LEGAL ASPECTS OF CASE A healthcare professional shouldtryandfindoutif a patienthasindicatedif theywishtodonate theirorgans.Thiscan be done bycheckingthe Organ Donor Register,lookingforanorgan donor card on the person,or checkingthe patient'smedical records.If thisisthe case,organdonationcan thengo ahead,legally. The Human Tissue Act2004 detailsthe guidelinesforwhichorgandonationcanoccur. If the patienthasindicatedtheirwishfororgandonation,buttheirfamilyobjectstoit,thenlegally under the Human Tissue Act 2004, the familycannot vetothis consent. In practice th ough,few surgeonswouldconsidercarryingoutorgan retrieval overthe family'swishes. If the patienthasnotindicatedtheirwishfororgandonationbefore theirdeath,consentcanbe givenposthumously,byapersonina 'qualifyingrelationship'(HumanTissue Act 2004). The Human Tissue Actactuallyrankspeople whocouldbe ina 'qualifyingrelationship'withthe patient,asto whocan give consentfirst.
  3. 3. ETHICAL ISSUES RAISED  In posthumousdonation,adeadpersonlackscapacityto consent.Soby giving'treatment'- ventilatingthem,are youactinginthe patient'sbestinterests?Butdoesadeadpersonhave any interestsanyway?  Consentto'treatment'by anotheradultisnot allowedinall otherbranchesof medicine, unlessthe patienthascreatedalastingpowerof attorney.Whyshoulditbe differenthere?  Whichorgans are beingdonated?Shouldall the organsbe usedfordonationtomaximise the benefitfromone donor? IN CLINICAL PRACTICE Organs and tissuessuitable fortransplantation:  Organs: kidney,heart, lung,liver,pancreas,small bowel  Tissues:cornea,bone,tendon,skin,heartvalve. Familiesmustneverfeelunderanypressure toagree todonation,andmustbe assuredthat their decisionwillbe respected. The NHSBT (NHS Blood & Transplant) service has strict rulesforthe subsequentorganallocation. Thissystemaimsto treatpatientsequally,toensure thatorgansare allocatedfairlyaccordingto patients'needs,andtoachieve the bestpossible matchbetweendonorsandrecipients. REFERENCES 1. Human Tissue Act2004 2. Organ DonorRegister p
  4. 4. Example Topic 2: Ethics of Medical Audit and Research Case Notes: LEARNING OBJECTIVES o Confidentialityforpublications/casereports/audits o The purposesand differencesbetweenresearchandaudit o Ethical,professional andlegal considerationsinvolvedinmedical researchandaudit o National/Local ethicscommittee o Ethical and legal issuesinconductingandreportingclinical trials LEGAL ASPECTS OF THE CASE  It isvital to define researchadequatelytofollowthe appropriate guidelines.  Informedconsentmustbe obtainedfromall participants.Thisincludesadequatelyproviding informationof the benefitsandrisksinvolved.The onlyexceptiontothisisif the patienthas impairedmental capacity.  Clinical researchmustbe approvedatnational andlocal levelsbyethicscommittees.The NHS site (R&Ddepartment) mustalsobe made aware of,and approve anyprojectsor investigations. ETHICAL ISSUES RAISED  Doctors have a dutyto do good fortheirpatients:the principleof beneficence.Medical research(involvingpatientsdirectlyorindirectly) isvital topromote andimprove existing healthcare inthe presentandalsoindiscoveringtherapiesandtreatments.
  5. 5.  Patients'autonomymustbe respected.'The relationshipbetweenadoctorand a patientis basedon trust,and the participants'rightstomake a decisionontheirinvolvementinany researchmustbe protected'.[1] Hence,anyparticipantsmustbe informedif they are tobe involvedinanyresearch,inordertogetconsent.  However,informedconsentisonlyvalidif patientsare givenhonestinformationaboutthe researchand are informedfullyaboutall the benefitsandrisks.  The principle of non-maleficence mustalsobe adheredto.Asmentioned,the primaryaimof researchisnot intendedtodirectlybenefitthe currentparticipants,andsotheymay notget any benefitsfromit.BUT, measure mustbe takento ensure thatall risksare minimised- and again,patientsare informedof thiswhenyougetconsent. IN CLINICAL PRACTICE DefiningClinical Research 4 keydiscriminantsare,aslaidoutin'DefiningResearch(2010)'by the National ResearchEthics Service (NRES):intent,treatment/service,allocationandrandomisation. [2] i. Intent.The primaryaimof researchisto derive new knowledge2,whichisbeneficial to future patientsandthe widerpopulation.Thisisdifferenttoservice evaluationsorclinical audits,where the aimsare to judge andevaluate currentstandardsof care. If a projecthasmultiple intentions,itmaybe harderto define whatitis.Inthiscase it may necessary to seekclarificationandjudgement,eitherfromaResearchEthicsCommittee (NationalorLocal),or eventhe ResearchandDevelopmentoffice locatedatthe NHS site where the projectistakingplace. ii. Treatment/Service."Neitherauditnorservice evaluationusesaninterventionwithouta firmbasisof supportin the clinical orhealthcommunity."(DefiningResearch,2010) [2] iii. Allocation.Allocationof Treatmentfollowsprotocol andadefinedframeworkinresearch. In auditsandservice evaluations,noallocationtakesplace.Treatmentischosenjointlyby the patient/clinicianbeforeeithertake place. iv. Randomisation.Researchmayuse randomisation.AuditsandService Evaluationsdonot. Applyingfor Research Approval: Afterthe projectisdesignedandinformedconsentisobtained,the followingprocedure needstobe followedtoobtainapproval: o Applicationsneedtobe made usingthe IntegratedResearchApplicationsSystem- IRAS ( o Applicationsthenneedtobe bookedinforreview withanappropriate REC,eithertovia the central allocationsystem,ordirectlyviathe local allocationservice.Once abookingis
  6. 6. made,the applicationandsupportingdocumentsneedtobe submittedtothe allocated REC within4 days. o Once a validapplicationisreceived,the REChas60 days to returnan opiniononwhether the researchcomplieswiththe currentethical regulations. REFERENCES 1. General Medical Council: 2. 'DefiningResearch':NationalResearchEthicsService, 2010.
  7. 7. Example Topic 3: Conflictsof Interestwith Financial Incentives Case Notes: LEARNING OBJECTIVES o Respectforthe role,responsibilitiesandrequirementsof the GMC andits primaryconcern to promote the healthandsafetyof patients o Importance of trust,integrity,honestyandgoodcommunicationinprofessional relationships o Acceptingpersonal responsibilityandbe aware of limitationsandseekingappropriate help. o Professionalboundarieswithpatients. o Conflictsof Interest o Respondingtoclinical errorsandreportingadverse incidents o Legal and ethical responsibilitiesforprotectingpatients LEGAL ASPECTS OF THE CASE NHS General Medical ServicesContract (2004)  Schedule 5 A GP may notaccept a fee froman NHS patientforservicesunlesstheyare specificallyoutlinedin the above document.Thisparticulararrangementisnotmentioned andthusthe doctormay not demandpaymentforit.  Schedule 6Paragraph 124 GPs mustkeepa registerof all giftsfrompatientsandoutside partiesabove the value of £100. This registermustbe made available tothe PCTon request. Thusinthissituation, if he acceptsa monetaryor non-monetarygiftof value greaterthan£100 for hisendorsement,itmustbe recorded.
  8. 8. GPPartnership Agreement Each GP practice has a PartnershipAgreement(essentiallyaconstituition)outliningfinancial policy. If,in this policy,extraearningsare sharedcommunallybetweenpartners,the GPmustensure that hispartnersare happyto endorse the dvdas well because byacceptingpayment,theirendorsement isimplied. ETHICAL ISSUES RAISED Is this GPqualifiedto assessthe qualityof the product? From the GMC Good Practice Guidance [2] "64. youmust alwaysbe honest aboutyour experience, qualificationsandposition.." Itisnotunreasonable toquestionthe expertise of aGP inthe areaof sportsscience.Itisunlikelythat the GPwill have the appropriate depthof knowledge inthisarea. Is there any clinical evidence supporting/opposingthe methodsinthe DVD? GMC Good Practice Guidance [2] "65. Youmust do yourbest to make sure any documentsyou write or signare not falseor misleading.Thismeansyoumust take reasonablesteps to verifythe informationinthe documentsand that youmust not deliberatelyleave out relevant information." The GP mustmake an informeddecisiononthe meritsof the exerciseprogramme.He must differentiatebetweenamedical andpersonal endorsement - if there issupportingresearchitisa medical endorsement,if notitisonlya personal endorsement.He musttake stepstoensure a personal endorsementisnotmis-leadinglyportrayedasa medical one.Thisisfurthercompounded by the GMC Good Practice Guideline "63.Youmust be honest andtrustworthy when writing reports..." Ethicallythe GPmust declare anyfinancial interesthe hasinan enterprise tohispatientswhen recommendingthe product. GMC Guidance [2] states "before takingpart in anydiscussionsaboutbuyingorsellinggoodsor services you mustdeclare any relevant financial orcommercial interest that you or your family mighthave in the transaction." IN CLINICAL PRACTICE Will the Dr-PatientRelationshipbyaffected? By enteringintoafinancial agreementwiththe patientthe GPisputtinghisprofessionalrelationship withthe patientat risk. From the GMC Guidance "MaintainingBoundaries"(2006);."Inmostsuccessful doctor-patient relationshipsaprofessional boundaryexistsbetweendoctorandpatient.If thisboundaryis
  9. 9. breached,thiscanundermine the patient'strustintheirdoctor,aswell asthe public'strustin the medical profession." Also,"The doctor-patientrelationshipmayinvolve animbalance of powerbetweenthe doctorand the patient."Inthiscase,by acceptingpaymentfroma patientthe balance of powermayshift towardsthe patient,whichcouldcause difficultiesforthe GPinthe future whendealingwith this man,or hisfamily.Thisisof particularconcerninthisscenario,where the patienthaslong-standing mental healthissueswhichthe GPissupportinghimwith. Will the public'strustin the Dr be affected? GMC Guidance states; "youmustmake sure that yourconduct at all times justifiesyourpatients trust in you andthe publicstrust in the profession." The GP shouldconsiderthatbyendorsingacommercial productof thisnature he may be seento be "selling-out".Thismaycause patientstoquestionhisjudgmentandclinical decisionmaking.If inthe future the DVDis provedtobe unsafe/inadequatethismayalsounderminepatientconfidence inhis practice. Wouldthisscenariobe more acceptable if the GP didnotreceive paymentforhisendorsement? REFERENCES 1. NHS General Medical ServicesContract(2004) 2. GMC: Dutiesof a Doctor 3. GMC: Conflictsof Interest(September2008) 4. Medical Act (1983) 5. PublicInterestDisclosure Act(1998) 6. HealthService Circular(1999/198) 7. GMC: MaintainingBoundaries - Guidance forDoctors(November2006)
  10. 10. Example Topic 4: Dealingwith Authoritiesand Confidentiality Case Notes: LEARNING OBJECTIVES o Informedconsent,voluntarinessanddisclosure of diagnosis o Recognitionof the legal andethical boundariesof the clinicaldiscretiontowithhold information o Whenit islegally,professionallyandethically justifiableormandatorytobreach confidentiality(balance of publicinterests) o Conflictsof interest LEGAL ASPECTS OF THE CASE GoodMedical Practice (2006) :-  "Patientshave arightto expectthatinformationaboutthemwill be heldinconfidence by theirdoctors"  There are seriousrepercussionsforthe doctorwhodisclosesconfidential informationranging fromdisciplinaryGMChearings,civil proceedingsandcriminal proceedings.  The patient'sbasiccontact detailsisconfidential informationalongwith theirmedical information. Data ProtectionAct (DPA),section29, paragraph 3 :-  Personal dataisexemptfromnon-disclosureprovisionsforpreventionordetectionof crime. So the police canrequestforpersonal datato be disclosedincertaincircumstances.
  11. 11.  However,despite the factthatthe DPA releasesthe dataholderfromobligationtoprotect data, itdoesnot require the holdertodisclose it.Inthiscase,the clinicianmustdecideif the circumstancesare seriousenoughandinthe publicinterest todisclosethe information. PreventionofTerrorism Act 2000 :-  If the doctoris suspiciousthatanact of Terrorismmighttake place,itis hislegal dutytoreport thisto the police. ETHICAL ISSUES RAISED  Under whatcircumstancesisitalrightfor a doctor to breachpatientconfidentiality?There are guidelinesfromthe GMCwhichdefinesseriouscrimesasapossible reasontodisclose information.Howevertheydonotlistwhattypesof crimesare involved.  What shouldcome first:the doctor'sduty to an individual patient,orthe dutyto the public and inthiscase,publicsafety?  By withholdinginformation,isthe doctorpotentiallywithholdinginformationthatcouldhelp protectsomeone else?Afterall,the police couldjustgetacourt order to requestthe informationlateronanyway. IN CLINICAL PRACTICE  The clinicianhasobligationstotheirpatienttokeeptheirinformationconfidential,including theircontact details.  No one outside the healthcare teamshouldsee theirmedical files;norshould anythingabout the patientbe discussedbyanyone outsidethe medical team,unlessthe patientconsents.  The clinicianshouldattempttofollow the "CaldicottPrinciples",whichsetouta wayin which the DPA can be followedwithinthe frameworkof the NHS.  If the clinicianisunsure astowhat to do,theycan contact the NHSTrust CaldicottGuardian, whocan advise insituationswhere confidentialityisatriskof beingbreached;oralternatively, contact theirmedico-legal team. REFERENCES 1. Data ProtectionAct1998, section29 2. CaldicottPrinciples 3. CaldicottGuardian
  12. 12. Example Topic 5: The Whistleblower Case Notes: LEARNING OBJECTIVES o The role,responsibilitiesandrequirementsof the GMC inwhistleblowing o The importance of trust, integrity,honestyandgoodcommunicationinall professional relationships o The needto knowhowand where toseekappropriate help Studentsshould be able to: o Respondappropriatelyclinical errors o Followproceduresforreportingadverse incidents o Adhere tolegal andethical responsibilitiesthatprotectpatients LEGAL ASPECTS OF CASE Is Dr A legallyprotectedif she makes a complaint? The PublicInterestDisclosureAct1998 (PIDA),statesthat"The disclosure mustrelate toraising genuine concernsaboutriskstopatients,financial malpractice,orotherwrongdoingfromthe followingcategories:  a criminal offence;  breachof any legal obligation  miscarriage of justice
  13. 13.  danger(or potential danger) to the healthandsafetyof anindividual  damage (or potential damage)tothe environment;and  the deliberate concealingof informationaboutanyof the above." PIDA givesrightnotonlyto full time staff butalsoto locums,studentsandcontractors.Thiswas designedtoprotectemployeesbyprotectinganybodywhoinformedthe authoritiesfrombeing victimisedordismissed.Therefore,inthiscase,the doctoris legallyprotectedasherregistrarmay be endangeringhispatients. What action can the GMCtake? The GMC has a setout a listof what theycan andtheycan't take actionagainst.Theycan take and have takenactionagainst:  Misconduct o E.g. misuse of alcohol/drugs,sexual advances,treatingwithoutconsent  Deficientperformance o E.g. notexaminingproperly,serious/repeatedmistakes  A criminal conviction  Physical ormental illness  A decisionbyaregulatoryboardinthe BritishIslesoroverseas Whenfitnesstopractice isfoundto be impaired,the possibilitiesincludesuspension, removal/imposingconditionsof adoctorsregistration.A warningcanalsobe issuedif itis not believedthatfitnesstopractice isnot impairedbutthere hasbeenasignificantdeparturefromthe principlessetoutinthe GMCs Guidance forDoctors: Good Medical Practice. In thiscase,the Registrar,isguiltyof misconductwithalcohol.Furtherinvestigationtoelucidateif thiswas a onetime occurrence,orarecurringproblemisnecessary.His/herperformance shouldbe evaluated,toensure patientcare hasnot beencompromised. What is the correct reportingprocedure to follow? The firstport of call inthissituationisthe consultant.Afterthis,the PCTshouldbe informed. Ideallythe followinginformationshouldbe providedinwriting,sothatan investigationcan begin:  The doctor's full name,orsurname,initialsandreference number  The doctor's address,or the addressof the hospital/practice where theywork  A full accountof the eventsorincidentsthatconcernyou,withdates,if possible  Copiesof any relevantpapersand/oranyotherevidence youhave
  14. 14.  Detailsof anyaction youhave takenalready - for example,if youhave spokentothe doctor,or made a complainttothe doctor'semployer  Detailsof anyone else whowillsupportyourcomplaint. If a doctor isconcernedthatby providinginformationtheywillbe breachingpatientconfidentiality theymay wishtotake advice fromthe GMC or theirdefence organisation. ETHICAL ISSUES RAISED Is the Registrar putting hispatient'sinterestsfirst? In thiscase,the Registrarwouldnotbe able to make hispatienthisfirstconcernsince alcohol will impairhisdecisionmaking.The GMCGuidance alsostatesthat 57 "You mustmake surethatyour conductatall times justifiesyourpatients'trustin you and thepublic's trustin theprofession." Obviously,practisingmedicine whilstunderthe influenceof alcohol doesnotpromote publictrustin the profession. As the Consultantis not there,is the Registrar leadingthe team appropriately? GMC Guidance:ManagementforDoctorssetsout what isexpectedof aDoctor ina positionof leadership,whichinthiscase inthe absence of the Consultantisthe Registrar.Inparticularthe followingare relevanttothiscase:20. "Whether you havea managementroleor not,yourprimary dutyis to yourpatients.Their care and safety mustbeyourfirst concern."And21. "Management involvesmaking judgementsaboutcompeting demandson availableresources."Inthiscase,by drinkingthe Registrarisimpairinghisabilitytodoeitherof the above. Is a Doctor responsible fora colleague'sperformance? GMC Guidance:GoodMedical Practice 43. statesthat "If you haveconcernsthata colleaguemay not be fit to practice,you musttake appropriatestepswithoutdelay,so thatthe concernsare investigated and patientsprotected wherenecessary.Thismeansyou mustgivean honest explanation of yourconcernsto an appropriateperson fromyouremploying orcontracting body,and followtheir procedures".Inthiscase,if the reporting doctorignoresthisincident,she isneglecting herduty and wouldbe inbreachof the GoodMedical Practice Guidelines. Is the healthof the Registrar affectinghisability? GMC Guidance:GoodMedical Practice 79. "...if yourjudgementorperformancecould beaffected by a condition or its treatment,you mustconsulta suitably qualified colleague.You mustaskforand followtheir advice aboutinvestigations,treatmentand changesto yourpracticethatthey consider necessary.You mustnotrely on your own assessmentof therisk you poseto patients."Alsorelevant here isGMC Guidance,ManagementforDoctors,58. "Doctorsshould also protectthosethey managefromrisksarising froma colleagueshealth and respond constructively to signsthat colleagues havehealthproblems,in particularmentalhealth problems,depression and alcoholand drug dependence." IN CLINICAL PRACTICE
  15. 15. Ever since the Bristol HeartCase,where anumberof operationswere performedonchildrenwith sub-optimal results.Legislation hasbeenputinplace sothatpoor clinical practise canbe reported withoutrepercussion.Currentlyitisthoughtthatthere are variousinequalitiesinhow whistleblowersare treatedinthe NHS,as well asa lack of adequate protection. AndrewLansley(HealthSecretaryof the UK) realisedthatthe NHSConstitutionshouldmore accuratelyreflectwhistleblowingculture tocounteractthe culture of silence andfearwithinthe workingenvironment.He hasestablishedaNHSConstitutionconsultationpaper. The paper statesthat dismissal of awhistleblowerwouldbe consideredunfairif theyare dismissed for makinga protecteddisclosureasdefinedbyPIDA 1998. At the time of writingthis,the paperisstill undergoingreview. REFERENCES 1. GMC Guidance:Good Medical Practice 2. NHS Departmentof Health:The NHSConstitutionandWhistleblowing(A paperfor consultation) 3. AntecedentsandOutcomesof RetaliationAgainstWhistleblowers:GenderDifferencesand PowerRelationshipsbyMichael TRegh,Marcia P. Miceli,JanetP.Near,JamesR.VanScotter in OrganizationScience Vol.19,No.2, March-April 2008, pp.221-240 4. The keyto effective whistleblowingisinterprofessionalcollaboration.BMJ2009;339:b3055
  16. 16. Example Topic 6: A Case of Pre-Eclampsia Case Notes: LEARNING OBJECTIVES o Maternal-fetal conflictsof interest o Ethical,legal andprofessional aspectsof terminationof pregnancy o Human FertilisationEmbryoAct1998, Abortionact LEGAL ASPECTS OF THE CASE Under the AbortionAct 1967 :- Justificationformedical terminationof pregnancyinclude:  The pregnancydoesnot surpass24 weeks,andthatcontinuationof the pregnancywould entail greaterrisk(tothe mental/physical healthof the pregnantladyoranyexistingchildren of herfamily) thanif the pregnancywere terminated.  Severe permanentinjurytothe physical ormental healthof the pregnancyladywouldbe preventedbyterminationof the pregnancy.  The risk to the life of the pregnancyladywouldbe greaterbycontinuationof pregnancythanif it were terminated.  if the childwere born,there isconsiderable riskthatitwill sufferfromphysical ormental abnormalities,astobe significantlyhandicapped. In thiscase point3 and 4 wouldjustifyterminationof pregnancy.
  17. 17. Under the HFEA 1990 Act,it amendsthe AbortionAct1967 to allow abortionswhere thereisa seriousriskof foetal handicapuptobirth. ETHICAL ISSUES RAISED  The rights of the motherand the interestsof the foetustolife.  The rights of that fatherand hiswishes.  At whichpointdoesthe foetusattainshumanrights?  Whichis more important,the life of the motherorthe life of the unbornfoetus?How doyou decide?Inreality,the obstetricianismore concernedaboutthe lifeof the mother.However the motherhas beentryingforso longto getpregnant,thisbabyisveryspecial toher,and therefore she islesswillingtoterminate the pregnancy.  Psychological traumatothe motherand herhusbandneedtobe consideredastheyhave to choose betweenthe life of the motherandthe life of ababy.Alsoif she terminatesthe pregnancy,she maynot be successful ingettingpregnancyagain. IN CLINICAL PRACTICE  Incidence of preeclampsiais5%(range 5 - 10%) of all pregnancies.Maternal complicationsof preeclampsiainclude:- o HELLP (10-20%) o Pulmonaryoedema(2-5%) o Acute renal failure (1-5%) o Placental abruption(1-4%) o Eclampsia(<1%)  These risksincrease inthose <33wk gestation.  The importance of recognisingearlystagesof pre-eclampsia.  A recentstudyinthe UK amongstmedical studentshowedthat62% were pro-choice and33% pro-life and7%wasundecided.Thiswascomparablyalowerpro-lifepercentage thanasimilar surveyof GPs, the authorswere unsure whetherthiswasasocietal change toabortion,or because doctorsbecome more pro-choice astheydevelop. REFERENCES 1. AbortionAct1967 2. HFEA 1990 Act 3. Medical students'attitudestowardsabortion:aUK studyJ Med Ethics 2008;34:783-787
  18. 18. Example Topic 7: ChildProtectionand Non-Accidental Injury Case Notes: LEARNING OBJECTIVES o Rightsand Interestsof children o Capacityof youngpeople toconsenttoandrefuse treatment o Role of parents/guardians/HCP/courtsindecisionsabouttreatmentof children o Ethical & legal issuesinchildprotection o Applicationof the dutyof confidentialitytoyoungpeople LEGAL ASPECTS OF THE CASE ChildrenAct 1989 and 2004 :-  The Act outlinesthatthe child'swelfare isof paramountimportance whenmakingdecisions  Basedon the ChildrenAct,local authoritieshave a"dutyto investigate...if theyhave reasonable cause tosuspectthata childis ...likelytosuffersignificantharm"(section47)  Medical practitionershave adutyof care towardstheirpatients,whichmeansthatwhen abuse issuspected,there isalegal imperative toreportthissuspiciontothe relevant authorities  If a childstatesthattheyhave beenthe victimof abuse,these claimsshouldbe investigated.In these cases,parental consentisnotrequiredtoconducta formal investigation Protectionorders :-
  19. 19.  Protectionordersare givenoutwhenadoctor believesthatthe childrenisatriskof significant harm.  EPOs (Emergencyprotectionorders) are usedtopreventsignificantharmand/allow investigation.  If it is a true emergency,the police mayissue aPPO(PoliceProtectionOrder) whichlastsfor72 hours.  If the childisnot at immediate riskthenanCAO (ChildAssessmentOrder) isgiven ETHICAL ISSUES RAISED  Whenchildabuse issuspected,itmaybe acceptable tospeakto and examine the child withoutthe parents'consent.Thisisespeciallytrue of sexual abuseswhenthe perpetuators may try andsilence the child.  Shouldthe doctorbreakthe child'sconfidentiality?He is12. If confidentialityisbroken,the childmaynot trust thisdoctor again.Causingpossibleevenmore harm?  Again,comesbackto ChildrenAct1989 - takingintoaccountviewsof children,treating themwithrespectandtakingtheirownwishesintoaccount.  Doctors have a dutyof confidentialitytopatients.However,thiscanbe breachedinthe publicinterest(whichincludespreventionof crime,includingabuse) IN CLINICAL PRACTICE  There islittle likelihoodthatdifferentclinical conclusionswouldbe foundinthiscase  In general,childabuse shouldbe suspectedif presentationof injuryisdisproportionate toits "history"  In clinical situations,parentswouldlikelybe discussedwithbefore aprotectionorderis issued  Wouldhe be willingtotalkto the Police andmake a formal statementaboutthisissue.If not ...what shouldhappen?  Issueswhichmightcome intoplayinclude childrenwithlearningdifficulties - are theyat more riskof abuse? REFERENCES 1. ChildrenAct1989 and 2004