Ethical Practice

Question 1

Bioethics - What are ethics?

Answer 1

Ethics are not a set of rules, they are a process of critical reflection.

Using an analytical approach (System 2 decision-making) helps
us to consider ethical issues from a number of different perspectives.

Question 2

brief history of ethics

Answer 2

• Prior to the mid-20th Century paternalism was dominant in
  medicine
• Paternalism is the idea that “Father knows best”
• An unquestioning faith in the doctor’s knowledge and ability
• Since then we have seen the rise of:
• Patient centred care
• Greater knowledge and participation by the patient and carers
• Greater autonomy of the patient and carers

Question 3

Post - mid 20th Century

Answer 3

Since then we have seen the rise of:
* Person centred care
* Greater knowledge and participation by the patient and carers
Reduction of authoritarian/paternalistic approach
Greater diversity of health practitioners and greater team based care
Focus on previous unethical behaviour
* Such as lack of Informed Consent in medical research

Question 4

Ethics today

Answer 4

Delivery of Health Care
* Who gets treated? (Access and Equity)
* Who decides the treatment? (Paternalism versus Autonomy)
Ethics in research
* Is the experiment justified? (especially in regard to animals)
* Will anyone be potentially harmed?

Question 5

Bioethics

Answer 5

“Bioethics is concerned with questions about basic human values such as the rights to life and health, and the rightness or wrongness of certain developments in healthcare institutions, life technology, medicine, the health professions and about society’s responsibility for the life and health of its members.”

Question 6

Bioethics cont.

Answer 6

Childress and Beauchamp (2001)
It is a framework, and not a set of rules.

1. Respect for autonomy
2. Beneficence
3. Non maleficence
4. Justice

Question 7

Can All Four Principles be Satisfied?

Answer 7

• The Bioethics framework is not a set of rules.
• Rarely can all four principles be satisfied.
• It is a process for critical reflection.
• We use each principle as a lens to examine the issue.

Question 8

Autonomy

Answer 8

“Respecting the decision-making capacities of autonomous persons, enabling individuals to make reasoned informed choices.”

• The patient’s right to make the decision
• The patient’s ability to make an informed decision

Question 9

Informed Consent

Answer 9

AUTONOMY&raquo_space; INFORMED CONSENT&raquo_space; INFORMATION + CAPACITY TO CONSENT&raquo_space; TYPES OF CONSENT&raquo_space; WHEN + WHO

Question 10

Autonomy relies on informed Consent

Answer 10

Health Practitioners need to obtain informed consent before they treat patients
Health Practitioner needs to ensure that the patient:
* fully understands what is involved in the treatment
* has the capacity to consent

Question 11

Understanding the Information

Answer 11

The patient or representative must demonstrate that they understand the information given.

• Has the information been delivered in a way which can be
  understood?
• Appropriate to their level of health literacy
• Accommodating language and cultural issues
• In consideration of the circumstances of the patient (such as place and time)
• Does the person have the capacity to consent based on this
  information?

Question 12

Capacity to Consent

Answer 12

Under the Victoria Medical Treatment Act 1988, a patient must be of sound mind and over 18 years of age in order to give or refuse valid informed consent. Competency is to be assumed unless there is clear evidence to the contrary. If there are any questions around a patient’s competence, an assessment should be undertaken by the treating
doctor or other appropriate personnel, e.g. psychiatrist.

Question 13

Capacity to consent

Answer 13

All patients may be considered capable of consent if they are:

• Sufficiently mature and intellectually capable of understanding the procedure (age may not be a factor)
• Over 18
  Where the patient is a minor (under 18) or incapacitated:
• Under 18 – parent or guardian consent usually required
• Guardianship Legislation (such as Medical Power of Attorney)

Question 14

When is Informed Consent Required?

Answer 14

Except in life saving, emergency situations, consent is always
required.

The patient (or nominated representative) must be told the:
* Diagnosis and prognosis
* Explanation of the treatment, including:
* What it will be
* Who will perform it and where
* Potential risks, complications and side effects
* Expected outcomes
* Alternatives

Question 15

Types of consent

Answer 15

Written consent is where a document is signed (e.g. a consent form).
* Usually only where there is significant risk, such as a surgical
procedure.
Verbal consent is where the patient states their consent
* Used in low risk situations
Implied consent is where the patient indicates agreement through their actions or by cooperating with the health practitioner’s instructions.
* Used in routine situations (such as receiving a medication)

Question 16

Beneficence

Answer 16

The healthcare professional should act in a way that benefits the patient.
* Not offering a treatment that is ineffective
* Antibiotics for colds?
* Colonic cleansing for toxins?
* Not offering a treatment that is purely of financial benefit to the practitioner
* Not allowing personal feelings to interfere with decision making

Question 17

Non maleficence

Answer 17

• Avoiding the causation of harm, the healthcare professional should not harm the patient.
• All treatment involves some harm, even if minimal, but the harm should not be disproportionate to the benefits of treatment.
• Cosmetic surgery?

Question 18

Beneficence versus Non maleficence

Answer 18

Chemotherapy may prolong a patient’s life by 6 – 12 months
* In very rare cases it might even cure them
* Chemotherapy may cause severe side effects,
resulting in diminished quality of life
* Who should decide (autonomy versus paternalism)?
* What information is required (capacity to understand and consent)?

Question 19

Justice

Answer 19

• Distributing benefits, risks, resources and costs fairly
• In the USA, if you can’t afford treatment, is it ethical that you will not get the treatment you need?
• If you are in remote Australia, is it ethical that you have less access to Specialists?

Question 20

Ethical Dilemmas

Answer 20

Ethical dilemmas are designed to:
* Make you think
* Make you think about your thinking (metacognition)

Question 21

Is there a ‘right’ answer?

Answer 21

Ethics is not about answers, it is a process of critical thinking.
* Decisions arise out of ethical dilemmas, but they are reasoned judgements, not absolutes.
* Practitioners must learn the process of critical thinking to reach fair and equitable decisions.

Question 22

Name 2 Ethical Approaches

Answer 22

Deontology and Consequentialism (Utilitarianism)

Question 23

Deontology

Answer 23

From Deon, meaning rules
* There are rules that we must obey, it is our duty
* These rules must be applicable to all people in all situations
* All human beings must be respected (not used as a means to an end)
* The rights and wellbeing of the person/patient must come first

Question 24

Consequentialism or Utilitarianism

Answer 24

It is not the act which is important, it is the outcome.
* The greatest good for the greatest number of people.
* The needs of the many outweigh the needs of the one, or the few.
* The end justifies the means.
* The overall wellbeing of society may override the rights and
wellbeing of the individual.

Question 25

Is either approach right in Healthcare?

Answer 25

A doctor comes out of a room after witnessing a patient suffer a distressing death. The family approach the doctor and ask if he suffered. The doctor lies and says, “He went peacefully”.

• Consequentialist view - this eases the burden
  of the family at a distressing time.
• Deontologist view - lying is fundamentally
  wrong and the family are entitled to the truth.