Ethics

Question 1

Two patients come into ER both requiring a lung transplant

• 12 year old girl with cystic fibrosis
• 64 year old chronic smoker with wife and two children

Who gets it?

Answer 1

Firstly link to medicine: This is quite a horrible question but it does go to show that in medicine decisions like these need to be made daily

• Look into autonomy which is the patient’s right to choose, so make sure both patients actually want the lung transplant and would be able to carry through with the follow up.
• Look into alternative treatments, for example there could be one that helps one patient more than the other. That said we want to use beneficence and reduce maleficence so do the least amount of harm to the patient who doesn’t receive the lung
• It is worth saying that I would discuss this with my colleagues as isn’t a straightforward decision to make: Medicine is about teamwork and working in a multidisciplinary team
• Look at waiting list to see who has been on it for longer. It is very important that we don’t discriminate based on age or the fact that he has been smoking
• I would probably give the lung to the younger girl with cystic fibrosis

Question 2

Are there any times when lying can be justified in medicine?

Answer 2

In most cases i believe patients always have the right to the truth about the mistakes of doctors or about their illnesses. This is because of their autonomy.

Duty of Candour: GMC states doctors have to be open and honest with patient about any mistake they’ve made.
So majority of the time no, however if the patient is going into a very risky surgery and asks you ‘am I going to make it’ some doctors could decide to say yes to put the patient at ease. However this could technically be lying

When I was doing work experience in a hospital near me a 16 year old girl came in who had overdosed on paracetamol.
The doctors prescribed her acetylcysteine to counteract this, but they accidentally gave her double the dosage of it because of miscommunication between them and the nurses.

However the amount given wasn’t actually a toxic amount so they had a group discussion about the pros and cons of telling her. For example a con is that she stops trusting the healthcare staff, however it is also important to respect the pillar of maleficence to do no harm and you could argue that they technically didn’t do any harm.

Overall they made the decision to not tell her to not worry her.
So in this case they technically lied but they believed it was for a good cause and I understand why they made that decision.

You could bring in Gillick competence, that she is 16 so has the right to know about what is happening to her so she can make her own decision about it.

Question 3

What ethical principal of medicine is the most important?

Answer 3

I believe all principals of medicine are important, for example autonomy, confidentiality, justice, beneficence and maleficence

Autonomy is important because giving the patient a say in their treatment is vital for maintaining a trusting patient doctor relationship. It is also their body at the end of the day that will have to endure that medication or treatment so it is important they get a say in that.

Justice also ensures that no one is discriminated against when it comes to be treated so helps society become a fairer place.
Beneficence is about always seeking to do good and help people to make a positive change in their lives. This would be the reason I’m very interested in studying medicine because I want to know I’m improving the world in some way.

Overall, I believe Beneficence is the most important pillar because it is important to consider all treatment options to find the best course of action for the patient. Also at the end of a patients life, beneficence requires they feel comfortable and supported thoughout that process, which I believe quite strongly is very important.

Question 4

You walk in on a doctor drinking from a glass bottle then hiding it in his locker, then he slurs his words and is forgetting things.

Answer 4

The priority here is patient safety, so I’d make sure there is no risk to patient health immediately.

Situation: Make sure he is on his own when you try to talk to him, to avoid embarrassment and causing a scene.

I think first it is important not to jump to any conclusions so I would begin by approaching him in a polite manner and ask to have a conversation. Then I would ask what is in the bottle, without judging him to see if he wants to voluntarily explain the situation to me.

However the priority here is patient safety so I’d have to make sure he isn’t seeing any patients that day as this could compromise care.
I’d suggest he go home and that we can talk about it tomorrow when he is in a better state.

If he admits it I’d explain why it compromises patient care.
I’d also like to learn about the reasons behind it, maybe he’s depressed and needs help so I could recommend a therapist.

However It is a very dangerous thing to do in a healthcare setting where peoples lives are depending on you, so I’d have to talk to a senior member to discuss what to do. Then escalate the issue. Maybe file it on Datix.

Practitioner health programme helps doctors with addiction or other mental health problems.

Question 5

What is the duty of Candour

Answer 5

The general responsibility to be open and transparent with your patient.

Question 6

What is Gillicks competence

Answer 6

The ability for teenagers, like people under 16 to make their own decisions about their treatment.
So children under the age of 16 can consent to medical treatment without the consent of their parents.

This can only happen if the doctor is certain the child has the capacity to understand and is emotionally mature enough.
If a child lacks this capacity under the age of 16, someone else can consent on their behalf

So although they are looked after by their parents, it is their decision in medicine unless they don’t have the capacity to make that decision themselves.

Question 7

What are fraser guidelines

Answer 7

Similar to Gillicks competence, where patients under the age of 16 are competent to make their own medical decisions.
However this usually is in the context of birth control or contraception.

Beneficence is the pillar to do good and try your best to improve a patients life. It can be argued that giving a 16 year old contraception could be doing good as it can stop the spread of STDs, and can stop a pregnancy happening.

Question 8

Dr Brain gave a patient his mobile phone number to the parents of a diabetic child in case of emergency However now the parent is messaging to ask if he knows a diabetes specialist

Answer 8

• It is important to approach this situation from both the perspective of the doctor, and also the perspective of the patient.
• The online booking system may have very long wait times for booking appointments and can be seen as a long and difficult measure to see a GP. The patient has a quicker and more convenient method now to contact the GP so it isn’t weird that they would use it.
• However from the doctors perspective it is his morning off so by giving his phone number to a patient this removes the professional aspect of working hours. So this means that although going home should be a time to relax or do sport, or spend time with his family, it is now impacting this quality time. This stress can negatively impact patient care as he may get burnt out and tired.
• Ethical considerations are that by giving your phone number out to specific patients, this is possibly unfair to the other ones. They may feel that they are less important and less cared for by the GP which would negatively impact that patient doctor relationship built on trust.
• Electronic communication changes the dynamic between the doctor and patients and could be potentially overstepping boundaries in the profession. Face to face consultations are important because you can see the body language of the patient so a higher level of communication can occur. However it is difficult to read the tone of the patient through a text message to understand the urgency of the situation.
• The urgent help stated by Mary could either mean the son requires immediate attention where in that case it could be the doctors duty of care to tend to the patient immediately.
  However it could also simply be her contacting him because it is quicker and more efficient.

It would be a good idea in my opinion to reply to Mary asking her to book an appointment the following morning. This addresses the urgency of the situation, but also allows him to have his morning off. It could however leave Mary feeling disheartened or uncared for, so an immediate response could keep the doctor patient relationship

Question 9

What is a naturopath

Answer 9

Someone who gives herbal remedies and focusses on natural cures for diseases rather than medicines from pharmaceutical companies.

Question 10

Why are doctors given gifts

Answer 10

• It is very important for patients and doctors to have a strong relationship based on trust. A consultant I shadowed explained how it is almost like a partnership of expertise as the doctor is an expert in diagnosing, whilst the patient is an expert of themselves and what treatments work for them.

This means that often GPs especially may be left in patients wills because of this relationship. They also may be gifted things because the patient wants to express their gratitude.

Question 11

What ethical issues are there around doctors being given gifts

Answer 11

• Harold Shipman case is one that comes to mind. This is basically where a GP in yorkshire in the 80s would find a way to write himself into the wills of elderly vulnerable patients during home visits and would then kill them by injecting them with a poisonous medication.
  So an ethical consideration is whether or not the patient has been coerced into gifting the doctor either a present or money.
  Doctor patient relationships also often could have a power dynamic as the doctor could be the person to spend time with them when they’re at the end of their life
• Also, it is possible that doctors who know they will be gifted will work harder with those patients than with others which could compromise patient care. This could negatively impact the image of that specific doctor, or the profession as a whole.
  So maybe patients with less money will feel they are receiving an inadequate amount of care compared to wealthier patients who can gift doctors.

Bribery is also an issue here as it can be difficult to understand the intentions behind gift giving. Most of the time patients will be very grateful for their GP so will want to give them something to say thank you, however it does open doors for other patients maybe trying to bribe a doctor to possibly spend more time on their case. This would compromise patient care for others.

Having said that, refusing to accept a gift can negatively impact the doctor- patient relationship built on trust. The patient could feel offended if their gift isn’t accepted.

Question 12

What does the GMC say about receiving gifts as doctors

Answer 12

The 2024 ‘Good Medical Practice’ states that doctors can only accept gifts of minimal value.
So for example flowers, cake and fruit.

They can only be accepted if there is no position of influence being exerted on the patient.
Gifts below £10 don’t need to be recorded in the Gifts and hospitality register.

However above this, gifts must always be recorded in gifts and hospitality. It can be shared with colleagues, donated to charity, or returned.

Question 13

What do you know about placebos

Answer 13

A placebo comes in two forms: Pure and impure.
A pure placebo is completely made of saline or sugar and is given to the patient as a pill.
An impure placebo can be a different medication that isn’t supposed to affect the patients illness. Eg giving antibiotics to a viral infection.
One aim is to see how effective a new treatment is.
The placebo effect is where patients feel themselves getting better even though they haven’t taken medication for it.

Placebos can be given to patients in drug trials so you can have single blind ones where the doctor knows if they are prescribing the placebo to patients or not.
Or double blind to remove bias where neither the doctor or patient knows if the drug is being given to them.

Question 14

Placebos are commonly used by GPs, why?

Answer 14

A placebo is either a pill or injection that is given to a patient. These contain saline or maybe sugar and do not actually have a chemical impact on the patient at all.

Patients believe they’re being given a treatment that will be effective.
Sometime the symptoms of an illness a patient have will decrease and they will feel better, as it is an illusion.

If they believe they’re taking medication to help them, their bodys may start working better

Question 15

What is the nocebo effect

Answer 15

Patient experiences adverse side effects from a harmless placebo.
So the patient expects to get negative symptoms from a medication and starts getting them even with placebo.

Question 16

Do you think giving a placebo is moral

Answer 16

• I think there are two perspectives here:

From the patients perspective they are technically being lied to by their GP. The doctor patient relationship is based on trust and is a partnership so if the patient found out they weren’t actually being given medication they may feel like the doctor doesn’t believe them and could feel lied to. They may also feel like they’ve been exaggerating but actually the brain has the power over the body to make it feel a lot better just by believing.

The two primary ethical duties of doctors is to act in the patient’s best interest and to respect the patients autonomy.
Doctors may feel they’re improving symptoms for a patient by intervening with the brain which could arguably be acting in the patients best wishes.

Question 17

What do you know about organ donation

Answer 17

• I know that it started in the 1950s
• It is where an organ is taken out of one person and is given to a patient in need of one.
• These organs can be taken from a deceased person, where they may take the heart.
• They can also be taken from a living person who could donate a kidney as we have two.

Question 18

What are the two systems in countries around organ donation

Answer 18

Opt out system: Where everyone is automatically on the list for organ donation when they die. Organ donation is default position.

Opt in system: Where donors are automatically not on the register and have to ask to be added

The opt out system has proven to have higher rates of organ donation and is used in countries such as spain

Question 19

What are the two systems for organ donation considering families

Hard
Soft

Answer 19

Hard system means the family doesn’t have the power to refuse organ donation

Soft system means family does have that power

Question 20

What are some problems with the opt out system

Answer 20

• If you assume everyone is donating organs when they die, it might be quite difficult for elderly people to understand that they have the option to opt out.
  For example if you have to go in person to sign a form stating you want to opt out, there could be many people who aren’t aware of this so aren’t technically consenting.

A solution to this could be making the option to opt out very simple eg by email or filling out an online form.

However it is technically saving lives as there are more donors

Question 21

Should family members be allowed to decide our organ donation

What is your opinion

Answer 21

• We should encourage people to reflect on what they want to do with their organs when they die.
• Currently even if someone wants to donate their organs, their family can veto their decision after they’ve died. GPs usually respect this decision
• I think our organs aren’t of any use to us when we’re dead so I would be happy to save the lives of up to 10 people by donating my organs.
• It is worth bringing up article about pig kidney transplant, so maybe this will be an option for the future

Question 22

What is confidentiality

Answer 22

Balancing a patients right to privacy with the information needs of family and others

Question 23

Why can confidentiality be difficult

Answer 23

• When a loved one is on end of life treatment or care, families may feel they aren’t getting told enough about the condition and management plan.
  Failure and refusal to disclose information can lead to family members getting angry and maybe even violent.
• Healthcare professionals have a duty of confidentiality to their patients so a general rule is they seek permission from the patient to tell others.

This is obligated in law so going against it is breaking the law and is professional misconduct.

Question 24

When is confidentiality breached

What is an example case

Answer 24

When it is believed there is a serious threat to the health and safety of others

The Harold Shipman case is where although he killed many patients, when the inquiry happened lots of confidentiality had to be breached.

For example the police accessed doctor patient records where there was medical information about patients. However this was required to look at patterns in the dosage of painkiller he used to kill people. Also looking at death certificates etc.

Also, family members had to provide testimony so gave information to the court so it was publically shared.

It is argued that this was for the greater good however as we uncovered flaws in the medical system

Question 25

What flaws in the medical system did Harold Shipman’s case uncover

How has the system changed since

Answer 25

• One flaw is how reliant we are on doctors to fill out death certificates
• Lots of cremation forms were filled out by him and were trusted

NOW:
- More careful when looking at the drugs prescribed by patients
- There are now stricter protocols for giving death certificates

Question 26

When can a person not give consent

Answer 26

Consent is the ability to look at all the information given to you by doctors in an unbiased way, and for the patient to decide if they want to go ahead with a procedure or not.
They should not feel pressured, and usually people over the age of 16 can consent for themselves.

Anyone who is emotionally immature, eg with mental illness so lack the ability to make an informed decision. If a patient can’t refuse, then the doctor can decide to tell the parents etc if it is necessary as the doctor has a duty of care.

Question 27

What do you do as a doctor if your patient has mental illness but is refusing to disclose information to family members eg parents

Answer 27

• Clinician should first discuss the issue with the patient
• To allow patient to reconsider consenting to disclose the information
• It may be that the refusal is directly linked to the features of his or her mental illness
• This means they don’t have capacity to give consent
• It is the doctors duty of care for the patient, pillar of beneficence to do good and try to help the patient
• If the doctor feels it will do the patient good to discuss with family member and if the patient can’t consent, then it should be allowed.
• However it is worth trying to understand where the patient is coming from as they may have significant reasons for objecting

Question 28

What do you do if family members are getting upset that you can’t tell them information

Answer 28

• Majority of the time if people understand the reasoning for a rule they are more likely to accept it
• So maybe sit down with the family and explain to them confidentiality and how it is actually against the law to tell them
• Say you understand why they’re upset and it must be very frustrating for them to hear
• But you have to respect the patients right to privacy

Doctor can only tell to protect the patient from harm so can be done without consent from the patient as they don’t have capacity to consent or because the law allows it in these circumstances.

Question 29

A woman has a family history of breast
cancer in her family, her daughter would like to test for the BRCA gene while the woman does not want to know.

What are the ethical issues here?

Answer 29

• One point to bring up here would be autonomy, where the mother has the right to not know her medical status. By telling her you could be harming her mental health which would be doing harm, so non-maleficence pillar would be broken.
• At the same time, the daughter has the right to know if she has the gene and she has autonomy over her decision.
  She wants to know to make decisions about her health and future. There is a potential conflict here.
  Beneficence pillar here
• Confidentiality should be considered, because if the daughter has the gene it will reveal information about the mothers diagnosis

To solve this problem, compromise so maybe inform the daughter but ensure she doesn’t reveal the information to her mother

Support: Offer support in the form of therapy or support groups to help them in this tough time

Question 30

You are a GP. A HIV patient reveals to you that they have not told their partner about their recent diagnosis.

Discuss the ethical issues involved.

Answer 30

• Patient confidentiality is a key issue here, as a doctor patient relationship is built on trust so you would break that trust by repeating the medical information to their partner.
  This would go against Good Medical Practice by the GMC where confidentiality is vital when working in the NHS.
• Healthcare providers also have the duty to prevent harm, eg non-maleficence pillar. By not informing the partner, they may catch HIV which can lead to aids. This would be doing harm.
• Autonomy: The patient has the right to control their treatment, as well as how they want to disclose their diagnosis. The partner should be informed about their own health, and they currently can’t make informed decisions on it.
• Also, there are societal problems as HIV can be spread around the population which would put a strain on the NHS and reduce the level of patient care given.

Overall, Good Medical Practice states that confidentiality may be breached if there is a significant risk to others and if all other options aren’t possible.

Question 31

When is it appropriate to breach patient confidentiality?

Have you observed or
researched any incidents where patient confidentiality has been broken?

Answer 31

The GMC Good Medical Practice states that confidentiality can be breached if there is possibility of significant harm to others.

A case that comes to mind here is the Harold Shipman case. This is where in Yorkshire in the 80s a doctor was killing elderly vulnerable patients by injecting them with lethal amounts of painkiller.

During the court rulings, it was important to gather evidence by looking into the files of these patients to potentially see what he wrote as the cause of death.
This would technically be breaching confidentiality as this is private information about their health conditions.
However there could be harm done to others if Shipman wasn’t convicted so it can be seen as for the greater good.

Question 32

Is it right for junior doctor or medical
students on electives to provide substandard care in order to learn to be better doctors?

Answer 32

I believe there are many ethical considerations around this issue.

The first one being patient care, and if it is compromised by medical students. The priority in every hospital scenario is the patient and if their care is up to standard so if having a junior doctor there compromises it, one could argue it shouldn’t be allowed.

However, it is vital to teach medical students skills in a clinical setting with real patients so they can understand the importance of a patient doctor relationship. They could pick up on many skills such as empathy and communication which will improve the NHS workforce in the long term.

Another ethical consideration to take into account is informed consent, so if the patient understands all the information given to them about having junior doctors present. They can then decide for themselves if they want junior doctors present because of the pillar of autonomy where patients have the right over their bodies.

Principal of Beneficence is doing good, and one could argue that training junior doctors will improve the standard of care in the NHS in the long term. Hopefully this will give patients a higher quality of life.

Overall, there are methods to not compromise patient care whilst still having junior doctor electives. Supervisors should use guidelines to make sure junior doctors are being safe and their actions don’t compromise patient care.
Good medical practice by the GMC states here that patient safety is the priority so violating these standards could have huge repercussions.

Question 33

A parent brings in her 14-year old daughter who has been getting bullied about her appearance on social media. The daughter is demanding cosmetic treatment but the mother strongly disagrees.

How would you resolve the situation?

Answer 33

I think it is very important to show empathy towards the daughter first, and really listen to what she’s saying and where she is coming from. Maybe a private conversation could be helpful here.

You should gather information from both parties, so talk to the mum privately also.
Encourage open communication about the subject where they can both give their opinions.

Address the bullying, and explain that on social media there are people who will say mean things to everyone. Discuss ways to stop it such as involving the school, or local authorities.
You want to increase the confidence levels of the teenager so encourage her attendance to body positive workshops or possibly therapy.

It is important to explain to her that being 14 could raise many problems about getting the treatment. Explain that her mind and body are still developing and decisions she makes now she could regret in a few years.
You could consider Gillicks competence here where if she has the capacity to consent. Also autonomy of the patient where she has the right to decide what happens to her body.
Get her informed consent.

Cosmetic treatment shouldn’t be taken unless all other options are exhausted

You could start by discussing alternative tre

Question 34

Should the NHS fund surgery for those
whose cosmetic surgery has gone awry

Answer 34

• It is important to consider the pillar of justice here, which is one of the 4 pillars that the NHS is built on.
  It states that everyone has the right to healthcare so we shouldn’t discriminate based on past choices.
  The NHS gives care based off of clinical need rather than the ability to pay.
• Consider the medical state of the patient and if the surgery going wrong has damaged their health, mental or physical.

To look into the other side of the argument, the patient chose to have a cosmetic surgery, aware of the risks so some may say they should suffer the consequences.
Not only this but the NHS is understaffed and underfunded so could be allocating its resources to more deserving patients. This can jeopardise the care for other problems.

To prevent this occurring in the future more guidelines should be in place, so ensuring high standards of care during cosmetic surgery will reduce the amount of complications in the NHS.
Also educate individuals more on the implications of surgery.

Overall the NHS should intervene if patient health (mental or physical) has been jeopardised as it is their duty to deliver help. However there should be more regulations put into cosmetic surgeries to stop them going wrong in the first place.