ETHICS Flashcards
Under the age of ___ is technically a child
18
Family Law Reform Act 1969 said what about child consent?
16-18 should be treated as though they are adults
Gillick Case (<16): what did Department for Health circular state?
Prescription of contraception was matter of doctor’s discretion, and that they could be prescribed to children under 16 without parental consent
Describe Gillick competence
“Whether or not a child is capable of giving consent will depend on child’s maturity and understanding and nature of consent. Child must be capable of making reasonable assessment of pros + cons of Tx, so consent can be fairly described as true consent”
What did Lord Scarman (in Gillick) comment on parents’ versus children’s rights?
“Parental right yields to child’s right to make own decisions when he reaches Gillick compentence”
Gillick competence does NOT apply to which ages?
16, 17, 18
Gillick competence: Lord Fraser stated a doctor could proceed to give advice + Tx provided he is satisfied in following criteria:
Patient, can understand advice; Can’t persuade pt to inform parents; Pt v. likely to have sex regardless; Pt’s mental/physical health likely to suffer; Pt's best interests
Law distinguishes between minors
13
13-16
What decision can parents/courts/doctors override in a child that is Gillick competent?
Refusal of therapy
Confidentiality in children 16 or 17
To be treated as adults for purposes of consent to treatment and are therefore entitled to same duty of confidence as adults
Confidentiality in children <16 Gillick competent
(Generally) entitled to have their confidentiality protected and respected
Confidetialty in children <16 non-competent
Lots of uncertainty. Use Gillick criteria to evaluate competence (function not status based assessment). Consider distinction between consent to, and refusal of, Tx. Consider place of confidentiality and duty of care for a minor who is assessed NOT to be Gillick competent
GMC guidance on protection of children by doctors
“Drs must safeguard + protect health and well-being of children & young people. Well-being includes treating young people as individuals & respecting their views, as well as considering physical + emotional welfare. Must always act in best interest of children”
Why do people migrate from their place of birth to other places? 2 types of factors
Push and pull factors
Describe PUSH factors that cause people to migrate - 3 broad factors
- Poverty vs wealth: Nutrition, Shelter, Education, Health
- Persecution vs rights: political, religious, social, death threats, “disappearances”, torture, rape
- War vs peace (inc. civil war)
Describe PULL factors that cause people to migrate - 3 broad factors
- Wealth: Healthcare, education, clean water etc
- Basic rights (freedom from persecution)
- Peace (safety, security from war)
80% of people live on less than how much per day?
$10
Health considerations for overseas patients relating to communicable diseases - 4 issues
- Immunisations
- Hepatitis B, HIV, Malaria, Typhoid etc. Consider the country they have come from
- TB - can be associated in HIV. May be taboo or stigma issues
- Rheumatic fever - rare in UK
Why is it important to consider mental health in migrants?
Mental health is seen and managed differently in different countries
Given an example of a non-communicable disease that should be considered in migrants
Sickle cell or thalassemia status
Four countries where FGM is rife
Somalia, Eritrea, Ethiopia, Sudan
How many types of FGM are there?
3
To where do doctors report suspected FGM?
Police
Cross-cultural factors in healthcare. What should you consider?
People may express symptoms differently. May wish to use traditional healing. Consider religious/spiritual framework:
○ Witchcraft
○ Beating out spirits
Stigma attached to certain conditions
What makes healthcare interventions difficult in refugees?
- Lack of stability
- Worries re. immigration
- Poverty
- Ongoing trauma/missing family members
- Language/social isolation
Law vs ethic in right to movement across borders
Law is clear: no legal right to freedom of movement across state borders. Ethics is not: movement as basic human right v right of states & societies to control borders
Article 13 of UN Universal Declaration of Human Rights states what about free movement?
Everyone has right to leave or enter country and move within it
Who can consent for a child?
Child
Individual with “parental responsibility”
Courts
People who have “care for a child” (e.g. teacher)
At what age can you not refuse lifesaving Tx?
Under 18
Which parent always has parental responsibility?
Birth mother always has PR
In what situations does the biological father (England and Wales) have parental responsibility? 2 situations
→ If married to biological mother at time of conception, birth, or currently
→ If not married then can get PR via written agreement with mother, court order, or being named on birth certificate as father
Take home messages when it comes to Parental Responsibility
Do NOT assume adult accompanying child has parental responsibility
When is consent for a child not required? 3 listed
To save life in emergecy
Abandonment by parents
Abuse by parent
What to do if there are disagreements about care between doctors, parents, child?
Best practice:
→ Communication is key
→ Shared decision making is best model for ethical paediatric care
What should be done if doctors want to treat (or not), but child/parent does not want treatment (or wants) and disagreement cannot be resolved?
Apply to courts for decision of “best interests”. Drs cannot be forced to provide Tx, however.
What should be considered by the courts if there is disagreement between doctors and parents/child over treatment?
→ Views of medical team → Views of parents → Best interests of child → Balance all conflicting considerations → Considerable weight must be given to prolongation of life but principle may be outweighed if quality of life are sufficiently small and pain + suffering of living are sufficiently great
What happens if child disagrees with parent?
Gillick competent children can consent without agreement from parents. Cannot refuse consent. Thus, parents can consent and thus overrule child’s refusal. If serious disagreement, wise to apply to courts for judgement about best interests
What about when parents disagree about treatment?
Parental responsibility is shared and unilateral consent usually suffices legally. But ethics of allowing one parent only to consent is contested
GMC guidence on on how doctors should treat children
Protect well-being, this includes treating young people as individuals & respecting their views, as well as considering physical and emotional welfare
GMC: Assessing best interests. What should be considered? 6 listed
→ Views of minor, inc previously expressed wishes
→ Views of parents
→ Views of others close to minor
→ Cultural, religious or other beliefs/values of minor & parents
→ Views of other healthcare professionals involved in providing care
→ Which choice will least restrict future options
What do the Gillick and Axon cases confirm about child confidentiality?
Children have right to confidentiality where child is Gillick competent
When can you breach confidentiality against a child’s wishes? 3 situations
Overriding public interest
Best interest of incompetent child
Disclosure required by law
Give examples of what ‘resources’ are in healthcare - 5 listed
Money Time (patient, carer and clinician) Energy (patient, carer and clinician) Bed and clinic space Personnel
What are the problems with the liberatarian free market in healthcare? 5 points
Might exclude poor from medical cover
People might not have enough info to choose policy wisely
Possibility of discrimination: gender, genetics, lifestyle etc.
It may be inefficient? (insurance company bureaucracy)
Should healthcare be treated as a market commodity?
What is the veil of ignorance?
Device to facilitate thought about what a ‘just’ system would look like. We are all behind ‘veil of ignorance’ and know nothing of status, ability, ethnicity, wealth etc. Therefore we would create the most fair society
What are the different appraches to rationing of healthcare? List 8
Free market Lottery Need Consequentialism Responsibility Social Worth Democracy Pluralism
What are the pros of allocating health resources based on a lottery?
Everyone is treated equally
No discrimination on basis of age, gender, lifestyle etc.
What are the cons of allocating health resources based on a lottery?
Does not take into account: Age, Need, Cost effectiveness, Responsibility
Problems with allocating resources on the basis of need
How to compare – e.g. my need for a hip replacement v your need for eye surgery v his need for prostate cancer screening. Too simple? How to define need? Takes no account of cost-effectiveness. No account of responsibility
Allocation of healthcare using consequentialism
Maximisation of utility. Requires cost-effectiveness calculations to give a numerical, utilitarian, value of health
Issues with allocating healthcare based on responsibility
Not all choices are free (e.g. addictions)
Overly moralistic approach?
Smoking & drinking v cervical cancer & pregnancy?
Creates judgmental medics?
Too harsh?
What is pluralism?
Allocate resources on the basis of some or all of the values discussed. A very reasonable approach (takes into account our complex views). But… Incommensurability. Can we weigh the different values?
Key function of NICE
“Technology appraisals intended to assess the clinical and cost effectiveness of health technologies, such as new pharmaceutical and biopharmaceutical products, procedures, devices and diagnostic agents. This is to ensure that all NHS patients have equitable access to the most clinically and cost-effective treatments that are available”
Procedures for safeguarding adults - 5 points
Raising alarm Referral and risk assessment Strategy discussion or meeting Investigation Case conference and protection plan
List some services offered for elderly
Home care Meal services Equipment adaptations Day Centers Accommodation Intermediate care Community Nursing
Pros of intermediate care for elderly
Avoid hospital admission or longer stay
Allow recovery at home
Help faster recovery by going home sooner
Support independent living
After assessment services provided by specialist inter disciplinary team, part of free health care
What is the Care Act 2014?
Sets out in one place, local authorities’ duties in relation to assessing people’s needs and their eligibility for publicly funded care. Local authorities must carry out assessment of anyone who appears to require care, regardless of likely eligibility for state-funded care
For the purposes of the Act, a person is unable to make a decision for himself if he is unable to do which 4 things?
- understand information relevant to decision
- retain information
- deliberate information as part of process of making decision
- communicate decision
If a person lacks capacity, what 2 options have legal power?
Is there a valid Lasting Power of Attorney?
Is there a valid Advance Decision?
There is growing recognition that elderly people in care homes are vulnerable. Their rights can be breached in a number of ways. Give examples
→ Leaving someone in soiled sheets
→ Not giving patients enough to drink
→ Leaving food when the person needs help to eat
→ Using excessive force to restrain someone
→ Changing a person in an open area etc
Define patient autonomy
Right of patients to make decisions about their medical care without healthcare provider influencing decision. Patient autonomy does allow for healthcare providers to educate patient
