ethics Flashcards
what is the bma ?
the BMA is a doctors ’ organisation which, among other activities, provides ethical and medico-legal advice.The nhs uses this
Does medical ethics help and how?
W hen professionals have to work through a problem and feel justifi ed about the options they take or recommend, they need some consistent benchmarks. Traditionally, codes of ethics helped by setting out a framework of duties and principles. Modern medical ethics still provides the framework but also needs to take account of professional regulation, law and quasi law.
Self-determination or autonomy
– The ability to think, decide and act for oneself is summed up in the concept of self-determination or personal autonomy.
When patients have the mental capacity to make choices, their decisions should be respected as long as they do not adversely affect the rights or welfare of others.
Adults with capacity who understand the options are entitled to accept or refuse them without explaining why. They can make choices that seem very harmful for them (as long as those things are lawful), but they cannot choose things that harm other people
Mental capacity –
to exercise autonomy, people need to have the mental capacity to understand and weigh up the options so that they can make a choice.
All adults are assumed to have this, unless there is evidence to the contrary and, in practice, most people (unless unconscious) are capable of making some decisions.
Adults ’ decisions can still be valid when they appear unconventional, irrational or unjustifi ed, but health professionals may need to check that patients have the mental capacity to exercise their autonomy, when such choices have major life-changing implications.
Honesty and integrity –
Health professionals are required to be honest and to act with integrity.
This means more than simply telling the truth. Their actions should never be intended to deceive and there should be transparency about how decisions are reached.
One of the major challenges in this context is giving patients bad news about their prognosis, when the temptation may be to imply more hope than is justifi ed. Good communication skills are essential. A failure to communicate effectively can undermine trust and invalidate patient consent if information the patient needs and wants to know is left unsaid
Confidentiality
– All patients are entitled to confidentiality, but their right is not absolute, especially if other people are at serious risk of harm as a result.
Cases arise where an overriding public interest justifi es disclosure, even against the patient ’s wishes. Although this is one of the oldest values reiterated in ethical codes, it is increasingly diffi cult to defi ne its scope and limitations in practical terms, not least because notions of public interest change.
Fairness and equity –
The individual patient is the main focus, but health professionals also have to consider the big picture and whether accommodating one person ’s wishes harms or deprives someone else unfairly.
There are various ways of approaching justice besides the obvious one about equality
trying to treat all similar cases the same), including the suffi ciency view (what matters most is that everyone has essential care – although views can vary on what counts as essential – and beyond this, inequalities are less important).
Fairness under the law is another aspect which is considered further below. Fairness to patients is also a consideration when confl icts of interest arise and doctors ’ professional judgement risks being infl uenced by factors such as the prospect of personal gain.
Harm and benefit
– Notions of maximising benefi t and minimising harm are among the trickiest aspects of modern medical ethics, although the ancient ‘Hippocratic’ commitment to benefi t patients and to do so with minimal harm remains central to medical ethics and, indeed, to other healthcare professional codes.
Keeping people alive and functioning was traditionally understood to encapsulate the obligation to avoid harm and promote benefi t but, although the terminology has not changed, the interpretations have. Actions are harmful if the person experiencing them believes them to be so or has clearly rejected them. An example would be the use of invasive technology to try and prolong the life of someone who has refused it. Although they can be slippery, notions of harm and benefi t continue to feature strongly in any problem-solving methodology and increasingly preoccupy the courts. There is no clear and universal defi nition and interpretation of the terms depends in different contexts on a number of variables, including individuals ’ preferences as well as legal and professional benchmarks
professionalism
Professionalism is closely linked to modern ethical precepts and refl ects traditional core values.
Key challenges include finding and maintaining ways in which core values, such as compassion, benefi cence and a strong obligation to promote the interests of patients, can still underpin and guide practice in a commercially orientated and consumer-led health environment.
Duties and rights
Traditional ethical codes were all about doctors ’ duties without spelling out any explicit rights (or responsibilities) for patients. By inference, if doctors and other health professionals have certain duties, such as to avoid harm and provide benefi ts, logically patients have concomitant rights, but until relatively recently, health care was not primarily seen from the patient ’ s perspective.
) Now, rights – especially those linked to patient autonomy and self-determination – are often the main focus of ethics and law. A distinction can be made between moral rights and those which are legally enforceable. Many rights are moral claims which we intuitively consider appropriate but because these are not always clear-cut and as the moral claims of different individuals often clash, much depends on the context of the case. In ethics (unlike law), few rights are absolute and often one person’ s moral rights may be overridden in exceptional cases in order to prevent a greater harm..) Ethical analysis can provide a useful problem-solving tool, taking into account the context of the dilemma in order to balance out such confl ict
The public interest
it limits individuals’ freedom to act, or keep information secret, in situations where other people might be harmed.
The public interest is usually defined by law and is the basis of all public health legislation, such as the duty to report infectious diseases. Other common examples of the public interest argument arise when a disclosure of information from medical records is needed to prevent accidental harm, such as when a patient with bad eyesight continues to drive, or to detect a serious crime . The General Medical Council (GMC) also advises that, in some circumstances, a disclosure without a person ’ s consent can be justifi ed in the public interest to enable medical research.
1 In all cases, the facts must be subject to close scrutiny as to whether there is a genuine public interest at stake. Although ‘public interest’ is the usual terminology and is used throughout this book, some people prefer to think of it in terms of ‘the public good’ to emphasise that there is a clear distinction (particularly in relation to information disclosure) between what is in the public interest and what the public is interested in.
Medical law and healthcare law
which for doctors is the GMC. An understanding of medical law is as crucial for doctors as an awareness of ethics or of GMC rules,
but the law relating to health care is fast moving, making it a challenge to keep abreast of new developments. Increasingly too, legislation differs in England, Wales, Scotland and Northern Ireland. This book draws attention to relevant legal provisions throughout the UK and to where they differ, and regular updates are provided on the BMA’ s website. Often, common dilemmas cannot be resolved by concentrating on the ethics because, in many cases, the law actually dictates what must be done. Law’ s ever-increasing role in health care can be seen in the important guidance on best practice which has evolved through court judgments. In practice, law and ethics are often intertwined so that judgments in legal cases draw on traditional ethical principles and moral analysis. The two are often so inseparable that it is diffi cult to disengage moral considerations from legal rules.
Statute and common law
Statute describes laws made by Parliament which govern many contentious areas such as abortion, reproductive technology and the use of human tissue as well as everyday matters such as the use of health data
. common law . This develops as precedents set by judges in individual cases establish rules or benchmarks for other similar cases. The court’ s ruling in one situation can often be extrapolated to resolve disagreements in other similar scenarios. Judges are expected to abide by the precedents of earlier cases unless there are strong reasons to challenge them.
human rights law
Human rights law is one category of statute law.
It is formal, enforceable and generally non-negotiable, although some legitimate interference with people ’ s rights is permitted, as long as it is proportionate and justifi able. Unlike moral rights, legal rights are less dependent upon context and are generally less fl exible even though there can be scope for interpretation. Human rights law has some signifi cant implications for medicine, not least in the manner in which its concepts and terminology have infl uenced medical ethics. The relevant Articles have also been relied upon heavily to argue medical cases before the courts. In 1998, the UK incorporated the bulk of the rights set out in the European Convention for the Protection of Human Rights and Fundamental Freedoms into British legislation. The UK ’ s Human Rights Act came fully into force in 2000.
