framework for ethical analysis Flashcards
GMC: Good medical practiceDuties of a doctor (2013, 14, 19)
Knowledge, skills & performance
Make the care of your patient your first concern
Safety and quality
Communication, partnership and teamwork
Maintaining trust
Consequentialism
it promotes best consequences.
Most common form is utilitarianism
deontology
it is in accord with a moral rule or principle. Duties and Rights based morality
virtue ethics
it is what a virtuous agent would do in the circumstances.
e.g. a good doctor is one who is: Caring, Disciplined, Skilful Trustworthy
Four Principles of Medical Ethics
autonomy - respecting the patient’s wishes; helping them come to their own decisions
no maleficence - do no harm
justice - fairness in the provision of care; distributive justice; rights based justice; legal justice
beneficence - doing good and acting in the patients best interests
Four Quadrants
medical indications
patient preferences
quality of life
contextual features
medical indications
Consider each medical condition and its proposed treatment:
Does it fulfil any of the goals of medicine?
With what likelihood?
If not, is the proposed treatment futile?
patient preferences
What does the patient want? Does the patient have the capacity to decide? If not, can anyone advocate for the patient?
Do the patient’s wishes reflect a process that is: informed? understood? Voluntary? Continuing?
quality of life
Describe the patient’s quality of life in the patient’s terms and from the care providers’ perspectives.
contextual features
Circumstances that can either influence the decision or be influenced by the decision
Prof Bowman’s guide to helping you think through cases (p10):
- Summarise the case or problem
- State the moral dilemma
- State the assumptions that are being made
- Analyse the case
- Acknowledge other approaches and state the preferred approach with explanation
why do basic errors happen? - Sokol & Bergson
- Stress
- Fatigue
- Covering for colleagues (too little locum support)
- Professional culture (unwillingness to use support structures)
- Feeling that decisions must be made alone
- Unable to admit to uncertainty
bowman - why is it difficult to admit and report errors in medicine
- Consequences:
- Does error = incompetence? (after all, everyone makes mistakes…)
- Whistle-blowing is not without risk (far from it in fact…)
- Medicine is not an exact science
- Some argue that there is a “norm of non-criticism”
Francis Report
• Stafford Hospital
• “They (Stafford Hospital patients) were failed by a system which
ignored the warning signs and put corporate self-interest and
cost control ahead of patients and their safety.“
• 290 recommendations including:
– Duty of Candour: A statutory obligation on doctors and nurses for a duty of candour so they are open with patients about mistakes
Duty of Candour (2015)
‘To place a duty of candour on health and social care organisations. This would create a legal requirement for health and social care organisations to inform people when they have been harmed as a result of the care or treatment they have received.
• To establish new criminal offences of ill-treatment or wilful neglect in
health and social care settings; one offence applying to individual health and social care workers, managers and supervisors, and another applying to organisations’
apology
a statement of sorrow or regret in respect of unintended or unexpected incidence
GMC – Duty of Candour 2015
- tell the patient (or, where appropriate, the patient’s advocate, carer or family) when something has gone wrong
- apologise to the patient (or, where appropriate, the patient’s advocate, carer or family)
- offer an appropriate remedy or support to put matters right (if possible)
- explain fully to the patient (or, where appropriate, the patient’s advocate, carer or family) the short and long term effects of what has happened.
What might happen in responseto errors or inadequate care?
- Negligence (legal approach): patient might take legal action
- NHS Complaints Procedure: patient might make a complaint
- GMC (professional body): disciplinary action or removal from register
Four outcomes from GMC investigation:
Case concluded, no further action
Issue a warning
Agree undertakings
Refer to MPTS (Medical Practitioners Tribunal Service)
Legally: Negligence
- He/she is owed a duty of care by the defendant
- That the defendant breached that duty by failing to provide
reasonable care; and - That the breach of duty caused the claimant’s injuries
(causation), and that those injuries are not too remote (proximity).
The Bolam (1957) test:
“A doctor is not guilty of negligence if he has acted in accordance
with a practice accepted as proper by a responsible body of
medical men skilled in that particular art.” Judge McNair (p113,
Ibid)
The Bolitho (1997) test:
Modified Bolam to add: the professional opinion must be
capable of withstanding logical analysis (note: a move away from
the deferential approach of Bolam) (p115, Ibid)
The impact of Montgomery(2015)
• Does the patient know about the material risks of the
treatment I’m proposing?
• Does the patient know about reasonable alternatives to this
treatment?
• Have I taken reasonable care to ensure that the patient
actually knows this?”
causation
There must be a clear link between the action (or inaction) of a
doctor, and the harm the patient experienced
• a key factor is also proximity
Often causation is where a patient’s case may fail
NHS complaints procedure(Scotland)
2012 Charter of Patient Rights and Responsibilities
• Stage 1: Local resolution
• Stage 2: Scottish Public Services Ombudsman
• Judicial review
How best to learn from errors?
• Person-centred approach
– Focussed on the individual doctor
• Systems-based approach
– Considers the environment, and seeks to minimise opportunities for error
How has medicine sought to address some of the failures in the current system?
• Dedicated centres – Beneficial for less common and uncommon procedures • Requirement to retrain – New procedures and techniques • Data collection of incidents • Improved instrument design • Protocols & guidelines • Checklists
National Patient Safety Agency
Established in 2001; abolished in 2012 (England & Wales)
