PPD - Medical Law and Ethics

Question 1

Outline the principles of conducting an ethical analysis of a medico-moral case. - WHAT ARE THE FOUR MODELS?

Answer 1

The ‘four principles approach’
The paradigm case process / 4 quadrants
Structured case analysis model
Ethical grid

Question 2

What is the ‘four principles approach’?

Answer 2

Method of conducting an ethical analysis of a medico-moral case
Non-maleficence, beneficence, autonomy, justice

Question 3

What is the paradigm case process / 4 quadrants?

Answer 3

Method of conducting an ethical analysis of a medico-moral case
medical indications, patient preferences, quality of life, contextual features

Question 4

What is the Structured case analysis model?

Answer 4

Method of conducting an ethical analysis of a medico-moral case
SUMMARISE, STATE the more assumption, state assumptions beting made, ANALYSE the case in terms of ethics, consequences, ‘virtuous HCP’, law, IDENTIFY justifyable solutions, state preferred approach

Question 5

What is the ethical grid?

Answer 5

Method of conducting an ethical analysis of a medico-moral case
Complex grid incorporating respect, honesty, outcome analysis and all peripheral considerations such as law, evidence

Question 6

What are the benefits of being ethical?

Answer 6

better patient care, happier employees, maintains reputation, lack of moral distress, more productive, inclusive and effective teams

Question 7

What are the challenges of doing ethics?

Answer 7

limited resources, integrating into habits so it is part of every clinical process, ethics constructed or treated like ‘jumping through hoops’

Question 8

Explain the ethical and legal significance of the concepts of consent in clinical practice.

Answer 8

Consent - voluntary agreement, permission to examine/investigate/treat, waiving of right to bodily integrity
Key principles are INFORMED, VOLUNTARY, COMPETENCE (and patient can change mind at any time!)

Question 9

PARQ

Answer 9

procedure, alternative, risks, questions

Question 10

Components of competence

Answer 10

Competence incorporates ability to UNDERSTAND, RETAIN, WEIGH UP and COMMUNICATE DECISION

Question 11

What are the theories/models regarding how much information patients should be given?

Answer 11

Professional practice standard, reasonable / prudent person standard, subjective standard (what does this patient likely care about)

Question 12

What is the Bolam test

Answer 12

opinion of a responsible body of medical opinion

Question 13

Requirements of a decision being ‘voluntary’

Answer 13

Voluntary means patients must be able to refuse, know they can refuse, and must be free from undue pressure

Question 14

What is the information-giving standard following the Montgomery case

Answer 14

Patient must be aware of any ‘material’ risks that a REASONABLE person would be concerned about (or the specific patient if the doctor is aware of any specific concerns)

Question 15

Potential issues with getting consent

Answer 15

must be SPECIFIC, can be delegated but only if rules are followed, signed consent does not mean you have sufficient evidence
How did you present the information?
What is the complexity of the information?
What are the effects of fear, social status, embarrassment, etc. on decisions?
Time consuming

Question 16

When is consent NOT required?

Answer 16

patient not competent (what is in their best interests or reflects their most recent wishes?), do they pose a serious risk to others if not treated?, they decline all information

Question 17

Discuss medical error in relation to professional competence - discuss likely causes and potential impact on work culture

Answer 17

Rarely due to poor performance
Usually systemic problems
Best solution is: systemic improvement (e.g. clinical governance, reporting to agencies etc.)
Rarely “one offs”
Everyone makes mistakes (and that includes you!)
Do not blame yourselves for every mistake
The “blame culture” is not healthy

Question 18

Principles to avoid professional competence issues following mistakes

Answer 18

ALWAYS COMMUNICATE OPENLY, EXPLAIN ISSUES/MISTAKES
ALWAYS APOLOGISE
BUILD RAPPORT WITH PATIENTS

Question 19

Explain the potential legal and professional ramifications of medical errors and negligence - how can patients hold HCPs accountable?

Answer 19

NHS Complaints Procedure - very convoluted
General Medical Council - Fitness to practise panel
The Law - Criminal or civil (tort of negligence, breach of contract - private only)

Question 20

What elements are required to prove negligence?

Answer 20

The doctor had DUTY OF CARE, which was BREACHED, this breach CAUSED HARM

Question 21

What is the principle of candour in medical error?

Answer 21

patients must be told if there was an error made which caused them to suffer OR COULD HAVE

Question 22

What is defensive medicine? and discuss the various issues that may come up

Answer 22

“the practice of performing tests as a safeguard against possible malpractice liability rather than to ensure the health of patients”

Defensive medicine is also…
rarely a sustainable explanation for action
makes litigation more likely (unnecessary investigations/treatment)
very expensive
violates the trust that patients have in doctors

Question 23

Describe a systematic approach to the analysis of the causes of medical error and threats to patient safety.

Answer 23

NHS Redress Act 2006 - Alternative to litigation, no court system involvement, goal is to move away from blame culture, reduce costs and prevent harm by allowing doctors to learn from mistakes

Should NHS have a no fault scheme?

Question 24

Explain the ethical and legal significance of the concepts of confidentiality in clinical practice. Why is confidentiality important?

Answer 24

Autonomy
Rights to privacy
Welfare/beneficence
Trust depends upon it
Argument from utility
Common law duty to keep confidences (not contractual)
Ethical emphasis on confidentiality (e.g. see GMC Confidentiality (September 2000))

Question 25

Outline requirements for public disclosure

Answer 25

in the public interest AND not competent to consent OR obtaining consent would put others at risk OR obtaining consent would undermine the purpose OR time is of the essence.

Question 26

Describe the ethico-legal issues relevant to the prescription of pain relief.

Answer 26

Doctrine of double effect - ie the pain relief may kill them more quickly, but the express purpose is pain relief - FOCUS ON INTENTIONS (but does that matter if the consequences are the same?)
Law states that doctors can prescribe pain relief even if there is a risk of abbreviating life (with proper consent, understanding, etc.)

Question 27

Explain the distinctions between active, passive, voluntary, non-voluntary and in-voluntary euthanasia

Answer 27

Discuss difference

Question 28

Explain and ethically evaluate the law relating to suicide and assisted suicide with particular reference to the guidance issued by the Director of Public Prosecution in relation to assisted suicide.

Answer 28

Assisted suicide is illegal and there is not immunity from prosecution but they have determined factors that weigh in favour or against prosecution

In favour:
Person who dies is under 18, may lack capacity, has no clear / settled wish to die, questioning their decision, they did not initiate the process, they do not have a terminal illness
The person helping them is not motivated by compassion / long term relations, or there is evidence of persuasion or coercion
(against is opposite)