Medical Ethics - Master of Hospital Administration (MHA)

Introduction to issues in medical ethics

V Raman Kutty

Professor, AMC

Medical Ethics
[vs. Professional ethics]

• Principals to guide physicians in their relationships with others

• Ethical dilemma is a predicament in which there is no clear course to resolve the problem of conflicting moral principles

• Dynamic environment/evolving field

Principles

• Autonomy

• Beneficience

• Nonmaleficence

• Justice

Autonomy

• Right to self-determination

• Requires decision making capacity

– Lack should be proven not assumed

• Competence – legal determination

• Liberty – freedom to influence course of life/treatment

Preservation of Autonomy

• Advance Directives

– A document in which an individual either states preferences or designates decision maker

– Living Will

• Takes effect when terminally ill and lacking decision making capacity

Preserving Autonomy

• Surrogate Decision Makers

– Represents patients interest

– Best identified before critical illness

– In absence of specific advanced directives should use substituted judgement

Preservation of Autonomy

• The primary responsibility of the physician is to serve the patients interest

The patient self determination act of 1990

• At the time of admission information re: the patients’ right to refuse care or create an advance directive must be dispensed

Informed Consent

• Requirements

– Decision making capacity

– Volutariness

– Reasonable person standard

• Present all alternatives f/b recommendation

• Respect refusal

• All surgical and experimental procedures

Implied Consent

• Invoked when true informed consent not possible

• Emergency situations when harm would result without urgently needed intervention

Disclosure

• Truth telling on part of physician is an integral part of patient autonomy

Paternalism

• Justifiable if patient at risk of significant preventable harm, paternalistic action will prevent harm, benefits outweigh risks and the least autonomy-restrictive course of action is used

Confidentiality

• Obligation of physician to maintain information in strict confidence

• Exceptions if failure to release data to data to appropriate agencies may result in greater societal harm

Futility

• Unilateral decision made on part of physician to withold or withdraw medical intervention based on predictable futile outcome

• Physiologic futility

• Medical futility – none of last 100 cases like this…

Beneficience

• Obligation to preserve life, restore health, relieve suffering and maintain function

• To do “good”

• Nonabandonment – obligation to provide ongoing care

• Conflict of interest – must not engage in activities that are not in patients best interest

Nonmaleficence

• “Do no harm, prevent harm and remove harm”

Impaired Physician

• Physicians have the obligation to report impaired behavior in colleagues

Principle of Double Effect

• Act must be morally good

• Actor intends good effect

• Good effect outweighs bad effect

• Bad effect not means to good effect

Justice

• Allocation of medical resources must be fair and according to need

• Physicians should not make decisions regarding individuals based upon societal needs

DNR

• DNR orders affect CPR only

• Other therapies should not be influenced by DNR order

• Should be reviewed frequently

• Rationale should be in medical record

Withdrawing of Support

• Brain death is not required

• Same as not initiating

• Does not conflict with basic principles

Persistent Vegetative State

• Uncnsciousness/ loss of self awareness lasting more than weeks

Death

• Irreversible cessation of circulatory and respiratory function

• Irreversible cessation of all brain function (including brainstem)

The Nuremberg Trials

Nuremberg Code (1947)

“The voluntary consent of the human subject is absolutely essential.”

“This means that the person involved should have legal capacity to give consent; should be so situated as to be able to exercise free power of choice … and should have sufficient knowledge and comprehension of the elements of the subject matter involved as to enable him to make an understanding and enlightened decision. This latter element requires that before the acceptance of an affirmative decision by the experimental subject there should be known to him the nature, duration and purpose of the experiment; the methods and means by which it is to be conducted; all inconveniences and hazards reasonably to be expected; and the effects upon his health or person which may possibly come from his participation in the experiment.”

RESEARCH ETHICS CODES

DECLARATION OF HELSINKI – 1964 (revised in 1975, 1983, 1989, 1996, 2003)

• Issues addressed include:

• Research with humans should be based on the results from laboratory and animal experimentation

• Research protocols should be reviewed by an independent committee prior to initiation

• Informed consent from research participants is necessary

• Research should be conducted by medically/scientifically qualified individuals

• Risks should not exceed benefits

ICMR guidelines

• Recently developed by ICMR (available on website)

• All medical research in India mandated to follow guidelines

Implications

• Informed consent requirements should be carefully followed

• IRB mandatory in large institutions- otherwise, can request other institutions’ IRB to review proposals

• Collaborative research should be approved by IRBs of all institutions