1. BASIC MEDICAL ETHICS3
Four basic ethical principles
i) The Principle of Respect for Autonomy
Autonomy is Latin for "self-rule" We have an obligation to respect the autonomy of other persons,
which is to respect the decisions made by other people concerning their own lives. This is also
called the principle of human dignity. It gives us a negative duty not to interfere with the decisions
of competent adults, and a positive duty to empower others for whom we’re responsible.
Corollary principles:
 Honesty in our dealings with others & obligation to keep promises.
ii) The Principle of Beneficence
We have an obligation to bring about good in all our actions.
Corollary principle:
 We must take positive steps to prevent harm. However, adopting this corollary principle
frequently places us in direct conflict with respecting the autonomy of other persons.
iii) The Principle of Non-maleficence
We have an obligation not to harm others: "First, do no harm."
Corollary principles:
 Where harm cannot be avoided, we are obligated to minimize the harm we do.
 Don't increase the risk of harm to others.
 It is wrong to waste resources that could be used for good.
Combining beneficence and non-maleficence:
 Each action must produce more good than harm.
iv) The Principle of Justice
We have an obligation to provide others with whatever they are owed or deserve. In public life, we
have an obligation to treat all people equally, fairly, and impartially.
Corollary principle: Impose no unfair burdens.
Combining beneficence and justice:
 We are obligated to work for the benefit of those who are unfairly treated.
Source: http://ministryofethics.co.uk/?p=6
2. ETHICAL SCENARIO
Lower respiratory tract infections (LRI), including pneumonia, are the leading cause of mortality in
dementia patients. Whilst intensive treatment may prolong life to variable lengths, there are longlasting impacts on the patient’s quality of life, more so if the patient has severe dementia. In
addition, a study observed a 40% mortality rate within 3 months despite intensive treatment.
Mr A is a 70-year old man who lives in a nursing home due to severe dementia. He was recently
taken to hospital with a diagnosis of pneumonia and was in respiratory distress, which was likely to
require intubation and intensive care. Prior to this hospitalisation, Mr A was in excellent health,
which enabled him to enjoy the amenities of the nursing facility, stroll on the grounds, participate
in art and music, and enjoy visits from his family on a weekly basis.
STAGE 1
You are the doctor in charge of Mr A’s treatment. Due to his dementia and incapacity of decisionmaking, you are required act in Mr A’s best interest and decide what to do.
DO YOU OR DO YOU NOT TREAT?
STAGE 2
It was discovered that 5 years ago, when Mr A did not suffer from dementia, he made a signed
advanced directive stating that if he should ever become demented and was found to be in a
position to require resuscitation, he refuses it. Whilst advanced directives can be binding, it is
important to treat the patient relative to the current time and situation.
DO YOU OR DO YOU NOT TREAT?
STAGE 3
Families play an important role in determining the patient’s best interest. When speaking with his
family, they acknowledge this advanced directive but insist that it should not be acted upon. His
three children explained that, despite his compromised cognition, their father was currently
enjoying his day-to-day life in the nursing home, and should be intubated.
DO YOU OR DO YOU NOT TREAT?
STAGE 4
It was found that Mr A had written the advanced directive shortly after his close friend, Mr B, had
passed away. Mr B’s end-life treatment was messy as the doctor had difficult in determining Mr B’s
capacity due to his dementia. Mr B had no prior advanced directive and no close family members,
thus his doctor decided to continue treatment, which resulted in major complications. Mr A
struggled with bouts of depression following Mr B’s death and decided on the advanced directive
without consulting his family members. This news greatly affects the validity of the Mr A’s
advanced directive.
DO YOU OR DO YOU NOT TREAT?
BONUS ROUND
You discover that Mr A was a serial killer in his younger days and killed your own best friend’s
father in one of his shootings. Your best friend struggled with depression thereafter and dropped
out of university as a result. You have been supporting your friend throughout the years and have
developed a crush on him/her. You are angry at the struggles your crush has had to go through and
now fates intertwine. Mr A is now your patient.
DO YOU OR DO YOU NOT TREAT?
3. SYNOPSIS OF SCENARIO
Current situation
 Mr A in nursing home due to dementia
 Good health, enjoys strolls and interacts well with other inhabitants, enjoys music
 Frequently visited by family
Emergency
 Admitted to hospital with case of pneumonia, in respiratory distress
 Require intubation and possible intensive care
Advanced directive
 Do not resuscitate if circumstances demand it
Validity of advanced directive
 Not done with family members
 Influenced by best friend who died without advanced directive. Friend had dementia and
poor end-of-life treatment
Patient’s best interest
 Family acknowledges advanced directive but argues for overrule
 Family feels he is having a good life, and prognosis is good
Prognosis following treatment
(van der Steen et al., 2007)

Lower respiratory tract infections (LRI), including pneumonia, are the leading cause of
mortality in dementia patients

Following LRI, almost half of patients followed (45.8%) had no activities of daily living (ADL)
decline, 21.0% declined, and 33.2% had died within 3 months.

Few variables were statistically significantly associated with both outcomes. Severe
dementia was the strongest predictor of decline (OR 2.5; 95% CI, 1.3–4.8), following
baseline ADL.
(Rello et al., 1996)

There was a 40 percent mortality rate among those who required intensive care (87 percent
of all study patients were intubated). In addition, survivors spent 15.6 days on average in
the ICU.
4. APPENDIX: UK MEDICAL LAW AND ETHICS
i. Capacity
Mental Capacity Act 2005
What is capacity?
•
Understand information relevant to decision
•
Retain information
•
Use or weigh information
•
Communicate the decision
Re T (adult: refusal of medical treatment) [1992]
4. What the doctors cannot do is to conclude that if the patient still had had the necessary
capacity in the changed situation he would have reversed his decision. … What they can do
is to consider whether at the time the decision was made it was intended by the patient to
apply in the changed situation.
5. The patient’s right of choice exists whether the reasons for making that choice are
rational, irrational, unknown or even non-existent
7. If an adult patient did not have the capacity to decide at the time of the purported refusal
and still does not have that capacity, it is the duty of the doctors to treat him in whatever
way they consider, in the exercise of their clinical judgment, to be in his best interests.
Lord Donaldson MR
Beauchamp and Childress, 2001
In some cases, a person’s lack of awareness of even a single risk or missing fact and deprive him or
her of adequate understanding.’
ii. Advanced directive
Mental Capacity Act 2005
Suicidal intentions during advanced decision
9.9 Healthcare professionals may have particular concerns about the capacity of someone with a
history of suicide attempts or suicidal thoughts who has made an advance decision. It is
important to remember that making an advance decision which, if followed, may result in
death does not necessarily mean a person is or feels suicidal. Nor does it necessarily mean
the person lacks capacity to make the advance decision. If the person is clearly suicidal, this
may raise questions about their capacity to make an advance decision at the time they made
it.
Criteria of an advanced decision
9.11 An advance decision to refuse treatment:
- Must state precisely what treatment is to be refused – a statement giving a
general desire not to be treated is not enough
- May set out the circumstances when the refusal should apply – it is helpful to
include as much detail as possible
- Will only apply at a time when the person lacks capacity to consent to or refuse the
specific treatment.
iii. Doubts over advanced directive
HE v A Hospital NHS Trust [2003]
‘Doubt over the continuing validity of an advance directive must be resolved in the favour of life
unless clear and convincing evidence is offered to the contrary.’
Munby J
Mental Capacity Act 2005
9.64 It is ultimately the responsibility of the healthcare professional who is
in charge of the
person’s care when the treatment is required to decide whether there is an advance
decision which is valid and applicable in the circumstances. In the event of disagreement
about an advance decision between healthcare professionals, or between healthcare
professionals and family members or others close to the person, the senior clinician must
consider all the available evidence. This is likely to be a hospital consultant or the GP where
the person is being treated in the community.
9.65 The senior clinician may need to consult with relevant colleagues and others who are
close to or familiar with the patient. All staff involved in the person’s care should be given
the opportunity to express their views. If the person is in hospital, their GP may also have
relevant information.
9.66 The point of such discussions should not be to try to overrule the person’s advance
decision but rather to seek evidence concerning
its validity and to confirm its scope and its
applicability to the current circumstances. Details of these discussions should be recorded
in
the person’s healthcare records. Where the senior clinician has a reasonable belief that
an advance decision to refuse medical treatment is both valid and applicable, the person’s
advance decision should be complied with.