University of Manchester
Year 5 Medical Students (Ethics & Communication)
Moral Management in Moral Medicine
Negotiating Solutions to Ethical Dilemmas using
Communication Skills
Revised by Ruth Bromley July 2011
Based on original work by Caroline Boggis, Rosie Illingworth and Mark Perry
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11
Contents
Outline of session....................................................Page 3
ILO’s...............................................................................Page 3
Timetable.....................................................................Page 3
Administrator’s planner.........................................Page 4
Organisational Information..................................Page 5
SP Rota............................................................................Page 5
Instructions to lead tutor........................................Page 6
Instructions to tutors................................................Page 7
Key questions...............................................................Page 10
Cases with tutor notes...........................................From Page 11
DVLA epilepsy Dr p 11 / SP 12/ Tutor p 13
Advanced Directive Dr p 15/ SP p 16/ Tutor p 17
15 yr with diabetes Dr p 20/ SP p 21/Tutor p 22
Negligent surgeon Dr p 25/ SP p 26/Tutor p 28
Bibliography................................................................Page 32
Student Handout........................................................Page 33
Page 2 of 32
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11
Outline of session
This is a 3h session which allows students to practise using their communication skills
within ethical scenarios. After a brief introduction, there is a front of house scenario
followed by small group work where they will experience 3 further scenarios. It ends
with a plenary session which gives the students further opportunity to discuss
unanswered questions.
ILO’s
By the end of this session, the students will have gained experience of applying their
ethical knowledge to reasonably common clinical scenarios. They will have observed
(and, in some cases, practised) using good communication skills eg listening, empathy,
exploring ideas, concerns and expectations to negotiate management/patient care.
Please see each case for further ILO’s.
Timetable Negotiating Skills (Ethics)
Updated Nov 10
Running Duration What
Time
O mins 5mins Introduction to session and explanation of day.
Basic instructions and details of running, as per
power-point presentation
5 mins
15mins Case- front of house (Epilepsy/DVLA) with key Q
on power-point, emphasis on data-gathering
20mins 10mins Divide into small groups, distribute scenarios for
research of legal and ethical principles
30mins 30 mins Library research time and Reading
1h
30 mins Plenary in main group/ room
1h30mins 35mins Case
2h5mins 10mins Break
2h15mins 35mins Case
2h50mins 35mins Case
3h25mins 5mins Return to main group/room
3h30mins 30 mins Plenary. Q&A
Page 3 of 32
Who
Lead tutor
Lead and SP
Tutors
groups
All
Selfled/tutored
Selfled/tutored
Selfled/tutored
All
Lead tutor
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11
Administrator’s planner for theY5 Ethics Course
In advance












E-mail student notes 1 week prior to session
Students must be informed of the dates well in advance and nearer the time
Arrange booking of rooms
Book/arrange refreshments
Confirm/book tutor availability – ideally groups of 10 or fewer students
Book simulated patients and send out scripts. Remember to book one of the SPs to
do the front of house role too and arrive early for this
Prepare grid/timetable for who, where, doing what, when!
Liaise with other staff who may have student teaching at the same time as your
course (essential!)
Photocopy student handouts and a copy of ‘Key Questions for use in groups’
Make sure all tutors have tutor notes
Ensure overheads/power point presentation is available/downloaded from master
Photocopy evaluation sheets. Evaluation sheets to be returned to Sue Pennill at
Wythenshawe – she will scan and collate evaluation across all sites.
Sort tutor packs to contain:
Timetable for the course
Grid of who (tutor/group/SP) is where/when each session (ensure no group has the
same role twice!) and copy of room and SP timetable for SPs
Timings for session
Tutor notes – one document covers the whole course
Instructions to doctor for each role/case (1 copy for each case for each group)
Allocation of students to groups (list will double as a register)
Name badges (use computer labels)
Sheets of blank paper (for note taking in the groups)
List of ‘key questions’ for each student
Student handout (1 copy per student)
Evaluation forms
Page 4 of 32
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11
Sort simulated patient packs to contain:
Timetable
Grid
SP roles for the sessions
Student handout
Confirm bookings
Consider training session for staff/SPs?
Organisational information
Overall group size Any number
Small group size
Ideally 10
Number of groups Increments of 3
Number of SPs
Increments of 2, preferably to include on Black SP
Rooms
Large room for opening talk/plenary
1 small room/area for each group
Tutors
Lead tutor and 1 tutor per small group/tutors to circulate
Page 5 of 32
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11
SP Rota
Group 1
Group 2
Group 3
Group 4
Group 5
Group 6
Seymour/
Gale
Williams
Student-led
Williams
ie no SP needed
Seymour/
Student-led
Gale
ie no SP needed
Student-led
Williams
Seymour/
ie no SP needed
Gale
Seymour/
Gale
Williams
Student-led
Williams
ie no SP needed
Seymour/
Student-led
Gale
ie no SP needed
Student-led
Williams
Seymour/
ie no SP needed
Gale
Notes to lead tutor
Thank-you for running this session.
Your main role is as ‘ethical’guide for the introductory scenario and plenary. The powerpoint at the outset provides the aims & objectives for the session as well as the running
order of the day.
You may well end up as ‘doctor’ in the front-of-house scenario but if possible nominate
another tutor so that you can concentrate on facilitating. Allow 5-10 mins of
consultation to occur then ‘pause’ the scenario wherever it is and, using the questions
on the power-point, guide the students through the scenario. As the discussion is
concluding, use the subsequent slides to emphasis the ethical components of the case
and the knowledge required.
See additional notes relating to the Power-point presentation.
By the time of the plenary, the groups should have reached some answers for each case
and drawn up a list of unresolved questions. Ask the scribe to begin presenting these
back to the group, a case at a time (I’ve always tended to use the case each group did
last to focus who presents) and then open up the discussion.
If there is time, the student feedback has indicated that they would welcome the
opportunity to ask general questions around preparation for OSCE and other ethical
scenarios. At present, they don’t get another opportunity to do this (I’m working on
that!).
POWERPOINT PRESENTATION ATTACHED AS SEPARATE FILE
Page 6 of 32
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11
Tutor notes
Thank-you for volunteering to facilitate a group.
Your task is two-fold, firstly to keep the group moving, get them organised into roles as
quickly as possible and to time-keep. Secondly, to push their thinking forward and help
them to advance their arguments and decisions.
Guidance on running the small group sessions
Before the first SP arrives
Distribute sticky labels to be used as name badges - ask each student to write the name
that they would like to be known by during the session! Make sure that the chairs are in
a circle and that you are sitting in the circle so that you give the sense of being
collaborative.
Explain what will happen in the session. That is you will be visited by 2 simulated
patients and for one case a student will take the role of SP; there will be three
interviews and time to give feedback to the interviewer. There is 30mins/case.
Explain that as this is a safe environment.
Before the first case, a scribe needs to create a poster of the ‘key questions’ (provided on a
separate sheet) and attach it to the wall/whiteboard/use smart-board to focus thinking
during each case.
Preparing for the role play with the SP
Either ask for a volunteer to conduct the first interview or allocate people for all three
interviews to save time later in the session.
Give the student conducting the interview the doctor’s role notes - while he/she
familiarises themselves with the role, you read the role out to the group. Check if there
are any questions or points of clarification – the students may need to share their
knowledge of the illness/condition described in the role.
A scribe is needed for each case, to note the groups answers to the ‘key questions’ and
to draw up a list of ‘learning needs’ for the plenary. To ensure the other students don’t
passively watch, allocate tasks for giving feedback/analysing each scenario. For
example, each student/pair could be asked to consider one of the key questions from
the list. Ensure observers make precise notes to enable specific & focused feedback.
Pause button/rewind facility
Page 7 of 32
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11
Tell the students that they may use an imaginary pause button if they get stuck. This
means they can temporarily come out of the interview to talk with the group about what
to ask next or which areas they may want to pursue.
Reinforce that using the pause button [as often as necessary] is a positive thing to do,
showing that students want to think about the issues/questions.
The student can also rewind the interview and try a different question or approach. The
SP will be ready for this possibility.
The interview
Check that the interviewer is clear about how he/she is going to start. If the student is
not sure, have a brief group discussion to pool ideas. Possible questions for you to ask
the student at the beginning are: ‘How are you going to start?’; ‘What help do you need
before starting?’; ‘How are you going to explain…?’
The interview should last approximately 8-10 minutes. You can bring it to a close or
pause it if necessary. Keeping to the overall time schedule is crucial.
You could ask other students to have a go at a section of an interview or even ask
students to try something different.
Feedback/Discussion
It is essential that students reflect upon the ethical and legal content of the cases and their
learning needs that arise. However, communication is an essential skill in managing these
scenarios and so relevant feedback on consultation style will also be important. Tutors
have an essential role in facilitating discussion towards the key ethical issues.
We generally use Pendleton’s Feedback Rules. First, the student interviewer reflects
on what he/she did well. Then the group also suggests what was done well. The SP in
role should be invited to contribute to this aspect of the feedback.
The next phase is for the interviewer to reflect on what could have been done
differently. Contributions should again be made by the group and the SP.
At the end of each case, ask them to summarise the key learning points and identify an
‘action plan’ for further learning. Ask the scribe to note these down, this will form the
basis of the plenary.
Page 8 of 32
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11
Key questions for use in groups
(1) What are the ethical/legal components of this case?
(2) What ethical/legal KNOWLEDGE is required?
(3) What sources of information are needed to resolve this case? Eg support from a
clinician, reference to relevant documentation
(4) What is the ‘right’ answer?
(5) How can communication skills best be employed to give a positive outcome in
this case?
Page 9 of 32
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11
Cases
Front-of-house: DVLA/Epilepsy
Student instructions
You are an FY2 in Neurology. You are about to start an out-patient clinic. You are about to review
Mr/Mrs Smith, a patient that you have not met before. They were presented on the ward round
whilst they were in hospital but you had to go and answer an emergency bleep that day. You know
that they were admitted for investigations of episodes of collapse and diagnosed with Generalised
Tonic-Clonic Seizures. They had 2 seizures, a few days apart, whilst on the ward. They were
discharged 4w ago on Epilim chrono 300mg bd. Prior to admission, they were working as a taxi
driver.
Before you call them in, the nurse in clinic informs you that as she came into work she saw Mr/Mrs
Smith parking their taxi in the hospital car park.
Page 10 of 32
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11
DVLA/Epilepsy- Simulated patient role front of house
Patient’s name
Setting
Age
Sex
Mr/Mrs Smith
Neurology out-patient clinic
25-50
M or F
Background
25-50 year old male/female with 4 children (pick suitable ages) and a partner who does not work
outside the home. You have always earned your living as a self-employed taxi driver. You have
always worked hard but maintained a reasonable standard of living for your family. You own your
home, with a mortgage. You have some credit card debts and a loan on your car. You have never
seen the point of Critical Illness Insurance. You are tee-total.
Recent Past
You were admitted to hospital a month ago after a 6 week period where you had collapsed several
times. You have been diagnosed with epilepsy (Generalised Tonic Clonic Seizures). You had 2
seizures on the ward. You were discharged 4 weeks ago. Since then, you have been taking Epilim
Chrono (a long-acting 300mg tablet) twice a day without fail.
When you were in hospital, you were warned by several clinicians that you should not drive and that
in order to be a taxi driver again, you would need to have stopped medication for 10 years AND have
had no more fits during this time. You think this is ridiculous as you feel fine. This illness is a
devastating blow to you and your family as your only source of income is from driving. You have not
had any fits since discharge from hospital. As a result, you have continued to drive a few hours a day.
You feel guilty about this as you know that it is against medical advice, but you need the money and
are feeling quite well. You do have some niggling worries about what would happen if you had
another fit whilst driving.
You are quick to reassure anyone who shows concern for your well-being, friends, family and
clinicians alike, that you are fine. You don’t like any fuss or attention and are certainly not prepared
to be held back by an illness like epilepsy. You are not in denial so much as keen to get your life back
to ‘normal’ as soon as possible.
Role play behaviour
When challenged by the doctor about your driving, accept responsibility but downplay the
significance. The student may need a cue eg ‘What will you do if I don’t stop driving?’. Your tone
should be civil but perhaps a little too light-hearted. You should not be easily persuaded to inform
the DVLA about your diagnosis of epilepsy and only concede at the point that the doctor has advised
you that if you will not tell then they will. If they are persuasive in their reasoning as to why you
should not drive, express your frustration and fears but agree to stop immediately and inform the
DVLA.
If the doctor does not give you the opportunity to inform the DVLA yourself, then ask them if there is
another option.
Page 11 of 32
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11
Case notes for tutor
Front-of-house: Mr(s) Smith
Key ethical features *Conflict of pt’s autonomy and personal liberty vs dr’s obligation
to act to protect patient safety
Key knowledge *DVLA guidelines re Epilepsy
*GMC guidance re Good Practice
Candidate expectation *Elicit the pt’s ideas and concerns
*Explaining the reasoning why pt can’t drive
*Know GMC/DVLA guidelines and advise pt accordingly
Relevant documents
www.gmc-uk.org/guidance/current/library/confidentiality.asp#22
Disclosures in the public interest
22. Personal information may be disclosed in the public interest, without the patient’s consent, and in
exceptional cases where patients have withheld consent, where the benefits to an individual or to society
of the disclosure outweigh the public and the patient’s interest in keeping the information confidential. In
all cases where you consider disclosing information without consent from the patient, you must weigh
the possible harm (both to the patient, and the overall trust between doctors and patients) against the
benefits which are likely to arise from the release of information.
23. Before considering whether a disclosure of personal information ‘in the public interest’ would be
justified, you must be satisfied that identifiable data are necessary for the purpose, or that it is not
practicable to anonymise the data. In such cases you should still try to seek patients’ consent, unless it
is not practicable to do so, for example because:

the patients are not competent to give consent (see paragraphs
28 and 29); or

the records are of such age and/or number that reasonable
efforts to trace patients are unlikely to be successful; or

the patient has been, or may be violent; or obtaining consent
would undermine the purpose of the disclosure (eg disclosures
in relation to crime); or

action must be taken quickly (for example in the detection or
control of outbreaks of some communicable diseases) and there
is insufficient time to contact patients.
24. In cases where there is a serious risk to the patient or others, disclosures may be justified even
where patients have been asked to agree to a disclosure, but have withheld consent (for further advice
see paragraph 27).
Page 12 of 32
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11
25. You should inform patients that a disclosure will be made, wherever it is practicable to do so. You
must document in the patient’s record any steps you have taken to seek or obtain consent and your
reasons for disclosing information without consent.
26. Ultimately, the ‘public interest’ can be determined only by the courts; but the GMC may also require
you to justify your actions if a complaint is made about the disclosure of identifiable information without
a patient’s consent. The potential benefits and harms of disclosures made without consent are also
considered by the Patient Information Advisory Group in considering applications for Regulations under
the Health and Social Care Act 2001. Disclosures of data covered by a Regulation4 are not in breach of
the common law duty of confidentiality.
Disclosures to protect the patient or others
27. Disclosure of personal information without consent may be justified in the public interest where
failure to do so may expose the patient or others to risk of death or serious harm. Where the patient or
others are exposed to a risk so serious that it outweighs the patient’s privacy interest, you should seek
consent to disclosure where practicable. If it is not practicable to seek consent, you should disclose
information promptly to an appropriate person or authority. You should generally inform the patient
before disclosing the information. If you seek consent and the patient withholds it you should consider
the reasons for this, if any are provided by the patient. If you remain of the view that disclosure is
necessary to protect a third party from death or serious harm, you should disclose information promptly
to an appropriate person or authority. Such situations arise, for example, where a disclosure may assist
in the prevention, detection or prosecution of a serious crime, especially crimes against the person, such
as abuse of children
From www.dvla.gov.uk medical rules ‘At a glance’
Epilepsy- more than 1 fit, 12m fit-free on/off tx with medical assessment prior to resuming
driving. Will be issued a 3y license, rolling until 70y. DVLA must be informed. For taxi driver
to resume working, although this is licensed by local authorities, DVLA advised that best
practice is to invoke Group 2 ie HGV/PGV limitations. For epilepsy, pt must be fit-free, OFF
TREATMENT, for 10 years.
Page 13 of 32
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11
Advanced decisions
Student instructions
You are the on-call FY1 doctor, attached to a medical firm. You are asked to come and speak to the
son/daughter of Mr Ernest Seymour. Mr Seymour is a 72y old man who has been an in-patient for 2
days. He has end-stage Multiple Sclerosis and a chest x-ray has just confirmed pneumonia. As you
are led to the interviewing room by the staff nurse, she informs you that Mr Seymour has an
Advanced Directive in his records, it is legally robust and refuses active treatment should he contract
an infection; it specifically mentions pneumonia. Mr Seymour has given you permission to speak
openly with his son/daughter.
Page 14 of 32
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11
Advanced decisions- Simulated patient role
Patient name Mr Seymour/Mrs Gale
Age
40-55
Sex
M/F
Ethnicity
(preferably) Black British
Setting
Ward sideroom
Background You are the son/daughter of Ernest Seymour. You live in Surrey and are recently
divorced. You have had a very stressful time of late due to the breakdown of your marriage and so
haven’t been as attentive to your father’s needs as you know you should have been. You know he
has Multiple Sclerosis (a deteriorating and, in this case, ultimately fatal illness) but he has always
been a very independent man, more so since your mother died from cancer 5 years ago. You have
not been involved in your father’s care. You were planning to visit your father in 2 weeks time having
not seen him for almost 12 months but have been prompted by your guilt and his admission to
hospital to attend sooner.
You have a sister who lives nearby. She has been attending to your father daily. You are not close
and she is resentful of your lack of involvement. Channels of communication are limited. You were
raised in a strictly Catholic household, but since your mother’s death, your father has renounced his
religion. You still attend mass regularly and hold a firm belief in the Catholic faith.
Reason for speaking to doctor You have arrived on the ward and found your father much changed
and very frail. The staff have advised you that your father has a pneumonia, confirmed on chest xray. Although your father is ill, he has conveyed to you that he is declining antibiotic treatment and
that this is a deliberate attempt to shorten his life. The staff have mentioned an ‘Advanced
Directive’- you do not understand what this means.
You are devastated by what you have seen and angry with your father that he is not ‘fighting’ this
illness. You are convinced that he is too ill to make a rational decision and want the hospital to override his refusal of treatment. His actions totally contradict what you were raised to believe about the
sanctity of life.
You have asked to speak to the doctor on the ward so that they can make your father start antibiotic
treatment.
Role play behaviour You are motivated by guilt but this is expressed as frustration rather than
anger. You are suspicious of authority and medicine and suspect there may be reasons why your
father is not being treated. You are keen to persuade the doctor that your parent must have been
coerced or lacking competence to agree to an Advanced Directive.
If the student displays good listening skills and empathy and establishes a rapport then be prepared
to listen to their explanations. Ultimately, I would hope that the student would be able to explain
the need to abide by the Advanced Directive and although you disagree with this you accept that
this has to be the plan.
Page 15 of 32
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11
Tutor notes Advanced decisions- Mr Seymour
Key ethical features *pt’s legal right to choose medical treatment in advance of event.
Underpinned by Mental Capacity Act 2005 (MCA), legal since Oct 2007.
Key knowledge *What is an advanced directive/decision(AD)?
*What rights does this give a patient?
*What would constitute a legally binding AD?
*What rights does a relative have in these circumstances?
*Issues surrounding autonomy, capacity/competence and consent.
*Some details and understanding of MCA
Candidate expectation *Enough knowledge of an AD/MCA to advise correctly
*Good communication skills and sensitivity
*Robust exploration of ‘ideas, concerns and expectations’
*The ability to say ‘no’ but resolve conflict
Relevant information
MCA 2005 codifies law
(1) Assumption of capacity
(2) Enables decision making
(3) Unwise does NOT mean lack of capacity
(4) Best interests when lack capacity
(5) Least restrictive option when lack capacity (does not allow deprivation of
liberty)
Capacity –concept is task specific
(1) Understand
(2) Retain
(3) Use/weigh info
(4) Communicate decision
Now criminal offence to ill treat or wilfully neglect a person lacking capacity
WRT Mr Seymour, he may lack capacity now but he will not have when his AD was
drawn up if it has been officiated. Although his lack of capacity is reversible, ie if
Page 16 of 32
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11
infection treated he would likely regain capacity, this is no reason to treat him against
an AD.
Advanced decisions
Written vs oral
Refusal/acceptance of treatment/ refusal of life-sustaining treatment= legally-binding
Preferences for tx= ‘guidance’
Limitations:
(1) Cannot demand treatment
(2) Cannot refuse treatment that would pose a threat to others
(3) Cannot refuse basic care (this is warmth, safety but not artificial hydration etc
and is open to debate in its interpretation)
Assume capacity when AD made.
Before the Act came into force, the courts had decided that some decisions were so serious that each case
should be taken to court so that a declaration of lawfulness could be made. The Act’s Code of Practice advises
that the following cases should continue to go before the court:

Proposals to withdraw or withhold artificial nutrition and hydration from patients in a persistent
vegetative state

Cases involving organ or bone marrow donation by a person lacking the capacity to consent

Proposals for non-therapeutic sterilisation

Some termination of pregnancy cases

Cases where there is a doubt or dispute about whether a particular treatment will be in a person’s
best interests

Cases involving ethical dilemmas in untested areas
Advance decisions refusing treatment
Although the legality of valid and applicable advance refusals of treatment has been established at common
law, [see reference 13] the Act provides welcome statutory clarification. The Act’s powers are restricted
explicitly to advance decisions to refuse treatment. Although broader general advance statements or ‘living
wills’ which indicate treatment preferences may well be relevant to a broader ‘best interests’ assessment, they
are not legally binding. An advance refusal of treatment is binding if:

The person making the directive was 18 or older when it was made, and had the necessary mental
capacity

It specifies, in lay terms if necessary, the specific treatment to be refused and the particular
circumstances in which the refusal is to apply

The person making the directive has not withdrawn the decision at a time when he or she had the
capacity to do so
Page 17 of 32
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11

The person making the directive has not appointed, after the directive was made, an attorney to make
the specified decision

The person making the directive has not done anything clearly inconsistent with the directive
remaining a fixed decision
Although advance decisions can be oral or in writing, an advance refusal will only apply to life-sustaining
treatment where it is in writing, is signed and witnessed, and contains a statement that it is to apply even
where life is at risk. Advanced decisions cannot be used to refuse basic care, which includes warmth, shelter
and hygiene measures to maintain body cleanliness. This also includes the offer of oral food and water, but not
artificial nutrition and hydration.
In an emergency or where there is doubt about the existence or validity of an advance directive, doctors can
provide treatment that is immediately necessary to stabilise or to prevent a deterioration in the patient until
the existence or applicability of the advance directive can be established.
from
www.bma.org.uk/ethics/consent_and_capacity/mencapact05.jsp
Relatives have no right to make decisions on behalf of pt’s whether an AD is in place or
not but best practice would say they should be informed/consulted when pt has lost
capacity.
Other resources
Can view MCA in it’s entirety at www.opsi.gov.uk/acts
www.dca.gov.uk ‘mental capacity act’
www.gmc-uk.org With-holding and withdrawing life prolonging treatments: Good
practice in decision-making
See also, MCA Toolkit (pdf) available c/o BMA website
Page 18 of 32
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11
15y old with diabetes
This case will be role-played by 2 students, one as doctor, one as patient
Student instructions for Doctor
You are an FY2 on a Paediatric ward. You have been looking after 15y old Daniel/Danielle for the last
2 weeks. They have suffered with diabetes throughout their teens and have had multiple admissions
as a result of this. They have been less than compliant lately, preferring to go out and drink in the
park with their mates. On this occasion, they were admitted through A&E with hypoglycaemia,
having been found collapsed and drunk in the park by the police. Their parents are very supportive
but somewhat despairing as they can see how awful this is for their son/daughter but have concerns
about their long-term health.
Daniel/Danielle’s diabetic control has been erratic during admission and your consultant wants to try
a new insulin regimen which involves injections four times a day, instead of twice a day (which has
never been ideal, but was all that Daniel/Danielle would accept). Despite the best efforts of the
multi-disciplinary team, Daniel/Danielle is refusing to even entertain this idea.
You have sat up for several nights when on-call playing computer games and talking about music
with Daniel/Danielle and your consultant is aware that you have a good rapport. In a final attempt to
influence their decision, your consultant has asked you to talk with them and see if a compromise
can be reached.
Try to uncover their concerns and see if there is any common ground upon which you can negotiate.
Page 19 of 32
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11
15y old with diabetes
This case will be role-played by 2 students, one as doctor, and one as patient
Patient role
Background You are a well-loved but somewhat stroppy teenager who has been testing boundaries
lately. You come from a stable, comfortable family background and will leave school with good
qualifications next year. You hope to go to Uni.
You have a good friendship group and hang out at weekends. You have started to experiment with
alcohol lately and have had the odd cigarette and joint. You resent how your diabetes, which you
have had for 4 years, singles you out from your friends. You resent that your parents have to prompt
you to take regular meals and medication. You don’t care about the future; you just want to be like
your mates. You are in a new relationship and worry that you might be dumped if you are perceived
to be weak or ill.
Personal Behaviour You like the doctor who is coming to speak to you, they are not such an
authority figure as the Consultant, who you also know well. They seem more in tune with you and
your generation. However, you are an ‘expert’ in your diabetes and know what they are going to try
to convince you to do. Whilst you are happy to continue to take insulin twice a day, you are not,
under any circumstances, going to take it four times a day.
Role play behaviour Really make the most of the chance to re-live your teenage days. Be as uncooperative and monosyllabic as you wish. You are going to take some cajoling even to discuss your
diabetes with this doctor.
You are more than happy to chat with this doctor. You have a good relationship with them. The
bottom line is that you will not allow yourself to be discharged on four times a day injections but you
might be prepared to come back to clinic next week to discuss this further.
You should remain challenging, using statements like ‘There’s nothing you can do to make me do
what you want!’
Page 20 of 32
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11
Tutor notes 15y old with DM- Daniel(le)
Key ethical features *knowledge of the guidance around consent and refusal for
treatment in under 16’s and concept of capacity as per Fraser guidelines.
Key knowledge *GMC guidance and best practice re Children
Candidate expectation *use rapport to facilitate communication
*accept/assess the pt’s capacity and work with it
*negotiate a compromise whilst maintaining relationship
Relevant information
0-18 years: guidance for all doctors
Making decisions:
Assessing the capacity to consent
24. You must decide whether a young person is able to understand
the nature, purpose and possible consequences of
investigations or treatments you propose, as well as the
consequences of not having treatment. Only if they are able to
understand, retain, use and weigh this information, and
communicate their decision to others can they consent to that
investigation or treatment.5 That means you must make sure
that all relevant information has been provided and thoroughly
discussed before deciding whether or not a child or young
person has the capacity to consent.
25. The capacity to consent depends more on young people’s ability
to understand and weigh up options than on age. When
assessing a young person’s capacity to consent, you should
bear in mind that:
a.
at 16 a young person can be presumed to have the
capacity to consent (see paragraphs 30 to 33)
b.
a young person under 16 may have the capacity to
consent, depending on their maturity and ability to
understand what is involved.6
26. It is important that you assess maturity and understanding on
an individual basis and with regard to the complexity and
importance of the decision to be made. You should remember
that a young person who has the capacity to consent to
straightforward, relatively risk-free treatment may not
Page 21 of 32
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11
necessarily have the capacity to consent to complex treatment
involving high risks or serious consequences.* The capacity to
consent can also be affected by their physical and emotional
development and by changes in their health and treatment.
If a young person refuses treatment
30. Respect for young people’s views is important in making
decisions about their care. If they refuse treatment, particularly
treatment that could save their life or prevent serious
deterioration in their health, this presents a challenge that you
need to consider carefully.
31. Parents cannot override the competent consent of a young
person to treatment that you consider is in their best interests.
But you can rely on parental consent when a child lacks the
capacity to consent. In Scotland parents cannot authorise
treatment a competent young person has refused.10 In
England,Wales and Northern Ireland, the law on parents
overriding young people’s competent refusal is complex.11 You
should seek legal advice if you think treatment is in the best
interests of a competent young person who refuses.12
32. You must carefully weigh up the harm to the rights of children
and young people of overriding their refusal against the benefits
of treatment, so that decisions can be taken in their best
interests.13 In these circumstances, you should consider
involving other members of the multi-disciplinary team, an
independent advocate, or a named or designated doctor for
child protection. Legal advice may be helpful in deciding
whether you should apply to the court to resolve disputes about
best interests that cannot be resolved informally.
33. You should also consider involving these same colleagues
before seeking legal advice if parents refuse treatment that is
clearly in the best interests of a child or young person who
lacks capacity, or if both a young person with capacity and their
parents refuse such treatment.14
from www.gmc-uk.org/guidance/ethical_guidance/children_guidance
ie a parent cannot over-ride a competent child’s refusal of treatment.
Page 22 of 32
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11
In this case, I would deem that a compromise should be sufficient to move Daniel(le)’s
care forward and that the greater risk to treatment would come from over-riding their
autonomy.
Also, extrapolation from consent to tx for a minor wrt Gillick vs West (contraception)
and Fraser criteria (minor can consent if understand risks vs benefits, cannot be
persuaded to involve parents, tx in their ‘best interests’).
Page 23 of 32
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11
Negligent Surgeon
Student instructions
You are a GP. Sean/Julie Williams is the next patient in your morning surgery. They are a surgeon at
the local hospital. You know them by good reputation and have heard them speak on a few
occasions. You see from their records that they usually see your partner and that the last entry in
the notes was scanty, alluding to stress at work.
Ascertain what he/she has come to see you about and try to help the best you can.
Page 24 of 32
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11
Negligent surgeon- Simulated Patient Role
Patient name
Age
Sex
Setting
Sean/Julie Williams
30-45
M/F
GP Surgery
Background You are 30-45 year old Surgical Registrar at the local Trust. You have worked in the
operating theatres for 5 years and have, to date, been a highly respected surgeon. You are single but
have an on/off relationship with another doctor in the hospital. There has been a lot of restructuring
taking place at work, you find your colleagues distant and unsupportive and lately the pressure has
been getting to you. You have not been sleeping and, are feeling increasingly desperate and
depressed. You don’t have much experience of depression as an illness but you think you may have
it.
About 6 months ago, began to drink whisky at bedtime to help you sleep. You are now drinking a
bottle a day. You have also used a few diazepam (valium- a calming medication) that an anaesthetist
friend had ‘spare’!
You feel that your mood has continued to deteriorate and in the last 2 weeks you have taken a
‘dram’ of whisky before leaving for work at 7am. You have been careful to conceal the smell but are
worried that one theatre nurse may have smelled alcohol on your breath. You joked with her about
it and think that she was reassured but you are concerned for your reputation as you know how
gossip spreads in hospitals.
You have continued to operate three mornings a week and do not feel that your ability has been
impaired. There have been no untoward incidents to date.
Personal behaviour You have come to see your GP today. You want their help with your current
situation but do not want anyone at work to know. You report your ‘low mood’ as the problem but
will discuss openly your alcohol intake if questioned. You will not accept that your current drinking
habits are causing your problems or putting patients at risk. You will accept any help offered
regarding your stress levels but do not want to accept a sick note as you are worried what they will
put on it. You know that if you go off from work, this will be perceived as a sign of weakness and that
your colleagues will judge you for this. You will not speak with senior management and you do not
want occupational health involved. You are open to other suggestions.
Role play behaviour You are open about your predicament but firm about what help you are
prepared to accept. Start with something like ‘I’ve been struggling lately. I’ve been feeling really
stressed and I don’t like how it’s making me feel...’
A good student will want to assess your safety to continue working. If the student is empathetic but
firm about what must be done, accept that you have a responsibility to your patients to act safely
and accept their management plan. Ultimately, you know you will have to concede to their wishes
but would like a little tact around the way in which work is informed/advised of your absence. Eg a
sick note could say ‘stress’ or something else suitably vague at this stage.
Page 25 of 32
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11
If they become too ‘clinical’, say something like ‘I’d prefer to be the patient and let you be the
doctor, if that’s okay?’. If they use technical details that are unclear, either reflect the question back
‘What do you think?’ or admit that you don’t know what they mean. It would be perfectly legitimate
that a surgeon would not be up-to-date with management of depression/Occupational Health/sick
note certification/alcohol support services etc- this is the GP’s specialist area.
Page 26 of 32
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11
Tutor notes Negligent surgeon- Sean/Julie Williams
Key ethical features autonomy vs patient safety
Key knowledge duty of care as per GMC guidance on ‘Duties of a Doctor’
Candidate expectation *firm but supportive stance
*listen carefully to what their colleague has to say
*elicit pt preferences around treatment options
*if their colleague will not act, they should be prepared to
Relevant information
Both you and your colleague/pt are bound by the GMC code....
Good Medical Practice (2006)
The duties of a doctor registered with the General Medical Council
Patients must be able to trust doctors with their lives and health. To justify that trust you must show
respect for human life and you must:

Make the care of your patient your first concern

Protect and promote the health of patients and the public

Provide a good standard of practice and care


o
Keep your professional knowledge and skills up to date
o
Recognise and work within the limits of your competence
o
Work with colleagues in the ways that best serve patients' interests
Treat patients as individuals and respect their dignity
o
Treat patients politely and considerately
o
Respect patients' right to confidentiality
Work in partnership with patients
o
Listen to patients and respond to their concerns and preferences
o
Give patients the information they want or need in a way they can understand
o
Respect patients' right to reach decisions with you about their treatment and care
o
Support patients in caring for themselves to improve and maintain their health
Page 27 of 32
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11

Be honest and open and act with integrity
o
Act without delay if you have good reason to believe that you or a colleague may be
putting patients at risk
o
Never discriminate unfairly against patients or colleagues
o
Never abuse your patients' trust in you or the public's trust in the profession.
You are personally accountable for your professional practice and must always be prepared to justify
your decisions and actions.
Good Medical Practice (2006)
Health
This is the Health section of Good Medical Practice.
Health – paragraphs 77-79
77. You should be registered with a general practitioner outside
your family to ensure that you have access to independent and
objective medical care. You should not treat yourself.
78. You should protect your patients, your colleagues and yourself
by being immunised against common serious communicable
diseases where vaccines are available.
79. If you know that you have, or think that you might have, a
serious condition that you could pass on to patients, or if your
judgement or performance could be affected by a condition or
its treatment, you must consult a suitably qualified colleague.
You must ask for and follow their advice about investigations,
treatment and changes to your practice that they consider
necessary. You must not rely on your own assessment of the
risk you pose to patients.
Furthermore, if your colleague refuses to engage in a suitable plan, you are bound to act to
ensure patient safety and can act to breach confidentiality if the pt is informed.
Good Medical Practice (2006)
Relationships with patients
Confidentiality Disclosures to protect the patient or others
Page 28 of 32
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11
27. Disclosure of personal information without consent may be justified in the public interest
where failure to do so may expose the patient or others to risk of death or serious harm.
Where the patient or others are exposed to a risk so serious that it outweighs the patient’s
privacy interest, you should seek consent to disclosure where practicable. If it is not
practicable to seek consent, you should disclose information promptly to an appropriate
person or authority. You should generally inform the patient before disclosing the information.
If you seek consent and the patient withholds it you should consider the reasons for this, if
any are provided by the patient. If you remain of the view that disclosure is necessary to
protect a third party from death or serious harm, you should disclose information promptly to
an appropriate person or authority. Such situations arise, for example, where a disclosure may
assist in the prevention, detection or prosecution of a serious crime, especially crimes against
the person, such as abuse of children.
A similar case study with robust advice is out-lined below:
A colleague under the influence
A GP sought advice about a female colleague who had been turning up late recently and
there was suspicions of alcohol abuse
Dr Catherine Wills, MDU medico-legal adviser
Publication date: 21 April 2006
A colleague under the influence
A GP member called the MDU Advisory Helpline to ask for advice about a female colleague
(a salaried GP employed by the PCT). He had noticed for some weeks that she had been
turning up late for surgery and for practice meetings. When she did attend meetings, she
rarely contributed and seemed distracted.
The member's call early in the New Year was prompted because things had come to a head
over the Christmas period: the practice nurse had reported that the female colleague had
smelled strongly of alcohol during surgery one day, and had been seen through the window
putting what appeared to be a small gin bottle in the bin outside the surgery on her way out to
do visits. The practice nurse had also witnessed a "near miss", when the GP had drawn up the
wrong injection to give to a patient.
The member said that he might not ordinarily have worried too much if a colleague had
obviously been drinking over the festive period, but he thought things in this case had "gone
too far".
The adviser reminded the member of his ethical duty, as set out by the GMC, to "protect
patients from risk of harm posed by another doctor's or healthcare professional's conduct,
performance or health, including problems arising from alcohol or substance misuse. The
safety of patients must come first at all times."1
Page 29 of 32
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11
The member had not spoken to the colleague in question, but after discussion he decided that
a reasonable first step would be for him to speak to her. They had always got on well, and he
hoped that she would value the support of being able to speak to somebody about her
problems.
The adviser pointed out to the member that, if he felt that the doctor's problem was posing a
risk to patients, the GMC would expect him to "give an honest explanation of [his] concerns
to an appropriate person from the employing authority".2
A doctor who feared that the health of a colleague might be placing patients at risk could be
called upon to justify a decision not to act on their concerns. However sympathetic to her he
felt, the member would need to be ready to speak to his colleague about the perceived
problem. If he believed that she had a problem that might be placing patients at risk, and she
refused to do anything about it, he would need to be prepared, if necessary, to speak to an
appropriate officer of the PCT (such as the medical adviser) or refer the matter to the GMC if
local systems were unable to resolve the problem.
The member called back some days later, having discussed the situation with the doctor in
question. She had admitted heavy alcohol use, which she said was related to depression and a
difficult relationship at home. They had had a constructive discussion, following which she
had decided to take sick leave and see her own GP. She also planned to call the Sick Doctor's
Trust Helpline.3
The member thanked the adviser, saying that he had found it helpful to be able to discuss the
matter first with the MDU and be sure of his ground before having what could otherwise have
been a very difficult conversation.
Reference
1. Good Medical Practice, GMC, May 2001, paragraph 26.
2. ibid. paragraph 27.
3. The Trust's Helpline number is: 0870 444 5163; its web address is: www.sick-doctorstrust.co.uk. See also the article "Services for sick doctors: A changing but ongoing need" in
the October 2002 issue of The Journal of the MDU (Volume 18, Issue 2), p.10.
From www.the-mdu.com
RB 8/7/11
Page 30 of 32
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11
General Bibliography
www.bma.org.uk
www.gmc-uk.org
www.the-mdu.com
www.dh.gov.uk
www.dca.gov.uk/legal-policy
www.opsi.gov.uk/acts
Baxter, C, Brennan, MG, Caldicott, Y & Moller, M (2005) The Practical Guide to Medical Ethics &
Law, 2nd Edition, PasTest
Brazier, M & Cave, E (2007) Medicine, Patients and the Law, 4th Edition, Penguin Books
Kuhse, H & Singer,P (1999) Bioethics An Anthology, Blackwell Publishers
Searle, E, Sewart, A & Vernon, MJ (2006) Core Clinical Cases: Questions & Answers in Medical
Ethics, PasTest
Tutor notes: RB 8/7/11
Page 31 of 32
Negotiating Solutions to Ethical Dilemmas Year 5 2010-11
STUDENT HANDOUT
The following is a list of resources used in preparing this session which provides useful background
information.
Useful books
The first text would be ample if you are planning to invest. The second, part of the same series,
gives further examples of ethical scenarios.
Baxter, C, Brennan, MG, Caldicott, Y & Moller, M (2005) The Practical Guide to Medical Ethics &
Law, 2nd Edition, PasTest
Searle, E, Sewart, A & Vernon, MJ (2006) Core Clinical Cases: Questions & Answers in Medical
Ethics, PasTest
DVLA/epilepsy
www.gmc-uk.org/guidance/current/library/confidentiality.asp#22
www.dvla.gov.uk medical rules ‘At a glance’
Advanced Decisions
www.bma.org.uk/ethics/consent_and_capacity/mencapact05.jsp
Can view MCA in it’s entirety at www.opsi.gov.uk/acts
www.dca.gov.uk ‘mental capacity act’
www.gmc-uk.org With-holding and withdrawing life prolonging treatments: Good practice in
decision-making
See also, MCA Toolkit (pdf) available c/o BMA website
15y old with DM
www.gmc-uk.org/guidance/ethical_guidance/children_guidance
Negligent surgeon
www.the-mdu.com
www.gmc-uk.org Good Medical Practice (2006)
Page 32 of 32