Medical ethics
Dr D Grace MD. FFARCSI. Dip.ICM.
Dept of Anaesthesia & Critical Care Medicine
Altnagelvin Area Hospital
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Aims
Consider medical ethics & clinical practice
Outline and define ethical principles
Outline practicalities & challenging issues arising
in medical practice
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Ethics
A branch of moral philosophy & the theoretical
study of practical morality
Medical ethics - value judgements applied in a
professional context
Ordinary morality
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Principles of medical
ethics
Autonomy
Beneficence
Non-maleficence
Justice, equity, utility
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Autonomy
The capacity to think, decide and act freely and
independently on the basis of such thought &
decision
Linked to autonomy are issues pertaining to:
Consent
Competence
Advance directives
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Consent - principles
“Every adult has an inviolable right to determine what
is done to his or her body” Lord Donaldson
Required for examination, treatment, care
Verbal, written, implied, presumed
Given voluntarily
Informed / valid if the quality & clarity of information
given is adequate and appropriate
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Competence
> 16 years competence presumed unless
evidence to the contrary
Adults may be competent to make some
decisions but not competent to make others
Mental disorder / impairment does not of itself
imply incompetence
Implies that one can understand, retain, evaluate
and choose freely
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Advanced statements
Autonomy (expression of)
Uptake limited
Facilitate communication
Impact limited
A useful guide to wishes
Potential for disagreement
Facilitate a good death
Wording crucial
Circumstances unanticipated
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Beneficence / nonmaleficence
The promotion of what is best for the patient - do good
Objective professional assessment v autonomous choice
by patient - paternalism v autonomy
Non-maleficence - do no harm
Sanctity of life - quality > duration
Futility - inappropriate provision of life-prolonging therapies
when there is no expectation of survival
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Justice
Healthcare resources are finite
One strives for fair distribution
Futility is very costly
Funds are rationed / treatment options are
restricted
Advocates and rationers - medical profession,
patient groups, government
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Utility
The maximizing of outcomes / preferences
Tension exists between utility & equality
Concentrate resources?
Utility implies making service & provision choices
Requires measurement and research
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Challenging scenarios
Right to treatment
Ordinary v extraordinary measures
Futility & treatment limitation
End of life issues and care
Commissions and omissions
Do not attempt resuscitation
Death & organ donation
Research
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Should all patients be
treated?
Natural claim to care / natural duty & professional duty
Statutory “right” to care (consultation, advice, treatment)
Right to be received, respected, heard, advised, treated
appropriately if available
Responsibility for the treatment chosen rests with the
clinician
When consulted Courts authorize but do not order care
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Ordinary / extraordinary
treatment
Treatments with a reasonable probability of benefit with
minimal burden
Actions may involve pain + distress
Proportionate v disproportionate measures
Duty to provide proportionate care
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End of life
considerations in ICU
(E.O.L.)
ICU aims to restore patients to well-being or to a
functional existence
Medical intervention may prolong life / postpone
death
E.O.L. issues including symptom palliation arise
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Futility + withdrawal
Balance likelihood of survival to discharge
against risks & burdens of therapy
Institute/continue/escalate/limit/withdraw
treatment - all ethically equivalent
Communication is paramount
Ensure dignity, rights, comfort, wishes (of patient
or proxy)
G.M.C., B.M.A., professional bodies provide
guidelines & standards
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Omissions, commissions
& double effect
Inability to benefit
Withholding & withdrawing differ from killing
Intent v foresight / double effect:
palliation & cardiorespiratory depression - relieve
burden + allow to die
Physician-assisted suicide / active euthanasia –
illegal
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D.N.A.R. / P.N.D.
(do not attempt resuscitation – permit natural death)
Cardiorespiratory arrest may -> cardiopulmonary
resuscitation (C.P.R.)
C.P.R. success is circumstance-dependent
Consent (for C.P.R.) is invariably assumed when unknown
Communication re E.O.L. care absolutely essential
Patient’s wishes & preferences determined
Multi-disciplinary input to decision invaluable
Treatment status / wishes recorded + reviewed
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Death and B.S.D.
(brain stem death)
Death = the irreversible loss of the capacity to
breathe and the capacity for consciousness occurs when the brain stem ceases to function
Brain stem - the critical part of the critical organ
Traditional cardiorespiratory death v B.S.D.
Brain stem or “beating heart” death
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Organ donation
Demand rising, supply falling
Beating-heart (B.S.D.) & non-beating heart
Life-saving & life-enhancing
Requires consent/assent – patient or N.O.K. (next of kin)
Advance statement - register as potential donor http://www.organdonation.nhs.uk
Presumed consent / opt out largely irrelevant as
N.O.K.’s wishes actually paramount
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Medical research
An imperative – today’s research is tomorrow’s
medicine
Requires funding & regulation
Potential conflict b/n public & personal
interests?
Nuremberg code (1946)
Declaration of Helsinki (1964/2000) – concern for the
interests of the subject must prevail over the interest of science &
society.
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Research guidelines
Respect autonomy of potential participants thus
rigorous consenting: (i) research (ii) not contrary to subject’s
interests (iii) outcome unpredictable (iv) freedom to withdraw
Risk of harm - quantifiable, identifiable? Ideally
risk < minimal!
Research of quality and of value
Justice
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Summary
Ethical concepts, definitions & context outlined
Autonomy, beneficence & non-maleficence, equity justice
& utility - the pillars of medical ethics
Consent + associated difficulties considered
Futility, commission, omission & double effect discussed
Special circumstances – D.N.A.R. - P.N.D. / death & organ
donation
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