Medical Ethics
Unit 19
HIV Care and ART:
A Course for Healthcare Providers
Learning Objectives
 Explain the importance and utility of medical
ethics
 Describe the methodology of ethical deliberation
 Analyze practical issues in the clinical setting
from an ethics perspective
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Skepticism and Medical Ethics
Trainer Role Play
Basic Rights and Ethical Duties
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Human
Human Rights
Dignity
Access to health care
Right to non-discrimination
Right to privacy and confidentiality
Right to environment that is not harmful to health
or well being
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Medical Ethics: Definition
 The practice of medicine is rooted in a covenant of trust among
patients, healthcare professionals, and society.
 The ethics of medicine must seek to balance the healthcare
professional’s responsibility to each patient and the professional,
collective obligation to all who need medical care.
The Council of Medical Specialty Societies, 2000
http://www.nyu.edu/gsas/dept/philo/faculty/ruddick/papers/medethics.html
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Utility of Medical Ethics
 Medical ethics principles provide a framework
for discussing ethical issues and for medical
decision making
 The principles provide consistent guidance
where there are substantive considerations on
both sides of an issue
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Ethical vs. Legal Obligations
 Medical ethics and the law are not the same, but
often help define each other
 Breach of ethical obligation may not necessarily
mean breach of law
 Breach of ethical obligation may be used to
prove medical malpractice or medical
negligence
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Healthcare Professional Role
 Paternalistic model
 Emphasizes health and well-being (beneficence) over
respect for autonomy and patient choice
 Patient is selectively given information
 Evolution of newer decision-making models
 Independent choice vs. enhanced autonomy
 Paternalistic vs. informative vs. interpretive vs.
deliberative
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Interconnectedness of Rights,
Trust, and Obligation
Public
Trust
Patient
Rights
Health Care
Worker
Obligations
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Benetar’s Levels of Ethics in HIV/AIDS
 Micro Level
 Individual doctor-patient relationship
 Meso Level
 Civic and public health ethics, including equitable
access to health care
 Macro level
 Ethics of interdependance and international
relationships
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Micro Level Ethical Principles
 I. Respect for Autonomy (or Person)
 Respect the decisions of autonomous persons
and protect persons who lack decision-making
capacity (e.g., confused pts, mentally ill).
 Recognize the capacity of mentally and legally
competent patients :
 To think and make decisions independently
 To act on the basis of their decisions
 To communicate their wishes to health workers
 Uphold patient confidentiality
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Ethical Principles (2)
 II. Non-Maleficence (Not inflicting harm)
 Health professionals should not inflict harm on
patients (Premum non nocere)
 III. Beneficence
 Act in the best interests of patients or research
participants.
 Contribute to patient welfare – help patients
further health interests
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Ethical Principles (3)
 Sometimes there is ethical tension between
beneficence (attaining a beneficial outcome) vs.
non-maleficence (not inflicting harm)
 It is important to weigh the chance of success
against risks of treatment
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Ethical Principles (4)
 IV. Justice
 Requires that people be treated fairly. (It is often
understood to require that benefits and burdens be
distributed fairly within society.)
 Treat all patients equally – no unfair discrimination
 Distributive justice
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Informed Consent
 Definition: A patient’s willing acceptance of a medical
intervention after adequate disclosure from their MD of
the nature of the intervention, risks, benefits and
alternative treatment options
 What constitutes informed consent?
 Disclosure: information to allow reasonable person to make a
decision
 Understanding: comprehension of the information given
 Voluntary: no coercion or incentive to accept or deny a treatment
 Agreement: verbal or written (preferred) to discussed
intervention
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Confidentiality
 Patient confidentiality must be upheld
 Breaching patient confidentiality may be merited
only:
 When ordered by court of law – a court case
 Where statutory requirement – public health laws
 Where required in health professional’s defense –
malpractice suit
 Where necessary for appropriate patient carespeaking to another provider in the medical care
system
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Honesty
 The percentage of patients who would like to be
told their diagnosis if it is a:
Metastatic cancer Terminal
Prognosis
European Americans
87%
African Americans
88%
Mexican Americans
65%
Korean Americans
47%
Ethiopians (can you guess?)??%
69%
63%
48%
35%
??%
Source: Blackhall LJ, et al. (1995) JAMA 274: 820-5.
 The more traditional the culture … the less truth
telling regarding patient condition
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Framework for Medical Ethics
Development in Ethiopia
Capacity
Standards
OUTCOMES
Awareness
Ethics
Committees
Declarations
Legislation/
Guidelines
Ethics
Teaching
Academics/
Teaching/
Research
Publications
Seminar/
Workshops/
Trainings
• platforms for
ethical action
• intensive public
debate
• informed public
opinion
• (inter)national
normative
frameworks
• morally sensitized
professionals and
health
professionals
• assisted policy18
making
Case Studies
Case Study: Lake
 Lake, your 36-year-old patient, has just tested
positive for HIV. He asks that you not inform his
wife of the results and claims he is not ready to
tell her yet.
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Case Study: Lielit
 Lielit, a 22 year-old woman, is admitted to the
hospital with a headache, stiff neck and
photophobia but an intact mental status. Lab
tests reveal cryptococcal meningitis, an infection
commonly associated with HIV infection. When
given the diagnosis, she adamantly refuses to
be tested for HIV.
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Case Study: Berhan
 Berhan, a 35 year-old man with AIDS, admits
that he is often unable to take his medicines
regularly because of his alcohol and chat
addictions. His lab profile is consistent with
immunological treatment failure.
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Case Study: Mihret
 Mihret, a 27 year-old healthy looking mother,
brings her 3 year-old son to a clinic with chronic
diarrhea, weight loss, and failure to thrive. She
reports that an older child died several years
ago, at age 2. She is advised to have her son
tested for HIV, but she adamantly refuses
because of her fear of knowing her own HIV
status and that of her husband.
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Case Study: Mikael
 You are have been caring for a 12 year-old HIVinfected boy who has been clinically stable until
recently. He now meets criteria for ARV
treatment but you are very concerned because
his mother has refused to allow disclosure of his
HIV-status to him. He has been asking questions
about why he keeps getting sick.
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Medical Ethics
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Key Points
 The most commonly accepted principles of
medical ethics include:
 Respect for Patient Autonomy
 Beneficence and Nonmaleficence
 Justice
 Other principles include informed consent,
confidentiality and honesty
 Medical ethical discussions need to take into
account the cultural situation in which they
occur.
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