Assistant professor family

medicine
Hanan abbas

H ow To D eal W ith A n Eth ical

D ilem m a In C lin ical P ractice

Identify the ethical issue

Determine why you feel that there
is an ethical dilemma.
How would you frame the ethical
dilemma?
Is this a clinical issue that you need
more information about?

 Clinical information
Is the diagnosis clear?
What other information do you

need and how will you get it?

How are you going to clinically
manage this case: what options are
possible, what
prognoses are possible?

 Do you know what the patient wants?

If the patient is competent
Have they expressed a preference

(informed/after dialogue)?
Can the patients expectations/choices
be met legally/clinically?
Is the patient making an unusual
choice indicating that further dialogue is
necessary and/or capacity is formally
assessed?

 If the patient is not competent

Is there an advance decision is it valid

and applicable?
Has the patient appointed a proxy to
make decisions?
What treatment option is in the patients
best interests?
Can the patients relatives/carers provide
insight into what the patient would have
wanted?

 If the patient is a child

Have the parents been informed

and consulted about the treatment

options and likely outcomes?

 Resolving the ethical dilemma

Identify the main ethical principles that are

relevant, including:
Patient autonomy
Confidentiality
Provision of information
Duties to the patient, to colleagues, to
oneself, to others
Best interests
Avoid/limit harms
Competence

 Is there a tension between any of

these ethical principles which

ones?
Which ethical principle do you think
carries most weight? Justify why.

 Seek advice or a sounding board

Always speak to your consultant,

your educational supervisor or

another consultant.
Does professional guidance clarify
the issue?
Can you refer the matter to a
clinical ethics committee?

 Make a decision
Who should be involved in the decision-making

process?
When does the decision need to be made?
What are the foreseeable consequences of your
decision?
What would be the implications of your decision if it
applied in all similar cases?
Can you justify this decision to: the patient or the
patients family; to your
consultant; and to your peers?
Review your decision with the benefit of experience
and learn from it!

Case 1
Ziad is a child born to a positive HIV

mother, the parents didnt want to

have him tested for HIV, as he is
small and cant stand for the
treatment side effects, and he looks
well now.

 Is it in Ziads best interests to be

tested to see if he is HIV positive?

To what extent is the assessment
of a childs best interests left to the
decision of the parents?
What can be done if both parents
are against medical intervention
that is objectively considered to be in
the childs best interests?

conclusion
Although parents have the right to be

involved in healthcare decisions for their

children, this is always subject to the
overriding principle that such decisions are
in the best interests of the child. Children
have separate rights of their own.
Best interests means that the procedure
or treatment is therapeutic. This is given a
wide interpretation and may incorporate
non-medical benefits.

 Where there is disagreement

between the parents, and discussion

fails to reach agreement, the lead
clinician may take the decision
whether or not to proceed if there is
good evidence that it is in the childs
best interests.
In some situations best interests are
not quite as clear cut.

 Those with parental responsibility

can make healthcare decisions in the

best interests
of the child.
A temporary carer, such as a
teacher or grandmother , can
consent to essential medical
assistance following an accident

 Doctors cannot be compelled to

perform a procedure that they do not

consider to be
in the best interests of a child.
There will be a point at which
societys interest in protecting its
vulnerable members
will limit the choices parents can
make for their children.

 Refusal of treatment solely on religious

grounds does not promote the best

interests of the child.
There is scope for a difference of
perspective the autonomous decision of
the parents will be respected where the
procedure is one which is elective and a
refusal will have no major adverse outcome
on the childs health, for example,
immunization.

 Fear can be so overwhelming that it

temporarily removes capacity to

consent to
treatment.

W ithholding Inform ation

From A M inor
Do doctors have a duty not to

deceive their patients?

Is there a moral difference between
lying and deception?
If pt does not ask what is wrong
with her then should the doctor
inform her of her condition?

 The duty of the consultant is to act in

the patients best interests.

Respecting the treatment choices of
a competent informed young person
will usually be in her best interests.

 If pt has enquired about her treatment and at

her age she has the potential to make

competent treatment decisions.
Without knowledge of her diagnosis she is
deprived of the information she needs to
exercise her autonomous choice. It is both a
legal and ethical requirement to seek consent
before treatment of a competent person.
She should be informed of her diagnosis so
that she can give consent to future treatment.

 Every human being of adult years

and sound mind has a right to

determine what shall be
done with his own body; and a
surgeon who performs an operation
without his patients
consent commits an assault for
which he is liable in damages.

 The General Medical Council (GMC)

states
that written consent should be
obtained in certain circumstances,
such as where the treatment or
procedure is complex, or involves
significant risks and/or side-effects,
except where there is an emergency.

Essentialelem ents ofconsent

The patient must be competent to

give consent.
It must be voluntary, and not
coerced.
The patient must be provided with
information about the procedure.

 To make a valid choice a person must

be given information of the broad

nature and purpose of the proposed
treatment at the very least what
the procedure involves and why it is
needed and the likely outcome.
There is an imbalance of power
between the informed and
experienced doctor and the
vulnerable patient, whose autonomy

 Is consent valid if the patient is not

informed of risks because he does

not want to know?
From a legal perspective this is
problematic because consent must
be based on an informed decision.
Consent can be withdrawn prior to
the procedure

 Salwa a 29-year-old woman,

presents to accident and emergency

in extreme pain. She fell over on her
knee in the afternoon the day
before. Her left knee is now
extremely painful, swollen and
erythematous and she cannot bend
her leg or weight bear.

 You suspect that she has a septic

arthritis secondary to her knee injury.

This is a medical emergency, and
without immediate drainage and
antibiotic treatment there is a risk of
destructive joint damage and
permanent disability.
You explain to slawa that she needs
to have the joint aspirated and the
risks associated with aspiration.

 You are not sure that she is taking in

what you are telling her because she

is in pain and scared.
Is the patient competent to make
such a decision?
How is this assessment made?
Who makes this assessment?

The term s capacity and com petence

tend to be used interchangeably,
Capacity is assessed at the time the

relevant decision is taken.

Persons lack capacity if they cannot
make the decision because of an
impairment of or a disturbance in the
functioning of the mind or brain, due
to, for example, mental illness,
dementia or learning disability.

 persons should not be treated as

unable to make a decision merely

because they make an unwise
decision.
Reference to age, appearance or an
aspect of the persons behavior is
not sufficient to
establish lack of capacity.

 Where there is doubt about a

patients capacity, a medical

assessment should be carried out,
usually by a consultant psychiatrist.

 Capacity can evolve and fluctuate over

time, and treatment should be postponed if

capacity can be restored.
It is task specific a person may have
capacity to make a particular decision but
lack capacity for other more complex
decisions.
Before it is concluded that someone lacks
capacity to make a decision all possible
steps should be given to help them to reach
the decision.

 a person lacks capacity if they cannot do

one or more of the following:

understand the information relevant to
the decision
retain that information
use or weigh that information as part of
the process of making the decision
communicate the decision (whether by
talking, using sign language or any other
means)

 Mary has been referred to the

hospital by her general practitioner

as she is now 40 weeks pregnant
with her third child. Previous children
were delivered by normal vaginal
delivery. She is divorced now.
She has received good antenatal
care and is well apart from having
iron deficiency and

 The baby is breech, and the

consultant obstetrician suggests that

the baby is turned by external
cephaloversion.
However, Mary refuses to consent to
this and she seems very frightened
at the suggestion.

 The consultant considers that the

only alternative is a caesarean

section.
Mary is unwilling to undergo a
caesarean section as she is a
Christian Scientist, and her faith
forbids medical intervention.
You explain to her that both she and
her baby will be at serious risk if a
caesarean section is not carried out

 Can a competent adult refuse any

treatment including life-sustaining

treatment?
In what circumstances can medical
intervention be performed on a nonconsenting competent woman to
preserve the life of a viable fetus?

 A woman has a right to refuse

treatment but not if this may result

in the death of a viable
fetus.
Her rights are not diminished by any
duties owed to the fetus, but she
harm her child.
An assumption of incapacity should
not be made merely because a
patient is refusing