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Bio-medical Ethics

Leslei Kahari:
Department of Linguistics
University of Zimbabwe
October 09, 2014

What is ethics?

The rules of conduct recognized in


respect to a particular class of human
actions or a particular group, culture
Ethics is a branch of philosophy that
deals with distinctions between right
and wrong with the moral
consequences of human actions.

ethics, or moral philosophy, is critical,


analytical thinking about the behavioural
expressions of human interdependence
and what is the morally right thing to do

What is Bioethics?

Bioethics: a field of study


concerned with the ethics and
philosophical implications of
certain biological and
medical procedures,
technologies, and
treatments, such as organ
transplants, genetic
engineering, and care of the
terminally ill

Domain of ethics

Ethics is an understanding of the nature of conflicts arising from moral


imperatives and how best we may deal with them.
Specifically ,it deals with conflicts in potential outcomes (consequences of
actions) or with duties and obligations.
Ethics does NOT decide what is morally right or wrong; rather it considers
how we should act best in the light of our duties and obligations as moral
agents.
HP have specific duties of care to their patients and to society.
It is generally held that HP should always act in the best interest of their
patients; but sometimes there is a conflict between obligations to a patient
and those perceived to be owed to the community or to other patients.
It may not always be the case that what the clinician believes is in the best
interest of the patient is what the patient wishes or will consent to.
Central to modern medical ethics is a respect for patient autonomy and
the fundamental principle of informed consent.

Domain of ethics

Ethics deals with choices.


Where there are no choices there is no need for
ethics.
There are almost always choices to consider and
there is almost always a need for ethics.
Any choice we make involves ethics, although
sometimes we may not realise or consider it.
Ethical practice involves a systematic approach
to decision making and actions, considering
the interests of all affected by the decision

Domain of ethics

Ethics is NOT a set of rules, nor is it a formula:


following rules blindly or rigidly is likely to lead to
unethical practice because it fails to take account of
circumstances or specific exceptions and fails to
recognise new dimensions.
Each case should be treated on its merits and specific
circumstances
E.g. not all premature babies will have the same
outcome.
A one rule fits all approach might be unethical as it
fails to consider the specific interests of those involved

What is an ethical issue?

When you have to judge what is right or wrong

Choosing between options

Deciding whether to do something or do nothing

Should I or shouldnt I?

Weighing up the potential impact of your decisions


or actions

A dilemma making a difficult choice

A classic bioethical decision

One heart available who should get it?

17-year old girl

40-year-old
school principal

70-year-old
woman

A classic bioethical decision

One heart available who should get it?

17-year old girl

40-year-old
school principal

70-year-old
woman

A classic bioethical decision

A baby born prematurely at 24 weeks


gestation is put in intensive care. However
she is not thriving and scans suggest she has
profound brain damage. She cannot breathe
unassisted and the care team believe she is
suffering and it is not in her interest to keep
her alive. The parents do not agree.
What should the clinician do?

TOPICS IN ETHICS

Abortion
euthanasia
the right to health care
the patient's rights while receiving
health care,
the limits of experimentation with
human subjects

TOPICS IN ETHICS

Deciding criteria for allowing a patient/ family to refuse


treatment.
Accepting gratuities or gifts from patients/families.
Deciding what to do when your values and beliefs are
at odds with a patient's/family's values and beliefs.
Setting the limits necessary to maintain professional
relationships with patients/ families.
Controlling access to privileged or confidential
information about a patient/ family.
Choosing a form of dress that assure professional
respect and maintains identity as a HP

TOPICS IN ETHICS

Deciding when you do not have adequate


therapeutic knowledge to treat a patient.
Setting financially sound fees that maintain a
patient's ability to receive treatment.
Providing accurate information to consumers
about the costs of treatment.
Determining methods for making the particulars of
physical therapy services known to health care
consumers.
Deciding the limits for standing by my your own
ethical principles

TOPICS IN ETHICS

Many issues of conflict between good of


the individual and good of society
Immunization, chlorination, fluoridation
Food fortification
HIV/AIDs, MDRTB, DOTs vs. DOTS Plus
Aging and chronic diseases
Genetically modified foods
Technology and resource allocation
Stem cell research

Ethical contexts

1.conflicts may arise between an individual's


private convictions and his conception of the
requirements of his professional role.
2.ethical dilemmas may be encountered when
the attitudes, values, and goals of one
profession conflict with those of another
3. the ethos (ideology) of a profession and that
of the society in which it functions may be in
conflict.

Ethical principles
The ethical principles that arise in health
practice and research include:
Informed consent
Confidentiality
Respect for human rights
Beneficience
Paternalism
Autonomy
Justice

Paternalism

Paternalism is against the informed


consent.
It is derived from Hippocratic Oath .
It insists that patients believe in doctors
conscience and skill and act as doctors
tells patients to do.
We are doing things benefitting patients
,leave it to us

Paternalism

doctor knows best the exception not the rule


Modern medicine seeks to avoid a paternalistic (doctor
knows best) approach to their patients.
Instead it considers the doctor and patient mutually
engaging in the decision making with the final decision
on treatment options being that of the patient.
Respect for autonomy, informed consent and
confidentiality are now key markers for ethical
practice and there must be exceptional
circumstances or reasons for breeching them
Nevertheless, there may be circumstances where the
paternalistic approach is still a major factor.

Autonomy

The principle is based on the principle of respect for persons ,which holds that individual persons have a
right to make their own choices and develop their own life plan.

In health communication the principle translates into the principle of informed consent; You shall not treat
a patient without the informed consent of the patient or his /he lawful surrogate except in narrowly defined
exceptions

Clients right to make own decisions


Clients independence, freedom to choose & direct ones own actions
Centered in respect for clients values and culture
Decision making involves consideration of impact of actions on others

On one hand, patients may refuse treatment even though it is reasonable and would be beneficial

Respect for individual autonomy individuals are regarded as moral agents with duties and obligations
and the capacity to understand and make ethical decisions.

Autonomy

Respect a persons right to make their own decisions

Teach people to be able to make their own choices

Support people in their individual choices

Do not force or coerce people to do things

Informed Consent is an important outcome of this


principle

Autonomy

You are a clinician working in a fetal medicine unit in a major


city in the Zimbabwe.
The fetus of one of your patients is likely to die unless a blood
transfusion is given to replace fetal red blood cells that are
being destroyed by the Rh-sensitized mother's immune
system.
This treatment is meant to keep the fetus healthy until he or
she is mature enough to be delivered, but the woman refuses
to give her consent to this procedure for religious reasons
(She is a Jehovahs Witness for whom blood transfusions
areforbidden).
What should you do?

Autonomy

A very sick premature baby in intensive care


must have blood samples taken regularly to
check pH, blood gases etc. The blood
samples taken over time must be replaced or
the baby will become anaemic and is likely to
die.
The parents are Jehovahs Witnesses and
refuse to give consent to this procedure
because it involves blood transfusion.
What should the clinician do?

Autonomy

Autonomy and Confidentiality


You are a doctor working in a busy practice in
Chiredzi.
One of your patients is a fifteen year old girl who has
come to see you to ask advice about contraception
and sexually transmitted diseases.
She explains that she has a regular boyfriend with
whom she is now having sexual intercourse.
At age fifteen in Zimbabwe she is considered a minor.
What should you do?

Autonomy

A couple who have been married for ten years visit a gynaecologist
for infertility treatment.
The woman has a history of irregular menstrual cycles.
The Gynaecologist treats the patient to stimulate the ovaries
without success.
After a few cycles of treatment the patient decides to see the
gynaecologist on her own.
She reveals that she had never had cycles (primary amenorrhea).
The patient does not wish her clinical condition to be discussed with
her husband because she is concerned about the consequences in
relation to her marriage.
Considering that the doctor was consulted by the couple for fertility
treatment.
whatshould the doctor do?

Beneficence
Principle of beneficence seek to do good
Counselor's responsibility duty - to promote and to
contribute to the welfare of the client.

Means to do good, to be proactive and also to


prevent harm when possible (Forester-Miller &
Rubenstein, 1992).
First priority, do no harm, second priority is to do
good client should be better at end of
relationship than at the beginning

Beneficence

Our actions must aim to benefit people health, welfare, comfort,


well-being, improve a persons potential, improve quality of life

Benefit should be defined by the person themselves. Its not what


we think that is important.

Act on behalf of vulnerable people to protect their rights

Prevent harm

Create a safe and supportive environment

Help people in crises

Beneficence

A baby born prematurely at 23 weeks gestation is


being kept in intensive care. However she is not
thriving and scans suggest she has profound brain
damage.
She cannot breathe unassisted and the parents
believe she is suffering and also that the quality of life
she can expect will be very poor and further treatment
is harmful.
The parents believe that her survival should be
placed in the hands of God and ask that the ventilator
should be switched off.
What should the clinicians do?

non-maleficence

Principle of non-maleficence avoid doing harm

A major concern in ethical decision making and a


long held belief as the most important of the ethical
principles Hippocrates
Nonmaleficence = not causing harm to others.
Avoid practices that have potential to harm
Includes the concept of not harming self or acting
in ways that would cause harm to others

non-maleficence

do not to inflict harm on people


do not cause pain or suffering
do not incapacitate
do not cause offence
do not deprive people
do not kill
Both Beneficence and Non-maleficence
underpin HPC

Justice

Principle of Justice people should be treated fairly

The even distribution of benefits and risks throughout society


Treating people equally in all circumstances would lead to
unfairness because it would fail to take account of differing
physical and mental abilities or of the social and economic
circumstances of the individual.
Treating people equally without regard for their interests, their
abilities or their circumstances is likely to be unfair.
Clearly from a moral sense (moral equality) we do not mean
the same, or equal in terms of endowment.

Justice

Treating people fairly

Not favouring some individuals/groups over others

Acting in a nondiscriminatory / non-prejudicial way

Respect for peoples rights

Respect for the law

Justice
Distributive Justice sharing the scarce resources in society in a fair
and just manner (e.g. health services, professional time)

How should we share out healthcare resources?

How do we share out our time with patients?

Deciding how to do this raises some difficult questions

Patients should get..

an equal share ?
just enough to meet their needs ?
what they deserve ?
what they can pay for ?

Justice
Fair is not synonymous with the same
Quality of services; matters of access to service; fees; time
allocation
Involves examining the interests and needs of both the
client and those involved and impacted by her/his actions
Client needs considered in context to those of others
The presence of stereotypes suggests absence of justice

Justice

Consider the following case scenario in relation to


justice:
A 16 year old girl is accompanied to a clinic by her
parents. The girl has a low IQ (below 80). She is
pregnant and is having the pregnancy terminated. Her
parents have requested that she also be sterilised by
tubal ligation which they feel would be in her best
interests as she is promiscuous and is not able to
understand contraceptive methods.
Should the clinician agree to this request?
How should the clinician best deal with the request?

Informed Consent

Informed consent is a key factor in modern


ethical medical practice and great emphasis
is placed upon it.
The main issue is not simply that consent to
a procedure is obtained, but more
importantly, how it is obtained; not simply
that the patients have been told of what
happens in the procedure and what the key
risks may be, but how they are informed.

Informed consent

A patient should not be exposed to risk of harm unless he has


agreed to that risk, which he/she cannot do without being properly
informed.
This is particularly important where there are choices of treatment,
each carrying different types and levels of risk and potential
outcomes.
The circumstance of each patient will be different and they may wish
to make different choices about their health and lives.
A terminally ill patient, for example, may prefer a therapy which gives
him a reasonable quality of life for a few months to be with his family,
than a drug regime that may prolong his life for longer but may
involve a greater burden of sickness.
Clearly this is a personal decision, not solely a clinical one, and only
the patient is in a position to decide which option is best for him/her.
But the patient cannot do so unless they are properly informed.

Privacy vs. Informed consent

It is perfectly legitimate for a clinician to withhold information which


they may believe to be unnecessarily distressing (a therapeutic
decision), but if such information is necessary for the patient to
make a reasoned
decision then it should not be withheld.
In such circumstances the clinician should consider how best such
information is given and in what circumstances for example, does
it require further support or counselling; should the patient have
someone with them to support them etc.
Patients respond to bad information in a variety of different ways.
People have a right to privacy
People also have a right to receive the information they need for
informed consent

Informed consent

There are essentially two views of consent:


1. The first is a clinician-centred view, which is a
legalistic approach to consent and considers what the
clinician should tell a patient about the nature of a
procedure and the risks.
It is the minimum required to protect the clinician from
a charge of common assault.
2. The second is a patient-centred view, which
considers what is necessary to enable the patient to
make an informed choice.
This is what is referred to in ethics as informed
consent

Informed Consent
what to communicate

1.The nature of the procedure what is to be done and in


simple terms how it is to be done.
2. The risks involved (but as above, this is not simply a list of
all possible risks). They are the most likely risks and any that
the patient themselves might be concerned about in making a
decision. If a patient asks about a risk that the clinician has not
mentioned, then the clinician should inform the patient about
that risk.
3. The consequences what are the likely outcomes of the
procedure and alternatives
4. The alternatives this includes information about what the
likely outcome would be if the patient chooses not to have the
procedure and any other alternative the patient themselves
may ask about where relevant

Informed Consent

A 16 year old girl is referred with primary


amenorrhea. Primary amenorrhea is usually
caused by genetic or congenital disorders and is
often associated with developmental problems
during puberty. In this case no uterus can be
found on a scan.
Should the doctors inform the parents of the
diagnosis before the patient is informed, or should
they inform the patient directly?
How best should they proceed?
What are the major ethical dilemmas

Informed Consent
Autonomy and informed consent.
Downs screening test: A pregnant woman decides to
have a triple marker test for Downs screening.
After she has given the blood she decides she does
not want to know the result as she wants to have the
baby. The test result shows a high risk of Downs
syndrome.
The clinician feels there will be a high social and
economic burden on the family and would like to
convey the test result to the patient to inform her
decision making.
What should the obstetrician do?

DIMENSIONS OF TRUTH
TELLING

In the area of doctor-professional


relationship,truthteling can be categorised
into 4 different ways of conveying
information to patients;
Strict paternalism.
Contractual honesty
Benevolent deception
Unmitigated honesty

TRUTH TELLING

Is honesty indeed the virtue we often claim it is?


If so, why is lack of honesty as common as it is?
Under what circumstances, if any, is deception justified?
Do patients want to now the truth about their condition.
How much do patients need to be told?
What if the truth could be harmful?
What if patients family asks me to withhold the truth from the
patient
Is it justified to deceive a patient with a placebo ( any
substance given to a patient with the knowledge that it has no
specific clinical effects)

Truth-telling

Hippocratic Paternalism: Rationale for concealment


medicine had little to offer but hope and it was
believed that bad news destroyed hope --concealment was in the patients best interests since
the physician and medicines reputation was at stake.
concealment was in the physician and professions
best interests
Long-standing physician policy of concealment
sometimes motivated by self-interest
Long-standing institutional policy of concealment
often motivated by self-interest

TRUTH TELLING

A father of a child wants to donate marrow to


the child. Analysis of a DNA paternity test
reveals that the father is not the father of the
child and not a match.

Question: Should the genetic counselor


inform anyone of these results?
Who, if anyone, is entitled to the results?

TRUTH TELLING

You are caring for Tawanda, a six-year-old boy with leukemia who is
clearly in end stage disease. Unable to accept that he is dying, his
parents continue to insist on aggressive management to the dismay
of many members of the team.
You realize too late to your horror that you inadvertently drew up
and administered a massive overdose of Tawandas s analgesic.
Returning to Jean Marcs room fifteen minutes after administering
the med you find him dead.
A DNR was in place so there is no need for intervention. Tawandas
parents are uncharacteristically not in the hospital that morning and
there were no witnesses to the death. You find yourself imagining
the horrible repercussions that will accompany an admission of this
error, especially since you havent been getting along well with your
supervisor.

TRUTH TELLING

It is possible that Tawanda could have died of other causes


and there really is no reason to suspect error. You begin to
think that Tawanda was going to die anyway and is probably
better off dying this way than having his dying painfully
prolonged by parents who arent ready to let him go and an
attending who always caves in to the parents demands.
Will you admit your error?
Why or why not?
Would you institutional culture support telling the truth
and disclosing medical error?
Do you have a policy about this

Dimensions of truth telling

Benevolent Deception

When a HP withholds some truth but not all of the


truth from the patient.
a lie in order to benefit patients, is used by doctors in
order to avoid negative effects the direct truth may
bring upon patients and their families.
This type of deception used by doctors produces both
positive and negative results that are unpredictable,
making it verycontroversial.
E.g Doctor telling patient that she has kidney cancer
that can be treated but at the same time withhold
information that her prognosis is poor even with
treatment.

Benevolent Deception

One negative effect that is important to keep in mind is the


principle of autonomy, which is violated when patients are
deceived.
Autonomy is seen when the patient has the capacity to act
intentionally, with understanding, and without controlling
influences that would mitigate against a free and voluntary
act
Benevolent deception may be permissible in cases where the
benefits affect the patients actual health and well being, and
should not develop from the fear of telling patients the truth.
Doctors are to understand that the entire truth whether
relevant or not is best for the patient

Benevolent Deception

Although benevolent deception may be


appropriate in certain circumstances, overall
the entire truth whether relevant or not is best
for the patient.
The truth allows patients to understand all
parts of their very own situations and
eliminate all outside controlling influences.
With this type of perspective the principle of
autonomy is given priority

Benevolent Deception

Tamuka has a young patient who would like to donate her


kidney to her father. After he discovers that the man receiving
the kidney is not her father Tamuka understands this is
important information that it is relevant to the surgical
procedure.
The effects of this information may alter his patients decision
to follow through with the donation of her kidney. Her
autonomy is one reason Takunda felt he ought to have let his
patient know about the potentially important information.
After his patient received this information she was able to
make a decision with knowledge of all information relevant to
the procedure.

Benevolent Deception

12 year old child has undergone several treatment regimes for


cancer over a period of years none of which have been
successful. New treatments might offer some benefit but are
considered unlikely to lead to a complete cure.
Research trials indicate that the benefit can be between a few
months to a year of life. After much discussion the parents
withhold their consent when the new treatment is suggested
by the clinical specialists at the hospital.
The parents are concerned that the potential side effects
outweigh the possible extension of the childs life. They
believe their child has already suffered enough over the years
of treatment.
Consider what the clinicians should do and what factors
should be taken into account

Benevolent Deception

consider the following similar case:


A 12 year old child has undergone several treatment regimes
for cancer over a period of years none of which have been
successful. The parents have heard of a new treatment which
clinical trials suggest might prolong life of some cancer
patients by between a few months and a year.
As a result they have requested that this treatment be given
to their child. However, the specialist clinicians at the hospital
do not believe there would be any significant benefit for the
child and that the side-effects of the treatment can often be
debilitating.
Consider what the clinicians should do and what factors
should be taken into account.

CONTRACTUAL HONESTY

When the professional tells the patient as


much information as the patient wants to
know.
E.g. cancer patient: Give me only hopeful
information I dont want dismal
percentages about my chances of
survival

UNMITIGATED HONESTY

When the HP tells the truth, whether or not


the patient want to hear it
More common because it avoids malpractice
suits and is a self protective mechanism
Being truthful means giving facts and even
though truth can be brutal, the telling of it
should not be
E.g. You have a huge tumour in your lung,
there is not much I can do, and your chances
of survival are nil

STRICT PATERNALISM

When a health professional blatantly lies


to the patient for the presumed well being
of the patient.
E.g. Not telling a 94 year old that she has
cancer because doctor thinks he is more
likely to die for old age than cancer.

CONCLUSION

Of the 4 types of honesty,


contractual honesty may be preferable
because it respects patients desires and
patients autonomy.
Strict paternalism violates patients rights for
information
Benevolent deception deceives patients.
Unmitigated honesty overrides the patients
preferences for information

Thank you!

ASSIGNMENT 2
Question: Design a typed health risk message.
The message should in cooperate a text and
pictures to demonstrate the effect of verbal
and non-verbal strategies of communication
in health care.
The project will be based on health
communication concepts ,theory ,and
research
DUE DATE:30 October 2014
In groups of 5