IB WCS 9
MEDICAL ETHICS
Prof. C Kumana
Wed 28.08.02
LEARNING OBJECTIVES
- Principles of ethics in general and medical ethics in particular
- Responsibility to Pt's and relatives
- Responsibility to doctors and other professionals
- Responsibility to the community
- Medical Council
and its code of conduct
- Specific issues
HIPPOCRATIC OATH
- Hippocrates: 420 BC, Greek
- "Father of Medical Ethics"
- See original Hippocratic Oath
Aspects of the Classical Hippocratic Oath
- I will apply dietetic measures for the benefit of the sick according to my ability and judgement; I will keep them from harm and injustice ® "Use all means of healing; Protect sick from harm"
- I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to any woman an abortive remedy ® "Sanctity of life"
- I will not use the knife, not even on sufferers from stone, but will withdraw in favour of such men as are engaged in this work ® "Realise your limitations: be prepared to refer Pt's"
- What I may say or hear in the course of the Tx or even outside of the Tx in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things to be spoken about ® "Pt confidentiality"
- Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves ® "Interests of Pt come first, avoid taking advantage of Pt"
Medical Ethics
- "The science of moral reasoning" pertinent to the medical profession
- The application of:
- Beneficence: actively intervene to do good
- Non-maleficance: do no harm
- Autonomy: respect for individual choice
- Justice: unprejudiced, fair delivery
Priority depends on individuals, what matter is ethical awareness
These are principles that often conflict
Why "Medical Ethics"?
Universally acknowledged need for code
- To avoid atrocities in the name of Science (as revealed at Nuremberg trials in 1947 about doctors working for the Nazi's)
- To regulate application of new technology 'Scientists attempting to play God'
- Advance human rights awareness: (1) Basic health - to which all need equitable access (2) Confidentiality (3) Individual autonomy
MEDICAL COUNCIL
Specific Issues of Concern to the Medical Council
- Assisted reproduction: increasing fertility, cloning
- Genetic counselling
- Clinical trials: GCP (Good Clinical Practice)
- Euthanasia
- Organ transplantation: allocation, harvesting
HKMC Statutory Body (set up in 1957)
Functions
- Registration and maintenance of Registers
- General
- Specialist
- Self-regulation in areas of professional misconduct; ethics, standards , discipline
- Conduct of Licentiate Examinations
Membership
- Director of Health
- Representatives from HA, Academy of Medicine, Universities, HKMA
- Elected professionals
- Lay-persons
Responsibilities
- Draw-up Professional Code of Conduct and appoint / convene
- Health
- Disciplinary
- Ethics, Education and Accreditation (incl. Licentiate) committees
MC issues all locally registered practitioners
- Professional Code and Conduct Pamphlet
- Guidelines on prescription of dangerous and habit-forming drugs
Disciplinary Actions
- Issue a warning letter to a registered medical practitioners (RMP)
- Order that an RMP be reprimanded
- Order the name of an RMP be removed from registry temporarily
- Order the name of RMP be removed from registry permanently
Relationship to Other Practitioners
- Doctors should behave towards colleagues as they would have them behave towards them Doctors should not entice patients from other colleagues (eg. Should not entice patients - grey line between informing and advertising)
- Doctors referring Pt's to any other practitioners or diagnostic or therapeutic services - should not receive fees for such referrals
Functions of Ethics Committee
- To study and review any case related to Medical Ethics or Professional Misconduct - on its own initiative or if duly requested in writing
- To advise and recommend to Council on matters of Medical ethics and Professional Conduct
Situations that Raise Ethical Issues
DNR Decision (DNAR - do not attempt resuscitation)
- Doctors decision
- Discuss early on if expected in a particular Pt: this prepares relatives for eventual decision
- Patient expressly refuses resuscitation
- Respect Pt's autonomy regardless of what relatives want)
- Resuscitation futile
- If Pt has non-recoverable physiological function: eg. Coma with massive cerebral function
- Resuscitation judged as harm > benefit (decreased QOL - eg. Terminal malignancy, end-organ failure)
Downside of Attempted Resuscitation
- Injury / pain: eg. # ribs
- Loss of dignity: intubation, cannulation
- Disturbed tranquillity, whilst family is denied access - at a vital time
- Very often not successful
Case Scenario
History
- 75/F, frail and cachectic
- Admitted c/o abdominal distension and slight abdominal pain +/- vomiting, constipation, for about 5d
- Emergency laparotomy = inoperable ca colon + liver spread; palliative colostomy, postoperatively extubated in ICU
- Relatives requested withholding Dx from Pt
- After 2d pneumonia, poor cough + sputum retention -> tracheostomy + mechanical ventilation (with Pt's informed consent)
Ethics Issues
- Was is appropriate to withhold Dx from Pt?
- Depends on whether you judge Pt to be the type who wants information or doesn't
- Would you tell a 5yo child that they have a terminal illness? Prof. Kumana thinks not, but it's an individual decision
- Was consent for tracheotomy genuinely informed, without knowledge of the Dx?
- Yes, as you still need to make the more comfortable (asphyxiation is very uncomfortable - a very hard way of dying)
- With limited life expectancy (even if Pt survived surgery), was resort to tracheotomy + mechanical ventilation appropriate?
- Yes, because death by asphyxiation is not appropriate