Ethical Dilemmas – how to resolve them

Scope of session Raise awareness of ethical and legal dimensions of clinical decision making Practise skills in ethical analysis and its application to clinical situations (especially in GP context) Provide overview of key areas of English law relating to clinical practice

Your experience of an ethical dilemma Write down the story What made it an ethical dilemma? (not just a situation where you didn’t know what to do) What was most important to you about the decision you had to make? (e g getting it right, protecting yourself, avoiding conflict) What did you base your decision on? (e g guidelines, law, advice (who from?), your moral values or just feeling it was the right thing to do) What was the most difficult thing about it? (e g not having enough information, upsetting other people, or the responsibility you had)

How do people make ethical decisions? - 4 moral theories Virtue (Aristotle) - good people make good decisions Duty (Kant) - there is a supreme moral law which means Do not treat anyone in a way you would not want to be treated yourself (universalisability) People have intrinsic worth - no one should be treated as a means to an end Utility (Bentham, Mill) - the greatest happiness of the greatest number Rights - legal vs moral rights; rights vs obligations

The 4 ethical principles Approach should be applicable by anyone, whatever their personal philosophy, religion etc The principles: Beneficence Non maleficence Respect for autonomy Justice (fairness, respect for rights, respect for morally acceptable laws) Need to reflect on their scope of application - whom do we apply them to? NB they may conflict with each other A framework for analysing ethical dilemmas, not a formula for solving them

2 interesting points from the Curriculum Statement Respect for patient autonomy requires a holistic approach - to help them make choices, doctor must explore what’s important to them overall, not just share clinical information Contextual aspects - how do the values and beliefs prevalent in the local culture impact on patient care?

Some areas raising ethical considerations Professional duties Confidentiality Consent Reproductive issues End of life issues Mental health Children Screening Rationing (resource allocation) Genetics Research

Legal aspects of consent Form of consent (implied or explicit) Treatment without consent could lead to charge of battery (criminal or civil law) or negligence (civil law) How much information should we give? Who can give legally valid consent? Who has capacity to consent?

To have capacity to consent, patient must be able to understand in simple language what the medical treatment is, its purpose and why it is being proposed understand its principal benefits, risks and alternatives understand in broad terms what will be the consequences of not receiving the proposed treatment retain the information for long enough to use it and weigh it in the balance in order to arrive at a decision

Who is ‘competent’ (has capacity to consent)? People over 16 presumed to be competent unless there is evidence to the contrary Under 16s are only considered competent if they have sufficient intelligence and understanding to understand fully what is proposed Parent can consent on behalf of anyone under 18 who lacks capacity If someone over 18 lacks competence, no one can consent on their behalf - decision to be made by medical team ‘in the best interests of the patient’; consulting relatives considered good practice to help medical team make decision

Power of Attorney Enduring Power of Attorney (pre 2007) only applied to financial affairs Lasting Power of Attorney (since Mental Capacity Act 2005, implemented 2007) - 2 kinds Property and Affairs LPA (like Enduring Power of Attorney pre 2007) Personal Welfare LPA which can specifically include health decisions. Attorney’s decision could override Advance Directive made prior to the POA being registered

Advanced directives Advanced directive specifies how you want to be treated if circumstances arise when you don’t have capacity to make decisions Now considered binding in Common Law and under the Mental Capacity Act 2005 Not valid if Unsigned Doubt re authenticity (e g not witnessed) Concern it was written under duress Concern about mental state at time of signing Advisable to discuss with family before writing No use if clinical team don’t know it exists

Confidentiality All personal info given to a health professional must be treated confidentially except in particular circumstances This includes friends and relatives Duty of confidentiality continues after death Most breaches of confidentiality are inadvertent

Exceptions to confidentiality Patient’s consent Need to know Statutory duty (eg DVLC) Instruction from Judge (in Court or via a warrant under Police and Criminal Evidence Act Wider public interest Child Protection

Access to information Data Protection Act 1984 (computer records) Access to Health Records Act 1991(manual records) Access to Medical Records Act 1988 (medical reports) Data Protection Act 2000 (access to all records) Safeguards against having to disclose harmful or third party information

Other important legal areas Mental Health Act Reproductive Issues End of Life Issues Human Rights Act

When you have an ethical dilemma, consider Talking to colleagues Getting advice from your defence organisation

Further info RCGP curriculum statement refs GMC website BMA website Ethics in General Practice - a practical handbook for personal development - Anne Orme-Smith and John Spicer. Radcliffe Medical Press 2001 Scenarios on VTS website