1. MEDICAL HUMANITIES III DEONTOLOGY
Prof.dr.sc. Marija Definis-Gojanović
Split, October 2015.

2. Meaning of deontology
deontology (from deon, "obligation, duty") - normative ethical position that judges the morality of an action based on the action's adherence to a rule or rules.
or "rule-" based ethics,
because rules "bind you
to your duty.”

3. Meaning of deontology
Older usage of the term goes back to Jeremy Bentham (Deontology, 1834): "the knowledge of what is right and proper".
The term deontological was first used to describe the current, specialised definition by C.D. Broad (Five Types of Ethical Theory, 1930).
The more general sense of the word is retained in French, especially in the term code de déontologie, in the context of professional ethics.

4. Theories (deontological ethics)
Theory of society’s agreement and
Theory about human rights
- Today 2 main deontological theories in medical ethics

5. Theories (deontological ethics)
Kantianism
theory of ethics argues that:
to act in the morally right way, people must act from duty (deon),
it was not the consequences of actions that make them right or wrong but the motives of the person who carries out the action,

6. Theories (deontological ethics)
to act in the morally right way one must act purely from duty begins with an argument that the highest good must be both good in itself and good without qualification,
those things that are usually thought to be good (intelligence, pleasure), fail to be either intrinsically good or good without qualification.

7. Theories (deontological ethics)
Immanuel Kant concludes that there is only one thing that is truly good:
Nothing in the world - indeed nothing even beyond the world - can possibly be conceived which could be called good without qualification except a good will.

8. Theories (deontological ethics)
Kant's significant formulations of the categorical imperative are:
- Act only according to that maxim by which you can also will that it would become a universal law.
- Act in such a way that you always treat humanity.
- Every rational being must so act as if he were through his maxim always a legislating member in a universal kingdom of ends.

9. Theories (deontological ethics)
Moral absolutism
believing that certain actions are absolutely right or wrong, regardless of the intentions behind them as well as the consequences.
(IK argued that the only absolutely good thing is a good will. If they are acting on a bad maxim, e.g. "I will lie", then their action is wrong, even if some good consequences come of it).

10. Theories (deontological ethics)
Divine command theory
The divine command theory is a cluster of related theories that state that an action is right if God has decreed that it is right. If God commands people not to work on Sabbath, then people act rightly if they do not work on Sabbath because God has commanded that they do not do so.

11. Theories (deontological ethics)
Contemporary deontology
The Principle states that one may harm in order to save more if and only if the harm is an effect or an aspect of the greater good itself.

12. Medical deontology
is a system of moral principles that apply values and judgments to the practice of medicine.
two main types of duties: scientific - studying ethical and moral aspects of medical workers’activity; practical - the formation and application of ethical standards and rules of the professional medical activities.

13. Medical deontology The premises of the Medical Deontology
The medical ethics studies and defines the solution of various problems of inter-personal mutual relations in three basic directions:
- medical worker  – patient,
- medical worker  – relatives of the patient,
- medical worker – medical worker.

14. Medical deontology Values in medical ethics 1. Autonomy
- The principle recognizes the rights of individuals to self determination.
2. Beneficence
- In the medical context, this means taking actions that serve the best interests of  patients.

15. Medical deontology
Values in medical ethics 3. Non-maleficence - concept of non-maleficence is embodied by the phrase "first, do no harm”: that it is more important not to harm your patient, than to do them good. 4. Justice - concerns the distribution of scarce health resources, and the decision of who gets what treatment (fairness and equality).

16. Medical deontology
Values in medical ethics 5. Dignity - the patient (and the person treating the patient) have the right to dignity. 6. Truthfulness and honesty - the concept of informed consent. We can add some principles such as 7. Medical privacy - allows a person to keep their medical records from being revealed to others.

17. Medical deontology
Values in medical ethics 8. Confidentiality - is commonly applied to conversations between doctors and patients. This concept is commonly known as patient-physician privilege. 9. Fidelity - is the quality of being faithful or loyal to one’s patients.

18. Medical deontology Values in medical ethics 10. Veracity
- Truth telling or Obligation to full and honest disclosure, of the information, concerns or any such matter, in context with a patient’s health/ disease state to himself/herself and their near and dear ones.

19. Duties and obligations
Duties—Sources
Legal Obligations
Emergency treatment
Reporting duties
Institutional Obligations
Practices of hospital
Professional norms and obligations
Inhere with being a physician

20. Duties and obligations
Duties to whom or what?
Individuals
Patients and patients’ families/guardians
Colleagues and co-workers
Self
Groups
Profession
Society

21. Duties and obligations
Duties to whom or what?
Ideas/Principles
The Law
Truth
Justice
Individual value

22. Duties of medical doctor
Toward patient
Toward him/her-self and colleagues
Toward society

23. Toward patient Two main attributes of medical ethos:
• humanity: love to a man,
• justice: recognition of the same health rights to all.
„The deepest base of medicine is love “ – Paracelsus
„Only good man can be a good doctor “ – Nightingale
- Doctor must not do harm, must treat every patient, must keep secret, must not use a patient...

24. Toward himself and colleagues
Take care of appearance
Maintain accurate life
Not to expose life and health to danger
Learn and follow professional and scientific literature
Teach younger colleagues

25. Toward society Take care of and promote people’s health
Fight against infective diseases
Practice social-medical work
Protect life environment
....

26. Mistakes vs. malpractice
What kinds of mistakes can amount to medical malpractice?
Medical malpractice occurs when a patient is harmed because a doctor (or other medical professional) failed to perform competently under accepted standards of medical care.

27. Mistakes vs. malpractice
In order to prove medical malpractice, it must be shown that the doctor was negligent in some way (not reasonably skillful and careful in treating the patient).
A doctor's negligence might be established by proof that the doctor: failed to diagnose (or misdiagnosed) an illness or condition, did not follow proper medical procedure in treating a patient, or forgot to warn a patient of known risks of a procedure/drug.

28. Mistakes vs. malpractice
There are other elements that must be established in a medical malpractice claim - including the existence of a doctor-patient relationship and damages linked to a resulting injury.
Reformers argue that the threat of malpractice claims also increases the use of "defensive medicine," placing additional costs and burdens on the health care system.

29. Social responsibility
Disciplinary
Criminal
- Health care worker is disciplinary responsible when he commits a fault against duties he has as a member of professional organizations or as a public servant
- Criminal responsibility is based on breaching the concrete regulations of Criminal Code

30. Responsibilities could be:
Individual and institutional
Of one or more participants
Of management of hospital or whole organization or some of its parts
- Everybody should be responsible for his/her acts but the principle of superiority in decision-making should be respected

31. Codes of medical ethics
Historical Aspects
Third Dynasty (Egypt) 2700 BCE
Code of Hammurabi (Babylon) 1750 BCE: If the physician succeeds, he gets paid. If he fails, at worst he loses his hands.
Oath of the Hindu Physician (Vaidya’s Oath) 15th cy. BCE
Indian “The Book of Life” (“Ayurveda” – 5-4 centuries BCE)
Hippocratic oath (Hippocrates, ca BCE)

32. Codes of medical ethics
The term "ethics", meaning “a concept of human morals” was introduced by Aristotel ( BCE)
The Oath of Asaph and Yohanan (ca 6th cy. CE)
Advice to a Physician (Persia) 10th cy. CE
The Canon of Medical Science” and “Ethics” by Ibn Sina (Avicenna, centuries - the medical school of Salerno, 1213)
Oath of Maimonides 12th cy. CE
Ming Dynasty (China) 14th cy. CE

33. Codes of medical ethics
Seventeen Rules of Enjun (Japanese Buddhist Physicians) 16th cy. CE)
Percival's Code (England), 1803: basis for first AMA Code of Medical Ethics.
Beaumont's Code (United States), 1833: experimental treatments when all else fails. Get voluntary, informed consent. Stop experiment at subject’s request.
American Medical Association (AMA) - Code of Medical Ethics, 1847.

34. Codes of medical ethics
Walter Reed (United States). 1898: Introduces written consent “contracts”. Allows healthy human subjects in medical experiments.
Berlin Code, or Prussian Code (Germany), 1900: No medical experiments when subject not competent to give informed consent, in the absence of unambiguous consent, or when information not properly explained to subject.
Reich Circular (Germany), 1932: Concerned with consent and well-being of the subjects.

35. Codes of medical ethics
Modern issues and statements
Nuremberg Code (1947)
Medical research
Declaration of Geneva, W.M.A. (1948, 1968, 1984, 1994, 2005, 2006)
W.M.A. International Code of Medical Ethics (1949)
AMA revisions (1957, 2001)
Declaration of Helsinki, application to medical research (1964, last rev. 2000)

36. Ethics Committees and Consults
Designed to minimize some of the challenges to making good decisions. Ethics consultants are responsible for patient care, while ethics committees are administrative bodies whose primary task is to advise in creating institutional policy.

37. What Ethics Committees/Consults (Should) Do
Gather Relevant Data, through:
discussions with involved parties
examination of medical records other relevant documents
Identify Values and Principles Implicated in Case
e.g. autonomy, informed consent, confidentiality, etc.)
 Identify Related Normative Issues
Social norms
laws
institutional policies
Identify and analyze Range of Morally Acceptable Options for the Case
Building Agreement on Act to extent Possible
Ensure that involved parties have their voices heard (patients, families, surrogates, health care providers)
Assist involved individuals in seeing range of values they hold that are involved
Help facilitate (to extent possible) building of morally acceptable shared commitments or understandings within the context

38. Types
Research ethics committees (REC) or institutional review boards (IRB)
To ensure that the research is designed in conformity with relevant ethical standards
To asses the adequacy of the design of the study reviewed
Healthcare ethics committees (HEC) or clinical ethics committees or hospital ethics committees
Deals with making treatment decisions (Quinlan case)
Multidisciplinary membership structure!
National bioethics committees: to issue recommendations and opinions on specific ethical issue, to participate in the drafting of legal provisions, to encourage and participate in public debate