1. Ethical Dilemmas – how to resolve them

2. 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

3. 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)

4. 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

5. 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

6. 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?

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

8. 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?

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

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

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

18. 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