1. Ethical Principles, Consent and Confidentiality
Richard Dawson

2. Aims
To provide to time discuss ethical principals, consent and confidentially issues in relation to primary care.

3. Objectives: 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

4. Why learn about ethics?
Previously Dr’s have used a pragmatic system governed by the use of experience, intuition and common sense?

5. Why learn about ethics?
More chance of recognising the full range of issues in any given situation
Could promote a wider choice of options for action
Gives insight into deep-seated attitudes and prejudices that influence decisions
Could provide impartiality and the chance of better outcomes for patients

6. Some areas raising ethical considerations
Professional duties
Confidentiality
Consent
Reproductive issues
End of life issues
Mental health
Children
Screening
Rationing (resource allocation)
Genetics
Research 6

7. The 4 ethical principles
Approach should be applicable by anyone, whatever their personal philosophy, religion etc
Respect for autonomy
Beneficence
Non maleficence
Justice
They may conflict with each other
A framework for analysing ethical dilemmas, not a formula for solving them 7

8. Four Ethical Principals.
Autonomy (‘self rule’)
Help patients to make their own decisions and respect these decisions even if you disagree
Understanding, Freedom from coercion, Capacity
Beneficence (Do Good)
Doing what is best for the patient – but what is the best? May conflict with autonomy
Non-maleficence (Do no Harm)
Justice/Equity
time and resources
Societal justice

9. Consent The agreement by a person to a procedure or intervention
Form of consent (implied or explicit)
Legal: Intention, Voluntariness, Competence
Autonomy: Understanding, Freedom from coercion, Capacity
Treatment without consent could lead to charge of battery (criminal or civil law) or negligence (civil law) 9

10. 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

11. 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

12. 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

13. 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 13

14. 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

15. Confidentiality Underlying ethical principals:
Non-maleficence: damage to relationship, career etc
Autonomy: the right of the patient to determine want information is passed on and to whom
Societal Justice: where serious harm may be prevented by disclosure without consent

16. 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 16

17. 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 17

18. Other important legal areas
Mental Health Act
Reproductive Issues
End of Life Issues
Human Rights Act 18

19. When you have an ethical dilemma, consider
Talking to colleagues
Getting advice from your defence organisation 19

20. 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) 20

21. 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 21