1. Medical Ethics and Law Introduction Dr Gordon Linklater

2. Medical Ethics and Law system 2013ampm Mon 17 th Ethics IntroductionMedicolegal part 1 Tue 18 th Community courseMoral theories/ reasoning Wed 19 th Beginning of life Thu 20 th AnatomyDebate: abortion Fri 21 st Research/ human rights/ resource allocation Mon 24 th End of lifeMental health/ complaints Tue 25 th ChildrenDebate: assisted suicide Wed 26 th Medicolegal part 2 Thu 27 st Social media Fri 28 nd Assessment

5. Morality and Ethics

6. Two traditions: 1. Duties, “right” & “wrong” actions, absolute values 2. Look at benefits and harms to individual and society; look at the consequences.

7. Two traditions: 1. Duties, “right” & “wrong” actions, absolute values DEONTOLOGY 2. Look at benefits and harms to individual and society; look at the consequences. UTILITARIANISM (a type of consequentialism)

9. Hippocratic tradition “as to diseases, make a habit of two things – to help and not to harm.” “I will never give a poison to anyone to cause death, not even if asked.”

10. Hippocratic tradition “into whatever houses I enter, I will enter to help the sick, and I will abstain from all intentional injustice and harm, especially from abusing the bodies of man or woman, bond or free.”

11. Kant Immanuel Kant (1724 – 1804) –Categorical Imperative Act only in such a way that you would be happy for it to become an universal law –Treat people as ends in themselves, never just means

12. Religion e.g. the ‘sanctity’ of human life

13. http://www.gmc-uk.org/guidance/good_medical_practice.asp

15. Doctors are powerful We get to look at you naked We can cut you open We might tell you that you are going to die We can decide what is in your best interests

16. Doctors are trusted Trust to tell the truth% –Doctor92 –Teacher88 –Professor80 –Judge80 –Journalist22 –Politician13 MORI poll 2009

17. Deontology Good points –Gives you some certainty Duty not to kill –Defines behaviours Duty of care

18. Deontology Bad points

19. Consequentialism The moral worth of an action is determined by its outcome

20. Utilitarianism Jeremy Bentham (1748 – 1832) The greatest good for the greatest number (maximising pleasure/ happiness and minimising pain/ unhappiness)

21. Utilitarianism Classic –Judges the consequences of a particular act Rule –Judges the consequences of particular rules Preference –Maximising choice rather than pleasure

22. Utilitarianism Good points –Flexible Can adapt to the particular circumstances of a decision –Avoids need for a belief system –Measurable Do you want a nice doctor or an effective doctor?

23. Utilitarianism Bad points

25. Ethics and clinical decisions Duties 4 Principles Ethics grid

26. Duties

28. Having watched a caesarean section whilst on my medical elective in Kwa-Zulu Natal I thought, ‘that looks fun – I’ll have a go on the next patient’

30. A young woman comes to your surgery very distressed. She tells you she had unprotected intercourse last night whilst drunk. She does not want to get pregnant. She asks if there is anything that can be done…

32. 4 Principles Respect for Autonomy Non-maleficence Beneficence Justice

33. 4 Principles Respect for Autonomy –Promote the right to self determination Non-maleficence Beneficence Justice

34. 4 Principles Respect for Autonomy Non-maleficence –The avoidance of harm Beneficence Justice

35. 4 Principles Respect for Autonomy Non-maleficence Beneficence –To do good Justice

36. 4 Principles Respect for Autonomy Non-maleficence Beneficence Justice –Fairness/ equality –Individual vs population

37. Which chemotherapy? Mr Jones has non small cell lung cancer Chance of benefit % Chance of death % Cost £ Chemo A 1021 000 Chemo B 50331 500 Chemo C 6010100 000

38. AutonomyChemo C Non-maleficenceChemo A BeneficenceChemo C JusticeChemo B Chance of benefit % Chance of death % Cost £ Chemo A 1021 000 Chemo B 50331 500 Chemo C 6010100 000

39. Justice –you cannot use chemo C Non-maleficence –you must not use chemo B Beneficence –chemo A is better than nothing Autonomy –Patient can chose either chemo A or nothing Chance of benefit % Chance of death % Cost £ Chemo A 1021 000 Chemo B 50331 500 Chemo C 6010100 000

41. Should we use data from medical ‘research’ carried out in the concentration camps of Nazi Germany? –Specifically research into the effects of hypothermia on the human body

46. A synthesis of ethics and the current UK law Duty of care, right to life, sanctity of life –If in doubt, doctors have a duty of care to save life and preserve function –Euthanasia and physician assisted suicide are illegal –Doctors must not intend to hasten death, but may in certain circumstances administer treatment that will hasten death (Doctrine of Double Effect) –Not keeping alive versus killing (usually not considered equivalent) Autonomy, justice –Patient autonomy allows the refusal of any treatment, even if refusing the treatment will result in their certain death –Patients cannot demand a treatment that a doctor does not consider indicated (but they can get a second opinion) Also remember that healthcare is rationed. Treatment may be indicated but not affordable –Family members cannot make medical decisions for patients (unless they have been legally appointed proxy decision maker)