An introduction to medical ethics

AN INTRODUCTION TO MEDICAL
ETHICS
Prof. Amer Eltwati Irhuma FRCS
Consultant surgeon

Quote
 If you don't stand for something,
You will fall for anything…!

primum non nocere,
“ above all, do no harm ”
First

Medical ethics
 Learning Objectives
– To define the Medical Ethics .
– To understand the theories of Ethics
– To apply the ethical principle
– To know how to deal with ethical dilemma
– To understand the concept of informed consent
– To recognize the best way for making desion

The difference between Ethics and Moral
 The word “Morals” and “Ethics” originally meant
much same thing:
 Ethics came from “Greek” while Morals came
from “Latin” Both words refer to the general area
of right and wrongs in the theory and practice of
human behavior.
 Morals refer to standards of behavior actually
held or followed by individuals and groups while
 Ethics refer to the science or study of morals
and its activity in the academic context .

What is Ethics?
 A system of moral principles or standards governing
conduct.
 a system of principles by which human actions and
proposals may be judged good or bad, right or wrong;
 A set of rules or a standard governing the conduct of
a particular class of human action or profession;
 Any set of moral principles or values recognized by
a particular religion, belief or philosophy;
 The principles of right conduct of an individual.
(UNESCO/IUBS/Eubios Living Bioethics Dictionary version 1.4)

What makes an action moral or not ??
–The act itself “ What ”
–The motive “ Why ”
–The circumstances: when, where, how,
to whom and how often.

Ethical Terms
 Morals: standards of right and wrong
learned by socialization and based on
religious believes
 Statement of etiquette: describe expected
professional behaviors established in ethical
codes‫دستور‬ ‫او‬ ‫ميثاق‬

Ethical Terms
 Values: concepts or ideals that give meaning to life and
provide frame work for decisions and action
 Laws: rules of social conduct designed to prevent the
actions of infringing on the right of others.
 Rights: entitlements that one deserves according to just
claims, legal guarantee, or moral lower principles.
 Categories of rights:
1.Option rights: freedom of choice (cloths)
2.Welfare rights: legal rights (speech)
3.Ethical rights: moral rights (health care)

Ethical Terms
 Ethical dilemma: situation requires a choice
between two equally unfavorable alternatives.
 Accountability: answerability or responsibility:
1. Personal: to one self and patient.
2. Public: to employer and society.

Ethical Terms
Attitude
manner , way,
position and feeling
toward a person
hypothetical
construct of like or
dislike (expression of
favor or disfavor)
toward a person,
place, thing, idea or
event

Ethical Terms
behaviour :
is the range of actions
and mannerisms made by
organisms, systems, or
artificial entities in
conjunction with their
environment

Ethical Terms
 Believes: building blocks or attitude , the
strength of attitude depend on how strongly
believes are held to the extent to which they
are consistent to each other.
 Attitude are changeable and easy to change
 Values are difficult to change

What’s right = what a culture
believes is right ??

Where does the ethics comes from.?
 Tradition :
– That's the way its always been
 Religion/Authority :
– That’s the way I was thought to do it
 Reasons
– That’s the way reality determine to believe

Main Western
Philosophies
Other
philosophies
Abrahamic
Philosophies
Oriental
philosophies
Utilitarianism African, Asian, etc. Islamic Buddhist
Deontology Human Rights Jewish Confucius
Feminist ethics Catholic Indian
Casuistry
Virtue ethics Protestant Persian
Principlism Jehovah Witnesses
Taxonomy of Ethics
Christian
Ethics

What is Bioethics?
 It is derived from Greek bio- life and ethicos moral.
 The science/art that aims at identification, analysis,
and resolution of the ethical issues in almost any field
that is related to human life and health.
deciding what we should do (what decisions are
morally right or acceptable);
explaining why we should do it (how do we justify
our decision in moral terms); and
describing how we should do it (the method or
manner of our response when we act on our
decision).

Medical ethics
 Medical ethics
– is a system of moral principles that apply
values and judgments to the practice
of medicine .
– It is the branch of bioethics that is related to
the identification, analysis, and resolution of
moral problems that arise in the healthcare of
individual patients.

Ethics
Bioethics
Clinical Ethics
Research
ethics
Resource
Allocation
ethics
Public Health
ethics
Nursing
ethics
other
Business ethics
Environmental
ethics
Social ethics
Organizational
ethics
IT ethics
Other

Comparing Law and Ethics
 Law, ethics, and bioethics are different but
related concepts.
 Laws are mandatory to which all citizens must
adhere or risk civil or criminal liability.
– some actions that are illegal may not be unethical  (kill)
– some actions that are unethical may not be illegal  (secret)
– laws can be unethical or immoral ( colonialism)

Reasons to discuss ethics
 We face ethical dilemmas everyday
 Ethical issues are often harder to deal with
than clinical.
 There are often no black or whites, but greys
 It has been recognised as an area important
in medical education.
 If dealt with poorly can lead us into sticky
situations

Why is Ethics an Increasing Issue for
Health Care?
 an increasingly technological society with
complicated issues that never had to be
considered before.
 the changing fabric of society, particularly in
terms of family structure.
 health-care has become a consumer-driven
system based on clients becoming more
knowledgeable.

What is an “ Ethical Issue ” or a “Moral
Problem”?
There is an ethical issue when:
– we encounter conflicting values, beliefs, goals, or
responsibilities
– we are concerned that persons or their rights are not
being respected
– we are concerned about fairness and justice
– we are unsure what we should do or why we should do
it, morally speaking

Doctors Mission
 Doctor's primary goals are :
–To treat and cure where possible
–To bring relief in suffering
–To help the patient cope with illness,
disability and death

The duties of a doctor GMC
– make the care of your patient your first concern .
– treat every patient politely and considerately .
– respect patients' dignity and privacy .
– listen to patients and respect their views .
– give patients information in a way they can
understand .
– respect the rights of patients to be fully involved in
decisions about their care .
– keep your professional knowledge and skills up to
date .
– recognise the limits of your professional competence.

The duties of a doctor GMC
– be honest and trustworthy .
– respect and protect confidential information .
– make sure that your personal beliefs do not
prejudice your patients' care .
– act quickly to protect patients from risk if you have
good reason to believe that you or a colleague
may not be fit to practise .
– avoid abusing your position as a doctor; and
– work with colleagues in the ways that best serve
patients' interests .
GMC

Scope of ethics in Medical Practice
1. Historical background
• Hippocratic oath
• Geneva (1947)
• Sydney (1968)
• Tokyo (1975)
• Lisbon (1981)
• AMA Revised principle (2001)
2. Multidisciplinary nature

Ethical Theories
 Teleology / Consequentialism
 Deontology
 Situational Theory
 Caring-Based Theory - focuses on emotions,
feelings, and attitudes.

Ethical Theories
 Consequentialism: Also called Teleological,
Greek word, Telos, meaning end or
consequence.
 Actions are determined and justified by the
consequence of the act. Consequentialists
consider all the consequences of what they
are about to do prior to deciding a right
action. This also answers the question:
What should I do and why should I do it?

Ethical Theories
 Deontology /Nonconsequentialism:
Derived from the Greek word, Deon, meaning
duty.
Considers that some acts are right or wrong
independent of their consequences. Looks to
one’s obligation to determine what is ethical
and answers the question:
What should I do and why should I do it?

Ethical Theories
 Situational Theory
–holds that there are no set rules or
norms. Each situation must be
considered individually

Ethical Theories
 Caring-Based Theory - focuses on
emotions, feelings, and attitudes.

What Are Ethical Principles, and
How Do They Help With Decision
Making?

Ethical principles
{ Codes that direct or govern actions}.
Conflict is inevitable, Ethical principles
provide the framework/ tools which may
facilitate individuals and society to resolve
conflict in a fair, just and moral manner.

Ethical principle
1. Autonomy
2. Paternalism
3. Beneficence
4. Nonmaleficence
5. Utility
6. Justice
7. Truth telling (veracity)
8. Fidelity
9. Confidentiality

Autonomy ‫االستقاللية‬
 Autonomy can be defined as
the ability of the person to
make his or her own
decisions.
 The right to participate in
and decide on a course of
action without undue
influence.
‫استبداد‬ ‫يكون‬ ‫الفردية‬ ‫على‬ ‫يقضي‬ ‫ما‬
‫عليه‬ ‫نطلقه‬ ‫الذي‬ ‫االسم‬ ‫كان‬ ‫مهما‬...
…………‫ميل‬ ‫ستيوارت‬ ‫جون‬

Paternalism ‫الضعفاء‬ ‫حماية‬
- One individual assumes the right
to make decisions for another.
- Justifiable if patient at risk of
significant preventable harm,
paternalistic action will prevent
harm, benefits outweigh risks
and the least autonomy-
restrictive course of action is
used

Autonomy vs. Paternalism
The Central Conflict in Medical Ethics
 Autnomy
– Agents have the right
to be self-determining,
individuals have a right
to conduct their lives
as the see fit.
– Autonomy is typically
taken to be core
component of a good
practice
 Paternalism
– It is sometimes legitimate
to restrict agent
autonomy, for their own
good.
– Soft paternalism- agent
is incompetent in some
relevant way.
– Hard paternalism-agent
has less than ideal value.

Beneficence (Doing Good) ‫الفائدة‬
 The principle and obligation
of doing good and avoiding
harm.
 A practitioner should act in
the best interest of the
patient

Nonmaleficence ‫األذى‬ ‫منع‬
Many consider that should be the main
or primary consideration Much harm has
been done to patients as a result, as in
the saying, "The treatment was a
success, but the patient died."
It is not only more important to do no
harm than to do good; it is also
important to know how likely it is that
your treatment will harm a patient
 "above all, do no harm"

Justice ‫العدالة‬
- The principle that deals with fairness,
equity and equality and provides for an
individual to claim that to which they are
entitled.
- and the decision of who gets what
treatment
– Comparative Justice: Making a decision based
on criteria and outcomes. ie: How to determine
who qualifies for one available kidney. 55 year
old male with three children versus a 13 old
girl.
– Noncomparative Justice: ie: a method of
distributing needed kidneys using a lottery
system.

Veracity ‫الحقيقة‬ ‫قول‬
 The duty to tell the truth.
 Truth-telling, honesty.
‫الحقي‬ ‫على‬ ‫خطورة‬ ‫أكثر‬ ‫الراسخة‬ ‫القناعات‬‫قة‬
‫األكاذيب‬ ‫من‬...
‫نيتشه‬ ‫فريدريك‬

Fidelity ‫بالعهد‬ ‫الوفاء‬
 Strict observance of promises
or duties.
 The need to keep promises
 This principle, as well as other
principles, should be honored
by both provider and client.
‫نخون‬ ‫عندما‬....‫ف‬‫ضمائرنا‬ ‫إال‬ ‫نخون‬ ‫ال‬ ‫نحن‬…
‫كونراد‬ ‫جوزيف‬

Confidentiality ‫ثقة‬/‫الخصوصية‬
Keeping privileged
information private.
،‫خيانة‬ ‫اآلخرين‬ ‫سر‬ ‫كشفك‬
‫حماقة‬ ‫لسرك‬ ‫وكشفك‬…
‫فولتير‬

Utility ‫المجتمع‬ ‫حماية‬
The good of the many
outweighs the
wants/needs of the
individual.

Informed consent
 Definition: A patient’s willing acceptance of a medical
intervention after adequate disclosure from their MD of
the nature of the intervention, risks, benefits and
alternative treatment options .
 What constitutes informed consent?
 Disclosure: information to allow reasonable person to make a
decision
 Understanding: comprehension of the information given
 Voluntary: no coercion or incentive to accept or deny a treatment
 Agreement: verbal or written (preferred) to discussed intervention
 Many are screening patients for HIV without informed
consent ?
.

Ethical Dilemma
 Situations necessitating a
choice between two equal
(usually undesirable)
alternatives.
 A conflict between two or
more ethical principles.
 In an ethical dilemma, there is
no “correct” decision.

Major Types of Ethical Dilemma
 Euthanasia.
 Refusal of Treatment.
 Scarcity of Resources.

Euthanasia
 Intentional action or lack of action that
causes the merciful death of someone
suffering from a terminal illness or
incurable condition.

Euthanasia
 Active: an active intervention to end life
 Passive: deliberately withholding treatment that
might help a patient live longer
 Voluntary :euthanasia is performed following a
request from a patient
 Doctor assisted suicide: a doctor prescribes a
lethal drug which is self administered by the patient
 Non-voluntary :ending the life of a patient who is not
capable of giving permission
 Involuntary: ending life against a patients will

Refusal of Treatment
 Based on the principle of autonomy.
 A patient’s rights to refuse treatment
and to die often challenge the values of
most health care providers.

Scarcity of Resources
 The allocation of scarce resources
(e.g. organs, specialists) is emerging
as a major medical dilemma.

To make appropriate ethical
decisions:
The doctor must
use a professional
approach that
eliminates trial and
error and focuses
on proven decision-
making models or
problem-solving
processes.

Ethical Decision Making
EVALUATION
Evaluation of outcome of moral actions
"Were the actions ethical?" "What were the consequences?"
IMPLEMENTATION
Carrying out selected moral actions
PLANNING
Consideration of priorities of claims
Consideration of consequences of alternatives
ANALYSIS & DIAGNOSIS
Identification of problem: Statement of ethical dilemma
ASSESSMENT
Determination of claims and parties

Decision Making Model:
(ADPIE)
Assessment
Evaluate
Diagnose
Planning
Implementation
On-going Assessment
On-going Diagnosis
On-going Planning
On-going Implementation
On-going Evaluation

Ethics Committees
 Decision making in health care often
involves more than just medical facts of the
case
 Ethical principles and values will be the
determining factor in which course of action
to take.
 Many health care facilities have established
Ethics committees.

‫رضوان‬ ‫بن‬ ‫علي‬ ‫وصايا‬:‫سنة‬ ‫توفي‬ ‫الذي‬ ‫العربي‬ ‫الطبيب‬543‫هجريه‬
‫األصول‬ ‫كتابه‬ ‫في‬.
‫ابقراط‬ ‫رأي‬ ‫على‬ ‫الطبيب‬‫اجتمعت‬ ‫الذي‬ ‫هو‬‫فيه‬‫خصال‬ ‫سبع‬:
1-‫الجسم‬ ‫كامل‬ ‫يكون‬ ‫ان‬,‫االعضاء‬ ‫صحيح‬,‫الذكاء‬ ‫حسن‬,‫عاقال‬,‫الطبع‬ ‫خير‬
2-‫الملبس‬ ‫حسن‬ ‫يكون‬ ‫ان‬,‫الرائحة‬ ‫طيب‬,‫والثوب‬ ‫البدن‬ ‫نظيف‬
3-‫امراضهم‬ ‫من‬ ‫بشي‬ ‫أليبوح‬ ‫المرضى‬ ‫ألسرار‬ ‫كتوما‬ ‫بكون‬ ‫ان‬
4-‫من‬ ‫اكثر‬ ‫المرضى‬ ‫ابراء‬ ‫في‬ ‫رغبته‬ ‫تكون‬ ‫ان‬‫رغبته‬‫اجر‬ ‫من‬ ‫يلتمسه‬ ‫ما‬ ‫في‬,
‫الفقراء‬ ‫عالج‬ ‫في‬ ‫ورغبته‬‫اكثر‬‫االغنياء‬ ‫عالج‬ ‫في‬ ‫رغبته‬ ‫من‬
5-‫الناس‬ ‫منافع‬ ‫في‬ ‫والمبالغة‬ ‫التعليم‬ ‫على‬ ‫حريصا‬ ‫يكون‬ ‫ان‬
6-‫القلب‬ ‫سليم‬ ‫يكون‬ ‫ان‬,‫النظر‬ ‫عفيف‬,‫اللهجة‬ ‫صادق‬,‫بباله‬ ‫يخطر‬ ‫ال‬‫شئ‬‫من‬‫امور‬‫النس‬‫اء‬
‫واألحوال‬‫عن‬ ‫فضال‬ ‫الناس‬ ‫منازل‬ ‫في‬ ‫شاهدها‬ ‫التي‬‫ان‬‫يتعرض‬‫منها‬ ‫لشئ‬
7-‫واألموال‬ ‫االرواح‬ ‫على‬ ‫ثقة‬ ‫مأمونا‬ ‫بكون‬ ‫ان‬,‫قتاال‬ ‫دواء‬ ‫يصف‬ ‫ال‬ ‫وان‬‫ال‬‫يعلمه‬,
‫حبيبه‬ ‫يعالج‬ ‫كما‬ ‫فيه‬ ‫يصدق‬ ‫عدوه‬ ‫يعالج‬ ‫وان‬..

CONCLUSION
 “If a structured approach to problem solving
is used, data gathering is adequate, and
multiple alternatives are analyzed, even
with a poor outcome, the manager should
accept that the best possible decision was
made at that time with the information and
resources available.”

Respect for persons
The patient and the person treating the patient
have the right to be treated with dignity.

primum non nocere,
“above all, do no harm”
FIRST

An introduction to medical ethics

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