Medical Ethics SEM 2

Contents
SEMESTER 2 (PRO MIDSEMS)
WEEK 1 PUBLIC HEALTH ETHICS
WEEK 3 IMMUNIZATION ETHICS
WEEK 4 ETHICS OF THE ELDERLY
WEEK 5 STANDARD OF CARE
WEEK 6 HUMAN ENHANCEMENT
WEEK 7 TRANSPLANT ALLOCATION
WEEK 8 RESEARCH ETHICS
12
WEEK 9 SUBSTITUTE DECISION-MAKING, AHD & EOL
14
WEEK 10 CONFIDENTIALITY & PRIVACY
16
SEMESTER 2 (POST MIDSEMS)
WEEK 11 NOTIFICATIONS
20
WEEK 12 DISABILITY ETHICS
22
WEEK 13 COMMERCIALIZATIONS AND MEDICAL ADVERTISING IN MEDCINE
23
WEEK 14 PATIENT SAFETY
24
WEEK 15 BOUNDARY CROSSINGS AND VIOLATIONS
25
WEEK 16 PATIENT & PROFESSIONAL CONCEPTS OF ILLNESS
26
REVIEW CONCEPTS
27

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Ethics Review Year 2/ 2015
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W EEK 0 1 P UBLIC H EALTH E THICS

Public Health
- I.e. Health of entire population (individual rights less important, smaller autonomy)
- Public (meanings): 1. Numerical 2. Political 3. Communal
o Numerical Public: Utilitarian view that each individual counts as 1 & only 1.
Ethics: Focus on Justice (measurement methods & interpretation crucial) Goal: net health benefits
for population
E.g. How do we define population? How do we compare gains in life expectancy w gains in health-
related QoL? Whose values should be used for judgments?
o Political Public: Government has collective responsibility as elective representative of community, compelled to
promote health of the people, cannot invade individuals rights in name of communal good (Gostin)
Ethics: Justification of use of states powers, limits of governmental coercion, duty of state to treat all
citizens equally in exercising power
Liberal pluralistic democracy coercive & policies need to be justified by moral reasons that public
can reasonably accept
o Communal Public: All forms of social & community action affecting public health
Ethics: Beyond political public. People (outside of government & w private funds) have greater freedom
to undertake public health interventions no need to justify actions to political public
Actions subjected to moral requirements (respect for individual autonomy, liberty, privacy &
confidentiality, transparency in closure of conflicts of interest)
- Shift in focus of public health: individual public/ population health, Rx Prevention. Health of the public is the
primary end sought & the primary outcome for measuring success
o Intervention visible at population level
o Preventive interventions: Pervasive (health risks everywhere allow people to make their own mistakes &
prevent nanny state), involve burdens/ risks (not everyone benefits)
o Target group may be healthy persons, without complaints concern w over-diagnosis incidentalomas
need to be persuaded (pressed/ forced) ensure actual benefits
o Individual health (Bioethics): Human rights/ civil liberties, individual autonomy, confidentiality/ privacy
personalized
o Population health (Public health): Utilitarian, paternalistic, social & legal responsibility to protect public health
community orientation, governmental responsibility collective
o Tension between individual rights & freedom vs. publics health & common good
- Growth in public health: Everyone has the right to a standard of living adequate for health ad well-being of himself and of
his family, including food, clothing, housing & medical care & necessary social services etc. (UDHR) Health for all
o Global health: developing countries, international level
o Further infectious disease control (SARS, pandemics, bioterrorism)
o Further health promotion (smoking, alcohol, nutrition), screening programs (cancer), justice & equity in health
o Rx Prevention, individual collective
Public Health Ethics
- Review of PH: influencing adults to change their behavior (ethical & political issue), analyze efficacy, human rights,
cultural respect, equity, individual choice, utilitarianism & communitarianism, compatible w liberal pluralism
- Global local: Obligation to protect health of the population
o Global: statements of human rights
o National governments: ratify UN declaration
o National & state government: powers to legislate, tax, spend, regulate, punish (seat belt laws & smoking
restriction of personal & business liberties)
o Inquires/ court decision: public scrutiny & accountability
o Economic & social impacts of intervention vs. non- intervention (inequities of poor & rural residents)
- Ethical Aims: Public Health code of Ethics Public health should provide communities with the information they have
that is needed for decisions on policy or programs, and should contain the communitys consent for their
implementation
o Right to health care (society & individual)
o Utility (maximize benefits over harms)
o Distributive justice (fair distribution of benefits & burdens)
o Balance personal & community good vs. responsibility
o Procedural justice (ensure public & affected partys participation)
o Autonomy (choice/ action), privacy & confidentiality
o Transparency (disclosing information)
o Trust
- Resolving ethical conflicts: 1. Childress 2. Stewardship Model w the Intervention Ladder
1. Childress - Test for:
a. Effectiveness:
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i. Infringing 1/ more moral considerations will probably protect public health

ii. Policies that infringe moral considerations in name of public health, but have little chance of realizing
public health goals, are ethically unjustified
iii. Even if policies do not infringe other moral considerations but are simply unlikely to be effective
infringe moral requirements (efficient public expenditure, efforts worthwhile)
iv. Plain packaging of cigarettes Assumption: appeal causes consumption BUT: discounting
consumption (no Regulation Impact Statement). Caveat: disputes about statistics/ confounders (tax
changes)
b. Proportionality
i. Probable public health benefits > infringed moral consideration (breached autonomy/ privacy & low
public health impact)
ii. Risk/ benefits ratio (Positive vs. Negative features, benefits vs. effects)
c. Necessity
i. Not all effective & proportionate policies are necessary to realize public health goal
ii. Strong moral reason to seek alternative, less morally troubling policy (TB & Immunisation: incentives >
forcible detain/ compulsory vaccination policy)
iii. Proponents of forcible strategies need to have strong moral proof, supportable evidence/ reasons
d. Least Infringement
e. Public Justification
2. Stewardship Model (UK): Whole levels of intervention to ensure focus on right level
a. Stewardship: states have duty to look after peoples needs (individual & collectively)
b. Obligation of state to ensure peoples health & health inequality primary asset of nation is its health
greater overall well-being & productivity
c. DO
i. Risk of ill health people impose on each other
ii. Cause of ill health (environment, hygiene, sanitation & housing)
iii. Health of children & vulnerable people
iv. Health promotion (information, advice, addiction program)
v. Ensure easy access to healthy life & appropriate access to medical service
vi. Health inequalities
d. DONT
i. Attempt to coerce adults to lead healthy lives
ii. Introduce interventions w/o individual consent of affected/ procedural justice arrangement
(democratic decision making procedures for adequate mandate)
iii. Introduce interventions perceived as unduly intrusive & conflicting w personal values
e. Least restrictive most restrictive
i. Do nothing/ simply monitor current situation
ii. Provide information/ education
iii. Enable choice to change behavior
iv. Guide choices through changing default policy
v. Guide choices through fiscal & other incentives (tax-break for bicycles) & disincentives (cigarette/
alcohol taxation)
vi. Restrict choice & options (unhealthy food/ ingredients)
vii. Eliminate choice (isolation of infectious patient)

Individual rights & freedoms are compatible w common good of public health because: Existence of individual rights & freedom
depends on provision of basic good e.g. sanitation/ immunization, up to a certain point on the ladder

- Swine Flu: withdraw rights to freely travel vs. ethical requirements
o Infectious disease control: notification/ contact tracing, forcible screening, social distancing, Criminal law (HIV
patients who still infect others)
o Ensure consistency in applying standards (Rx like cases alike), impartial & neutral decision making, dignity &
respect to affected pts, decisions based on accurate information & logical, limiting freedom if it puts others at
risk (common good)
- Fluoridation (in particular, eliminate choice e.g. compulsory isolation of infectious pts)
o Effective, risks of fluorosis, coercive/paternalistic (compulsory choice & infringement), satisfies some
stewardship DOs
o Whole area receives fluoridated water or not at all populations not static practically not feasible to seek
individual consent need to assess relative costs & benefits to population health & individual liberty

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W EEK 0 3 IMMUNIZATION E THICS

Public good v individual good
- Parental autonomy, consent, rights & interest vs. public & individual good Consent for children (In best interest, rely
on herd immunity if high enough even though it may not be in childs BI) address parents risk perception issues (risks
> advantages, risks > visible than disease when vaccination rates high/ disease rates low)
- Low immunization rates Fx: socially disadvantaged/ poor, frequent family moves, sole parents/ family disruption,
mother/ children chronically ill, demographic factors Barriers to immunization: social/ illness factors, anti-vaccination
campaign, suspicion of conventional medicine/ health consumerism & rise of alternative Rx.
- Herd immunity a type of common good (high vaccination rates unvaccinated benefit w/o risks). THEREFORE, Failure
to immunize harm to others?
o Directly harming another is usually seen as more serious than failing to benefit another. BUT if protection from
harm is seen as a basic (positive) right, failing to benefit is arguably a significant harm.
o Failure to immunize herd immunity/ public good protection from harm (risks to other children /
unborn)
- Immunization paradox (prisoners dilemma): Self-interest position (its best that everyone be vaccinated except me)
public good worse off if too many believe this hopefully no one else thinks like you, short-term effect only there are
good prudential (self-directed) reasons to moderate self interest, as well as public health/ altruistic reasons
- Compulsion:
o FOR: ensuring non-immunized group remains small maximizes herd immunity, costs are imposed by diseases
(esp. eradicable diseases)
o BUT: if same immunization rates achievable w/o compulsion, then better to avoid compulsion & better for GPs
to utilize shared decision-making model
Policy Overall aim: maximize immunization rates
- COAG (benchmarks for child immunization): states/ territories expected to maintain/ improve immunization rates for
children aged 4Y, for indigenous children- 1, 2 & 5Y & in areas of agreed low vaccination coverage
- National Health Performance Authority (NHPA): Provides locally relevant & nationally consistent info on the performance
of hospitals & Health Care organizations, set up under COAG & National Health Reform Act 2011, produces Healthy
Communities Report on Immunization
- Models: No regulation/ Compulsory/ Quasi-compulsory/ Compulsory choice/ Incentives
o No Regulation: UK No legislation, no mandatory program/ school- entry program
o Compulsory: Slovenia Mandatory program for 9 infant/ early childhood disease (no need for school entry
requirements), only medical exemptions. Mandatory system complemented by no-fault compensation scheme
(compulsory vaccination government obligation to ensure vaccine safety)
o Quasi-Compulsory: USA School entry vaccination requirements mainly, variation between states (entry
provision, documentation, enforcement & exemptions). System helps in rapid exclusions during diseases during
outbreaks. Criticism may cause delayed vaccination. Not in force in AUS, BUT has been urged by Australian
Medical Association
o Compulsory Choice: Response to NHMRC recommendations. Provisioned strengthened in NSW: Exemptions
if: GP advices that it would be medically harmful OR religious OR is on a recognized catch-up program (had been
ill, but not is catching up on vaccination); Parents needs to be counseled by DR about risks of not vaccinating.
QLD- no formal school entry requirement legislation, childcare centers required to record vaccination status,
school exclusion provisions.
Low rates in GC, inner Brisbane, Sunshine coast & Noosa
Government strategy: expansion of pharmacy vaccination trial to include adult (flu, pertussis &
measles), e-reminders for parents re due dates for childhood vaccinations
o Incentive Model: No Jab, No Pay Strategy (2016) restriction in scope of conscientious objection to 1. Objection
based on affiliation w formally objecting religious groups 2. Medical contraindication
BUT: financial incentives wont influence all, political campaign (?), punitive approach may cause
resistance, non-attendance at day care (?), alienates merely cautions parents by removing incentive
for discussion
- Public funding: Gap between best practice & political expediency; Issue of complacency vis a vis partial coverage by
vaccine; issues of equity & resource allocation
- Ethical framework for immunization programs (Isaacs, 2012) this is one proposal only
o The program should benefit the individual and the community
o Targeted disease should be sufficiently severe & frequent to justify the risks and expense of the program
o Vulnerable groups within the population should be targeted
o Obligation to monitor for adverse events and for disease incidence to sure safety and effectiveness
o When immunizations are voluntary, vaccine recipients or their parents or carers should be given sufficient
information to make autonomous, informed decisions
o Incentives to participate in public health immunization programs should not be coercive
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o Public health immunization programs depend on mutual trust, which may be threatened by circumstances such
as excessive media publicity about adverse events associated with vaccines.

W EEK 0 4 E THICS O F THE E LDERLY
Resource Allocation/ Limiting Care
- Expenditure on elderly high & might have less/ no benefit & poorer outcomes
o Fair innings argument (Callahan): limit care to symptom relief after set age & reallocate saved cost variability
in health status means that cut off is arbitrary. How much should we save?
o Balance between government/ family/ individual responsibility for care trend to increase individual
responsibility (carer break down), increasing retirement age, superannuation & health insurance.
o Limits to care to previous & next generation, heavy burden on 2-job families & women remain major carers
- Age Discrimination Act 2004
o Unlawful to discriminate on the ground of age
o Discrimination on the ground of age can be direct or indirect
o Unlawful to discriminate on the ground of age in relation to work & certain other areas
o Unlawful to discriminate on the ground of age if a particular exemption Is applicable
o It is an offence to do certain things related to age discrimination
o Unlawful for a person who, whether for payment or not, provides goods or services, or makes facilities
available, to discriminate against another person on the ground of the other persons age
o General exemptions
Exempted health programs & persons delivering them not acting unlawfully (Positive discrimination:
free influenza vaccination to older people due to higher risk of complications)
Individual decisions (health/ medical goods/services) NOT unlawful for a person to discriminate
against another person, on the ground of the other persons age, by taking the other persons age into
account in making a decision relating to health goods or services or medical goods or services if:
Taking the other persons age into account in making the decision is reasonably based on
evidence, and professional knowledge, about the ability of persons of the other persons age
to benefit from the goods or services (do most 80Y do well w this med?); and
The decision is not in accordance w an exempted health program
- Overtreatment: surgical procedures, gastrostomies (PEG), futility definitions (dialysis not futile as long as venous access is
maintained), legal liability concerns, sanctity of life
Medical Ageism
- Ageism: perceived burden of elder care vs. disability rights of distinct groups, younger people cannot & do not
conceptualize ageing youth omnipotence, unknown future, denial, fear of ageing & dependence, devaluing of social
non contributors ageism is discrimination against our future selves
o Can lead to economic, social & psychological costs due to age discrimination in employments e.g. job adverts &
culling processes directly discriminatory preference for young recruits by using words like energetic, dynamic,
innovative
- Definition: describes a broad array of discriminatory practices in health care- from demeaning age based references used
for elderly patients to stereotyping elderly patients, to inappropriate use of chronological age when treating them.
- Law adapted to recognized aged persons are not less worthy systems, policies & laws accommodate differences in the
ageing population, recognition that chronological age is not destiny (medically: old, confused =/= dementia)
- Residential care: resistance to moving from home to care (over-valuing independence vs. costs of loss) Tension
between independence & safety (paternalistic temptation)
o Staffs of residential care facilities poorly paid & have very low qualifications. Community care alternative also
expensive & stressful
o Aged Care Act 1997 (Cth)
Funding subsidies of aged care places
Quality of care: 1. Health care, management, staffing, lifestyle etc. (No kerosene baths)
Rights & dignity of those receiving care
Accreditation & licensing of facilities
o State legislation: various statutes inc Health Act, Residential Services Acts, Disability Services Act + Guardianship
legislation
o Restraint (chemical/physical) & seclusion: may be required for protection of patient/others/staff problems of
disorientation, aggression, violence, disruption Principle of minimal restraint necessary for safety &
protection, and as long as in best interest of patient
For patients w/o capacity: Guardianship & Administration Act 2000 (QLD)- Use of force: A health
provider & a person acting under the health providers direction or supervision may use the minimum
force necessary & reasonable to carry out health care authorized under this Act (some uncertainty
concerning application) AND various conditions on use of physical & chemical restraints. Access for
delirium first!
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Elder Abuse: Aged Care Act 1997 (Cth)

o Mandatory reporting by providers/ staff of reportable assaults e.g. unlawful sexual contact, assault,
unreasonable use of force
o Elder abuse subject to professional disciplinary sanctions e.g. even in self defense against aggression by patient,
if considered excessive
Anti-ageing movement Aims: 1. Prolonged disease-free lifespan 2. Early detection, prevention, treatment, and reversal
of age-related dysfunction, disorders & diseases 3. Delaying or preventing the occurrence of age-related diseases, or
modifying the processes of aging
o People w positive self-perception of ageing tend to have higher survival advantage in terms of years
W EEK 0 5 S TANDARD O F C ARE

Standard of Care (1. Diagnosis & treatment 2. Disclosure of information for decision making Negligence principles )
- Adverse Events/ Harm Health complaint units/ Medical registration boards, civil law suit for compensation
o Incompetence of health care: Medico-legal issues (negligence, de-registration, re-certification), risk
minimization in health system& individual competence (skills training) VS. Harm to patient
o Headache SAH (competent, huge harm but not as a result of fall below medical standards)
o Delay in diagnosis of meningococcal septicemia in baby w hemorrhagic rash & stiff neck (incompetence of
health care causing huge harm to patient)
o QLD: ALL complaints to registration authorities received & handled by Office of Health Ombudsman
o Negligence claims: commonly settled by parties to the dispute (defendant D/ health service) by financial
compensation (Medical indemnifiers/ insurers/ Medical Defense Organizations- MDOs), esp. when damage from
breach of SOC (i.e. patient plaintiff is likely to win)
- Diagnostic Strategy (Murtagh, GP 1996): 1. Probability diagnosis 2.Do not miss serious disorders 3.Pitfalls 4.The 7
Masquerades (Conditions that may not have text-book presentation: Depression, DM, Drugs, Anemia, Thyroid Disease,
Spinal dysfunction, UTI) 5. Is the patient trying to tell me something?
- Kinds of medical negligence:
o Failure to attend in an emergency
o Failure to adequately inform of consequences and risks
o Failure to diagnose (at all)
o Failure to diagnose accurately (wrong diagnosis)
o Failure to diagnose at an appropriate time (delayed diagnosis)
o Failure to attend/ examine (e.g. failure to make a requested house-call)
o Failure to refer, or negligent nature of referral
o Failure to adopt recognized precautions
o Failure to treat appropriately for a particular condition
o Failures in communication to others (e.g. wrong information or instruction provided to other staff with
consequent patient harm)
- Broad SoC applicable to all: exercise of reasonable care (medical: in utilizing the skills associated w medical practice) to
avoid foreseeable risks but breach of SoC varies between Dx/Rx, information or advice
o Dx & Rx: patients contribution limited to narration of Sx and relevant Hx D provides Dx & Rx according to his
level of skill
- Negligence Review:
o Act occurred, or was omitted, in context of duty of care
Ethical duty of care need for treatment, availability of someone with the skills to provide
Professional duty of care- community equips and expects its health professionals to provide care in an
organized way
General legal duty of care: where there is a neighbor relationship Foreseeability & proximity
(reasonable in the circumstances according to community standards)
o Breach of a duty of care occurred
o Causation breach caused damage
o Damage physical, mental, economic loss
- NOT negligence if acted in accordance w a practice accepted as proper by a responsible body of medical men skilled in
that particular art. A man is not negligent, if he is acting in accordance w such a practice, merely because there is a body
of opinion that would take a contrary view Bolam test for negligence in accordance w an established and accepted
professional practice in disclosure & Dx & Rx
- Rogers v Whittaker - Standard is not determined solely or even primarily by reference to the practice Followed or
Supported by a responsibly body of opinion in the relevant profession or trade (disclosure case)
o Whether a medical practitioner carries out a particular form of treatment in accordance w the appropriate
standard of care - responsible professional opinion are influential & decisive
o Whether the patient has been given all the relevant information to choose between undergoing and not
undergoing a treatment is a question of a different orderI.e. it is not a question the answer to which depends
upon medical standards or practices
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o Australian Courts will not accept current accepted medical practice as determining the SoC, but they will take it
into account when judging whether an acceptable standard has been reached. The court makes the final
judgment in all cases
o Disclosure what is of relevance to the patient- does not take its direction from what is accepted in the
profession i.e. D should disclosure what is material to the P, as determined by the court
o Bolam standards have stronger influence in Dx/Rx area than disclosure cases. But influence =/= determination;
court sill makes the final judgment.
Naxakis v Western General Hospital & Anor - Whilst evidence of acceptable medical practice is a useful guide for the
courts in adjudicating on the appropriate standard of care, the standard to be applied is nonetheless that of the ordinary
skilled person exercising & professing to have that special skill
Civil Liability Act QLD 2003 included many Ipp Review of the Law of Negligence recommendations (DRs to return to
SOC but to avoid defense relying on idiosyncratic opinions & ensure accepted opinions are soundly based): * In bold:
related to standard AND duty
o Duty to take precautions against risk of harm: risk was foreseeable (knew/ reasonably ought to have known of
risk), risk was not insignificant, in the circumstances, a reasonable person in your position would have taken
precautions
o What precautions, in the circumstances, would a reasonable person be expected to take? Consider:
Probability of harm if care not taken
Likely seriousness of harm
Burden of taking precautions to avoid risk of harm
Social utility of the activity that creates risk of harm
o SOC for professionals (s22) Bolam revisited
Provides definition of SoC & statutory defense that D can utilize in case of breach of the common law
of SoC for medical Dx/ Rx
Independent evidence-based, provided by well-respected medical experts
Clinical Practice guidelines (CPG) lack specificity to individual, variable quality and acceptablitiy
adherence is not a guaranteed defense to negligence, departure does not automatically imply fault
NO breach of duty in providing professional service if acted in a way that was widely accepted by peer
professional opinion, by a significant number of respected practitioners in the field, as a competent
professional practice (there can be differing peer professional opinions that are still widely accepted by
a significant number of respected practitioners)
BUT peer professional opinion cannot be relied on, if the Court considers that the opinion is irrational
or contrary to a written law
o Diagnosis & Rx information about accepted professional practice is very important, but not absolutely
determinative (modified Bolam test)
o Advice/ warning of risk Professional practices not influential in determining whether a doctor has acted
reasonably (Rogers v Whitaker)
o Causation: 2 stage approach
Factual Causation & Normative causation : breach of duty was a necessary condition for harm
occurring AND Scope of liability whether it is appropriate for scope of liability to extend to harm
caused, potential limit to legal liability i.e. we can only find defendant legally liable if it is appropriate to
do so (consider whether or not and why responsibility for the harm should be imposed on the party
who was in breach of the duty)
Plaintiff must prove (onus of proof)
Factual
No entitlement to damage if causation is not established, even if there is a breach of SOC

Clinical Uncertainty, Defensive Medicine & Legal Liability
- Defensive medicine: there is no absolute certainty in diagnosis more tests, over investigation, excessive expenditure
- Negligence claims 2 largest categories: Diagnostic errors (ing rates e.g. failure to diagnose, delayed diagnosis, wrong
diagnosis) & Surgical Treatment errors
- Law imposes reasonable standard, not perfection BUT legal judgments/ community demands contribute to defensive
medicine/ over-diagnosis/ over-treatment
- No-Fault Schemes for compensation e.g. NZ- compensation does not require demonstration of failure to adhere to SoC
compensate ALL personal injuries, including those resulting from medical misadventure

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W EEK 0 6 H UMAN E NHANCEMENT & T HE G OALS O F M EDICINE

Evolution, history & Enhancement
- Definition:
o Wish-fulfilling medicine DR & other health professionals using medical means in a medical setting to fulfill the
explicitly stated, prima facie non-medical wish of a patient symptoms not necessary, medical diagnosis not
required, treatment indicated by patient wishes
o Enhancement technologies refer to those medicinal and procedural interventions that can be used to improve a
human characteristic or state beyond what is necessary to optimize their health
- Developments: Man replaces God as sum of all things, the individual becomes central & science gives man power over
nature. Mans science can remove chance from evolution through deliberate design, human intervention can
dramatically improve quality of life. First occurs via meeting challenges of diseases etc. but rapid eclipse of treating/
preventing by enhancement possibilities. Medicine is enlisted in fulfillment of individual wishes Age of self-realization/
self-enhancement inauthentic selves OR can enhancement liberate a more authentic self?
- Categories of enhancement (not all enhancements have been/ are brought about/ aided by medicine):
o Cosmetic/ Aesthetic: body piercing/ tattooing, surgical (breast augmentation/ reduction, abdominoplasty, face-
lifts), height manipulation
o MSK/Athletic: Training at high altitudes, autologous transfusions, EPO, anabolic steroids, Insulin-like Growth
Factor (IGF increase muscle, decrease fat, improved skin elastin), amphetamine (plasticity & motor learning)
o Cognitive/ Affect: Memory training courses, external hardware/ software (PDA, collective intelligence on www.),
nutritional enrichment, drugs (Modafinil- arousal, retention & memory, cholinesterase inhibitors to improve
performance on high skill tasks, Trans-cranial magnetic stimulation. Affect e.g. SSRI, vitamins over-
prescription/ medicalization of normal sadness: vague boundaries of affective illness. Modulation of memories
of emotional events e.g. propranolol.
o Ageing/ Anti-ageing: disease per se/ normal process anti-ageing movement (ageing is undesirable) v diseases
are undesirable (anti-ageing is type of enhancement) Treatments: seem to both treat specific disease & allay
ageing: blurred distinction if drugs are for specific diseases, then greater TGA/ FDA scrutiny needed, if anti-
ageing treatments are enhancements, then may not be covered by insurance. Possible outcomes of ageing
research:
Prolonged senescence: prolonging life without improving health (on aging rather than age-related ds)
Compressed morbidity: reduce incidence of disease into old age (can conflate ageing and diseases of
ageing)
Decelerated ageing: healthier 90Y, discrimination against the young?
Arrested ageing: continual reversal of age-related damage from basic metabolic processes. Telomere
repairing & embryonic cloning of organs
o Moral: Morality evolved process/ institution, fails to keep pace w science & technology & suited to pre-
scientific times (acts/ omissions, sympathies limited to kin/ nearest) modern globalization: primitive morality
rd
unsuitable/ restricted (i.e. Peter Singer should do much more to assist 3 worlds, primitive morality only
limited to family)
o Negative enhancement: prevention of disease, aging by negative selection against undesired traits (criminality
genes?)

Conceptual & Ethical Themes and Issues
- Enhancement & goals of medicine
o Concept of integrity of medicine Hastings Center prevention of disease/ promotion of health, relief of pain
& suffering, cure of maladies/ cure when cure impossible, avoidance of premature death/ pursuit of peaceful
death
o BUT other definitions: well-being, happiness, QoL, length of life individual vs communitarian, internal v
societal definitions social pressures & competition influence perfections of well-being & health normal
o The Ashley treatment: growth attenuation of severely disabled child to maintain small body habitus alignment
w goals of medicine depends on which set of goals selected
o Goals: difficult to evaluation, problem of core of goals & hierarchy of goals, needs vs. wants, what is an
acceptable range of normal
- Treatment (and training) vs. enhancement Blurred boundaries & Vagueness
o Sorites paradoxes: heap of sand stops being a heap when only 1 grain is left who is to agree? Old (when do
you become old?) fine distinctions!
- Hubris, dignity, humility, identity
o Life cycle traditionalism, life as a gift/ religious versions (Gods plan & learn to accept), suffering as character-
building, chemical alterations affects personhood, infallibility objection (human wisdom is incommensurate to
manage our freedom & capabilities), enhancements are unnatural
o RESPONSES: we try to preserve the natural order of life, humility not necessarily a fixed virtue outside the
religious context.
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General purpose enhancements e.g. intelligence, memory, concentration- arguably OK in contrast to

specific enhancements that may not align w specific life plan
No one will reject preventions/ treatments that have already been achieved
Preference for status quo is an irrational bias
Justice: equity, fairness & access
o Enhancements are a western indulgence, will increase the inequality gap/ disparities potential problems of
victimization & enslavement of humans by post-humans, increased disparities threaten democratic
institutions & democracy per se Health systems cannot absorb extra expenses related to enhancements, but
private payment reflects & exacerbates inequities
o RESPONSES: natural genetic differences/ advantages generally not considered unfair. We already have wide
social disparities anyway. Democratic institutions are sufficiently robust to manage developments & minimize
harm. Enhancing the less gifted may reduce the perceived gap
Blurring of enhancement/ prevention/ treatment boundaries suggest that significant gains for
prevention & treatment for all may be had via enhancements, even for some
Safety
o Standard side effect considerations, some enhancements may cause deficiency/ harm in another area, issues of
privacy in external software enhancement Safety concerns should be much greater where enhancement is
non-therapeutic but improving on normal: less risk/benefit trade-off
o RESPONSE: utilize standard information disclosure, dangerous substances are currently marketed (e.g. alcohol)
w limited safety warnings, traditional education/ training applied to young who cannot rationally respond (non-
deliberated absorption e.g. hidden curriculum). Low cost, safe enhancers can contribute to public as well as
individual goods

Traditional higher education may increase the risk of becoming a professor or university don a profession characterized by
Friedell as involving a slow metabolism, a sluggish bowel, a penchant for gradualist doctrines, and pedantry

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W EEK 0 7 T RANSPLANT A LLOCATION

LEARNING RESOURCE Medical Approaches to Death & Dying
- Death is not bad assuming no subject left to experience VS. Death is bad deprived from positive good of life (unless
life cease to have net positive value from uniformly bad experience/ bleak outlook) preference to die NOW
- Historical Assumption: Approaches to death determined by cultural & metaphysical views AND Medicine is part of
cultural heritage & influence upon it
o Death as a natural event, religious & metaphysical & psychological evil, NOT morally evil Fatalism rejected,
moral obligation to use available means to avert death (which is evil), DRs not considered failures if patients
th
died 20 Century: If we can act to advance the sanctity of life, then we ought to act
- Medicalization & denaturalization of death strong moral imperative to prolong life medical failure not to
Responses to de-medicalize death:
o Right to refuse attorneys for substitute decision maker for incompetent pts, AHD
o Palliative care subjective & objective assessment of benefits & burdens
o Right to die dignified death
o Euthanasia active release from continuing & unbelievable suffering
- Diagnosis of death: to judge someone as being no longer capable of being attributed to any kinds of properties at all,
apart from those who survive (dualism mind vs. body)
- To love fully is to risk the grief & suffering implied by the loss of their love e.g. through death dying is necessary for
experience of love? death is personally/ individually bad, but also tied to deep human goods
LEARNING RESOURCE Defining Death & Transplanting organs: History & Ethics
- Deaths inevitability has become increasingly denied, repressed and compensated for
- Prolongation of life is a moral imperative sanctity of life medicalization of death death as a medical failure
sometimes
- Bad consequences of medicalization relentless prolongation of life & devotion to cure
- Definition, Criteria of death
o Death = permanent loss of integrated functioning of the whole organism (KIV biographic death in dementia)
o Criteria: What is the essential nature of persons?
o Tests: CR failure signs, neurological activity of brain
- Redefining death (for organ harvesting) brain death = legal criterion for death. Deceased Donor Regulations (DDR): a
person should be legally dead before organ donation for transplantation can occur
- If death is the loss of higher consciousness, life should be defined as the beginning of consciousness (but most define it
as BEFORE consciousness arises)
- Responses to link between brain death & procurement of organs

RESPONSE
ADVANTAGE
DISADVANTAGE
Make exceptions to the DDR by conceptually Based on principles of consent
Very difficult to revise the law to
& practically separating organ procurement
& harm prevention (organs can expand the scope of justifiable
from the prior diagnosis of death. Requires
only be procured from
homicide. More people favor retaining
acceptance that life can be intentionally
individuals who can no longer
DDR & expanding its scope, rather than
ended legitimately, given certain criteria
be harmed), rather than on a
complete abandonment
contrived death criterion

Slippery slope argument: exceptions to
Quality of Life view
current prescriptions on taking life may

weaken general resolve & lead to
Return to traditional definition
further exceptions
of death, especially for donor

families
Hard to establish starting point &

develop exceptions for whole brain
death vs. CR death
Rate of procurement would

as potential donors would
Problems of consistency in applying
include those now excluded by
exceptions to the DDR between organ
whole-brain criterion
procurement practices & other social
phenomena related to death
Expand the scope of the DDR more patients No need to change the law to
Counter-intuitive since this would
than currently would be classified as dead,
include new categories of
include PVS patients, whose
thus expanding the potential donor pool
justifiable homicide, or to
description as dead strains the general
develop new adjustments
idea of death even more than the
regarding organ procurement
whole brain criterion (Terry Schiavo)
and other social behaviors

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Supported by more people
Expand the scope of the DDR, and include a

conscience clause, which would allow
people to choose their own definition of
death from a limited range of alternatives
Retain the current legal definitions of death,

and seek other ways to increase the organ
donor pool. These could include encouraging
greater discussion of donation in the
community and amongst family members,
increasing the accuracies and efficiencies of
donor registers, commercial arrangements,
financial incentives for organ donation,
encouraging non-altruistic donations, lifting
priority on recipient lists in return for family
member organ donations,
xenotransplantation, streamlining consent
processes, utilising presumed consent (see
Law in Queensland, below and utilising
donation after cardiac death (see below)
Retain the current legal definitions of death

and associated organ transplant processes,
and put the brakes on the continuing
technological imperative which requires us
to try and secure more and more organ
donors. Realign the priorities between
continuing high tech medicine and a greater
commitment to other modalities of health
care, eg preventive health measures. Accept
that there must be limits to this as to other
medical developments

Would reflect the fact that

people vary in their willingness
to regard others with different
levels of serious brain failure as
dead.

Ability of people to choose
higher criteria (e.g.
neocortical death) would be
more consistent with current
ability of people to have life-
sustaining treatment
withdrawn.
Retains the current definitions,
does not require conceptual &
legal shifts which would be
difficult

Would maintain public trust in
the organ donation system
Expanded scope would threaten to

sever the relationship between the
biological phenomenon of death and
the social construction of death.
Transplant requirements should not be
the decisive factor in defining death

People may feel threatened by the
expansion of the definition of death,
fearing a loss of rights associated w
being alive, and indeed the right to life
Some people would regard those
choosing the higher criteria as being
actively killed
Various ethical problems with

commercialisation of health care,
equity issues etc. resulting from the
pricing of organs. Proposals such as
incentive payments (i.e. In excess of
compensation for incurred expenses)
are criticised for risking exploitation of
the poor and vulnerable, ie legalising
what is now agreed is happening in
black markets for organs.

Some people would consider that
these proposals, eg presumed consent,
would diminish, not maintain, trust.

Negative ethical perspectives on
xenotranplantation.

Initiative & Law reform in AUS & NZ
- QLD Transplantation & Anatomy Act 1979 Death: irreversible cessation of circulation & respiration OR irreversible loss
of all brain function
o Donors consent is sufficient for transplantation to occur (once donor is dead) BUT Organs usually not retrieved
if family of donor objects
o Potential donors register their consent to donate (Opt-In)
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Presumed consent (QLD Review of Organ & Tissue Donation Procedures Select Committee) Opt-out model: everyone
is assumed to be a donor, unless they register their dissent to tbe the one
o Hard model (Austria) does not allow any family involvement in donation decision
o Soft model (Spain, Belgium) allows family to object to donation, in cases where the deceased person has not
registered dissent to donation but the family is aware that this is the persons position, or in cases where
donation would produce significant distress to family members
o Paternalistic? BUT most are in favor of transplantation, presumed consent system is therefore MORE
respective & refusal will e respected
o Not adopted by QLD
- Donation after cardiac death (DCD): renewed attention due to low donation rates, improved ways of reducing ischemic &
damage to organs following cardiac death (antemortem heparin) Ethical issues: consent, harm to patients from
antemortem intervention
Live Donation
- Living donor: reducing as more kidneys from deceased donors now
- Advantages: 1. Avoid long waiting time for deceased donors (Blood group inequality in waiting list, Group A blood
donors> O). 2. Can be done as planned procedure 3. Longer graft survival rate- better results
- Disadvantages:
o Healthy person needs to undergo significant operation for no medical benefit primum no nocere justified
w social benefits to the donor
o Difficult to quantify risk e.g. Donors w heart disease or diabetes should you/ how much to restrict ability to
donate an organ
o Donors have increased risk of renal failure & earlier death
- Ethical issue: Advertising/ online matching? Compensation for lost income & expenses for donors? Paying donor
outright? (Exploitation of the poor)
Deceased Donation
- Most people better off w transplant than dialysis. Kidneys are scace, donors expect their organs to be treasured
Giving them to everybody irrespective of prognosis will greatly reduce community benefit (utilitarian)
- Balance rights of individual v society
o Kidneys for those who want one very long waiting list, more people die waiting, everyone worse off
o Kidneys for those w good life expectancy?
o Kidneys for those who has higher/ better societal contribution? No kidneys for criminals? Equity vs.
expectation of community that criminal ought not to have the same access to an organ
- Waiting list: depends on patients outlook, prognosis & medical conditions AIMS:
o To be as fair to everybody as possible, for all to have equal chance of getting onto waiting list regardless of
location (rural/not).
o To balance as fairly as possible: Responsibilities to give as many people as possible the chance to receive a
transplant vs. Responsibilities to maximize benefits from scarce community resources
o Issues: patients w cardiac disease, infection, cancer, compliance
Allocation
- Past: HLA Matching/ tissue typing - some discrimination for patients belonging to ethnic minorities (different background
w different HLA types from donor community)
- 1/3 of all kidneys allocated to those w best match.
- Mainly runs on waiting list (since the day patient starts dialysis)

-

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W EEK 0 8 H UMAN R ESEARCH E THICS & L AW

Research ethics (applied ethics)
- Clinical research:
o Evidence of safety & efficacy of new intervention (Rx/drug)
o Experimental intervention should be comparable to conventional standard treatment
o Justifies excluding the participant from receiving the accepted standard Rx (clinical equipoise)
o Autonomy: Consent: Participants understand that they are willing to be subjected to risk & burdens for the
purpose of contributing to knowledge for future generations out of altruism/ hope of possible benefit
- Vs. Clinical care 1. Best interest of patient (v Research: future focused) 2. Duty of care before interest of clinician 3.
Based on trust (beneficence) Research: legal duty from civil law principles to inform p about the trial to obtain
consent, take reasonable care, avoid foreseeable harm to them trespass & negligence, NHMRC & funding bodies
- Therapeutic Misconception: failure to research participation to appreciate the nature & purpose of clinical research
(overestimating benefits, underestimating risks, research options, misunderstanding about randomization)
- Legal obligation
o Civil law, duty to adequately inform
o Higher standard of disclosure for research than therapeutic procedures as per Rogers v Whitaker (accounts for
uncertainty & unconventional care)
o Assumes capacity to consent, free from coercion & duress. Decision maker mentally & physically able to arrive
at a decision
o Parents cannot consent to non-therapeutic research for their children (Baltimore Lead Paint Research)
o Best interest NOT limited to medical interests only includes mental & emotional interest
o HREC: advocacy for researchers & subjects
Declaration of Helsinki: safeguards research subjects, informed consent, minimizing risk, adhering to
approved research plan/protocol
- Ethical review needed when: 1. Before research can begin 2. Before full funding for a proposal is released judgement
that human research proposal meets requirements of the National Statement & is ethically acceptable Legal
requirements for Human & Animal research
- PRINCIPLES: research merit (research is justifiable by potential benefit based on current literature), integrity, justice
(Recruitment of participants is fair, no unfair burden of participation on any particular group), beneficence (accounting
for risk of harm & potential benefits to participants and wider community, sensitive to welfare & interest of everyone
involved, reflect on social & cultural implications) & respect (giving due scope to the research process & autonomy.
Balance of power: criminals, public patients less power?)
- Ethical consideration: WHO participants; HOW methods; THEMES: risk & benefit AND Consent
NHMRC Statement (AUS)
- Integrity (sound ethical research practice): Before, during and after conduct of research; Professional integrity & Data
integrity - confidentiality
- Respect for persons: Dignity & autonomy; Welfare, rights, beliefs, customs Consider if the research involves people w
impaired capacity (QCAT). Human participants (voluntary basis) instead of human subjects power shift of researcher v
subject
- Beneficence: Minimize harm & discomfort; Identify risk to participants, size of risks & probability of risks eventuating
- Justice: Avoid groups who are subject to over-researching (ATSI community, school children), unless justified research to
be important to that group. Design research so that selection, recruitment, exclusion & inclusion is fair
- Dignity & wellbeing: Takes precedence over the expected benefits of knowledge. Risks & benefits need to be fully
identified & evaluated
Risk: Potential for harm, discomfort or inconvenience.
- Harm: Physical harm (injury, illness, pain). Psychological harm (feelings of worthlessness, distress, guilt), devaluation of
personal worth, Social harm, economic harms
- Discomfort: less serious than harm, body&/mind (minor side effects, anxieties), when exceeded & distressful harm
- Inconvenience: time, street survey etc.
- Involves the: 1. Likelihood that harm will occur 2. Severity of harm 3. Consequences
- Ax of risks involves: identify risk, gauge probability & severity of risk, justify, minimize & managing risks engages:
researcher w their project in order to determine what risks are present, and can they be justified, minimized or managed
- Low risk foreseeable risk is one of discomfort. Negligible risk no foreseeable risk of harm or discomfort, no more than
inconvenience
Benefits: research is ethically acceptable ONLY when its potential benefits justifies ANY risks involved in the research e.g. Gains
in knowledge, insight & understanding, Improve social & individual welfare, Skill/ expertise for researchers/ institutions
Risks v Benefits
- Weigh up actual & potential risk vs. actual & potential benefit
- Risks & benefits to individual & community: Varies between people, ethics committees.
- Altruistic nature (place of autonomy vs. ethics committee paternalism)
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Direct participant benefit unlikely in many studies, difficult to weigh up risk to individual vs. benefits to community (from
research outcome)
INFORMED CONSENT
- Valid consent
o Participants must not be coerced or induced compensation must be reasonable
o Participants must know that they are participating in research. Must know in detail what is being asked of
them and what will happen
o Communicate any risks (clearly identified), any compensation
o Participants need to know how the project will benefit themselves, other people, or the world at large
o Must know that their data will be kept confidential (clearly state that data will be de-identified, no information
associated w their data will identify them)
o Participant must know if you plan to publish data from the project in which they are participating (Assure them
of confidentiality)
- Situations when subjects MUST NOT be recruited when subjects:
o Feel they have no other option but to agree
o Too ill/ frightened to think through what participation meant for them
o Are harried/ hassled into a decision
o Think they or their families will be disadvantaged if they do not take part, mentally unable or incompetent to
understand their participation
o Are under influence of medication
o May be from a vulnerable population (defined by NHMRC National Statement) i.e. Shared characteristic:
children, pregnant women, cultural minorities, Over-researched, Power imbalance (lecturers vs. students)
- Waiver of Consent- National Statements justification for consent:
o Participants would likely not object if asked
o Obtaining consent would be impractical/ not feasible (collating admission diagnoses for all previously admitted
patients)
o Involvement carries no more than low risk
o Sufficient protection of privacy (& adequate plan to protect data)
o Not prohibited by state or federal legislation
- May be expressed: orally, written, return of a survey or by conduct implying consent. Adults or adults for children all
broad/ general understanding
- Databanks/bases (epidemiology, pathology, genetics, social sciences): pieces of information HREC may grant waiver of
consent for research using personal information in medical research or personal health information
- PIS (Participant Information Sheet) & Consent Form adequate explanation of: purpose, methods, demands, risks,
discomforts, possible outcomes & result publication, voluntary to participate, entitled to withdraw consent at any stage,
confidentiality
- Summary
o Competence to consent if NO: approach guardians
o Capacity to make voluntary choice if NO: guardianship
o Provision of information include: methods, demands, risks, conveniences, discomfort, possible outcomes &
publication of results
o Voluntary to participate no coercion, can withdraw any time without penalty (e.g. refusal of Rx)
o No coercion payment to participate should only cover cost reimbursement
UQ SOM
- ALL research that involves more than low risk needs full review e.g.
o Interventions & therapy/ clinical trial, live routine collection of human tissue, human genetics & stem cells,
people w intellectual/ physical disability, ATSI & vulnerable groups, people involved in illegal activity
o UQ Form OR National Ethics Application Form (NEAF)- for multicenter projects, approval for all participating
institutions on the same project
- Gatekeeper Approvals
o Gatekeeper/ permission- giver: person authorized to write a Letter of Authority & Recognition from an
organization of any type involved with the research, which gives permission to the researcher for access to the
population under the gatekeepers: or permission-givers authority
o E.g. research in schools gate keeper approval = relevant education authority (Education Queensland) &
School principles
- Principles of Authorship: Vancouver rules authorship should be based on substantial contribution to:
o Concept & design of the article, acquisition of data, analysis & interpretation of data
o Drafting of the article or revising it critically for important intellectual content
o Final approval of the version to be published
o ALL above conditions should be met by ALL Co-authors, ALL authors take public responsibility for the article
st
Lead author (1 ) person who is responsible for planning, outlining & shaping structure of the first draft. Co-authors
responsibility continues throughout review process until paper is accepted
-
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W EEK 0 9 S UBSTITUTE D ECISION-M AKING , A HD AND E ND -O F-L IFE D ECISIONS

Priority in Decision Making: Known wishes (autonomy) Substituted Judgment (Sub decision maker when capacity is
lost, still expression of Ps autonomy) Best Interest (contention w autonomy)
- KIV Capacity (>18 YO- presumption of capacity understand nature & effect of decision). Incapacity permanent or
temporary intellectual disability, psychiatric disability, acquired brain injury, dementia, dual diagnosis, unconscious
state/delirium
Public Guardian
- Is an independent statutory officer, not under the Minister; Appointed by the Governor in Council protect adults
rights & interests
- Legislative framework: Power of Attorney Act 1998 (QLD) power to AHD, Statutory health attorney regime & nominated
decision makers, Guardianship & Administration Act 2000 (QLD) & Public Guardian Act 2014 (QLD)
- Concerned about: When is an adult unable to make their own decisions? What decisions can be made for an adult, who
can make substituted decisions for an adult, how are substitute decisions for an adult made & the agencies involved in
the guardianship system.
- Policy intent: rights protection, decision making, last resort (fundamental right to dignity to make our own decisions),
capacity (nature of impairment, type of decision, level of informal support), least possible restriction & interference w
decision-making (Adults have right to adequate & appropriate support for decision making)
- QCAT appoints public guardians for Ps w impaired capacity & make capacity declarations, instructs substitute decision
makers (i.e. impaired patient apply to QCAT informal support network public guardian makes decision)
- Health care = Care or Rx of, or a service or a procedure for, the adult- to diagnose, maintain, or treat the adults physical
st
or mental condition and carried out by/ under the direction or supervision of a health provider NOT 1 aid, non-
intrusive diagnostic examinations, OTC medications, futile treatments
- Life sustaining Measure health care intended to sustain or prolong life that supplants or maintains the operation of
vital bodily functions that are temporarily or permanently incapable of independent operation e.g. CPR, assisted
ventilation, artificial nutrition & hydration, NOT blood transfusion. Renal dialysis (?)
- Withdrawal Good Medical Practice (recognized standards, practices & procedures of the medical profession & ethical
standards) Principles of Withdrawal & activation of AHD in QLD:
o Adult has terminal illness/ condition that is incurable/ irreversible & thus, in the opinion of D, may reasonably be
expected to die within 1 year OR
o Adult is in a persistent vegetative state i.e. condition involving severe & irreversible brain damage which,
however, allows some or all of the principals vital bodily functions to continue e.g. heart beat/ breathing OR
o Adult is permanently unconscious i.e. condition involving brain damage so severe that there is no reasonable
prospect of the principal regaining consciousness OR
o Adult has an illness/ injury of such severity that there is no reasonable prospect that he will recover to the extent
that the adults life can be sustained without the continued application of life-sustaining measures
o AND if, for artificial nutrition/ hydration, it is considered that commencing or continuing it would be inconsistent
w GMP
o AND if, person has no reasonable prospect of regaining capacity for health care
- For Adults w impaired capacity: AHD Adults guardian (QCAT- appointed/ public) Adults attorney (Enduring Power
of Attorney/ AHD indicated attorney for personal matters) Adults Statutory Health Attorney (under Health Attorneys
Act a person declared by legislation to be a person w authority to make decision about health matters for an adult
who does not have capacity to make their own decisions, >18YO, readily available & culturally appropriate)
o Order of Priority for SHA: spouse/ partner (close & continuing relationship) > non-paid carer (OR Carer
Allowance) > close friend/family >Public Guardian
- Disputes: PG can make health decision even if there is a guardian/ attorney when: 1. Disagreement between the
guardians that cant be mediated 2. Guardian/ attorneys decision OR refusal to make a decision is contrary to the Health
Care Principle:
- Health Care principle: least restrictive of adults rights, adults best interest, least intrusive way, consider adults views &
wishes & considers information from adults health provider, ONLY if exercise of power is necessary to maintain/
promote health & wellbeing
- Substitute decision maker has same protection as if adult gave consent, can make all decisions except special health
care( only QCAT can consent to: donation of tissue, sterilization, termination of pregnancy, experimental health care &
special medical research)
- Some health care can be carried out w/o consent: urgent health care (imminent risk to life/ health, prevent significant
pain/ distress), LSM in acute emergency (withdrawal if commencement is inconsistent w GMP, immediate decision
needed, withdrawal is consistent w GMP, CANNOT withdrawal w/o consent if D knows P objects to withdrawing), minor
uncontroversial health care.

Objection: The adult indicated that he does not wish to have the healthcare; or the adult previously indicated, in similar
circumstances, the adult did not then wish to have the health care and since then the adult has not indicated otherwise
- Objection to health care can be overridden if:
-
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AHD
-
o The adult has minimal/ no understanding of :1. What the healthcare involves 2. Why the health care is required
o The health care is likely to cause the adult: no distress or temporary distress that is outweighed by the benefit
Use of Force: health provider & person acting under health providers direction or supervision may use the minimum
force necessary & reasonable to carry out health care authorized under this Act

Legal Status
o Common law AHDs remain lawful, QLD exception Powers of Attorney Act states that its provisions do not
extinguish common law directives BUT Guardianship & Administration Act 2000 fails to include directives in list
of instruments listed as governing relevant decisions
o Legislation in Advanced Care Planning
Provides greater certainty for patients that their wishes will be respected and Ds obligations &
circumstances under which they will be exempted from liability
Problems: different interpretation of statutes, imprecision of language, errors/ omissions during
drafting, lack of flexibility, greater specificity may weaken the underlying purpose
Limitations
o Principles of LSM withdrawal
o Common law AHDs: lawfulness is uncertain in QLD, probably are not lawful- less stringent requirements
o Good Medical Practice (Protection of health provider for non-compliance w AHD) Powers of Attorney Act:
applies if a health provider has reasonable grounds to believe that a direction in an AHD is: uncertain OR
inconsistent w GMP OR circumstances (including advances in medical science) have changed to the extent that
the terms of the direction are inappropriate. IF
GMP is defined in terms of standards, practices, procedures & ethical standards of the medical
profession in AUS
AND No Australian clinical practice guidelines exist in the are of withdrawal or withholding of
treatment,
AND considering that the standard of care is now defined in the Civil Liability Act 2003 as widely
accepted by peer professional opinion by a significant number of respected practitioners in the field as
competent professional practice
THEN, Refusal of Rx made in an AHD appears to depend, to some extent at least, on the discretion of
the medical profession in QLD
Philosophical arguments against AHD
o Interest of competent person who writes an AHD is different to the incompetent person later. Better respect by
responding to current/ present experiential interest RESPONSE:
Persons interest & values survives loss of capacity, remains relevant & takes priority over current
experiential interests
Critical interests - morally more significant than mere experiential interest (life is more than
unconnected sensory experiences) Substitute decision makers not very good at knowing what these
are.
Survival of interests depends on individualistic + communitarian sense of interest (memories of
individuals witnessing out passing, communitys memories of us when we have died)
o Interests of incompetent person is different to the person who existed at the earlier time and who made the
AHD psychological discontinuity between the competent & incompetent persons person has NO right to
make an AHD as it would equate to making decisions for ANOTHER person/ even directing ANOTHER person to
die RESPONSE
NO person is present at all at the later time (strict criteria of personhood) individual who is no
longer a person does not have the same right to life as before acceptable that individual be allowed
to die in accordance w the AHD no persons right to life is infringed by allowing the ORGANISM that
the person becomes to die
Barriers
o DRs issues: fear losing control (AMA), over estimation (Ps avoid making decisions for themselves, asking DR to
make for them, upsetting family), problems w euthanasia by stealth & issues of dying
o Community: mis-perceptions of limited care, disruption of D/P Relationship, fear of replacement of dialogue
o Communication: consent/refusal/interpretation, difficulty anticipating options & progress, precision re
activation of AHD, lack of time (structural issue for Medicare)
o Issues of stability of prefences: asymmetry between current informed consent/ refusal & advance
consent/refusal due to inability to anticipate the future
o Interpreting/ activating AHDs: hard to define which circumstances to activate
o Time: for completing AHD & time needed for discussion hard to accommodate within current structure of
medical service delivery.
Response to issues
o Education: widespread public dissemination & education programs
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o Review & revision: regular review of AHD and make adjustments to changing circumstances (every 2 years, after
any loss of function, hospitalization, onset of depression)
o Generality/ specificity:state general statements of values/ values history, broadly agreed definitions
o Time: adequate education & preparation- embed ACP as routine medical care
o Legal concern: Legislative protection of D from liability (Rx P against express refusal in a AHD, when AHD is not
available/ invalid)
Doctors:
o Completing: AHD must be signed by D, stating that: 1. He has discussed the AHD w the P, P is NOT suffering
from any condition which would affect Ps capacity to understand the things necessary to make the AHD & the P
understands the nature & likely effect of the decisions in the AHD.
o Implementing (*): Is patient competent NO: Obtain consent/ refusal Form i.e. AHD, if limiting conditions met
If AHD does not cover/ NO AHD Consult Guardian (if 1 is appointed by QCAT) If NO Guardian Consult
attorney appointed under an EPA If NO appointed attorney Consult Statutory Health Attorney if NO
ONE available Consult the Office of the Public Guardian
W EEK 1 0 C ONFIDENTIALITY A ND P RIVACY

ETHICS
Confidentiality: Trusting completely imparting knowledge, believing in and relying on the knowledge being kept secret and not
rd
divulged to a 3 party. Loss of privacy in medical setting usually involves some sort of disclosure of information
- Confidentiality: Individual interest in privacy, more trust in D to reveal more details Public interest encourage frank
exchange between P & D Utilitarian benefits (substance abuse, engaging others to help Pt) vs. Harm
o BUT: Duty to respect confidentiality despite potential benefit of breach Breach also implies 1. Loss of control
of information 2. Violation of trust 3. Failure to keep promise (implicit promise in DPR) Deontological AND
beneficence duty to keep confidentiality respecting autonomy/integrity/identity, for the greater good
o Mature minors: if competent, obligation to protect confidentiality
but encourage involvement of parents/ guardians
- Breach: moral harm (potential harm to be averted) Patients & society
expect unconditionally/ keeping of an implicit promise Confidentiality
needs to approach absolute status or it will be pointless
- AMA Code of Ethics: Maintain patients confidentiality; Keep in confidence
information derived from your patient, or from a colleague regarding your patient, and divulge it only with the patients
permission. Exceptions may include where there is a serious risk to the patient or another person, where required by
law, where part of approved research, or where there are overwhelming societal interest (Exceptions to this must be
taken VERY seriously)
- Code of Conduct for Doctors in Australia:
o Patients have a right to expect that D and their staff will hold info about them in confidence, unless release of
info is required by law or public interest considerations. GMP involves:
Treating information about patients as confidential
Appropriately sharing information about patients for their health care, consistent w privacy law and
professional guidelines about confidentiality
Being aware that there are complex issues related to genetic information and seeking appropriate
advice about disclosure of such information
Privacy: more modern & broader concept, more directly based in legislation. Protects against intrusion of bodily privacy,
information privacy, and dignity/image/reputation (broader). Loss of privacy in medical setting usually involves some sort of
disclosure of information to others terms used interchangeably w confidentiality
LEGAL
Protecting Confidentiality
1. Disciplinary Process: Breach of confidentiality = breach of Code of Conduct unsatisfactory professional conduct &
disciplinary sanctions may be applied single instance likely to be reprimanded if overall poor performance/
unsatisfactory conduct, harsher sanction
2. Breach arises from D/PR. Remedy arises from: 1. Contract (implied term of confidentiality, requires demonstration that
confidentiality was of serious concern to patient) 2. Tort/ Duty of Care/ Negligence (requires damage AND causation BUT
hard to define quantifiable damage for negligence) NO AUS precedents
3. Equity: Breen v Williams D have a duty in equity not to disclose confidential information w/o Ps consent, although this
statement was obiter dicta (Common Law & Equity remain uncertain bases for the protection of confidentiality)
4. Statutes (Privacy Law) No Tort of privacy in AUS, but legislation covers privacy protection, conditions for disclosure,
freedom of information, access to records/ amendment of records
a. Privacy principles govern: collection & use of information, disclosure of information, data quality & security,
access & correction of information, transfer of information in relation to principal purpose of Rx & P care.
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b. Tension btwn Privacy & Medical Practice: Privacy law includes primary, secondary and other purposes for
collection & use of information. Data may be disclosed in relation to primary purpose or a directly related
secondary purpose.
i. D need to obtain consent from relatives for information concerning FHx threat of inefficient practice
nd
ii. 2 Purpose: divulging information to another entity e.g. insurance company Strict conditions (P
consent), practices must develop written privacy policy on managing, protecting & giving access to
health information
c. Cth: Privacy Act 1988, Privacy Amendment (Private Sector) Act 2000 Broad permitted health situations:
ordinary medical service provision, disclosure for research purposes, genetic threats to relatives, to substitute
decision makers
d. QLD:
i. Hospitals & Health Boards Act 2011: A designated person (incl. medical students) must not disclose,
directly or indirectly, confidential information to another person unless the disclosure is required or
permitted under this Act
ii. Public Health Act 2005 (notifiable & contagious disease): various confidentiality provisions related to
specific notifications, registers & processes
iii. Information Privacy Act 2009: National Privacy Principles for QHs handling of personal information
(KIV Cth Privacy Act), confidentiality & privacy in private medical sector. Principles cover the collection,
storage, use, disclosure, transfer of & access to data including health information, right to amend
inaccurate records
iv. Health Practitioner Regulation National Law Act, GMP (Code of Conduct): Patients have right to expect
that D & their staff will hold information about them in confidence, unless release of information is
required by law or public interest consideration.
v. Right to Information Act 2009 (QLD): right of individuals to access information held or controlled by the
government via FOI process
vi. Access to medical records not recognized in common law, (Breen v Williams records are property of
DR/ Hospital, no right of access), requires legislative provision of access Access/ righ to amend
records available via statues (IPA/RIA)
Exceptions to keeping Confidentiality
1. Legally Mandatory Disclosure
a. Notifiable conditions & other statutory notifications: Public Health Act, Notifiable Conduct/ National
Registration Scheme (sexual inappropriateness, impairment, intoxication at work, poor clinical standards),
Health Insurance Act (Medicare fraud, PSR), Traffic Act (police investigation)
b. Court orders: subpoena (of records, of D to appear), writ of non-party discovery (supply info on particular event,
not the entire record) i.e. D treats someone involved in traffic accident, lawyer can request D to supply medical
records/ appear in court.
c. Disciplinary matters (info given to health practitioner board in course of investigation into competence, conduct
or impairment)
d. Substitute Decision makers (attorneys have access to information for d-m under POA Act 1998, although
technically a waiver of confidentiality by principal)
2. Patient consent/ implied consent
a. Med Certs (patient wants you to breach his confidentiality/ implied consent), referral, prescriptions (chemist
rd
knows your condition), reports to 3 parties (insurance, also explicit written consent) Consent to disclose
rd
only certain material (3 parties have duty of confidentiality)
b. Designated persons includes medical students
3. Medical Research: legislation protects personal details (Privacy Act) + De-identification of data + Ethics committee
research approval requires adherence to NHMRC guidelines for protection of privacy & requirements
4. Confidentiality & genetics (genetically transmitted disease involving relatives) National Statement 2007- disclosure
allowable w/o consent. ALRC/AHEC recommends conditional disclosure where there is serious risk.
5. Quality Assurance: information shared for QA purposes but confidentiality required beyond committee process
6. Public Interest Exception: statues require breaches & protect doctors in many but NOT all cases. No fail-safe guidance as
to how to weight interests e.g. in AMA Code of Ethics/ any other laws Consider a case of probable infliction of serious
harm on another by a patient e.g. domestic violence D feels compelled to breach confidentiality Legal
justification for breaching confidentiality =/= Legal duty to warn
rd
a. Duty to warn: imposition on D which provides a 3 party w basis for suing D who failed to warm them of
significant risk (US Tarasoff precedent) NO AUS precedent, NO established legal duty to warn
b. Legal justification for breaching confidentiality:
i. Specific serious imminent risk of harm to specific person/ category of people
ii. Risk likely to be reduced by disclosure
iii. Minimal disclosure necessary to avert risk
iv. Damage to public interest in maintaining confidentiality < public/ patient interest served by averting
risk
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v. Risk must be disclosed to appropriate authority

vi. BUT uncertainty prevails need to exercise professional judgment in determining when to breach
confidentiality
c. Hospitals & Health Boards Act 2011
i. If required/ permitted by law.
ii. Consent to disclosure by adult, or by child if child understands the consent to disclosure, or by childs
parent/ guardian if child does not understand consent to disclosure. To protect safety/ welfare of a
child
iii. If closure is for care/ treatment of the person.
iv. Disclosure to person w sufficient interest (spouse) unless patient objects
v. To lessen/ prevent serious risk to life, health or safety of person whose information is disclosed, or
such risk to public safety (authorized by Director General). In the public interest (authorized by Director
General)
vi. To a health practitioner board, to the HQCC, to the Coroner
Confidentiality & privacy in the age of IT: telemedicine, e-linked medical records, social networking
- Healthcare Identifiers Act 2010 (Cth)
- Personally Controlled Electronic Health Records Act 2012 (Cth)
o Unique identifiers (numbers) patients, providers, health entities
o Create secure e-records that are accessible by patients, providers, patients representatives
o Improve quality, availability & coordination of health care information, reduce duplication & improve safety
- Costly electronic health record schemes have been abandoned (UK), postponed (US)

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W EEK 1 1 N OTIFICATION- C LINICAL, P UBLIC H EALTH, E THICAL & L EGAL D IMENSIONS

NOTIFICATIONS (Public Health Act 2005 QLD- protect persons from notifiable conditions through mechanisms that provide
appropriate balance between health of the public and right of individuals to liberty & privacy)

Voluntary: adverse drug reactions (ADEC), Pap smear register (voluntary inclusion of clinical & identifying information by patient.
Duty of provider to inform of PSR and voluntary status, duty to document decisions), medical fitness to drive (not legally required
for QLD DRs)

Obligatory
- Schedule 1 (of Public Health Regulation 2005)- Notifiable Conditions: a medical condition which is a significant risk to
public health
o Drs & hospitals must notify: 1. Clinical diagnosis & 2. Provisional diagnosis of notifiable conditions
o Pathologist must notify: pathological diagnosis & requires of notifiable conditions
o Clinical diagnosis notifiable condition: notifiable condition which is usually diagnosed as a result of a clinical
examination by a doctor based on a clinical history and signs and symptoms of the condition
AIDS, acute rheumatic fever, post-immunisation adverse event, Ciguatera intoxication, CJD, food/
waterborne disease in a food handler or in 2/more cases. HUS, Lyssavirus (ABL/rabies potential
exposure), pertussis, tetanus
Adverse events (AE) following immunization: anaphylaxis, common minor reactions, vaccine
specific & rare AE
o Pathological diagnosis notifiable condition: Notifiable condition where diagnosis has been made on the basis of
a positive pathological examination of human specimen
o Pathological request notifiable condition: notifiable condition for which is required to make a notification upon
receipt of a request for a pathology examination for the pathological request notifiable condition
Anthrax, Flavivrus (JE, MVE), Avian influenza, botulism, lyssavirus, plaque, poliomyelitis, SARS, small
pox, tularaemia, VHF, Yellow Fever
o Provisional diagnosis notifiable condition: a notifiable condition, for which a provisional clinical diagnosis can be
made based on clinical history and signs and symptoms of the condition, while awaiting laboratory confirmation
Acute viral hepatitis, avian influenza, CJD, Dengue fever, Diphtheria, HUS, HiB (invasive), Measles,
Meningococcal disease (invasive), SARS, smallpox, VHF
o Controlled notifiable condition: ordinary conduct of a person with the condition is likely to result in transmission
to someone else, transmission will result in long term serious deleterious consequences for the health of the
person to whom the condition is transmitted
AIDS, avian influenza, Hep C, HIV, Syphilis, TB
Quarantine Diseases: Cholera, Lyssavirus/ Rabies, Plague, SARS, smallpox, VHF, Yellow fever
- Schedule 2: Immediate notification condition is notifiable immediately after completing the clinical examination,
receiving the request or obtaining a result
o Avian flu, SARS, Botulism, Foodborne/ water borne disease in a food handler or 2/more cases, Cholera,
Ciguatera, Hep A, paratyphoid, typhoid, HUS, Hendra Virus, Lyssavirus, Legionellosis, Measles, Meningococcal,
HiB, Acute flaccid paralysis + Polio, Smallpox, tularaemia, anthrax, plague, Viral Haemorrhagic Fever, Dengue,
flavirus, yellow fever
o If not on Schedule 2 notification required within 48hours
- Child health (abuse/neglect): mandatory reporting of reasonably suspected abuse or neglect Department of child
safety offence not to report reasonable suspicion, protection from liability & protection of confidentiality, articulation
w Child Protection Act 1999 (QLD)
o Medical conditions: Contagious conditions & vaccine preventable condition
o Exclusion of children from educational facility if have or reasonably suspected of having a contagious condition,
exclusion periods as per prescribed period
- Cancer notifications (Cancer Registry- register of all new cases of cancer and deaths from cancer since 1982)
o Patterns of cancer distribution, trends, areas for cancer service based on demographic and cancer (type, stage
& grade, diagnosis, mets)details invasive cancers (BCC, SCC of skin), cancers of uncertain behaviors, in-situ
cancers, benign tumors of brain & CNS tumors (meningioma)
o No legal obligation on treating doctors to notify cancer, notification legally required only from pathology labs,
nursing homes & hospitals BUT treating doctors required to supply information to the cancer registry if
requested
- Births/ Deaths, immunization, reportable deaths (Coroners Act), Drug dependent persons (controlled drugs, Rx> 2
months)
- Blood Alcohol: Drs allowed to take patients blood without consent if under direct police order (community best
interest), but DR need not comply if he reasonably believes that it taking specimen would be prejudicial to persons
treatment (patients best interest)
- Medical Fitness to drive: NO legal obligation on health professionals in QLD to notify unfitness to drive (SA, NT do), but
recommended by state coroner in 2004 AND legal protection from liability from disciplinary action for health
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professionals who notified in good faith BUT still possible that DR can be held negligent (e.g. epilepsy) if patient is not
adequately informed of driving risk, so as not sufficiently informed to take action herself to notify Transport Dept
o Obligation on license holders to notify QLD Transport of the development of or adverse change to any
permanent or long term medical condition that affects their abilities to drive: Jets Law fine $4500 for not
notifying
o Issues: liberty (confidentiality & privacy vs. safety & public protection), testing DP relationship, restricting
freedom & ease of access, explore any alternatives (taxi subsidies, family, car pools)
Mandatory notification of Health Practitioners notifiable Conduct: 1. While intoxicated (alcohol/drugs), sexual
misconduct in connection w practice, risk of substantial harm from impairment, risk of harm due to significant departure
from accepted professional standards Failure to report unprofessional conduct MBA

Rationale & Principles
- Confidentiality (all collections, registers, processes):
o To the Doctor
A person who gives information requested under this section who would otherwise be required to
maintain confidentiality about the information given under an Act, oath, rule of law or practice: does
not contravene the Act/oath/rule of law/ practice by giving the information AND is not liable to
disciplinary action for giving the information
Further information may be required for the purpose of preventing an outbreak or occurrence of a
notifiable condition/ suppressing a notifiable condition
National Privacy Principles exceptions to privacy obligations where use/ disclosure if required or
authorized by or under law
The person cannot be held to have 1. Breached any code of professional conduct 2. Departed from
accepted standards of professional conduct
o To the patient
Explain that information is needed to attempt to prevent/ minimize the spread of a notifiable condition
Must comply w contact information requirement unless the person has a reasonable excuse (This does
not include concern that it might incriminate the person)
o PHU Confidentiality
A relevant person must not, directly or indirectly disclose confidential information
This does not apply if disclosure of the confidential information by a relevant person is authorized
under an Act or other law
o If patients behavior may constitute a public health risk counselling, education, support removal &
detention of a person suffering from controlled notifiable condition: initial examination order, behavioral order
& detention order (up to 28days)
- Balance disease containment w infringements on liberty
- Encourage individual responsibility to minimize community risk
- Use contact tracing powers ethically
- Protect those w diseases or other conditions from discrimination
- Provide statutory protection to those who must break confidences by making notifications (e.g. notifying child abuse),
Ensure patient confidentiality and minimize breaches
- Protection of community from foreseeable harm (infectious disease) e.g. Prevent, control & reduce disease, collect
information, respond to emergencies, contact tracing, coercion & education to minimize spread, impose obligations on
health professionals
o Other areas: data registries, causes of death, prevent child abuse, minimize drug side effects & road accidents

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W EEK 1 2 D ISABILITY E THICS

Disability: any condition that restricts a persons mental, sensory or mobility functions. It may be caused by accident, trauma,
genetics or disease. A disability may be temporary or permanent, total or partial, lifelong or acquired, visible or invisible.
(Increasing acquired disability due to more abortions)
- Disablelism: the production of disability. A set of assumptions and practices promoting the differential or unequal
treatment of people because of actual/ presumed disabilities
- Ablesim: production of ability. A belief that impairment (irrespective of type) is inherently negative which should, if the
opportunity presents itself, be ameliorated, cured or eliminated
- 3 Models: Moral, Medical, Social
o Moral: oldest paradigm, based on religious myth, result of sin & shame concealment & exclusion of
individuals laying down principles for human rights and social justice for people w disabilities (Radical Fat
Acceptance Movement fat as an immoral disability?)
o Medical: Individualized/ deficit model- disabilities as diseases/ illness to be cured. If no cure issues relating to
the disability lies with the individual and society has no obligations to take care of it Support services tend to
be limited and inadequate, lives of individuals w disabilities are determined by professionals
o Social: Vic Finkelstein (anti-apartheid activists) problem w the way society views a person w disability
disabled people should be included in society, society should see the person first and not the disablement,
diversity brings strength to all we are more disabled for social definitions/ societys low expectations than
physical limitations
Disability is the disadvantage/ restriction of activity caused by contemporary organization which takes
no or little account of people who have physical impairments and thus excludes them from the
mainstream of social activities
- Common assumptions that restrict people w disabilities
o Thinking of people w disabilities as partial, limited or lesser
o Putting people w disabilities on a pedestal
o Regarding people w disabilities as perfect objects of charity
o Seeing disability as a sickness to be fixed
o Stereotyping people w disabilities as a menace to themselves and society
o Attributing special talents to people w disabilities,
o Restricting the social circle of people w disabilities to other people w disabilities and
o Locating the problem within the individual w a disability rather than in societal attitudes or in the built
environment
- Results of negative assumptions
o Social degradation: rejection by family, neighbors, carers, isolation from non-disabled peers
o Restricted options for development, growth and enrichment
o Concentration of people with disabilities into social groupings of rejected people
o Circumscribed set of role options
o Loss of control and autonomy
o Material poverty, impacts on health, housing & life expectancy
o Diminished sense of individuality and uniqueness
o Restricted social relationships resulting in a lack of allies in times of need, and
o Neglect, damage & abuse
Ethics
- Utilitarian: it is valuable to consider consciousness & lives of those who wish to live, species membership not morally
significant. There are features that make life NOT worth living
- Sanctity of Life: all lives are worth saving, human life more precious than animal life (humanity!) to think otherwise =
eugenics & infanticide
- Specific ethical dilemmas: disability & stigma (quality of care affected), delinking disability & poverty, institutional vs.
home & community based care, choice & control (dignity of risk- right to failure, respecting autonomy about health care
choices), lack of medical & home care professionals, funding & cost of care
- Case 1: quality of life determined by intellectual quality vs sensory quality (e.g. deaf/ mute patients) what is an
acceptable threshold for a good sensory quality of life?
o Deaf Culture hearing impaired NO! deaf community does not consider themselves impaired Deaf &
Hard of Hearing YES Audism: An attitude based on pathological thinking which results in a negative stigma
toward anyone who does not hear like racism or sexism, audism judges, labels and limits individuals on the basis
of whether a person hears and speaks. Based on the medical view that deafness is a disability that must be
fixed. (history: deaf people are savages without language, language = humanity)
o Cochlear implants (CI) threat to the Deaf way of life & language, implanting children = genocide hearing
parents of congenitally deaf infants have no appropriate perspective (never experienced deafness & its rich
culture and unique opportunities) parents cannot make best interest judgment parents need to consider
experience of being deaf (info from deaf adult)
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o Deaf community: parents decision for CI are ill-informed, parental-child interest conflicts, deaf adult should be
rd
deaf childs advocate, 3 party can protect decision from parental bias & ensure consideration of all possible
alternatives
o Hearing community: inclusion of deaf adult does NOT reflect an unbiased disinterested third party, deaf
adults choice for no cochlear implant and as a member of Deaf culture = conflicting interest & unlikely advocate
for CI. Deaf cultures interest should not supplant or be given equal weight to parents decision regarding their
child.
Generally recognized parental autonomy to make decisions for and to care for their child should be
free from outside interference satisfies child & parental need for family integrity, continuity &
physical wellbeing

W EEK 1 3 C OMMERCIALIZATION O F M EDICINE, M EDICAL ADVERTISING & D PR
Commercialization
- Corporatization: Cth incentives for small/solo practices to amalgamate goodwill/ income/ flexibility/ less red tape as
incentives to GPs Alleged problems of reduced practitioner independence, over-servicing, reduced GPs for
rural/remote areas & home visits, consumer model affecting professional standing/ reputation & commercial
exploitation
o Conflicts of interest: clinical practice guidelines developed by panel members w connections, ghost writing by
drug companies/ p[professional writers, TV endorsements by doctors
- 3 Centuries of change
th
o 18 C: no uniform entry to medicine, no medical education/ licensing, contractual DPR, primarily self-interest
John Gregory (1772): duty of care/ trust/ commitment: fiduciary, commercial medicine incompatible w best
interest (driven by scientific advancements authority of Ds trust) truth telling, confidentiality
th
o 19 C: scientific basis for medicine, organized medical education & significant social status accorded to medical
profession medical licensing (social contract), ostracizing quacks & rejecting advertising DP contracts or
waiver of fees for poor
th
o 20 C: Professional self-regulation, exclusions based on science, restricted competition & restricted advertising
fee for service (D as individual P advocates) physician interest (professional world) = patient interest
(commercial world). LATER: health care more effective, but costly w insurance system, fee-for-service & high
patient demand strain on public funding need incentives to reduce services by: decreasing provider
numbers, fee restrictions & student number restrictions (but now Uni/commercially driven)
Now: doctors/ health systems expected to be practicing in cost sensitive/ cost-aware way best
interest & reasonable care acquire a cost component (PBS, competition policy & managed care in US)
but not explicitly acknowledged
- Deregulation & advertising: National Registration & Accreditation Scheme (2010) i.e. National Law (National
Competition Policy)health professionals obeys law of competition (more consumer choice unless public interest
justification, implications for education and training, advertising) s133 Advertising (Health Practitioner Regulation
National Law Act 2009)
o Nothing that is false, misleading, deceptive, offers gift, discount or inducements to attract person unless terms
& conditions of the offer are stated. Nothing that uses testimonials, creates an unreasonable expectation of
beneficial treatment or encourages indiscriminate/ unnecessary use of regulated health services.
o Benefits: cost efficiencies, reduction in medical monopolies, better information provision for patient decision-
making, advertising reduces medical paternalism, protection against unfair trading
o Problems
Regulatory mechanisms needed to protect P from power differences
Commercialization > altruistic values- medical care as product increases demand and widens scope
of medicine
Advertising creates demands wants instead of needs, market models inequities
Corporatization/ public listing/ managed care: profits not health; limits on care. Clinical decisions made
by tertiary payers shift in clinical autonomy
Legal advertising can bring profession into disrepute.

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W EEK 1 4 P ATIENT S AFETY

Patient Safety
- Safety = state in which risk has been reduced to an acceptable level
- Human error 3 levels of harm:
o 1: Permanent/ death (unexpected/ unwanted consequences of health care)
o 2. Temporary (AE but recovered soon enough)
o 3. Near miss (wrong bag of blood, but was avoided before devastating consequence- but how did it get there -
Systems failure)
- Causes of safety problems: Bad doctors (very rare, hard to detect), Incompetent doctors (Rare, usually due to failure to
act rather than failure to know), general graduates (very common to err is human), the healthcare system (very
common, not designed w safety in mind)
- Human error: we make errors all the time, lack of awareness of healthcare risks same error, different consequences
Errors are NOT intrinsically bad or morally wrong BUT health care professionals expect individual perfection/
professionalism and institutional culture tends to blame the individual without the bigger picture (i.e. how quickly you
own up? Safety & disclosure issues? Reporting culture?) Protection mechanism: ethics committee to protect the
doctor when harm has been incurred on a P, deals with the family & victim, but requires D to cooperate
o Error due to Fatigue knowing where your limits are: HALT (Hungry, Angry, Late, Tired)
- Error due to System Design: system is only as safe as it is designed to be
- Adverse Events commonly occur due to: communication failure, poor teamwork, HALT & professional culture (blaming
culture: errors viewed as failings that should be blamed, corrective actions focus on individual more than systems.
Organizational culture values production > safety, does not support safety) Noble & just culture (when harm happens-
is the patient safe? How is the doctor? What needs to be done next? How did the system contribute to this? Is the Ds
action accountable to his colleges expectation) System needs to be held to account as well, striking a balance
between cost of healthcare production and patient safety
o Australian National Emergency target: all patients admitted to ED needs to be out of the ED within 4h
admitted/ discharged Adverse Events (mostly in last 20min of the 4h)
o POST patient out of stretcher time (QLD/ Gold Coast) stopped ramping ambulances (ambulances w patients
on stretchers managed outside the ED due to lack of bed space) But ambulance queue waiting outside ED
o QLD health budgeting increasing too excessively high salaries to Ds a problem(MOCA4 Medical Officers
Contract Agreement)

To Improve Patient Safety
1. Swiss Cheese Model
2. Instill culture of safety (attitudes & behavior)
3. Safety Management System (encourage reporting &
Adverse Event analysis) focus on learning from
mistakes
a. Adverse Event analysis = quality improvement
tool that uses a systems approach to:
i. Understanding what had happened
ii. Why it happened
iii. How to prevent it from happening
iv. Rather than finding who is to blame
b. Defined system: Adverse event (harm)
recognize & notify of AE AE analysis local
& system wide corrective actions (all centered
upon patient experience)
c. Identifying Cause:
i. Systems culture redesign the system(very common)
ii. Unsatisfactory individual clinical performance remediate individual clinician (occasionally) based on
professional expectations/ standard
iii. Blameworthy acts punishment issued for individual act (rare)
4. Teamwork & communication
5. Human Factors Engineering (HFE) Forcing functions (ATM discharging cards before cash- forcing u to take the card first)
a. Track & trigger tools overall view of someones observation chart (Brown- panic, Red- be alert/ alarm, White-
regular), Bedside Handover, Block out alarm override
6. Regulation
EXAM written case: 1:10 patients harmed by hospital care. Problem is not bad doctors, but common human errors. Past focus on
punishing individuals does not make system safer System redesign traps errors before they cause harm, reporting & analysis of
adverse events is key part of safety system.

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W EEK 1 5 B OUNDARY C ROSSINGS & V IOLATIONS

CASE 1: QCAT- D involved in sexual misconduct w patient- D & P were both experiencing a vulnerable period, D had no predatory
intention, suffering from medical conditions, craved companionship, knew he was violating professional boundaries, now has
insight into own personality & psychiatric vulnerabilities breached trust patient placed in D by starting & continuing sexual
relationship, conduct fell short of standards the public/ his peers would reasonably expect of him & is discreditable to his
profession (NOTE ISSUES: vulnerability patient qua(as) patient, P & Ds particular circumstances; insight at the time & following
event; trust & professional standards)
CONSEQUENCES:
- D reprimanded (letter of warning and indication of unacceptable behavior)
- Suspended registration: 1 month if D complies w condition for 2 years if he fails 2 more months of suspension
active by order of Tribunal
o Continue Rx by treating psychiatrist (ONLY condition that does not need to be recorded in public register in 2
years)
o Patient contact not more than 40h/w
o D(at his own expense) must work under supervision of an experienced college registered w MBA
o D(at his own expense) complete course on ethical decision making (focus on boundary violation counselling) in
12m
o D must pay the Boards costs ($20,000)
Boundaries (Physical boundaries, D selling products, self disclosure, D treating other Ds, confidentiality)
- Consent: Consent to treatment (P authorizes what would otherwise be a boundary violation); Consent to a sexual
relationship (patient authorizes what remains a boundary violation)
o Sexual boundary: mostly in therapists/ psychiatrists (once a patient, always a patient!).
o Other types of perpetrators: uninformed, poorly trained, impaired by alcohol, drug addiction, mental illness,
predatory psychopath, in love mistake own needs for patients needs, D reacting to a personal loss
- Fundamental Principles: respect for persons, prevention of harm, maximization of welfare/ benefit. Person in power has
the responsibility to maintain appropriate boundaries Consent does not justify crossing the boundary Rule
utilitarianism: even if there are safe boundary crossings, do not be tempted (slippery slope)
- Professional boundary: limit to to professional behavior health professional is being paid for service i.e. fiduciary
relationship inherent power differential Rx must involve creation of atmosphere of safety & predictability for the
patient BUT not rigid/ remoteness, allows for demonstration of warmth, empathy & spontaneity within climate of safety
(different between being friendly vs. a friend) Should: Assume that ALL clinicians are at risk of violating boundaries
- Vulnerability during life stresses e.g. divorce, death of family, malpractice litigation, medical error
- Therapeutic frame: clinician should aim to be helpful & non-judgmental, understanding, solving patient problem>
personal gratification, respectful & promote Ps dignity
o No physical contact (except handshake/ clinical examination) depends on occasion offer comfort when
appropriate
o Circumscribed location & length of appointments depends on occasion, longer if necessary
o Maintenance of confidentiality, decline lavish gifts, avoid social/ financial relationships that might interfere w
DPR, relative asymmetry of self-disclosure (limit amount of personal information revealed to P)
o D bears responsibility for defining & maintaining proper personal distance w vigilance note changes over
time & potential for harm
- Common boundary crossings:
o Low/ no fee covert message that something is expected in return, disempowers patient (feel they cannot
express anger or dissatisfaction) & devalues Rx =/= open discussion & negotiation of fee
o Accepting gifts/ engaging in social contact unconscious bribe from P, controlling Rx so that unpleasant/
difficult issues are not raised & undermines capacity of D to raise these issues
o Treating close relatives/ friends issues w judgment & assessment, medication prescription (1 prescription for
a justified condition can lead to a slippery slope) D too mean, Family & friends may not have redress in event
of harm
o Social interaction cycling/ social drinking events need to limit interaction and amount of disclosure
o Business, ghost writing
o Self disclosure (generally low) distorts nature of the professional relationship, discussion about mutual
interest may help establish rapport (is it for the P or for myself?)
- Prevent violation: usually non sexual boundary violations > sexual, attentive to minor crossings to prevent slippery
slope, professional isolation is key factor in development of boundary violations attention to personal relationships
non-work things that are sustaining and satisfying, personal reflection on practice recognition of vulnerability, seek
advice if uncertain.

GMP & Health Practitioner Regulation National Law Act (2009 QLD)
- Professional boundaries: Professional boundaries are integral to a good DPR to promote good care for Ps & protect both
parties, involves:
o Maintaining professional boundaries
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o Never using your professional position to establish or pursue a sexual, exploitative or other inappropriate
relationship w anybody under your care, including those close to the P (carer, guardian, spouse, parent of child
patient) Sexual boundaries based on DPR & trust, power imbalance, loss of objectivity & patient safety
o Avoid expressing Ds own personal beliefs to P in ways that exploit their vulnerability or that are likely to cause
them distress
Reporting Obligation: D have statutory obligations under the National Law to report various proceedings or findings to
the MBA & professional obligations to report to the medical board and their employer if they have had any limitations
placed on their practice Includes:
o Being aware of these reporting obligations
o Complying w any reporting obligations that apply to the practice
o Seeking advice from the medical board/ Ds professional indemnity insurer if unsure about obligations
Definition (QLD HPRNLA)- The practitioner has
o Practiced while intoxicated by alcohol or drugs OR
o Engaged in sexual misconduct in connection w the practice of the practitioners profession OR
o Placed the public at risk of substantial harm in the practitioners practice of the profession because the
practitioner has an impairment OR
o Placed the public at risk of harm because the practitioner has practiced the profession in a way that constitutes
a significant departure from accepted professional standards

W EEK 1 6 P ATIENT & P ROFESSIONAL CONCEPTS O F ILLNESS, CAUSES & M EANING

Medical Records & Patient History
- Purposes of medical records: information for follow ups, tracing patient history & progress (includes Hx, Ex, Dx, Ix,
results, clinical reasoning, Rx, referrals, correspondence) Consider: continuity, efficiency (prevent duplication),
medico-legal document & patient contexts, narrative of distinct person DPR(bounded by laws, rules and legislation)
o Patient access records- then no, now yes (Information Privacy Act 2009 QLD Public Sector, Privacy
Amendment Act 2000 Cth Privacy Sector & Privacy Act 1988 Cth)
- Structure of record keeping reflects and may even determine the kind of care given
- SOAP: Subjective/ Objective (D needs to objectify some stuff that P say, we need to be mindful of the patients
experience at the same time)/ Assessment/ Plan
- History MOST important: active listening, translating, medicalizing, objectifying & consider the narrative (listening,
receiving, patients stories & needs & why they are seeking attention now, making sense in patients terms) editorial
function of medical consultation to objectify the biomechanical concepts & values assigned by P to the experience of
illness incorporate patients perspective into decision-making
- Taubers Proposal:
o Ethical concerns section as part of record & routine part of
Dx process
o Making patient values & value-structure of decision-
making more explicit
o Includes ordinary cases
- Sokols proposal (Fig.)
o Ethical Checklist section as part of record
o Prompt to confront ethical issues that may be overlooked
o Similar to WHO surgical list

Evans Lecture (Chronic Fatigue Syndrome/ME- myalgic encephalopathy)
- In 0.42% of population, commonly after viral infection, Sx includes orthostatic hypotension, severe fatigue, memory
problems, reading difficulties, sudden cold peripheries, weight loss, mycoplasma infection & ongoing enteroviral stomach
infection poor quality of life & poorly diagnosed
- CFS Poorly supported in medical care and regarded cynically (a joke), research projects few and hard to find funding
- Denigrating remarks, coercion into inappropriate psychiatric therapies & hard to get income replacement from
Centrelink/ insurance companies
- Rx CBT or graded exercise (GE) program usually worsens patient symptoms, involuntary admission into Mental
Health custody/ Childrens service, severe trauma through legal processes & actual treatment
- Current literature: plasma immune signature in early stage patient, physical abnormalities clear after induced exercise &
retesting, rituximab can help
- To improve patient experience: assist in disrupted sleep, food intolerance & pain management
- Risk factors: viral infection, nurses, female, long term stress & fatigue.

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REVIEW CONCEPTS

Duty of care (statutory definition in Civil Liability Act 2003 QLD based on the Commonwealth Review of the Law of Negligence)
1. A person does not breach a duty to take precautions against a risk of harm unless
a. The risk was foreseeable (that is, it is a risk of which the person knew or ought reasonably to have known); and
b. The risk was not insignificant; and
c. In the circumstances, a reasonable person in the position of the person would have taken the precautions.
2. In deciding whether a reasonable person would have taken precautions against a risk of harm, the court is to consider
the following (among other relevant things)
a. The probability that the harm would occur if care were not taken
b. The likely seriousness of the harm;
c. The burden of taking precautions to avoid the risk of harm;
d. The social utility of the activity that creates the risk of harm.

Standard of Care for professionals (Civil Liability Act 2003 QLD)
1. A professional does not breach a duty arising from the provision of a professional service if it is established that the
professional acted in a way that (at the time the service was provided) was widely accepted by peer professional opinion
by a significant number of respected practitioners in the field as competent professional practice.
2. However, peer professional opinion cannot be relied on for the purposes of this section if the court considers that the
opinion is irrational or contrary to a written law
3. The fact that there are differing peer professional opinions widely accepted by a significant number of respected
practitioners in the field concerning a matter does not prevent any I or more (or all) of the opinions being relied on for
the purposes of this section
4. Peer professional opinion does not have to be universally accepted to be considered widely accepted
Yuchi Zhang
42753333
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Medical Ethics SEM 2

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Medical Ethics SEM 2

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Contents

SEMESTER 2 (PRO MIDSEMS)

WEEK 1 PUBLIC HEALTH ETHICS

WEEK 3 IMMUNIZATION ETHICS

WEEK 4 ETHICS OF THE ELDERLY

WEEK 5 STANDARD OF CARE

WEEK 6 HUMAN ENHANCEMENT

WEEK 7 TRANSPLANT ALLOCATION

WEEK 8 RESEARCH ETHICS

WEEK 9 SUBSTITUTE DECISION-MAKING, AHD & EOL

WEEK 10 CONFIDENTIALITY & PRIVACY

SEMESTER 2 (POST MIDSEMS)

WEEK 12 DISABILITY ETHICS

WEEK 13 COMMERCIALIZATIONS AND MEDICAL ADVERTISING IN MEDCINE

WEEK 14 PATIENT SAFETY

WEEK 15 BOUNDARY CROSSINGS AND VIOLATIONS

WEEK 16 PATIENT & PROFESSIONAL CONCEPTS OF ILLNESS

Ethics Review Year 2/ 2015

W EEK 0 1 P UBLIC H EALTH E THICS

Ethics Review Year 2/ 2015

i. Infringing 1/ more moral considerations will probably protect public health

Ethics Review Year 2/ 2015

W EEK 0 3 IMMUNIZATION E THICS

Ethics Review Year 2/ 2015

Ethics Review Year 2/ 2015

Elder Abuse: Aged Care Act 1997 (Cth)

W EEK 0 5 S TANDARD O F C ARE

Ethics Review Year 2/ 2015

Ethics Review Year 2/ 2015

W EEK 0 6 H UMAN E NHANCEMENT & T HE G OALS O F M EDICINE

Ethics Review Year 2/ 2015

General purpose enhancements e.g. intelligence, memory, concentration- arguably OK in contrast to

Ethics Review Year 2/ 2015

W EEK 0 7 T RANSPLANT A LLOCATION

Ethics Review Year 2/ 2015

Supported by more people

Expand the scope of the DDR, and include a

Retain the current legal definitions of death,

Retain the current legal definitions of death

Would reflect the fact that

Expanded scope would threaten to

Various ethical problems with

Ethics Review Year 2/ 2015

Ethics Review Year 2/ 2015

W EEK 0 8 H UMAN R ESEARCH E THICS & L AW

Ethics Review Year 2/ 2015

Ethics Review Year 2/ 2015

W EEK 0 9 S UBSTITUTE D ECISION-M AKING , A HD AND E ND -O F-L IFE D ECISIONS

Ethics Review Year 2/ 2015

Ethics Review Year 2/ 2015

W EEK 1 0 C ONFIDENTIALITY A ND P RIVACY

Ethics Review Year 2/ 2015

Ethics Review Year 2/ 2015

v. Risk must be disclosed to appropriate authority

Ethics Review Year 2/ 2015

W EEK 1 1 N OTIFICATION- C LINICAL, P UBLIC H EALTH, E THICAL & L EGAL D IMENSIONS

Ethics Review Year 2/ 2015

Ethics Review Year 2/ 2015

W EEK 1 2 D ISABILITY E THICS

Ethics Review Year 2/ 2015

Ethics Review Year 2/ 2015

W EEK 1 4 P ATIENT S AFETY

Ethics Review Year 2/ 2015

W EEK 1 5 B OUNDARY C ROSSINGS & V IOLATIONS