Ethics of Clinical Care

Temidayo O Ogundiran MBBS (Ibadan), MHSc (Toronto), FRCS (Edinburgh), FWACS

Division of Oncology, Department of Surgery, University of Ibadan and University College Hospital, Ibadan West African Bioethics Programme, University of Ibadan

Ethics of Clinical Care

Professionalism Doctor-patient relationship The concept of harm Negligence and standards of care Paternalism and autonomy Improper conduct

Clinical ethics
the branch of bioethics that addresses ethical issues that arise in daily clinical practice in health care institutions, executed in one way through the establishment of hospital ethics committees and ethics consultation services its central purpose is to improve the process and outcomes of patents care by helping to identify, analyze, and resolve ethical problems

Being a physician
people come to physicians for help with their most pressing needs they allow physicians to see, touch and manipulate every part of their bodies, even the most intimate they do this because they trust their physicians to act in their best interests

Being a physician
Physicians should exemplify core values of medicine which serve as the foundation of medical ethics: Compassion- understanding and concern for another persons distress Competence- scientific, technical and ethical (knowledge, skill and attitude) Autonomy- clinical autonomy and patient autonomy Respect for fundamental human rights

Accountability of Physicians
To themselves colleagues in the medical profession God patients third parties such as hospitals and managed healthcare organizations medical licensing and regulatory authorities courts of law

Core issues in medical ethics

prescribing ethics of the doctor-patient relationship duty to maintain patient confidentiality the need to obtain fully informed consent

Professionalism
The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head Sir William Osler

Professionalism
The physician professional is defined not only by what he or she must know and do, but most importantly by a profound sense of what the physician must be -Jordan Cohen, MD, 2005

Professionalism
Professional competence is the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served. Epstein and Hundert, 2002

The Marks of a Profession

competence in a specialized body of knowledge and skill an acknowledgment of specific duties and responsibilities toward the individuals it serves and toward society the right to train, admit, discipline and dismiss its members for failure to sustain competence or observe the duties and responsibilities

The Marks of a Professional

Fiduciary duty: a particularly stringent duty to assure that decisions and actions serve the welfare of patients or clients, even at some cost to themselves Professions have codes of ethics which specify the obligations arising from this fiduciary duty

Obligations and values of a professional physician

Altruism: obligation to attend to the best interest of patients, rather than self-interest Accountability: Physicians are accountable to their patients, to society on issues of public health, and to their profession Excellence: Physicians are obligated to make a commitment to life-long learning

Obligations and values of a professional physician

Duty: availability and responsive when "on call," accepting a commitment to service within the profession and the community Honor and integrity: commitment to being fair, truthful and straightforward in interactions with patients and the profession Respect for others: respect for patients and their families, other physicians and team members, medical students, residents and fellows

Right and Good Healing Action

A right action: informed by the scientific and clinical evidence A good action: takes into account the patients values and preferences and is consistent with the physicians own clinical judgment

Steps in Clinical Judgment

The diagnostic question What is wrong with this patient?taking into account medical history, physical examination, laboratory test results, etc. The therapeutic question What can be done for this patient?frequently informed by the scientific evidence and which comprises the array of treatments that might help the patient The prudential question What should be done for this patient?which clearly needs to involve the patient to determine the option that will work best LM Kirk MD, 2007

Teaching Professionalism
Setting expectations White-coat ceremonies Orientation sessions Policies and procedures Codes and charters

Teaching Professionalism
Providing experiences Formal curriculum Problem-based learning Ethics courses Patientdoctor courses Community-based education

International electives Hidden curriculum Role models Parables The environment as teacher

Teaching Professionalism
Evaluating outcomes Assessment before entry into medical school (multiple medical interview) Assessment by faculty Assessment by peers Assessment by patients (patient satisfaction) Multiperspective, multidimensional (360degree) evaluation

Paternalism
To treat someone paternalistically is to treat the person in a way that ignores or discounts his/her wishes but aims at promoting the persons best interest
Generally, paternalism in medicine is viewed as being a bad thing Question: Whats wrong with paternalism?

The Trouble with Paternalism

Cases of paternalism are cases in which the principles of beneficence/non-maleficence win a fight with the principle of autonomy Respecting patient autonomy is widely seen as the most important element in the doctor-patient relationship today

Justifiable Paternalism?
In both medical and non-medical contexts, to say someone is acting paternalistically is to generally to say something bad about that persons actions

But there are occasions when paternalistic behaviour is appropriate or even required
Parenting (Parentalism) Incompetent Friends/Relatives

Therapeutic Privilege
In 1961, a study revealed that 88% of doctors routinely would not tell terminally ill cancer patients that they had cancer.
Therapeutic Privilege: When a doctor decides for a seemingly capable patient that it is in the patients best interests not to know certain information (Doing Right, 79)

The Doctor-Patient Relationship

Which model is most appropriate? 1. Pure Paternalism Model = Adult-Child (Hippocrates' view?)
Doctor as expert Focus is on care, but not autonomy The physician is readily recognised and accepted as the guardian who uses his specialised knowledge and training to benefit patients, including deciding unilaterally what constitutes a benefit

The Doctor-Patient Relationship

2. Technical
Model = Contractor-client Doctor presents options. Patient decides. Maximum autonomy for patient Assumptions:
- the physicians role in a medical encounter is no more than a passive information provider - all competent individuals are capable of managing their own affairs and pursue their own life goals according to their own values, beliefs and experiences

The Doctor-Patient Relationship

3. Friendship
Charles Fried - doctors are "limited, special-purpose friends" The doctor takes on the interests of the patient Leaves room for both paternalism and autonomy and for varying degrees of both in particular cases A friend will sometimes try to talk you into doing something 'for your own good' even if that's not what you say you want.

Standard of Care
Diagnostic and treatment process that a clinician should follow for a certain type of patient, illness, or clinical circumstance The level at which an ordinary, prudent professional having the same training and experience in good standing in same or similar community would practice under the same or similar circumstances

Standard of Care
Clinical

Research
Whose standard-local, regional, international?

Whose standard of care?

an ethically acceptable standard of care in any given research context is that which offers the best care that is achievable and sustainable at the national level as the minimum

Negligence
Medical negligence is the act or omission in treatment of a patient by a medical professional, which deviates from the accepted medical standard of care once a doctor agrees to treat a patient, he or she has a professional duty to provide competent care

Negligence
When a doctor or other medical professional breaks this oath, or duty, they are negligent in legal terms When determining if a doctor performed negligently, the court and an expert medical witness will compare their performance to the accepted medical standard of care

Establishing negligent medical malpractice

a duty of care was owed by the physician the physician violated the applicable standard of care the person suffered a compensable injury the injury was caused in fact and proximately caused by the substandard conduct

Examples of medical negligence

Misdiagnosis Failure to Diagnose in Time Surgical Error Failure to Follow Up With Treatment Failure to Treat in a Timely Manner Anesthesia Error Medication or Prescription Error

Medical Harm
the unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment), that requires additional monitoring, treatment or hospitalization, or that results in death 15 million instances of medical harm occur each year in the United States
(Institute for Healthcare Improvement)

Occurrence of medical errors

A commission or an omission with potentially negative consequences for the patient that would have been judged wrong by skilled and knowledgeable peers at the time it occurred, independent of whether there were any negative consequences Wu et al

Examples
transfusion of hiv infected blood foreign bodies like sponge or instrument left in surgical wounds extravasation of drugs into subcutaneous tissue resulting in skin necrosis forgetting a tourniquet in the upper arm resulting in arm gangrene and amputation mistaking 5mls of medazolam for 5mg thereby delivering 25mg many trivial ones

What should happen when an error is committed in health care?

not recognized recognized, covered recognized, acknowledged discussed/documented reported disclosed, apologized for, corrected lessons learnt, service improvement

Quests
Will disclosure lead to erosion of confidence in clinicians and the health care system? What is wrong with the tendency to let most (all) errors lie low or remain unreported?

In My Opinion
1.Our society has not evolved to appreciate that medical errors can occur overreacts and often adversarial when errors occur may lose hope in the system that it will take a long time to restore

In My Opinion
2. The present system treats all failures as a failure of character and personalizes errors, thus is unfair to health care personnel

In My Opinion
3. A system of identifying mistakes, reporting, analyzing, disclosing and correcting them in a non-punitive way should be put in place This requires a shift in orientation and perception about medical errors

In My Opinion
4.

Communication! Communication!! Communication!!!

In My Opinion
5. Gradually and ultimately, the flaws in the system will be identified and corrected

 LM Kirk. Professionalism in medicine: definitions and considerations for teaching. Proc (Bayl Univ Med Cent) 2007;20:1316 DT Stern, M Papadakis. The Developing Physician: Becoming a professional. N Engl J Med 2006;355:1794-9 AR. Jonsen, CH Braddock III, KA Edwards. Professionalism http://depts.washington.edu/bioethx/topics/profes.html J J Chin. Doctor-patient Relationship: from Medical Paternalism to Enhanced Autonomy. Singapore Med J 2002 Vol 43(3):152-155 Silverman ME, Murray TJ, Bryan CS, eds. The Quotable Osler. Philadelphia: American College of Physicians; 2003 Andrew Latus. Autonomy and Paternalism. www.ucs.mun.ca/~alatus/ClinicalSkills/Class12Autonomy&Paternalism.ppt Professional standard of care http://en.wikipedia.org/wiki/Standard_of_care http://legal-dictionary.thefreedictionary.com/Medical+negligence