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Ethics of Clinical Care
Temidayo O OgundiranMBBS (Ibadan), MHSc (Toronto), FRCS (Edinburgh),
FWACS
Division of Oncology, Department of Surgery, University of Ibadan andUniversity College Hospital, Ibadan
West African Bioethics Programme, University of Ibadan
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Ethics of Clinical Care
Professionalism
Doctor-patient relationship
The concept of harm Negligence and standards of care
Paternalism and autonomy
Improper conduct
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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 outcomesof patents care by helping to identify, analyze, and resolve
ethical problems
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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
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Accountability of Physicians
To
themselves
colleagues in the medical profession
God patients
third parties such as hospitals and managedhealthcare organizations
medical licensing and regulatory authorities
courts of law
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Core issues in medical ethics
prescribing ethics of the doctor-patientrelationship
duty to maintain patient confidentiality
the need to obtain fully informedconsent
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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
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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
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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
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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
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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
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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
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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 theirfamilies, other physicians and team members,
medical students, residents and fellows
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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
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Steps in Clinical Judgment
The diagnostic question
What is wrong with this patient?taking into accountmedical history, physical examination, laboratory testresults, etc.
The therapeutic questionWhat can be done for this patient?frequently informed bythe scientific evidence and which comprises the array oftreatments that might help the patient
The prudential question
What should be done for this patient?which clearly needs toinvolve the patient to determine the option that will work best
LM Kirk MD, 2007
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Teaching Professionalism
Setting expectations
White-coat ceremonies
Orientation sessions Policies and procedures
Codes and charters
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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
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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 (360-
degree) evaluation
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Paternalism
To treat someone paternalistically is to treat theperson in a way that ignores or discounts his/herwishes but aims at promoting the persons best
interest
Generally, paternalism in medicine is viewed as beinga bad thing
Question: Whats wrong with paternalism?
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The Trouble with Paternalism
Cases of paternalism are cases in which theprinciples of beneficence/non-maleficence win afight with the principle of autonomy
Respecting patient autonomy is widely seen as themost important element in the doctor-patientrelationship today
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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
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Therapeutic Privilege
In 1961, a study revealed that 88% of doctorsroutinely would not tell terminally ill cancer
patients that they had cancer.
Therapeutic Privilege: When a doctor decidesfor a seemingly capable patient that it is in thepatients best interests not to know certaininformation (Doing Right, 79)
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The Doctor-Patient Relationship
2. Technical
Model = Contractor-client
Doctor presents options. Patient decides.
Maximum autonomy for patientAssumptions:
- the physicians role in a medical encounter is no more thana passive information provider
- all competent individuals are capable of managing theirown affairs and pursue their own life goals according totheir own values, beliefs and experiences
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The Doctor-Patient Relationship
3. Friendship
Charles Fried - doctors are "limited, special-purposefriends"
The doctor takes on the interests of the patient
Leaves room for both paternalism and autonomy and forvarying degrees of both in particular cases
A friend will sometimes try to talk you into doingsomething 'for your own good' even if that's not what yousay you want.
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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 orsimilar circumstances
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Standard of Care
Clinical
Research
Whose standard-local, regional, international?
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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
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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
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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
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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
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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
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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, treatmentor hospitalization, or that results in death
15 million instances of medical harm occur
each year in the United States(Institute for Healthcare Improvement)
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Occurrence of medical errors
A commission or an omission withpotentially 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
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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
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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
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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?
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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 along time to restore
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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
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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
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In My Opinion
4.
Communication!
Communication!!
Communication!!!
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In My Opinion
5.
Gradually and ultimately, the flaws in the
system will be identified and corrected
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LM Kirk. Professionalism in medicine: definitions and considerations forteaching. Proc (Bayl Univ Med Cent) 2007;20:1316
DT Stern, M Papadakis. The Developing Physician: Becoming aprofessional. N Engl J Med 2006;355:1794-9
AR. Jonsen, CH Braddock III, KA Edwards. Professionalismhttp://depts.washington.edu/bioethx/topics/profes.html
J J Chin. Doctor-patient Relationship: from Medical Paternalism toEnhanced 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 carehttp://en.wikipedia.org/wiki/Standard_of_care
http://legal-dictionary.thefreedictionary.com/Medical+negligence