ethics of clinical care

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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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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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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

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