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Introducing medical ethics September 2011. Michael Parker Michael Dunn Tony Hope The Ethox Centre, University of Oxford. What is medical ethics?. Some people think of scandals. Alder Hey Hospital Organ scandal families accept £5m. Harold Shipman Serial Killer. Dr Huang Woo- suk.
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Introducing medical ethicsSeptember 2011 Michael Parker Michael Dunn Tony Hope The Ethox Centre, University of Oxford
A mother whose 14-year-old daughter had an abortion without her knowledge has criticised the law. Mother angry at secret abortion Mrs Smith "felt like someone had punched me in the stomach"
Player's assisted suicide probed • Police are investigating the death of a paralysed rugby player who travelled to a Swiss assisted suicide clinic. • Daniel James, 23, of Worcester, died on 12 September in a clinic where he had travelled with the intention of killing himself
Discriminating against the mentally disordered • A criminal who has served his sentence must be released from prison even if he remains dangerous. • A mentally disordered patient who remains dangerous may be kept locked up forever. • Is this fair?
Evidence-based practice • Paternalism in medical practice – a combination of doctor knows best and tradition i.e. we’ve always done it this way here • Modern medicine aims to be evidence-based • Modern medicine aims to be patient-centred – aiming for ‘shared decision-making’ • Both imply that doctors should be able and willing to justify (that is to give reasons for) why they advocate one course of action over another
Evidence-based ethics • Medicine involves scientific/technical judgements • It also involves value judgements • Just as it is importance to give evidence in support of the scientific judgements, so it is important to give reasons in support of the value judgements
Agreement in ethics • We tend to think of ethics applying in areas where there is controversy or disagreement • But, there are large areas of agreement e.g. • Being honest with patients • Being (generally) patient-centred • Maintaining high standards of confidentiality • Providing patients with information relevant to their decisions • Competent patients can refuse treatment even if we think it is in their best interests
Difficulties in practice • However, day-to-day practice in medicine does throw up situations in which: • There is disagreement • There is no clear answer to how to apply ethical principles in practice (but still need to decide and justify) • Conflict between ethical principles e.g. Respecting choices and benefiting patients
Home or Hospital Care? • Mr A, a 70 year old man with dementia and chronic lung disease, is cared for at home by his 72 year old wife. • He now has, yet again, a chest infection. It has not responded well to antibiotics. His condition is deteriorating. He is not eating, and is drinking little. At home he is likely to die. In hospital he is likely to recover this time, but will soon develop another infection. • Previous admissions to hospital have caused him distress. • His wife wants him to go into hospital. You think his best interests are served by his being allowed to die comfortably at home.
Ethics in health policy • Inherited enzyme deficiency diseases (e.g. Gaucher’s disease) • Costs, e.g. £80 000 per year to replace enzyme and keep person alive. • Treating many people with mildly raised cholesterol with statins (not currently funded) would cost around £15 000 per life year saved, BUT • We don’t know which people’s lives we have saved • How much moral weight should be placed on the ‘rule of rescue’?
“the European philosophical tradition … consists of a series of footnotes to Plato” [Whitehead 1929]
Not true of the ‘non-identity problem’ discovered in the 1980’s Oxford philosopher Derek Parfit
This argument is particularly important in reproductive ethics. To explore it’s implications, I will argue in favour of a couple having the right to use embryo selection to choose to have a deaf child. What do you think?
Case 1- deafening the embryo A couple with a genetic condition which causes deafness wish to have a child who is also deaf. They want the child to be part of the deaf community. The woman becomes pregnant. Prenatal genetic testing shows that the fetus does not have the gene for deafness. A drug is available that, if taken by a pregnant woman at a particular stage in pregnancy, will cause a healthy fetus to become deaf. It has no other effects and is otherwise completely safe.
Three questions a) Would the couple be morally wrong to choose to take the drug? b) Would a doctor be wrong to prescribe the drug at the couples’ request? c) If the parents did take the drug and their child (child X) were born deaf, would the child have a morally legitimate grievance against the parents, and/or the doctors?
The fundamental wrong is that the parents (and doctors) have harmed the child through taking the drug. The child would have been able to hear, but as a result of the drug taken in pregnancy the child can not hear.
Case 2: choosing a deaf embryo A couple with a genetic condition which causes deafness are seeking help with conceiving. Both the man and the woman are congenitally deaf. A number of embryos are created using IVF and are tested to see which have the ‘deafness gene’. Embryo A is an unaffected embryo. Embryo B has the deafness gene but is otherwise healthy. The couple wish to have embryo B implanted.
Three questions a) Are the couple morally wrong to choose, for implantation, embryo B rather than embryo A? b) Would doctors be acting wrongly to accede to their request? c) Does child B have a morally legitimate grievance against the parents and/or the doctors?
What are the implications of this? • In case 2 no child has been harmed. • The child born deaf – child B – could not have been born hearing. • Of course a different child (child A) could have been born who is not deaf. • But as long as child B’s life is not so bad as to not be worth living then child B has not been harmed as a result of the embryo selection
Conclusion • If it is acceptable for a couple to use embryo selection to select a ‘healthy’ child rather than a child with an impairment; then I conclude that it is acceptable to select for a child with the impairment as long as the impairment is not so severe as to make existence worse than having never been born.
Confidentiality and introduction to law Consent and treatment refusal End of Life issues Ethical dilemmas in modern genetics Ethics and medical research Allocation of scarce resources Abortion and assisting reproduction Consent, children and suspected abuse Infectious diseases and global health (student-led seminar) Ethics and law course
Students on the ward • Ensure patients are aware that you are students and not doctors. Wear clear badges prominently. Introduce yourselves as a student. • Gain permission from doctor or nurse before approaching a patient in order to carry out a medical examination. • Patients have a legal right to refuse to allow medical students (and indeed health professionals) to carry out a physical examination
Confidentiality • Same standards as expected of doctors. • Treat all clinical information in strict confidence to be discussed only with patient’s clinical team. • Do NOT discuss patient issues in a public place (e.g. lift; canteen; bus) • Do not gossip about patients (e.g. over dinner to your friends) • Read GMC Duties of a Doctor [www.gmc-uk.org]
