What are values?
Claims about, or expressions of, things like: Preferences Attitudes Emotions Aesthetic appreciation
What is values based practice?
A process that supports clinical decision making where complex and conflicting values are in play
Define facts
Claims about the world that have been, or can in principle be, verified by empirical methods
How would you assess facts?
Use empirical methods to determine the truth of factual statements
How would you assess values?
Moral theories:
1) Consequentialism/utilitarianism
2) Deontology
3) Virtue ethics
Describe the 3 key ethical theories
Key ethical theories:
Consequentialism/utilitarianism
- Consequentialism: assess the moral value of anything in terms of that thing’s outcomes or impact upon the world
- Need to provide and defend and account of:
a. The relevant good,
b. method of quantification,
c. how to rightness will be determined - Utilitarianism: aim for the best balance b/w benefit and harm; most effective use of resources
Deontology
- Rules govern actions and we have a duty to abide by them regardless of cost
- Respect autonomy
Virtue ethics
- Focuses on the character of the person (the doctor/professional?), not their actions
- A right act is the action a virtuous person would do in the same circumstances
- Not “what should I do?” but “what kind of person should I be?”
Key principles
1. Respect for autonomy e.g. informed consent
2. Beneficence – acting in the patient’s best interests
3. Consequentialism e.g. weighing patient’s interests against benefit of
training the student?
Application to clinical situations
PPP – remember when analyzing an ethical question
1. Principles - autonomy, beneficence, consequentialism
2. Particulars (context/facts of the case)
3. Perspectives (of all those involved or affected by the case e.g. patient
family, med student, dr, other patients)
What are the 3 elements needed for consent?
1) Competence/capacity
2) Information
1. Sufficiently inform patient considering:
1. Patient needs/wish
2. Patients’ Existing knowledge
3. Nature of condition
4. Complexity of treatment/risks
5. GMC requires you to give info on diagnosis/prognosis,
potential risks/benefit, alternative treatment including option not to treat.
3) Voluntariness
1. Consent given freely without coercion
2. Potential pressure from employers, relative, insures
What are the 4 things needed to establish capacity?
• Assessment based on ability to make a specific decision at a time it needs to be made
• Unable if they cannot do 1 or more of:
1. understand the information given to them that is relevant to
the decision
2. retain that information long enough to be able to make the
decision
3. use or weigh up the information as part of the decision-making
process
4. communicate their decision (by any means)
What is the underlying ethical principle that consent is based on?
Autonomy
Who should take consent?
• Dr. undertaking investigation/providing treatment
• If impractical, delegate it to someone who is:
1. Suitably trained and qualified
2. Sufficient knowledge or investigation/treatment, risks involved
3. Understand and agrees to act in accordance with GMC guidance
What are the different types of consent?
- Implied via compliance
- Oral
- Written - only considered evidence of consent. Not considered valid
informed consent document aspects of consent conversation
What are the different types of coercion?
- Explicit
- Implicit
- Power differentials in the patient/doctor r/ship
- Pressure from family
How would a doctor avoid coercion when trying to take consent?
- Talk to patient alone, establish whether there are any external pressures
- Speak to colleagues
- Identify appropriate solutions – e.g. power differentials patient doc
r/ship –> patient can decide to defer to someone else’s expertise - Give patient time/space to make decision instead of rushing them
Outline the ethical principles underpinning of person-centred care
Reasons to practice person-centred care:
- Respect - Recognising the moral value of a person as an autonomous
being. Treating people as ends and not simply as means - Autonomy – Deontological - It underpins the legal and professional
framework that governs the patient doctor relationship. - Dignity – support and promote self-respect
- Care – beneficence, best interest of patient - treat condition but care
for the patient - Consequentialist - consequences
a. Better patient outcomes
b. Fewer complaints
c. Less risk of litigation
d. Increased trust in the medical profession
What does the Human Tissue Act 2004 do?
- regulates removal, storage, use and disposal (scheduled purposes) of human tissues (relevant material) in England, Wales and Northern Ireland
- established a regulatory body: Human Tissue Authority
What 4 principles was the Human Tissue Act founded on?
1) Consent
2) Dignity
3) Quality
4) Honesty and openness
What are the three functions of the Human Tissue Authority?
- Issue codes of practice e.g. research, anatomical examination
- Issue licenses and inspect establishments
- Approve living organ and bone marrow donations
What is human tissue used for?
- Anatomical examination - teaching of the structure and function of
the human body to students or healthcare professionals. - Research – scientific studies which improve the understanding of the
human body. - Education and training – training of healthcare professionals, usually
those learning surgical techniques, as opposed to anatomical examination.
What consent is needed to donate body for anatomical examination?
Code of Practice C: Anatomical Examination
1. Only individual who has chosen to donate own body can give consent.
Nobody else
2. Must be written consent
• signed with at least 1 witness present, or
• signed at direction of person in his/her presence + at least 1 witness
or
• in will of concerned person
What consent is needed for human tissue for research?
Code of Practice E: Research
- Broad consent which saves researcher form going back to obtain further consent, maximize potential value of obtained samples BUT
- how generic can it be but still be considered informed consent?
- Risk of excluding some from participating
- HTAct does not include definition of research
What is common law?
- Made by judges using precedence (use of principles that are binding for all other like cases)
- Some cases establish new principles, which then become precedent for future cases, unless challenged in a higher court.
What is statute?
- May consolidate body of common law, clarify legal position e.g. Mental Capacity Act
- Reflect political agenda of govt, response to public opinion/scandal; e.g. Human Tissue Act in response to Alder Hay
- Examples:
a. Changes to reflect European Law e.g. Data Protection Act
b. Changes to reflect changing moral views e.g. Abortion Act
c. New laws to regulate technological possibilities e.g. Human
Fertilization and Embryology Act
What is European Union Law?
- all of its actions are based on Treaties approved voluntarily and democratically by EU Member States
- 2 main types – primary legislation (the EU Treaties, which give the EU power to legislate in Member States) and secondary legislation (EU Decisions, Directives, and Regulations)
- Examples:
a. General Data Protection Regulation, replacing the Data Protection
Act
b. EU Clinical Trials Directive of 2002, based on the UK Clinical Trials
Regulation
What is the Human Rights Act (1998)?
- lists all fundamental freedoms and rights that all individuals are entitled to
- The Act incorporates the European Convention on Human Rights (ECHR) , if rights are breached, defend through the courts of England and Wales and if required, European Court of Human Rights (ECtHR)
- all public bodies (such as hospitals) must protect and respect an individual’s human rights
- Convention rights covered by the Act important in medicine:
a. Article 2 – the right to life
b. Article 3 – freedom from torture and degrading or inhuman
treatment
c. Article 8 – respect for your private and family life
d. Article 9 – freedom of thought, belief and religion
