Oath of doctors
Hippocratic Oath
Declaration of Tokyo (torture and cruel and inhuman procedures)
Declaration of Helsinki (for medical research)
Belmont report (for medical research)
3 core principles: respect for other, beneficence and justice
-primary areas of application: informed consent, assessment of benefits and risk, selection of subjects
Declaration of Geneva
- THE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration
- I WILL RESPECT the autonomy and dignity of my patient
- I WILL MAINTAIN the utmost respect for human life
Utilitarianism
What is morally right:
- Greatest NET utility, defined in terms of happiness
- Greatest amount of good/happiness for greatest number of people (Best overall consequence)
- Human welfare is most important (any everyone’s welfare is equally important)
- ~Cost-benefit analysis
Calculation:
- everyone is equal
- net happiness
- intensity
- duration
- fruitfulness
- likelihood
Advantages:
- Clear and straightforward basis for designing policies
- Objective and attractive way of solving conflicts
- Flexible, result-orientated approach
Disadvantages:
- Do not consider intentions
- Should not only take results into consideration
Kant’s Deontology
Deontological theories are NOT goal-oriented but intention-oriented
Teleological theories are goal-oriented
- Egoism: right act bring good for SELF
- Utilitarianism: right act bring OVERALL good
Right motive:
- should be unconditional
Virtue ethics
Trait of character manifested in habitual action
Intellectual virtue: excellence of mind
Moral virtue: act well
Aristotle’s list of Moral Virtue:
- Courage
- Temperance
- Justice
- Pride
- Magnanimity (寬宏大量)
7 Virtues of good physicians:
- Fidelity to traits and promise
- Benevolence
- Effacement of self-interest
- Compassion and caring
- Intellectual honesty
- Justice
- Prudence
Advantages:
- Attractive account on moral motivation
- Allow the presence of partiality (中庸之道)
Bioethical principles
Moral principles:
- Respect for autonomy
- Non-maleficence
- Beneficence
- Justice
Principle of Proportionality: balanced approach, weighing risks and benefits
Principle of Subsidiarity: action taken only when all other options not available
Principle of Veracity: tell truth
Principle of Double effect: positive and negative effects are known but still permissible to take action for the intention of positive outcome
Principle of Non-abandonment: continuous care even though nothing else could be done for patient
Principle of Necessity: Give medical treatment only when there is a medical need
Principle of Family Solidarity, Integrity or Response
Good Samaritan Acts
- Doctor-passenger does not have a duty of care unless pre-existing doctor-patient relationship
- Bound by physician’s pledge to render medical assistance when asked for help, otherwise misconduct
- Bolam test: if a doctor has acted according to proper and accepted practice, he is not guilty of medical negligence, standards should be judged by own peers
- Bolitho test: defence could not be considered reasonable if body of doctors / supporting witnesses were not capable of withstanding logical analysis, defence and body of opinion must be reasonable and responsible
Patient’s charter
Right to medical treatment Right to information Right to choices Right to privacy Right to complaint
Right of information
Right of refusal
Right of confidentiality
Informed decision/consent
3 requirements for informed consent:
- Competent
- Understand the information
- Retain the information
- Use and weigh the information
- Communicate the decision - Patients must be provided with all necessary information
- Give their consent voluntarily
- free of coercion
Steps in obtaining informed consent:
- Assess competence of patient
- capable of understanding the information
- capable of using and weighing
- capable of communicating a decision
2. Provide sufficient information —> information particular to patient - nature of medical condition - available options include option not to treat + likely outcome - consequence - any uncertainty of doctor in his diagnosis —> information about procedure - description - common risks and complications - uncommon risk with serious consequence - what to expect before and after
- Additional questions by patient
Capacity / competency
Mental capacity - mental ability and understanding (decision specific)
Legal capacity - based on legal age
Autonomy - right to make own decision and to be assumed to have the capacity to do so
Assessment methods:
- Understand the information
- Retain the information
- Use and weigh the information
- Communicate the decision
Lack capacity:
- doctor to assess person’s ability to consent
- absence of proxy decision maker: due to principle of necessity —> justify treatment without consent
- any decision should be based on patient’s best interest - Proxy decision (major ethic principle: beneficence)
- family members DO NOT have automatic right to decision making
- unless appointed as guardian (Guardianship order)
- Not every mentally incapacitated adult need a guardian
- Advanced directive, Power of attorney, Best interests decisions
- Children (automatic parental consent unless provoked by Courts / Proxy decision is needed, unless the child is Gillick competent)
Gillick criteria
- whether a child (under 16 years of age) is able to consent to his or her own medical treatment, without the need for parental permission or knowledge.
- Doctor decides whether the child is Gillick competent
- Parents cannot overrule
Fraser guideline
- the young person will understand the professional’s advice;
- the young person cannot be persuaded to inform their parents;
- the young person is likely to begin, or to continue having, sexual intercourse with or without contraceptive treatment
- unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to suffer
- the young person’s best interests require them to receive contraceptive advice or treatment with or without parental consent
Confidentiality
- Moral
- Legal
- Contractual
Principles:
- Purpose and manner of collection
- no excessive collection
- lawful and fair collection only to purpose of organisation - Accuracy of data collected and retained
- amend errors, check and avoid errors
- appropriate duration of retention - Use of personal data
- only used for same purpose / related purpose of collection
- change of purpose requires consent - Safe retention of data
- appropriate level of security
- protocols for disposal of data - Publication of policy on how to deal with personal data
- Ensure right of access to data stored
- rights to request copy / demand correction of data
Exceptions:
- Consent to publish
- Patient’s interest
- Public’s interest
- Required by law
- HIV? Not in HK yet
- Domestic violence etc.
- Medical research (consent from patients)
- Medical records (clinic/institution are owners of records, but patients are entitled to unrestricted access and copies of their own records, covered by Personal Data Ordinance, only applied to living individual)
Physician assisted suicide, Active voluntary euthanasia, Passive euthanasia
Physician assisted suicide:
Prescription of lethal dose of substance in which person takes with definite intention to end life at patient’s request
Active voluntary euthanasia:
Administration of lethal dose of substance at request of patient
Passive euthanasia:
Administration of lethal dose without asking consent / against patient’s will
Doctor patient relationship
- Paternalistic model: doctor knows best
- Informative model:
- doctors offer scientific facts and delivery technical solutions
- patients know their own circumstances best - Fiduciary model:
- doctor act in patient’s best interest, show loyalty and inspire confidence
- patients able to perceive that doctors are acting in good faith and trustworthy manner - Legal model
- service provider and customer relationship
- strong sense of equality
- degree of formal protection for patients - Interpretive model
- doctors as MENTORS
- guide patients to clarify values and prioritising them, suggest interventions that best realise the patient’s values
- do not judges patient’s values
- obligated to assist
- patients: values not fixed
- doctor patient not assumed to be equal - Deliberative model:
- doctors as FRIENDS
- treating each other as equals
- sincere exchange of viewpoints (shared decision making)
