“Describe the Golden Triad of moral philosophy”
• Deontology: an action is right if and only if it is in accordance with a correct moral rule or principle.
• Consequentialism: an action is right if and only if it promotes the best consequences.
• Virtue ethics: an action is right if and only if it what a virtuous agent would characteristically do in
the circumstances.
“Describe the four principles approach”
• Non-maleficence – medical practitioner has duty to do no harm or allow harm to be caused to a
patient through neglect
• Autonomy – a patient has the ultimate decision-making responsibility for their own treatment.
Autonomy also means that the medical practitioner cannot impose treatment on the patient for
whatever reason except in cases where the individual is deemed to be unable to make
autonomous decisions
• Justice – weighing up if something is ethical or not, we must think whether its compatible with the
law, the patient’s rights and it’s fair and balanced. We also must ensure no one is unfairly
disadvantaged when it comes to access to healthcare
• Beneficence – all medical practitioners have a moral duty to promote the course of action that
they believe is in the best interests of the patient
“Describe the four quadrants approach”
• Medical indications – includes diagnosis, prognosis, proposed measures for evaluation and
treatment, and expected outcome of treatment. For all clinical scenarios, start by describing what
is known about the medical facts of the case.
• Patient Preferences: Patients’ preferences are relevant from both a medical and ethical standpoint.
If the patient has the capacity, their preferences should be respected and should guide their care.
If they do not have capacity, then the patient’s presumed wished or best interests serves as a
guide – relate to autonomy
• Quality of Life – illness or injury can negatively impact quality of life. Principal goal in medicine is to
preserve, restore and improve QOL and so it is important to discuss the impact of treatment on the
QOL. During this discussion, the principles of non-maleficence, beneficence and respect for
autonomy must be considered
• Contextual Features – clinical cases do not exist in isolation they form part of a larger context that
might be relevant to ethical analysis. Examples of contextual features are family dynamics, financial
resources or religious or cultural identity, potential legal ramifications of care and personal bias of
anyone involved in the care of the patient.
“What do the different quadrants of the Ethical Grid refer to?”
- Middle quadrant - refers to core considerations: create autonomy, respect autonomy, respect person equally, serve needs first.
- Red quadrant – refers to deontological reasoning – duties include: do the most positive good, minimise harm, tell the truth, keep promises
- Green quadrant – refers to consequentialism reasoning – includes: most beneficial outcome for individual, most beneficial outcome for oneself, most beneficial outcome for society, most beneficial outcome for a particular group
- Grey quadrant – refers to the contextual features – includes: resources available, effectiveness and efficiency of action, the risk, codes of practise, the degree of certainty of the evidence on which action is taken, disputed evidence or facts, the law, the wishes of others
“What is a Structured Case Analysis?”
- Summarise the case – extract information that is the most relevant and important from an ethical perspective
- State the moral dilemma(s)
- State the assumptions being made or to be made e.g. treatment will be successful due to evidence
- Analyse the case with reference to ethical principles
- Analyse the case with references to consequences
- Analyse the case with reference to the virtuous healthcare practitioner – think what they would do
- Analyse the case with reference to the law e.g. GMC
- Identifiable justifiable ethical solutions and those that are not justifiable
- State preferred approach with explanation
“What are the four main functions of the GMC?”
- Keeping up-to-date registers of qualified doctors
- Fostering good medical practice
- Promoting high standards of medical education and training
- Dealing firmly and fairly with doctors whose fitness to practise is in doubt
“What is the law?”
• Principles and regulations established in a community by some authority and applicable to its people, whether is the form of legislation or customs or policies which is recognised and enforced by judicial decisions
“What is Civil Law?”
- Dealings between private individuals or groups
- Rights and duties owed by individuals and groups to each other
- Legal action taken by claimants
“What is criminal law?”
- Matters serious enough to be considered offences against the whole community
- Right, duties and norms important for the whole community
- Legal action taken by crown prosecution service
“What is Statute Law?”
- Written law decided by the legislature or other government agency e.g. Acts of Parliament
- Difficult to change
“What is common law?”
- Based on precedent or case
- More malleable
- Created by decisions made by judges
“What are challenges of Ethics?”
- Limited resources e.g. time, expertise, staff, accountable sources of advice and variable quality
- Integrating ethics into clinical practice so it becomes automatic decision-making rather than settling for “moral mediocrity”
- Constructing ethics as “hoop jumping”, “common sense”, “yet more rules” or “irrelevant”
“Why does ethical analysis matters?”
- Morally important to behave morally
- Professional regulatory bodies require their members to behave professionally and ethically
- The law reflects ethical values and requires doctors to know about professional and ethical guidance
- Useful/important in practical terms
- Patient care is enhanced
- Staff avoid moral distress and potential ‘burnout’
- Teams function more effectively and inclusively
- Enhances productivity, efficiency, and morale
- Maintains reputation and accountability
- Ethics quality is integral to the wider quality debate in healthcare
- Clinical governance therefore demands what has been described as ‘ethicality’
Conduct an Ethic-Legal analysis of a clinical case
Miss F is a 32 year old lady who is in labour. On examination there are signs of foetal distress. The obstetrician has advised an emergency caesarean section. Miss F has refused consent because she would like “nature to take its course”. Without surgery the foetus will die and there is also a risk to the mother’s life. Miss F understands and accepts this. The medical team (obstetrician, anaesthetist and midwife) all agree that Miss F has capacity to make the decision. The obstetrician thinks they should operate. The anaesthetist disagrees. The midwife is unsure. Miss F’s husband is adamant that his wife should be operated on. He is concerned that his wife and child will die if this does not happen.
Reason, Reflect, Recognise and Apply Consequentialist view for operating Consequentialist view against operating Virtue ethicist view for operating Virtue ethicist view against operating Kantian (deontology) view for operating Kantian(deontology) view against operating Which of those reasons are strong/convincing in your view
“What is valid consent based on?”
Valid consent is based on information, competence and voluntary
“How can consent be expressed?”
Consent can be:
imputed (assume consent)
implied (patients actions suggest consent)
expressed (written and oral)
“Define consent”
Consent is a voluntary decision
Made by a sufficiently competent individual
Based on adequate information
Whether to accept or deny a treatment or procedure
“In what cases can consent be bypassed?”
Emergencies
Consent can be bypassed when patients who lack the capacity (competence) to provide consent need immediate treatment to preserve life or to avoid serious harm.
A 23 year old gentleman is unconscious and requires a life saving surgery. Define consent and state whether you think we can perform the surgery (5)
- Consent is a voluntary decision (1) made by a sufficiently competent (1) individual based on adequate information (1) whether to accept or deny a treatment or procedure.
- Patient is not competent (1)
- Half mark for conditions of competence (1/2)
- However we can treat based on best interests (1)
“What is a Gillick competent child?”
Children have the right to confidentiality where the child is Gillick competent
“What is a Gillick incompetent child?”
Unclear whether a doctor who judges a child as Gillick incompetent should respect the child’s confidentiality. SOME duty to do so
“What does the GMC say on confidentiality with children?”
The same duties of confidentiality apply when using, sharing or disclosing information about children and young people as adults
“When can confidentiality be breached against a child’s wishes?”
Overriding public interest
Best interest of incompetent child
Disclosure required by law
“Explain Gillick competence”
Each case is different
Willingness to make a choice
Understanding of nature and purpose of proposed intervention
Understanding of the proposed interventions risks and side effects
Understanding of alternatives to the proposed intervention, and the risks attached to them
Freedom from undue pressure
