V Kuttiali MD
VV Hospital, Thamarassery, Kozhikode, Kerala, India.
Address for Correspondence: Dr. V Kuttiali MD, VV
Hospital, Thamarassery, Kozhikode, Kerala, India. E-mail:
drkuttiali@gmail.com
Keywords: medical ethics
In the present scenario when the patient doctor relationship
is in jeopardy due to various reasons causing real challenges
to the physician physically, legally and financially I thought
it is prudent to review the medical ethics and its influence
on the medical profession.
Medicine has one of the first and foremost relationships. It
dates back to the days when man started treating fellow human
beings for pain or illnesses. In the present day when there is
so much publicity about the brain death, organ donations,
transport of the organs to a donor miles and miles away at
rocket speed with the help of transport, police and
other authorities and transplantation of the
harvested organs to a needy patient, the whole sequence is
displayed on television and all other media.
The scope of the article
1. To identify the four cardinal principles of medical ethics.
2. Relate the tension among the four principles of medical
ethics. The ethical dilemma in following principles of medical
ethics in clinical medicine.
3. Investigate the intersection of medical ethics and law.
4. Examine the ethical principles governing medical care at
the end of life, the terminal stages.
The doctor patient relationship is said to be fiduciary which
means there is skill, knowledge and privileges on one side and
there is none of the above on the other side, but only
trust that the doctor would do things best for him.
Ethical dilemma is a predicament in which there is a
conflicting moral principle in which there is no clear
solution or guidelines to follow.
Principles of medical ethics
1. Beneficence refers to actions only for
good
2. Nonmaleficience: Doing no harm by way of treatment or
interventions
3. Patients autonomy: Patient's right for self determination
4. Justice: Justice just like any other person
At times the four principles themselves may be conflicting.
For example, beneficent physician may recommend some
interventions which may be risky or cause harm at times and
the patient may reject any intervention.
Beneficence is an action to benefit the patient, lifesaving,
relieving suffering or restoring function.
1. Biomedically and physiologically benefit the patient
2. Personally benefit the patient and his family by avoiding
unnecessary investigations or surgical interventions which
have remote chances of success.
3. Ultimate benefit for the patient in terms of expenditure or
quality outcome.
Nonmaleficence means that the intervention by the physician
should not causes harm or injury. This has roots in
Hippocrates oath "on to disease help but at least do no harm".
This refers to verbal, physical or sexual abuse.
Nonabandonment: Abandonment is an action of leaving the
patient (for whom the physician had given medical care in the
past) without health care for the present time or future
times. Nonabandonment is an ethical obligation for ongoing
medical care for the present and future times once the
physician and the patient concur to an alliance.
Conflict of interest: Physician should refrain from activities
that are not in the best interest of the patient.
Impaired physician: A physician who is unable to practice
because of physical or mental disablement should refrain from
treating the patient. If reasonable care and skill cannot be
assured in delivering health care due to aging process or
illness and this fact is known to his colleague it is his
ethical duty of this colleague to report the matter to
authorities or medical council in the best interests of the
public.
Role of double effect: The act of beneficence may at
time contravene nonmaleficence. For example general
anaesthesia may relieve pain but cause morbidity or even
death.
Respect for patient autonomy: Patient autonomy confers
the right of confirming his right for establishing his values
and goals during treatment. Autonomy requires decision making
capacity. Decision making capacity is the physician's
determination of the patients' ability to understand his or
her situation and make appropriate decision regarding
treatment.
Competence is the legal determination and states that that an
individual has the right to take life effecting decision.
Confusion, delirium, disorientation metabolic
disturbances may affect decision making capacity.
Decision making capacity depends on:
1. The ability of the patient to communicate.
2. He should understand the nature and progress of the
illness, treatment options, and consequences of each.
3. The decision must be stable.
The decision must be consistent with values and goals of the
patient.
The principle of patient autonomy confirms the patients right
to refuse any form of treatment as a whole or in part even if
it is life saving. This is confirmed by many court decisions.
Advance directive: This is a document in which the patient or
a person decides the choice of treatment.
1. It may be in the form of a will.
2. It may be a durable power of attorney for health care
3. A document appointing a health care surrogate.
4. Advance treatment specific medical care directive.
This document appointing a health care surrogate for specific
directive or interest contains elements of living will and
durable power of attorney for healthcare. The living will
requires that the patient must be terminally ill before it
takes effect.
Durable power of attorney for health care is a document in
living will which makes surrogate decision making lawful if
the patient loses decision making capacity in terminally ill
cases.
A treatment specific directive may prohibit certain type of
treatment or interventions. For example some sections of
people don't allow blood or blood products to be transfused.
Surrogate decision making: Surrogate is a person who takes the
decision in the best interest of the patient previously
expressed by written consent of the patient that he may accept
or refrain from any interventions or treatment. All health
providers at the time of admission provide information to the
patient or their relatives, their right to accept or reject
any form of treatment and create an advance treatment
directive.
A surrogate is designated by the person before losing decision
making capacity. In the absence of explicit directive either
written or oral, a surrogate should use a substituted
judgement i.e. what the patient would have decided if he had
decision making capacity. If such substitute judgement is not
possible surrogate may take judgement in the best interest of
the patient. A person can designate a surrogate even when he
is capable of decision making. Sometimes surrogate decision
might differ from the earlier directives or views. When the
physician is not able to resolve the problem the matter may be
referred to a third party arbitrator for decision.
Informed consent: A planned intervention requires
patient's decision making capacity, voluntariness complete and
accurate information regarding the disease, treatment options,
and risks. Sufficient information means the information
provided is enough for a prudent person to understand the
disease and suggest treatment option. Physician should
give information with specific recommendation for
treatment option. If the patient rejects the recommendation it
should be accepted with respect.
In certain situations the physician may resort to treatment
without consent. The implied consent is assumed to help the
patient in emergency needs or life threatening situations.
Without such interference serious harm would result. In such
situations implied consent is accepted and provides legal
protection.
Truth telling and the patients privilege: The physician
should disclose truthful and complete information
sufficient to for decision making. With holding or imparting
partial information on the ground that such a disclosure might
cause more harm or injury is a concern of therapeutic
privilege. Such action has ethical support but may not
protect physician legally always.
Medical errors: Occasionally medical errors may occur during
treatment. Such errors should be honestly disclosed to
the patient and this helps to retain the trust. Usually there
will be an attempt on the part of the doctor to keep it a
secret and to withhold it from the patient. Most of the times
the honest disclosure might solve the problem.
Confidentiality: Confidentiality respects the patient's
privilege to keep sensitive information passed to the doctor
professionally, in the realm of doctor patient relationship.
The physician is legally and ethically bound to keep this in
strict confidence. This practice dates back to days of
Hippocrates oath but this rule may be overridden when such
secrecy causes serious harm to persons, society at large for
example infections which can become a public health issue,
gunshot wounds drug trafficking etc.
Genetic information and discrimination: Potential employer or
health insurance people are prohibited in discriminating
persons on genetic information received by any means like
requesting, requiring or purchasing.
Futility demand for nonbeneficial interventions: Futile
intervention or treatment is one in which the opinion of the
physician will not make any beneficial change even when
repeated several times.
A situation of conflict may arise where the patient or
surrogate may demand an intervention or treatment which may be
legally right but not acceptable for the physician
consciousness and is against the act and not against the
person. There should not be any discrimination against colour,
race, religion, or nation. A physician may not be doing an
abortion which may not be acceptable to him but he can't
refuse post operative health care.
Justice: Principles of justice refer to optimal care and skill
in treating a patient. This includes medical resources and its
utilizing to the needy people.
Ethical considerations relating to end stage of life:
Compassionate and careful treatment of terminally ill patients
is critical and difficult. The patient and close family should
be given ample opportunity to talk with the physician and
allowed to ask questions in an unhurried frank manner, willing
to listen to all their doubts and beliefs. This produces a
positive outcome as far as the physician patient relationships
are concerned. Physical, emotional and spiritual support must
be provided. Adequate fear control and respect for the dignity
of the patient and ongoing contact with the family is
critical.
Persistent vegetative state: It is a state of chronic
unconsciousness remaining for several weeks characterised by
sleep and wake cycles without behavioural or cerebral
metabolic evidence of cognitive function or not able to
respond to external stimuli in a wilful manner. In purely
vegetative state patient wants artificial hydration and
nutrition in addition to nursing care, the body retains
cardiac and respiratory function to maintain physiological
life. Many of them require artificial ventilation, hydration
and nutrition and intensive medical care.