Teleological/consequentialist theories
- Judge rightness/wrongness on an outcome based analysis
- E.g. utilitarianism (maximising welfare by securing the greatest happiness for the greatest number of people)
Deontological theories
The intrinsic rightness/wrongness of an action depends only on whether its consistent with certain basic moral principles
Secker: individuals barely resemble the Kantian free, independent, rational individual
Virtue ethics
A person acts virtuously if they do the right thing for the right reason
E.g. causing a person’s death may be virtuous only if her life lacks the most basic human goods
4 Ethical Principles (Principles of Biomedical Ethics by Childress and Beauchamp)
(1) Autonomy: respecting the right of competent adults to make informed decisions about their healthcare
(2) Beneficence: duty to do good and make decisions in patient’s best interests
(3) Non-maleficence: duty to avoid harm
(4) Justice: duty to treat everyone equally, fairly and in a balanced way
AUTONOMY
- Define
- Pros (Entwistle et al)
- Define
- Respecting the right of competent adults to make informed decisions about their healthcare
- Pinnacle of patient centered care
- Patients have right to refuse/consent treatment offered, but not to request treatment
(1) Capacity
(2) Consent: voluntary, informed, capacitous
- Pros
+Increased trust in the profession
+More adherence to treatment
+Better outcomes
Informed consent
- Define
- Pros
- Cons (Heywood and Akkad)
- Define
Where the patient has consented to a procedure/treatment, having been given and having considered all the facts necessary for them to make a decision in their own best interests - Pros
+Redresses imbalance of power between doctors and patients
+Encourages partnership model of decision making
+Consequentialist justification
+Teleological justification
Cons
- Heywood et al: simply necessary for treatment
- Akkad et al: protection for hospital
- Heywood et al: lengthy and elaborate forms detract from consent process
What should the patient be told?
- Options
- Aim of the procedure
- Details of the procedure
- Consequences
- Details of secondary interventions
- Who
- Reminder
- Layman’s terms
- Enough time so that they aren’t making a pressurised decision
Montgomery v Lanarkshire Health Board (2015)
- Facts
- Key legal question
- Dicta by Lords Reid and Kerr
- Test of materiality
- Pros and cons
- Dicta by Lord Reid and Kerr
“Patients are now regarded as persons holding rights rather than passive recipients of care” instead of a culture of “medical paternalism”
“It would be a mistake to view patients as uninformed, incapable of understanding medical matters”
- Test of materiality: “whether, in the circumstances of the case, a reasonable person in the patient’s position would be likely to attach significance to the risk”
- Pros and cons
+Subjective test better protects individual patients
+Redresses imbalance of power
+Bridges gap
-Court ruled that patient should have been offered a C section
-Information doctor should garner about patient is prescriptive
Abortion Act 1967
- Grounds within 24 weeks
- Grounds beyond 24 weeks x3
- If there is a risk to the physical or mental health of the patient or existing children
- Beyond 24 weeks:
- 1 Prevent grave physical injury
- 2 Risk to the life of pregnant woman
- 2 Substantial risk that if the child were born it would suffer from physical or mental abnormalities so as to be seriously handicapped
Fraser competence
- Definition
- Where it applies x3
- Guidelines x5
- Child has “sufficient maturity and intelligence to understand the nature and implications of the proposed treatment”
- Advice/treatment on contraception, terminating pregnancy and STIs
- Guidelines x 5
- 1 Sufficient maturity and intelligence
- 2 Cannot be persuaded to tell her parents or allow the doctor to tell them
- Likely to begin or continue sexual intercourse
- 4 Physical or mental health is likely to suffer unless advice refused
- 5 The advice or treatment is in their best interest
BENEFICENCE
Doctors have a moral duty to do good to their patients and must act in patients’ best interests
- Will this option RESOLVE the patient’s medical problem
- Is it PROPORTIONATE to the SCALE of the medical problem?
- Is this option COMPATIBLE with the patient’s individual circumstances
- -> GMC GMP: adequately assess patient’s conditions, taking into account psychological, spiritual, social and cultural factors, views and values - Is this option and its outcomes IN LINE with the patient’s EXPECTATIONS of treatment?
Non-maleficence
Doctors should do no harm to patients. Any decision in patients’ best interest should reduce or avoid harm
- What are the ASSOCIATED RISKS with intervention/non-intervention
- Do I possess the SKILLS AND KNOWLEGE to perform this action?
- Is the patient being treated with DIGNITY AND RESPECT?
- Is the patient being put at risk through other factors e.g. staffing, resources
Statutory Duty of Candour
Doctors have a duty to be open and honest to patients when mistakes or near mistakes have been made
They must
(1) Explain
(2) Apologise
(3) Find strategies to prevent mistakes happening
- E.g. prescribes wrong medication
- E.g. nearly gives medication to which a patient is allergic
- E.g. forgetting to book a patient for a scan, where no more slots are available
- GMC Document
JUSTICE
To treat everyone equally, fairly, in a balanced way
Lends itself to the idea of maximising beneficence (good)
- Is this action LEGAL?
- Does it infringe HUMAN RIGHTS?
- Does it PRIORITISE one group over another?
- If so, can it be justified in terms of overall benefit to society or does it agree with moral conventions?
QALY
+Objective attempt
+Values quality
+Holistic
-Assumes that society is neutral as to how health benefit are distributed
-Exacerbates discrimination against elderly and disabled
-Approach may be inconsistent with the principle of justice
-Emphasis upon maximising health gains is utilitarian
x
Charlie Gard (GOSH v Yates (2017))
- Facts
- Quote by Francis LJ in High Court
- Quote by McFarlane LJ in SC
- Facts; baby suffering from MDDS; parents wanted to take him to the US for experimental treatment
- Quote:
“it is impossible for any of us to comprehend or even begin to imagine the agony to which Charlie’s parents have been subjected”
“There are few stronger bonds known to mankind than the love parents have for their child” - Quote:
Many cases parents’ wishes likely to be determinative
Parents may find themselves in such appalling conditions that they lose their objectivity and are willing to try anything, even if, viewed objectively, t is not in the child’s best interests.
Confidentiality
- Benefits
- Breach x5
- Benefits: encourages trusts, greater disclosure, and facilitates better healthcare outcomes e.g. more accurate diagnosis or more effective treatment
- Breach
- 1 Public interest outweighs patient interest e.g. community is at risk
- 2 Notifiable disease (meningitis, measles, mumps, tuberculosis)
- 3 Suspected case of child abuse/neglect
- 4 Informing DVLA
- 5 Fight against terrorism
Alfie Evans (Alder Hey Children’s NHS Foundation Trust v Evans (2018))
- Facts
- Held (Hayden LJ)
- Quotes
- Facts: neurodegenerative disease; further treatment thought inhuman and futile; parents wanted to fly child to Rome for treatment
- Held: not in the best interests of patient
- 1 Alfie’s life is more vulnerable outside intensive care
- 2 Journey would be burdensome and could culminate in death in transit
- Quotes
“Parents’ views do not take precedence and do not give them an ‘unfettered right’ to make choices on behalf of Charlie”
“The gold standard for determining the rights of a child are an objective assessment as to what is in his best interests.”
