Patients- Values and Narratives (Ethics) Flashcards
How are values and narratives relevant to ethics ?
– Students should be able to demonstrate an appropriate understanding of:
• The influence of values, assumptions, attitudes & emotions on their (i.e. your) decision-making and practice
– Students should be able to demonstrate a critically reflective understanding of:
• The importance of the patient’s dignity, narrative and perspective in the clinical encounter
Explain the value of a patient’s narrative and its role in ethical decision-making
‘.. narrative is ever present in medicine and is an integral aspect of the doctor and patient relationship.. If the patient’s narrative is not heard fully, the possibility of diagnostic and therapeutic errors increases, the likelihood of personal connections resulting from a shared experience diminishes, empathic opportunities are missed, and patients may not feel understood or cared for.’”
In other words, “To do what is right and good for someone requires a reliable understanding of what is best for that person within the context of his or her lived life”
This is where empathy is useful: it allows the doctor to understand and appreciate another. NEVERTHELESS, it is important to get the balance right between empathy and sympathy: saying “I understand how you feel” is likely to be self-deceiving and cause resentment from the patient.
Describe the GMC position on personal beliefs and values in the practice of medicine.
- Recognise that personal beliefs and cultural practices are central to the lives of doctors and patients, and that all doctors have personal values that affect their day-to-day practice
- Not preventing doctors from practising in line with their beliefs and values, as long as they also follow the guidance in Good Medical Practice.
- Not preventing patients from receiving care that is consistent with, or meets the requirements of, their beliefs and values.
Name the 4 key attributes of care which must be maintained, whatever one’s values, as defined by GMC.
Doctors may practice medicine in accordance with their beliefs but they
• Must act in accordance with relevant legislation (e.g. no female genital mutilation)
• Must not treat patients unfairly
• Must not deny patients access to appropriate services or care (e.g. contraception, can refer to other doctor rather than doing himself)
• Must not cause patients distress
Outline the limits of conscientious objection as described by the GMC.
“You may choose to opt out of providing a particular procedure because of your personal beliefs and values as long as:
- this does not result in direct or indirect discrimination against, or harassment of, individual patients or groups of patients. This means you must not refuse to treat a particular patient or group of patients because of your personal beliefs or views about them.
- And you must not refuse to treat the health consequences of lifestyle choices to which you object because of your beliefs.”
- Note also, contractual obligations.
Name the areas in which BMA support conscientious objection, and know which of these are legally protected.
- Emphasise the balancing act between doctors’ freedom & the rights of the patient to receive appropriate care
- A treating doctor’s primary obligation is to their patient (remember Duties of a Doctor, and the first Duty)
- They support CO in 3 cases: abortion (Abortion Act, 1967), fertility treatment (Human Fertilisation & Embryology Act, 1990) & withdrawal of life-sustaining treatment (right to consciously object for all three)
- And for others may request, but not a right
HOWEVER, for abortion,
This shall not affect any duty to participate in treatment which is necessary to save the life or to prevent grave permanent injury to the physical or mental health of a pregnant woman.
How does one prove Conscientious objection ?
A statement on oath by any person to the effect that he has a conscientious objection to participating in any treatment authorised by this Act shall be sufficient evidence for the purpose of discharging the burden of proof
Define Conscientious objection.
refusal on moral or religious grounds to participate in a specific treatment
Summarise the Janaway case.
Janaway v Salford HA (to do with Abortion Act 1967 and conscientious objection):
- The plaintiff took work as a secretary at a health centre, but objected to having to type out letters referring patients to an abortion clinic, saying that she conscientiously objected to participation in the process.
- Held: Her appeal was dismissed. The phrase ‘participate in’ as used in the 1967 Act should be taken to have its normal and natural meaning. ‘any treatment authorised by this Act’ meant the process of treatment in hospital for the termination of pregnancy and ‘participating’ meant actually taking part in that process. It did not have the extended meaning given to participation by the criminal law. That meaning would not include a secretary’s activity as part of the treatment or medical process, and she had no right to be not involved.
Summarise the Eweida & others v the UK case.
About freedom to manifest one’s religion or beliefs.
- “Nadia Eweida, a Christian employee of British Airways, was asked to cover up a cross necklace which depicted a Christian cross, and was placed on unpaid leave when she refused either to do so or to accept a position where she did not have to cover it up. She was wearing the necklace on the outside of her uniform, contravening BA’s uniform policy for jewellery.
- Eweida planned to sue the airline for religious discrimination. Some Christian groups accused British Airways of double standards, as Sikh and Muslim employees are not prevented from wearing religious garments at work, since these are impractical to cover up.
- Ms Eweida subsequently issued a claim against BA alleging, amongst other things, that she had been indirectly discriminated against on the basis that BA’s rule put Christians at a particular disadvantage. Her claim was, however, unsuccessful in the Employment Tribunal, the Employment Appeal Tribunal and the Court of Appeal, as she was unable to demonstrate that wearing a cross was a scriptural requirement for Christians and so disadvantaged them as a group.
- Consequently, Ms Eweida took her case to ECHR, arguing that the UK had failed adequately to protect her right to manifest her religion. Eventually, European Court of Human Rights (ECHR) held that this represented a breach of Ms Eweida’s human rights (Article 9 of the European Convention of Human Rights i.e. everyone has the right to freedom of thought, conscience and religion, and freedom to manifest one’s religion or beliefs shall be subject only to some limitations)”
Explain medical students guideline on CO, and recognise why medical students have different guidelines on conscientious objection to medical doctors.
DIFFERENT because a) must meet GMC outcomes for graduates b) not making decisions about treatment options
- As a medical student, you also have the right to hold a conscientious objection to some types of treatment and you should discuss this with your medical school. However, you must meet the GMC’s outcomes for graduates (originally published in Tomorrow’s Doctors) and can’t be exempted from any of these outcomes.
- Showing respect means treating patients fairly and communicating in a polite and considerate way. It also means not expressing your personal beliefs to patients in ways that exploit their vulnerability or that would cause them distress
- As a medical student, you will not be expected to make decisions about treatment options, but you should bear in mind the importance of not letting your own judgements affect the way you treat people
- You must not unfairly discriminate against patients or colleagues on the basis of their lifestyle, culture, or social or economic status
State reasons why some argue that conscientious objection should not be allowed in medical practice.
– Inefficiency & inequity
– Inconsistency
– Commitments of a doctor (affects them)
– Discrimination
In general, the law, just distribution of finite resources and patient’s informed desires should determine medical care, not doctors’ values.
If there is only one able doctor and a life saving operation has to be performed, does the doctor have a right to conscientious objection ?
No, because the patient has a risk of death or grave permanent injury to physical/mental state.
