Ethics 4

NO LONGER ACCREDITED. DO NOT COMPLETE FOR CPD PURPOSES

This tutorial is worth 3 CEU’s. This tutorial is worth 3 CEU’s. The 2013 ethics tutorials will cost R200 for 2 tutorials (R400 in total for all 4). Complete the questionnaire at the end of the tutorial and get 70% or more. Once the payment has been received we will issue the certificates (see the Get CEU’S page for banking details). Certificates will only be issued on weekdays.

Law and Medical Ethics


Law is the established social rules for conduct; a violation of law may create criminal or civil liability.

Medical ethics<; is a discipline / methodology for considering the implications of medical technology / treatment and what ought to be.

There is significant overlap between law and medical ethics and good ethics has been described as beginning where the law ends. Law and medical ethics thus share the goal of creating and maintaining order in a medical setting. Often when legal issues arise in a health care scenario so too do ethical issues. Conversely, what is originally identified as an ethical problem may raise legal concerns. Although South Africa has yet to reach the stage where litigation against health professionals, for negligence, perceived or real, is a daily occurrence, there has been a steady increase in medical malpractice litigation. This is likely due to patients increasingly become aware of their rights as well as a chronically overburdened health system and limited resources. Legitimate claims obviously need to be compensated but increased litigation has other consequences, including: decreased finances for state sponsored health due to large payouts and a continuing increase in malpractice premiums in the private sector. In certain countries, the USA being the most notable, litigation is part and parcel of their practice. Hospitals have dedicated legal teams and professional insurance for health practitioners is extremely expensive. A healthy tension between the medical and legal professions should lead to an overall improvement in quality of health care, but the risk of constant litigation can lead to further pressure on scarce resources. Practitioners in the USA often perform seemingly unnecessary investigations to avoid ‘missing’ something. Adequate state funding will naturally reduce the risk of claims that result from inadequate human and other resources. The recent implementation of the Consumer Protection Act will place additional and direct responsibility on health professionals for claims made by patients for which they may be directly or indirectly held responsible

Despite the overlap, there are significant distinctions between law and medical ethics in terms of philosophy, function and power. A court ruling is a legally binding decision that determines the outcome of a particular ‘controversy’. Conversely, an ethics pronouncement or statement, if not formally adopted into law may be considered a significant professional and moral guide, but is generally not legally enforceable. Having said this, during the creation of laws, policy makers do generally consider medical ethics statements of professional organizations. The moral conscience is a precursor to the development of legal rules for social order and thus, health care providers may greatly influence legal standards by their work in creating professional ethics standards.

Some of the topics discussed in the first tutorial provide examples of ethical/legal overlap, including:

Access to medical care
Informed consent
Confidentiality of health care information and exceptions to confidentiality
Privileged communications with health care providers
Abortion
Physician-assisted suicide

In terms of South Africa’s constitution each person is entitled to human dignity, equality and freedom. This should be the case whether a patient receives medical treatment in the private or public sector. The Government has an obligation to protect the life of every person in South Africa and the patient has the right to receive medical treatment. In terms of section 27 (3) of the Constitution, urgent medical treatment may not be refused in private or public sector. This implies that any patient in need of urgent care should receive medical treatment by the nearest hospital to such an extent that the patient is stabilized.

A patient needs to consent to any examination as the patient has a right to privacy in terms of section 14 of the Constitution. according to the Castell v de Greef 1994 (4) SA 408 (C) decision, a doctor is obliged to warn a patient of relevant and inherent risks of any proposed treatment and or surgery. “A risk is material if, in the circumstances of the particular case, a reasonable person in the patient’s position, if warned of the risk, would be likely to attach significance to it or if the medical practitioner is or should reasonably be aware that the particular patient, if warned of the risk, would be likely to attach significance to it”

Furthermore a patient must consent to medical records being disclosed as this falls within the ambit of section 14 of the constitution. The Patient’s privacy and confidentiality is not legally absolute in terms of ethical requirements. As discussed in the first tutorial, in certain situations the medical professional or health care provider is required to disclose certain information even if it is contrary to the patient’s instructions. It obviously has to be legally justifiable that it was in the patient’s or the general publics’ best interest.

1) In terms of the International Code of Medical Ethics of the World Medical Association, a physician has to preserve absolute confidentiality of all aspects of the patient.
2) The declaration of Helsinki states that in medical research medical doctors should protect human privacy, health, life and dignity.
3) In terms of the South African National Patient’s Charter every patient or client has the following rights: A healthy and safe environment, Participation in decision-making and Access to health care services.

Should a patient be of the opinion that a medical care provider treated him/her in an unethical or unprofessional manner; the Health Professions Council of South Africa should be contacted provided that such a person is registered with HPCSA.

1) A written complaint should be lodged addressed to the Registrar of the HPCSA;
2) The complaint should be signed by the complaint in person;
3) The HPCSA could ask for further detailed information;
4) The relevant practitioner has to forward an explanation and attach any relevant documentation;
5) A committee of Preliminary Inquiry will decide whether a further inquiry should be held, if not the matter will be regarded as finalized;
6) Should a further inquiry be held, further consultations will be conducted and a charge sheet will be forwarded to the practitioner.

Spirituality


Most medical professionals avoid religious or spiritual discussion with patients. Reasons for not opening this subject include the scarcity of time in office visits, fear of imposing upon the patient and lack of familiarity with the subject matter of spirituality. Alternatively, some practitioners incorporate spiritual history into the bio-psycho-social-spiritual interview, and find occasions when sharing their beliefs is beneficial to that patient. Certain issues in modern medicine have major religious and spiritual significance. Some that come to mind are: whether or not to prolong life through artificial means, shortening life through the use of pain medications, or what duty one has to a new born with fatal genetic anomalies. These and numerous others deserve a sensitive dialogue with between health practitioners and patients facing these troubling issues.

Regardless of their own belief system, health professionals should appreciate the possibility that religion and spiritual beliefs play an important role for many of their patients. When illness threatens the health, and especially the life of an individual, the patient will probably come to the professional with both physical symptoms and spiritual issues in mind. For patients facing a terminal illness, religious and spiritual factors often figure into important decision making such as the desirability of CPR and aggressive life-support, or whether and when to fore-go life support.

In a country with the cultural and religious diversity of South Africa, ascertaining a patient’s religious or spiritual beliefs, may be necessary to the successful management of that patient. Religious resources may provide valuable support, both material and psychological to patients. Some patients have described gratitude to their religious community for bringing meals to their family while a parent was at the hospital with a sick child. Others spoke of a visit from a priest, a rabbi, or a minister during their hospitalization as a major source of comfort and reassurance. One patient, self-described as a “non-church-goer,” described his initial surprise at a visit from the hospital chaplain which turned into gratitude as he found in the chaplain a skilled listener with a deep sense of caring to whom he could pour out his feelings about being sick, away from home, separated from his family, frightened by the prospect of invasive diagnostic procedures and the possibility of a painful treatment regimen. Not every medical situation necessitates or warrants questioning into a person’s spirituality. In certain instances it may be construed as invasive or unnecessary. However, in other situations, including terminal cases discussion into spirituality and religion are more pertinent

Whether you are religious, not religious or vehemently anti-religion, your beliefs and portrayal thereof, may affect your relationships with patients. Care must be taken that the nonreligious physician does not underestimate the importance of the patient’s belief system and equally importantly that the religious professional who may have a different belief than the patient, does not impose his or her beliefs onto the patient. In both cases, professionalism and ethical responsibility should supersede the ideology of the health practitioner.

In conclusion, Health professionals can enter a spiritual discussion but they are not obligated to do so. Most importantly, the dialogue should generally be at the invitation of the patient, not imposed by the physician. The purpose of the dialogue should be of benefit to the patient and in no way should the professional put down the patients belief or try to impose their beliefs on them.

Breaking bad news

Breaking bad news is likely one of the more difficult aspects of being a health professional. The fact that it is of such pivotal importance to patients, means that it will likely be well remembered. Most believe that breaking bad news is a born-with skill. This is incorrect. Most health practitioners, who are considered ‘good’ at discussing bad news with their patients report, it is a skill that they have worked hard at. Furthermore, studies in medical education demonstrate that all communication skills can be learned and have long lasting effects.

Oncologist, author and comedian, Robert Buckman, created a six step protocol to breaking bad news. (reproduced directly http://www.surgicalexam.com/interview/Ethics.pdf)

Getting started.
The physical setting ought to be private, with both physician and patient comfortably seated. You should ask the patient who else ought to be present, and let the patient decide–studies show that different patients have widely varying views on what they would want. It is helpful to start with a question like, “How are you feeling right now?” to indicate to the patient that this conversation will be a two-way affair.

Finding out how much the patient knows.
By asking a question such as, “What have you already been told about your illness?” you can begin to understand what the patient has already been told (“I have lung cancer, and I need surgery”), or how much the patient understood about what’s been said (“the doctor said something about a spot on my chest x-ray”), the patients level of technical sophistication (“I’ve got a T2N0 adenocarcinoma”), and the patient’s emotional state (“I’ve been so worried I might have cancer that I haven’t slept for a week”).

Finding out how much the patient wants to know.
It is useful to ask patients what level of detail you should cover. For instance, you can say, “Some patients want me to cover every medical detail, but other patients want only the big picture–what would you prefer now?” This establishes that there is no right answer, and that different patients have different styles. Also this question establishes that a patient may ask for something different during the next conversation.

Sharing the information.
Decide on the agenda before you sit down with the patient, so that you have the relevant information at hand. The topics to consider in planning an agenda are: diagnosis, treatment, prognosis, and support or coping. However, an appropriate agenda will usually focus on one or two topics. For a patient on a medicine service whose biopsy just showed lung cancer, the agenda might be: a) disclose diagnosis of lung cancer; b) discuss the process of workup and formulation of treatment options (“We will have the cancer doctors see you this afternoon to see whether other tests would be helpful to outline your treatment options”). Give the information in small chunks, and be sure to stop between each chunk to ask the patient if he or she understands (“I’m going to stop for a minute to see if you have questions”). Long lectures are overwhelming and confusing. Remember to translate medical terms into English, and don’t try to teach pathophysiology.

Responding to the patients feelings.
If you don’t understand the patient’s reaction, you will leave a lot of unfinished business, and you will miss an opportunity to be a caring physician. Learning to identify and acknowledge a patient’s reaction is something that definitely improves with experience, if you’re attentive, but you can also simply ask (“Could you tell me a bit about what you are feeling?”).

Planning and follow-through.
At this point you need to synthesize the patient’s concerns and the medical issues into a concrete plan that can be carried out in the patient’s system of health care. Outline a step-by-step plan, explain it to the patient, and contract about the next step. Be explicit about your next contact with the patient (“I’ll see you in clinic in 2 weeks”) or the fact that you won’t see the patient (“I’m going to be rotating off service, so you will see Dr. Back in clinic”). Give the patient a phone number or a way to contact the relevant medical caregiver if something arises before the next planned contact.

Despite a good and detailed explanation, difficult situations and emotional distress mean that patients will forget certain facts and often ask the same question to you or different caregivers. Useful ways of dealing with this are getting patients to write down or email questions to which you can reply. Remember this when dealing with patients who have been delivered news by other health professionals. Their lack of the knowledge may well not be the result of poor communication by the health professional. If you do witness marked insensitivity by a health professional, first, examine what happened and if you deem it acceptable discuss it with the health professional. If you see the patient later, you might consider acknowledging it to the patient in a way that doesn’t slander the insensitive caregiver (“I thought you looked upset when we were talking earlier and I just thought I should follow up on that–was something bothering you?”)

Accreditation: PPB004-MD271-0024-2-2013

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