Ethical Practice in Healthcare

Definition of health care ethics

•History and development of medical ethics
Theories of health care ethics[1hr]
•Consequentialism
•Deontology
Principles of healthcare ethics
Autonomy
Beneficence
Non-maleficence
Justice
Rules of health care ethics [30 min.]
•Veracity
•Privacy
•Confidentiality
•Fidelity –
Models to approach ethical dilemma
legal aspects in health care practice (2 Hrs.)
• Code of medical ethics
• Law and ethics intertwine
• Overview on health professional negligence
• Health professional-patient relationship
 Contents
• Definition of health care ethics • legal aspects in health care practice (2
• History and development of medical ethics Hrs.)
• Theories of health care ethics[1hr] – Code of medical ethics
– Consequentialism – Law and ethics intertwine
– Deontology – Overview on health professional
negligence
• Principles of healthcare ethics
– Autonomy
•  Health professional-patient
– Beneficence relationship
– Non-maleficence
– Justice
• Rules of health care ethics [30 min.]
– Veracity
– Privacy
– Confidentiality
– Fidelity –
 Models to approach ethical dilemma
 Objectives
• Recognize legal and ethical principles and frameworks governing
anesthesia practice
– Explain basic principles of ethics
 Definition;
• “...ethics is the study of morality – careful and
systematic reflection on and analysis of moral
decisions and behavior”
• The word ethics means custom or culture, a manner
of acting or constant mode of behavior.
• Health ethics may be defined as a code of behavior
accepted voluntarily, within the profession as,
opposed to laws, regulations and directives issued by
official body or scientific study of morality.
– It teaches us how to judge accurately the moral goodness
or badness of human action.
• Medical ethics – moral principles being considered by
health care practitioners in their dealings with each
other, their patients and state.
 Morality
• Morality – is the science concerned with the distinction between right and
wrong.
• Its the value dimension of human decision-making and behavior.
• The morality includes ‘rights’, ‘responsibilities’ and ‘virtues’; and ‘good’ and
‘bad’ (or ‘evil’), ‘right’ and ‘wrong’, ‘just’ and ‘unjust’.
• A moral act – is carried out with at least some degree of
knowledge and freedom, proceeding from man’s rational nature.
– An act done with full knowledge and full freedom of choice is a perfect
moral act while an act in which both knowledge and/or freedom is/or
deficient is called an imperfect moral act.
• An act, which may be either good or bad but carried out with good
intentions, is referred to a positive moral act.
– On the contrary an act which entails omission such as an offence committed
by neglect of duty, is called a negative moral act.
• Factors, such as ignorance, emotion, violence and habit, that may
lessen human knowledge or freedom, may result in hindrance to
accountability.
 Why ethics?
• To help health professional identify moral and
ethical issues,
• To know what is right and wrong about what
should and should not be done for and to client,
• To know and respect the issues of human rights,
personal and civic.
• To maintain standards of care and client wellbeing
• Minimize unnecessary damage
• Duty of anesthetists to patient
– Provision of anesthesia for a needy patient is implied contract
– Continue standard anesthesia care
– Earn confidence/ competence
– Duty to give proper directions
– Notify communicable diseases
– Examination and consent
– Duty as regards result of examination
– Continue standard anesthesia care
• Maintaining confidentiality
• Practicing within the scope of training and capabilities
• Preparing and maintaining medical records
• Documenting accurately
• Using proper guidelines when releasing information
• Duty of anesthetist to state;
– Notification of infectious diseases
– Notice to police
– Notification of births and deaths
– Respond to emergency service
• Duty of anesthetist to one another;
– Extend same honor, respect & good behavior as expected
from them
– Should not do or utter anything to lower down the name of
colleagues
– Should not entice patients away from colleagues
– Free medical service to fellow colleagues
 What is special about medicine?
• People come to health care worker for help with their
most pressing needs – relief from pain and suffering and
restoration of health and well-being.
• They allow physicians to see, touch and manipulate every
part of their bodies, even the most intimate.
• They do this because they trust their physicians to act in
their best interests.
 Who decide what is ethical?
• Individuals disagree among themselves about what is right and
what is wrong, and even when they agree, it can be for different
reasons.
• Health ethics have common features in different countries.
– However, each country adopts certain modifications according to prevailing
local culture, religious beliefs, social norms and standards of public health
practice.
– In Ethiopia, the need for modification of code of ethics is based on current
beliefs, standards of public health practice and religious concepts.
• Over the centuries the medical profession has developed its own standards of
behavior for its members, which are expressed in codes of ethics and related
policy documents; through professional associations. However; the directives are
more general = they cannot deal with every situation that physicians might face
in their medical practice.
• == hence they have to decide for themselves what is the right way
to act, but in making decisions, it is helpful to know what other
professionals would do in similar situations.
• the WMA has undertaken the role of establishing general
standards in medical ethics that are applicable worldwide; as
Declaration of Geneva.
• Therefore, there are structures when ethical claim arises.
• Ethics Consultation
– It is a process in which a team, or ethics committee to help patients,
providers, and other parties in resolving ethical concerns in a health care
setting.
• Objectives of this consultation is;
– improve health care quality by facilitating the resolution of ethical concerns;
through forum discussion.
– maximize benefit and minimize harm to patients, families, professionals and
institutions by fostering fair and inclusive decision-making processes that
honors patients’ preferences.
– facilitate resolution of conflicts in a respectful atmosphere with attention to
interests, rights, and responsibilities of those involved
 Ethical consultation…
• inform institutional efforts at policy development, quality
improvement, and appropriate utilization of resources
• identifying the causes of ethical problems and promoting
practices consistent with ethical norms and standards
• assist individuals in handling current and future ethical
problems in a compassionate, respectful, responsible and
caring manner by providing education to the health
workforce in healthcare ethics
• The clinical ethical consultation can be requested by
patient, family, professionals, social worker and or by any
others body.
• Once requested, consultation is done by physician and
other professionals trained by medical ethics.
 Basic Ethical Principles (General)

• There are five widely accepted ethical principles;

– Autonomy
– Beneficence
– Non-maleficence
– Justice
– Truth telling
• Principles of autonomy
• Every client with individual differences must have a
freedom to choose their own ways; with the
framework of the other principles.
• It involves respecting the persons rights and dignity
as a human being.
• Rights in relation to health care are usually taken to
include:
– The right to information
– The right to privacy and confidentiality
– The right to appropriate care and treatment
• Beneficence (doing good)
– Doing or promoting good as well as preventing,
removing and avoiding evil or harm.
– E.g.
• Giving clients clean needles, suction, ETT, and
laryngoscope
• provide information about emergency first aid to reduce
the risks of HIV infection or accident.
• Giving prophylaxis…N/V, anti-pain, O2,
• Applying cricoids pressure for full stomach pt
• Non-maleficence (doing no harm)
– Non-maleficence holds a central position in the
tradition of medical ethics and guards against
avoidable harm to subjects.
– Eg:
• Performing puncture on infected area
• Repeated attempt of intubation despite desaturation/
hypoxia
• Over dosing/ insufficient anesthesia, inappropriate
anesthesia agent selection.
• Justice (fairness)
– This principle states that human being should treat
other human being fairly and justly in distribution
goodness and badness among them. In other words
justice should include:
• Fair distribution of scarce resources
• Respect for individual and group rights
• Following morally acceptable laws
• The principle of truth telling (honesty)
– At the heart of any moral relationship is communication.
– A necessary component of any meaningful communication is
telling the truth, being honest to clients as well colleague.
– Eg: Risks associate with procedure, if not able to perform, error
committed, etc…
 Principles of ethics…
 Section 1: The principal objective of Health Profession is to render
services to humanity with full respect for dignity of people.
• Anesthesia professionals should merit the confidence of communities
and of individuals entrusted in their care, rendering always a full
measure of service and devotion.
 Section 2: Competence: Anesthesia professionals should perform only
those procedures in which the anesthetist is competent by virtue of
specific training or experience. Anesthetist must not misrepresent
credentials, training, experience, ability or results.
 Section 3: Anesthetist should recognize health and illness in the broader
context of social, environmental, political and economic factors as
related to anesthesia care services.
 Section 4: Anesthesia practice concerns in the surgical intervention of
illness and surgical diseases and ensuring the well being of the patient
perioperatively.
 Principle of Ethics….
 Section 5: The anesthetist should safeguard the public and them self against
health hazards.
• Anesthetist should observe all, polices and guidelines up hold the dignity and
honor in performing his/her duties at all times.
 Section 6: Anesthetist should achieve community health in a way that respects
the rights of individuals in the community at large.
• Section 7: Anesthetist should see that public health policies, guidelines and
programs, should be developed and evaluated through processes that ensure
an opportunity for input from community members,
• Section 8: Anesthetist should advocate for, or work for the empowerment of,
community members, ensuring that the basic resources and conditions
necessary for health are accessible to all people in the community. These
includes;
– Inform the clients and promote informed consent;
– Empower the client and protect autonomy;
– Protect the rights and interests of clients where they cannot protect their own;
– Ensure clients have fair access to available resources;
– Represent and support the views/desires of the clients and not just their needs.
 Section 9: Anesthetist must protect the confidentiality of information
that can bring harm to an individual or community.
 Section 10: Additional opinion(s) shall be obtained if requested by
• the client. Consultations(s) made to protect or safeguard client for
further investigations and management
 Section 11: The Impaired Anesthetist: A physically, mentally, or
emotionally impaired anesthesia professional should withdraw from
those aspects of practice affected by the impairment. If the
anesthetist does not withdraw, it is the duty of others who know of
the impairment to take action to attempt to prevent him from
harming himself or others.
• Section 12: Anesthetist should carry out the best interest of the
clients.
• Section 13: Anesthetist experience, judgment and practice must not
be affected by economic interest in, commitment to, or benefit from
health related commercial enterprises.
 Section 14: Communications to colleagues must be accurate and
truthful.
 Section 15: Communications to the community must be accurate.
• She/he must not convey false, untrue, deceptive, or misleading
information through statements, testimonials, photographs,
graphics, or other means.
• They must not omit material information, without which the
communication would be deceptive.
• Communications must not appeal primarily to an individual’s
anxiety or create unjustified expectations of results.
Communications must not misrepresent the Anesthetists
credentials, training, experience, or ability and must not contain
material claims of superiority that cannot be substantiated.
 Section 16: Anesthetists may not reveal confidence entrusted to
her/ him in the course of attending clients, or the deficiencies she
may observe in the character of clients, or unless it becomes
necessary in order to protect the welfare of the individual or
community.
 Section 17: The Anesthesia professionals in his/ her practice shall
avoid direct or indirect self-advertisement.
 Section 20: Anesthetist should participate and must have interest
in all activities of the community which have the purpose of
improving both the health and well-being of individuals and the
community.
 Section 21: The Anesthetist is expected to be friendly in carrying
out his/ her responsibilities.
 Section 22: The anesthetist is expected to be present on time for
every commitment s/he makes in duties and responsibilities.
 Section 23: The anesthesia professional is expected to
respect the confidential aspects of his/er assignment,
and the dignity and privacy of the clients with whom s/he
works.
 Section 24: The anesthetist must be involved, in a warm
and natural manner with the clients s/he serves without
becoming over involved.
 Section 25: The anesthetist should show empathy and
sympathy with the clients.
 HOW DO INDIVIDUALS DECIDE WHAT IS ETHICAL?
• There are two major approaches; non-rational and rational
1. Non-rational - does not mean irrational but simply that it is to
be distinguished from the systematic, reflective use of reason
in decision-making
• Obedience – following rules or instructions
• Imitation – it subordinate one’s judgment about right and
wrong is to another person.…following the example of role
model.
• Feeling or desire is a subjective approach
• Intuition is an immediate perception of the right way to act in
a situation.
• Habit – following the same with the previous moralissue.
•
Rational aproaches
Deontology involves a search for well-founded rules that can serve as the basis for
making moral decisions.
• An example of such a rule is, “Treat all people as equals.”
• Its foundation may be religious (for example, the belief that all God’s human creatures are
equal) or non-religious (for example, human beings share almost all of the same genes).
• Once the rules are established, they have to be applied in specific situations, and here
there is often room for disagreement about what the rules require (for example, whether
the rule against killing another human being would prohibit abortion or capital
punishment).
• Consequentialism bases ethical decision-making on an analysis of the likely consequences
or outcomes of different choices and actions.
• The right action is the one that produces the best outcomes; however, difficult to count
good outcome.
• One of the best-known forms of consequentialism, namely utilitarianism, uses ‘utility’ as
its measure and defines this as ‘the greatest good for the greatest number’.
• Other outcome measures used in healthcare decision-making include cost-effectiveness
and quality of life as measured in QALYs (quality-adjusted life-years) or DALYs (disability-
adjusted life-years). Supporters of consequentialism generally do not have much use for
principles; they are too difficult to identify, prioritise and apply, and in any case they do
not take into account what in their view really matters in moral decision-making, i.e., the
outcomes. However, this setting aside of principles leaves consequentialism open to the
charge that it accepts that ‘the end justifies the means’, for example, that individual
human rights can be sacrificed to attain a social goal.
• Principlism, as its name implies, uses ethical principles as the basis for making moral
decisions.
• It applies these principles to particular cases or situations in order to determine what is
the right thing to do, taking into account both rules and consequences.
• Principlism has been extremely influential in recent ethical debates, especially in the
USA.
• Four principles in particular, respect for autonomy, beneficence, non-maleficence and
justice, have been identified as the most important for ethical decision-making in medical
practice.
• Principles do indeed play an important role in rational decision-making.
• However, the choice of these four principles, and especially the prioritisation of respect
for autonomy over the others, is a reflection of Western liberal culture and is not
necessarily universal.
• Moreover, these four principles often clash in particular situations and there is need for
some criteria or process for resolving such conflicts.
• Virtue ethics focuses less on decision-making and more on the character of decision-
makers as reflected in their behaviour.
• A virtue is a type of moral excellence; being compasionate, honesty, prudence and
dedication. A one who possess these virtues are more likely to make good decisions and
to implement them in a good way.
• However, even virtuous individuals often are unsure how to act in particular situations
and are not immune from making wrong decisions.
• None of the approaches, proposed, has been able to win universal assent.
– each approach has both strengths and weaknesses.
• Therefore; a combination of all four approaches is the best way to make ethical decisions
rationally.
• It would take serious account of rules (deontology) and principles (principlism) by
identifying the ones most relevant to the situation.
• It would also examine the likely consequences (consequentialism) of alternative
decisions and determine which consequences would be preferable.
• Finally, it would attempt to ensure that the behavior of the decision-maker both in
coming to a decision and in implementing it is admirable (virtue ethics).”
• Such a process could comprise the following 6-steps:
1. Determine whether the issue at hand is an ethical one.
2. Consult authoritative sources such as medical association codes of ethics and policies
and respected colleagues to see how physicians generally deal with such issues.
3. Consider alternative solutions in light of the principles and values they uphold and their
likely consequences.
4. Discuss your proposed solution with those whom it will affect.
5. Make your decision and act on it, with sensitivity to others affected.
6. Evaluate your decision and be prepared to act differently in future.