Doctor and Medical Ethics IDI CABANG SURAKARTA

The oldest code of medical ethics : Hippocratic Oath “To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him…” “Nor will I give a woman a pessary to procure abortion;” “I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in his art.” “First, do no harm”

Ethics : What is right? Moral - comes from Latin ‘mos’(mores) Ethics - comes from Greek ‘ethos’ Both have meaning of customs or generally accepted social norm But ‘What is right’ is not just a matter of social norm (e.g. slavery was a social norm at one time) Professional norm is not always right, it does revise over time What is legally permitted is not always right

Ethical principles Commonly quoted ethical principles : – Autonomy – Beneficence – Justice – Nonmaleficence These are useful but by themselves are not adequate for ethical decision making

WHO : Patient rights understood as one aspect of basic human rights World Health Organisation : Formalized in 1948, the Universal Declaration of Human Rights recognizes “the inherent dignity” and the “equal and unalienable rights of all of the human family”. And it is on the basis of this concept of the person, and the fundamental dignity and equality of all human beings, that the notion of patient rights was developed. In other words, what is owed to the patient as a human being, by physicians and by the state, took shape in large part thanks to this understanding of the basic rights of the person. http://www.who.int/genomics/public/patientrights/en/

WHO : Patient rights can vary in different countries World Health Organisation (WHO) : Patients' rights vary in different countries and in different jurisdictions, often depending upon prevailing cultural and social norms. Different models of the patient-physician relationship—which can also represent the citizen-state relationship—have been developed, and these have informed the particular rights to which patients are entitled. http://www.who.int/genomics/public/patientrights/en/

Doctor - patient relationship based on medical ethics Some doctors are worried that the physician-patient relationship, a special humanism motivated by tradition and governed by the ethics of medicine, may be fouled up by the fiscal and economic constraints likely to occur in the health care system Alvan Feinstein, MD, professor of medicine, Yale University School of Medicine, New Haven, Conn.

William C. Hsiao : William C. Hsiao, PhD, Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass. "We have promoted the diffusion of some technologies that may not be cost-effective and encouraged their overuse…" "Furthermore, we undercompensate primary care physicians, discouraging them from rendering their services, and likewise (fail to encourage) the young medical school graduates to pursue a career in family care. "Instead of trying to align the economic incentives to improve costeffectiveness, we are creating an istrative organization that will intrude on this very personal relationship between doctor and patients, between the caring physician with the technical expertise and the patient," "Is that the best we can do to preserve this unique relationship?" Marwick, Charles. Preservation of Physician-Patient Relationship Seen as Integral to Health Care System Reform JAMA The Journal of the American Medical Association. Volume 271(12), 23 March 1994, pp 892-893

Models of Doctor-Patient Relationship There are three different kinds of models : 1. PATERNALISTIC 2. CONTRACTUAL 3. FIDUCIARY http://www.carroll.edu/~msmillie/bioethics/modelsdoatrelation.htm

Paternalistic model : Strengths and Weaknesses Paternalistic model : The doctor is the professional. He/she gives the order, the patient obeys. Strengths : Emphasizes the expertise and knowledge of the doctor Weaknesses : – Ignores the autonomy of the patient – Ignores non-health related but morally legitimate values of the patient

Contractual model : Strengths and Weaknesses Contractual model : The doctor and patient "contract" for each other's mutual benefit; the patient determines or agrees to the doctor’s decisions. Strengths : – Highlights the autonomy of both patient and physician – Acknowledges cooperative/shared aspects of medical decision-making

Weaknesses : – No "contracts" developed or signed in real doctor/ patient relationships – Model doesn’t allow for at trusting relationship

Fiduciary model : Strengths and Questions Fiduciary model : The patient confidently entrusts his/her health care

to the doctor, who takes on the obligation of working for the benefit of the patient (Fiduciary: relates to a holding of something in trust for another)

Strengths : – Preserves the freedom and autonomy of both patient and physician – The legitimate role of physician knowledge – The important role of trust in the doctor/patient relationship

Questions raised by skeptics : 1. Patient trust may be manipulated for further economic gain. 2. Patient trust may undermines consumer’s awareness of need for selfprotection 3. Serious illness and fear of death diminish patient autonomy and power to contract any relationship.

A few cases for thought

Case 1 : Refusal of treatment A is prescribed for an elderly cancer patient by the attending doctor, but he refuses. Must the physiotherapist insist on carrying out the treatment plan? Is it unethical to go against the patient’s wish (to refuse)?

Dealing with refusal of treatment When mentally competent and properly informed, the patient’s refusal must be respected. [Principle of respect for autonomy] Assess mental capacity Provide adequate and appropriate information Treatments can be provided to mentally incapacitated persons based on ‘best interests’principle [Principle of beneficience]

Case 2 : Autonomy and family member A patient’s son insisted that the doctor should not tell his mother that she has been diagnosed with chronic leukemia, otherwise he will take her home against medical advice. The mother seems to be generally ive and submissive to the son’s decisions related to her health care How should the patient’s right be addressed?

Resolving ethical dilemma related to autonomy – advice for clinicians Listen carefully – do not jump to conclusion of “patient not cooperative” too easily Gather more information relevant to the case situation Consider your own bias and assumptions Explore reasonable options of compromise Involve carers and friends trusted by patient as appropriate

Case 3 : Demand of medical treatment A patient with mental illness demanded to be treated with the newest psychiatric drugs The doctor assessed and found that the patient was not suffering from significant side effect from the existing drug, which is also one of the newer drugs that had ed the patent period (cheap generic drug is locally available) What is the extent of patient right in this case?

Thank you for your attention