PROBLEM CASES IN MEDICAL ETHICS

1. PROBLEM CASES IN MEDICAL ETHICS Roshan A. KhurooWorcester VTSOctober 2005

2. Confidentiality GMC Guidelines. Confidentiality is central to trust between doctors ant patients. Before providing information regarding patients you should; Seek patients’ consent, whether or not you should judge that patients can be identified. Anonymise data where unidentified data will serve the purpose. Keep disclosures to the minimum necessary.’

3. Confidentiality And Medical Practice Examples of situations in which doctors must not breach confidentiality. Casual breaches e.g for amusement. To prevent minor crime To prevent minor harm to another individual. Doctors working in genitourinary clinics. Doctors should not write a report or fill in a form disclosing confidential information without the patients consent.

4. Situations in which doctors have discretion to breach confidentiality Sharing of information with other members of the health-care team in the interests of the patient. A patient who is not medically fit to drive continues to do so. A third party is at significant risk of harm.

5. Examples of situations where doctors must breach confidentiality. Notifiable diseases. Drug addiction. Misuse of Drugs Act( 1973) Termination of Pregnancy. Abortion Act (1967). Births And Deaths. Registration Act ( 1953). To police on request. Name and address only, no clinical details. Road traffic Act ( 1988). Under court orders. Identification of patients undergoing in vitro fertility treatment with donated gametes. Human fertilisation and embryology Act (1990) Identification of donors and recipients of transplanted organs. Human organ transplant Act (1989).

6. Legal case of confidentiality W was a patient detained in a secure hospital for an indefinite period of time because he had killed five people and wounded two others. He was diagnosed with schizophrenia and found not guilty by reason of insanity. Then 10 years into his detention, he appealed to a mental health review tribunal for transfer to a less secure hospital. W’s solicitor asked Dr. Egdell, a consultant psychiatrist, for a report on W’s condition, hoping that the report would support W’s transfer. However, Dr. Egdell formed the opinion that W was suffering from paranoid psychosis and remained dangerous. His report strongly opposed W’s transfer. When Dr. Egdell discovered that W’s solicitors would not make his report available to W’s consultant or to the tribunal, he sent a copy to the medical director of the hospital with a suggestion that it be forwarded to the home secretary. When W realised what Dr. Egdell had done, he issued an injunction restraining the use of the report and seeking damages for breach of confidentiality. The case went to court of appeal. Was Dr. Egdell right or wrong?

7. To breach confidentiality the judgment found that Dr. Egdell was right to breach confidentiality, because the public interest was in favour of disclosure.

8. Consent in English Law Competent Adults Patients may refuse any life-saving treatment Patients should be given information about the nature of procedure, common and rare serious side-effects, benefits and reasonable alternative.

9. Incompetent adult Doctors should act in the best interests of patients. Relatives and friends may be sources of information when judging best interests, but cannot give or withhold consent.

10. Case report regarding consent Mrs D IS 77 YR OLD. She has been suffering moderate dementia for 7 years. She recently slipped and fell, fracturing the neck of her left femur.Both her GP and the surgeon believe that it is in her best interests to operate to repair the fracture. Her 45 year old son, who is her next off kin, refuses to give his consent-he says that he does not like hospitals and that his mother should stay at home in bed while the fracture mends itself. Questions What legal authority does the son’s consent have? What should the doctors do?

11. Neither the son nor his refusal has any legal relevance The doctor should assess what is in the patient’s best interest's.

12. Case history regarding incompetent adult Mr. C is a 70year old man with dementia and long standing COPD. He is cared for at home by his 72 year old wife. He suffers frequent chest infections for which he receives antibiotics, and requires oxygen at home. His most recent chest infection has not responded well to antibiotic tablets and his general condition is deteriorating. He is not eating and is drinking little.. Admission to hospital in the past has caused him distress because he does not cope well with changing environment. However,his wife says that he should go to hospital and receive the maximum treatment. Imagine that you are Mr. C’s doctor. You think that his best interests would be served by him staying at home and being made comfortable,but his wife wants him in hospital. Were do you go from here?

13. Options at the end of life Mr L has metastatic melanoma and respiratory failure. He has an intravenous syringe-driver with morphine for pain relief. He wants to die. What options do we have ?????

14. Do not place on a Ventilator, ( form of passive euthanasia ) Place on a ventilator, and withdraw on deterioration

15. English Law and the end of life Killing a patient for any reason is normally murder. Assisting suicide is criminal offence. A competent patient can refuse any, even life saving treatment. Treatment of incompetent patients should be in their best interests.

16. Thank you for your patience