Dr Freyja Brown Consultant Geriatrician Poole Hospital

1. Dr Freyja Brown Consultant Geriatrician Poole Hospital

2. Moral conflict and ethical dilemmas • Ethical theory • Making ethical decisions • Cases • Assisted suicide • Any other topics? ?

3. Morality • "manner, character, proper behaviour" is the differentiation of intentions, decisions, and actions between those that are good or right and those that are bad or wrong. • normative ethics addresses such questions as "What should I do?", endorsing an ethical theory and rejecting others e.g. deontology and consequentialism. • meta-ethicsaddresses questions such as "What is goodness?" and "How can we tell what is good from what is bad?“ • Moral conflict- when moral values collide, when doing something good will also have bad consequences or when doing something generally prohibited will prevent harm.

4. A Thought Experiment • You are an MI5 agent. A terrorist cell has informed the police that a bomb has been placed inside Wembley Stadium. The stadium is full and according to the threat there is less 30 mins before the bomb detonates. The bomb can not be found • You have identified the 7 year old daughter of one of the terrorists. She knows where the bomb is but wont tell anybody as has been told by her father not too. • Your partner is preparing to torture the girl, if she tells you where it is you can save the lives of 80,000 people perhaps more if it is a nuclear bomb. He expects you to help him……

5. What do you do?

6. What are the issues?

7. Rule of rescue How many lives would you risk to save one? • Mining disaster • RNLI- lost at sea • Mountain Rescue • Dialysis • Very expensive cancer drugs • NICE

8. Another thought experiment • 2 cells each with a small child inside • Mary is in box A • Charles is in box B • You have never met either child before • If you do nothing Mary will die • If you press the red button Charles will die but Mary will live.

9. What if Mary is your child and Charles is not known to you?

10. Ethical dilemmas • When doing the right thing for one person has negative consequences for other people. • When there is disagreement about what is the right action.

11. Medical Ethical dilemmas

12. Which theory? • Are there universal truths, values, principles or rules which, if always applied with wisdom and consistency will always give the right answer?

13. Ethical theory – defining good Deontology Consequentialism Outcome is what counts A morally right act is one that brings about good consequences Utilitarianism -Maximise human happiness/welfare Jeremy Bentham: the greatest happiness of the greatest number. John Stuart Mill Not how you do it but how it effects the overall calculus of good and bad The ends justify the means. • Universal moral rules/duties • Morality lies in the action not the consequences • Judeo-christian origins – do unto others as you would have done unto you. • Secular version - Immanuel Kant • The categorical imperative: • Act only according to that maxim whereby you can, at the same time, will that it should become a universal law • Duties are absolute – even if the consequences are bad. • Do not use people as a means to an end

14. More than one universal truth Ethic of care/ Feminist ethics Virtue ethics Person centred, Moral character, about being a good person Doesn’t give answers. Aristotle: the virtuous habit of action is an intermediate state between the opposed vices of excess and deficiency The virtues of a good professional Integrity Fairness Conscientiousness Compassion Trustworthiness Discernment • No universal laws of ethics • Have to take into account emotional life • Context is important • It is morally right to favour one’s family/loved ones over unknown strangers • Caring as important as doing • Not just what you do but how you do it.

15. What about rights and principles? Rights Principles of biomedical ethics Much more than just the principles: Autonomy Justice Nonmaleficence Beneficence Beachamp and Childress moral character, professional values/virtues the Dr-Patient relationship Veracity Privacy Confidentiality fidelity • Natural Rights • Universal Human Rights • European Convention on Human Rights • Human Rights Act • Protection for the individual against the interests of the state • A 2: right to Life • A 3: freedom from torture • A 5: liberty • A 8: privacy and family life • A 14: freedom form discrimination

16. What else is important? • Clinical/social context • Culture, beliefs and relationships • Legal context and Professional codes of practice • Rules of engagement

17. Making Ethical decisions • It is a process • What is the actual moral question? • What are the options? • Who is affected? • Who should be involved? • Who has final say?

18. Cases • 6 vignette • Groups • Discuss 2 each • 20 mins • Then feed back and discussion

19. You are called to the home of Anna a 55 year old woman who is unconscious. • Her adult son and daughter are present. They show you an empty bottle of antidepressants which they think she has taken. • They tell you that their mother made them promise not to call an ambulance. • Anna is well known to your practice although you have never met her before. She has a long history of bipolar affective disorder and she has been sectioned several times. • However for the last 5 years she has been stable. • Unfortunately she was diagnosed with ovarian cancer last year. She has had a course of palliative chemotherapy which made her very sick. She has a community DNAR and is under the specialist palliative care team for severe abdominal pain. • She has filled in an advance directive/preferred priorities of care which states that she wishes to die at home. • What do you do?

20. Adam is a 39 year man with athetoidcerebral palsy who lives in a residential facility. • He previously lived independently but moved to the care home after a prolonged hospital admission with septicaemia and liver failure. Liver cirrhosis was caused by alcohol dependency. • Adam started drinking because it lessoned the involuntary movements and made him feel less self conscious. • Unfortunately Adam is now unable wash, dress, toilet, feed himself or leave the home without help. • He wants to go out to the pub. The clinician involved believes he has capacity to make this decision. • Should the care home/ clinician facilitate his wish to go out to the pub?

21. Mr. Richards is 91 years old; he lives with his wife in a bungalow. He has been registered with your practice for twenty years but has never set foot inside the surgery and has refused all immunizations and health checks. You know his wife well, she comes to the surgery regularly with different minor complaints, and you think she is depressed but she always denies this. • Mrs. R calls you out to see her husband who has become very unwell. When you arrive at the house you find Mr. R in bed, he looks extremely wasted and is obviously dyspnoeic. The bedroom smells foul; Mr. R has been incontinent in the bed. Mr. R tells you to bugger off, he has never had any time for doctors which, is why, he says; he has lived such a long and healthy life. He says he is well aware that he is dying and he wants to die in peace. He is in a lot of pain but refuses any help or medication. • Mrs. R says she cannot cope; he will not allow anyone else to touch him and shouts at her when she inadvertently causes him pain. What are you going to do?

22. Samantha is 29 years old, she comes to see you to discuss breast reduction surgery. • She tells you that she is miserable and depressed and fed up with people making comments about her breasts. She says she gets a lot of unwanted male attention and that people think she is stupid because she has large breasts. • She says she can’t get a job because it has damaged her self-confidence so much. She is single and still lives with her parents. • She asks you to write a letter to the CCG supporting her request for breast reduction surgery.

23. Mr Harris is 70 years old, he has had a severe stroke leaving him with a dense right hemiparesis and aphasia, he is PEG fed. He has been in a nursing home for the last six months. His wife visits nearly every day. • Mr H develops pneumonia and you are called to see him at the care home. • Mrs H is present and begs you to allow him to die in peace. Previously he was a private fiercely independent man who would find his present predicament intolerable. • The nursing home staff report that Mrs H has been caught on several occasions giving her husband sips from her cup of tea. • The care home staff feel Mr H should be admitted to hospital for treatment. They say he smiles and responds to touch and music, they say he has a good quality of life. • What are you going to do?

24. Tony a 45 year old man with long standing chronic pain following abdominal surgery in his teens has had treatment for many years by the chronic pain team. • This has involved a procedure which the patient claims works for him but is not evidence based. The procedure is no longer recommended and the risks of the procedure have become more serious. • The chronic patient specialist has referred Tony for a second opinion and the second opinion agrees that the procedure should not be offered again as the mechanism of action is such that it should not require repetition more than once anyway. The procedure requires a GA and central venous access as peripheral access is no longer possible. • Tony suffers from severe abdominal pain which impacts on his ability to eat and drink such that at times he requires NG feeding in hospital. He says he is willing to risk death to have the treatment again as it works for him. • He comes to ask for your help to persuade the specialist to perform the procedure again. It has been performed over 50 times over 15 years.

25. The limitations of moral theory • No single theory seems capable of answering all our moral questions. • The answer given by the moral calculus seems at odds with our intuition. • The moral principles conflict and there is no solution to how they should be balanced.

26. Process • Who is involved • Who has overall responsibility for the decision? • Identify the moral question • ‘What is the right thing to do’ • ‘what is the ethical conflict’ • Differentiate from a questions of evidence(medical opinion) and fact. • Distinguish from inter personal conflict. • Get all parties to agree on a fair decision making process. • Agree the meaning of value laden terms: • statements that impart implicit personal values and are not true in the strictest sense but based on personal opinion. • Define important concepts e.g. moral significance of parties involved (animals, unborn children, brain dead) • On whom does the decision impact? • Patient • Family • Carers • Healthcare staff

27. Deciding • Moral theory • Law • Professional codes of practice • How does this compare with similar cases in the past – what are the similarities and differences? • Impact on patient/ referrer/carers/family • Could this decision be generalised? • Options • Reasons for choosing • Reasons for rejecting

28. Another thought experiment • Smith stands to gain a large fortune if his cousin dies. One evening he sneaks into the bathroom and drowns the child whilst he is having a bath. • Jones also stands to gain a fortune if his cousin dies. He also sneaks into the bathroom planning to drown his cousin, however before he can act he sees the child slip, hit his head and fall face down into the water. He does nothing and watches to make sure the child drowns.

29. The intention is the same. The consequence is the same. Therefore morally the same? • Therefore no difference between doing nothing to prevent death and actively causing death if the outcome is the same. • If the outcome is good then the action is justified? • Patient in severe pain, dependent on help for all ADLs. Pain relief is inadequate or causes drowsiness and confusion • Patient wants to regain some control over this last stage of life, to die a dignified death.

30. Assisted Dying • ‘Enable an adult who has capacity and who is suffering unbearably as a result of terminal illness to receive medical assistance to die at his own considered and persistent request.’ • Suicide not illegal • CPS often choses not to prosecute those who assist a suicide

31. Why not? • Duty of care – To improve health and relieve suffering. • Respect for autonomy – should include right to a dignified death? • If life causes unbearable suffering isn’t death a good outcome?

32. The slippery slope argument • Is this a good enough argument? • Just need to ensure the conditions are stringent?

33. I don’t want to do it -it is morally repugnant to me • Should Drs or society decide what their role should be?

34. Why not PAS? • Changes fundamentally the Dr patient relationship. • Vulnerable groups may feel a burden to society and therefore request it. • Every society places limits on autonomy. • An action that may be morally right in an individual case may still be morally prohibited because the consequence of generalising the act would be detrimental to society.

35. Thanks