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Tutorial for MRCP PACES Station 4 ( Last Modified : 4 November 2006 )
MEDICAL ETHICS
Originally, the words, 'Ethics' and 'Moral' were Greek and Latin expressions for the same idea-the code of conduct acceptable and normal within a particular society. Medical ethics represents an accepted code of behaviour within a particular gorup-in this case, the medical proffesion-whereas Morals now imply acceptance of a standard outside that group-in the form of a philosophy or a religion.
There are a few general principles you must remember when you are sitting for your MRCP PACES. Sometimes examiners would ask you what principle you are using when you approach your case in examination. I was asked by one of the examiners what principle I was using when trying to discuss about palliative care for a patient with advance hepatoma. Actually that patient insisted he wanted to try other alternative such as surgery. Answer the examiner was waiting for was ‘Non- maleficence’ ( DO NO HARM FIRST !)
There are four main principles you must always adhere to when you practice medicine, these are,
a) Non-maleficence
We should not harm our patients. Although some treatments may carry certain risks, doctors must always take into the consideration the potential benefits and risks. The benefits should out-weight the risks so that a treatment can be recommended to patients. In some scenarios, doctors may have difficulty to recommend certain new treatments to patients in view of scanty evidence to support them, therefore, we must discuss these alternatives with our patients and respect their decision.
b) Patient autonomy
Patients should be given rights to think, decide and act freely and independently. Doctors should respect patient’s decisions even though these decisions may not benefit the patient. However, we must remember that patient should be competent (ability to understand and take decisions upon any aspect of their healthcare) before they are allowed to make any decision pertaining their health.
Besides, there is another exception to this rule, although patient may not be agreeable to certain decision made by a doctor ( such as informing their spouse that they have HIV), there are rules that allow a doctor to breach medical confidentiality . These laws are,
1) Notification of an infectious disease –such as HIV ( Public Health Control of Diseases Act 1984)
2) Drug addiction ( Misuse of Drug Act 1973)
3) Termination of Pregnancy ( Abortion Act 1967)
4) Births and Deaths
5) Identification of patient undergoing in vitro fertility treatment with donated gametes
6) Identification of donors and recipients for transplanted organs
7) Prevention, apprehension or prosecution of terrorists connected with Northern Ireland
8) Police on request-name or address of driver of vehicle who is alleged to be guilty of an offence under the Road Traffic Act 1988.
9) Under Court Orders
Another common scenario in MRCP PACES, a patient with newly diagnosed epilepsy and insists to drive and refuse you to inform the authority. Actually, you have the right to notify the authority, however, you should inform the patient before doing so.
c) Beneficience
This principle reminds us to do good to our patients. We must always act in the patient’s best interest. In an emergency, the doctor may still act even without consent providing that the treatment is in the best interest of the patient!
d) Justice
Doctors are required to be just and fair to patients. We have to decide how much time to spend with different patients and we must know our limitations. We must make sure that patients with similar situations are treated equally. We must distribute our resources so that we can maximize our patients’ care and achieve optimum outcomes. We should avoid waste of scarce resources.
Besides that, there are a few medico-legal terms often asked in MRCP examination, they are as follow,
1) Medical Negligence
It is defined as breach of duty of care. A patient who wishes to succeed in a medical negligence action must prove three things:
a) The existence of a duty of care
b) Breach of that duty
c) Damage that has occurred as a consequence of the above.
2) Advance Directives
A formal advance statement of one’s values and preferences that is made before a person loses the mental capacity to decide or communicate how he/she wishes to be treated.
Always remember to ask about this from patient’s family members when you are dealing with a patient who is comatose or has lost his competency in whatever ways!
You may be given a case when a patient with multiple pre-morbid and currently he /she is intubated, you may be asked in MRCP PACES to discuss about resuscitation with the family members, therefore, advance directives is important in this case!
Source:
1) An aid to the MRCP PACES, Volume 2
2) PACES ahead, Dr Rashmi Kaushal
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