Ethical Dilemmas in General Practice Case Discussions Definition of Ethics Ethics is the moral limitation placed on power. Thus, the origins of medical ethics lie in the realization that the power of knowledge and skill brought to bear on
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Presentation Transcript
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Ethical Dilemmas in General Practice Case Discussions<br>
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Definition of Ethics Ethics is… the moral limitation placed on power. Thus, the origins of medical ethics lie in the realization that the power of knowledge and skill brought to bear on the vulnerability of the sick can be used to exploit and dominate. The ethics of service nourished in the history of western medicine goes beyond prohibiting the abuse of power and demands that power be dedicated to the strengthening of the weak.
- Jonsen A R. The End of Medical Ethics. J Amer. Ger. Soc. 1992:40;393-7<br>
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Ethics<br>
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Law Professional
standards Ethics<br>
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Principilism Powerful alternative to theory driven approaches
Uses middle level ethical principles that are not absolute – prima facie
Competing principles
Dominant mode of ‘doing ethics’ in USA
Beauchamp and Childress, Prof. Ranaan Gillon.<br>
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Four principles Autonomy
Beneficence
Non maleficence
Justice<br>
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Respect for Autonomy Respect the capacity of individuals to choose their vision of the good life and act accordingly
( Greek:- autos – self nomos – rule)<br>
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Beneficence Foster the interests and happiness of other persons and of society at large<br>
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Non maleficience Refrain from harming other persons
(Primum non nocere)<br>
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Justice Act fairly, distribute benefits and burdens in an equitable fashion and resolve disputes by the means of fair procedures<br>
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Deontology v Consequentialism So act as to treat humanity, whether in your own person or in that of any other, never merely as a means but always also as an end in themselves.
OR
What are the consequences of this decision? Looks to act in the way that produces the most good for the most people.<br>
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Other Ethical Tools Virtue ethics (Aristotle)
Distributive justice (Rawls)
Human Rights
Logic
Religious principles<br>
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GW - 57 year old man with severe cerebral palsy Multiple contractures. Difficulty swallowing
Looked after by mother – 81. PMH COPD. Health deteriorating.
Other care : Man paid by mother to carry out lifting duties
DN visits 3 x week for manual evacuation and dress pressure sore
Mother will not let any other care service in house including social workers due to perceived poor interest in family’s problems in the past
GW sleeps in a camp bed that is put up in living room at night and stored in the kitchen
Problem:
DN increasingly concerned re pressure sore on his left flank. Not improving despite dressings.
Mother will not allow any increase in care to be put into house. She refuses a bed with a pressure mattress as will not fit in the living room<br>
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Pam 47 years history of breast cancer Patient has had a dry cough for few weeks
OTC remedies not helping she is getting a bit worse and now a bit breathless
Looks after her disabled husband who is registered blind
Mastectomy for breast cancer two years ago
Depressed afterwards especially as she worried about her ability to care for her husband
Missed hospital check up last month
Chest sounds clear on examination – she is pleased with this news
However, you feel she warrants a CXR given her history
She asks you why this is necessary, what do you say?<br>
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Ed 45 years end stage alcoholic liver disease Drinking currently under control after many years of abuse
Married, two children, in and out of work
His gastroenterologist has considered him for a liver transplant but his PCT have decided not to provide the funds
Evidence seems to suggest that alcoholics do less well after the operation compared to other patients
Ed asks for your help to change the PCT’s view so that he can have surgery<br>
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Chris 23 years history of heroin abuse New patient to the practice
Has had several convictions for drug related offences
Hepatitis C positive HIV negative
Just moved in locally with girlfriend and keen to stop habit
Asks about methadone, when told he would need to go to local drugs abuse treatment service, says he would be happy with diazepam 40mg per day as this has worked before
You hesitate to do this and the patient starts to get agitated – says if you will not prescribe ‘then he will get his gear from the street!’<br>
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Harriet 85 years lives alone Patient has severe OA and has problems transferring from bed to chair
Carers visit twice daily they are increasing concerned re risks of falls
Care manager asks you to visit ?admission to nursing home
Harriet is rather deaf but mentally competent – she makes her opposition to admission quite clear
After some weeks of pressure by carers and her family Harriet reluctantly gives in and agrees to go to a nursing home
You feel uncomfortable with this and wonder if they were right to persuade her to go?<br>
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Alan, 43 years heavy drinker Well known patient who drinks heavily
Comes to tell you he is being prosecuted by the police for driving whilst over the limit
Is a delivery driver for local furniture outlet
Married with 3 children
Asks you for help – wants you to write in support, will lose his job if he is convicted<br>
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Doris 55 years wanting weight loss pills Patient was withdrawn from appetite suppressants she started many years ago last year
She required lots of PHCT input
Recently she has become very tired and is putting on a lot of weight again
Wants another ‘short course’ of diet pills to make her feel better<br>
