Ethics involves the application of a moral code to the practice of medicine.
Ideals and the Hippocratic Oath have been covered in another article but it is worth repeating the summary of the Oath here:
- 'A solemn promise:
- Of solidarity with teachers and other physicians.
- Of beneficence (to do good or avoid evil) and non-maleficence (from the Latin 'primum non nocere' or 'do no harm') towards patients.
- Not to assist suicide or abortion.
- To leave surgery to surgeons.
- Not to harm, especially not to seduce patients.
- To maintain confidentiality and never to gossip.'
It is no longer enough simply to treat the patient as you would wish to be treated yourself. Follow such a tenet blindly and you could well find yourself on the wrong side of the law. Medical and social ethics have advanced to an extent that doctors are likely to be faced with controversial issues on a regular basis. Euthanasia, information sharing and the use of human tissues are typical examples. Every clinician must keep up to date on current legislation and ensure that they are practising within the law and within the guidelines laid down by their professional body. In the UK, the principles enshrined in Good Medical Practice - the handbook of the General Medical Council (GMC) - are a good place to start.
Much has been written about medical ethics and it would be impossible to cover everything here. This is an attempt to cover some of the aspects that are more pertinent to general practice.
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Care of the patient as an individual
Treating the patient as an individual is an important principle. Dignity and respect for the patient are considered by the GMC to be of great importance and a whole section is devoted to it in their handbook. Providing care that meets the needs of individuals is not always easy when faced with demands to make efficient use of resources. Furthermore, one must consider the interests of the public at large and practise within legal boundaries. However, it is important to tailor care to the needs of the individual patient. Even that great promulgator of guidelines, the National Institute for Health and Clinical Excellence (NICE), prefaces its guidance to the effect that treatment and care should take into account patients' individual needs and preferences.
Caring for patients as individuals also means leaving one's prejudice at the surgery door. Patients should be provided with the best possible care irrespective of age, sexuality, ethnicity, religious beliefs or politics. This is particularly true of lifestyle issues. Whatever the clinician's view of smoking, obesity and drug dependency, it is his or her ethical duty to be supportive, not judgemental.
Good clinical practice
As part of doing our best for our patients we should endeavour to maintain a good standard of clinical practice. Medicine is changing rapidly and we cannot do this unless we keep our knowledge and skills up to date. This is no longer an optional extra but a fundamental requirement. We must all have a personal development plan. An exhortation that we should always practise evidence-based medicine (EBM) would be commendable if EBM were always available. A more realistic compromise would be to practise it wherever possible.
Good clinical practice also means being conscientious and ensuring that sufficient time should be devoted to providing care that is safe and effective.
The notion of confidentiality is enshrined in the Hippocratic Oath but it is not inviolable. The recommendations regulating the sharing of patient-identifiable information between NHS organisations and with non-NHS organisations are set out in the Caldicott Report. The legislation governing the processing of personal information is contained in the Data Protection Act. See separate article Data Security and Caldicott Guardianship for more details.
Breach of confidentiality is not to be taken lightly and it may have serious consequences for the doctor/patient relationship and the doctor's reputation. However, there are occasions when one's obligations to the safety of others and the greater public good must override one's duty of confidentiality to the patient, such as the disclosure of a serious crime.
Fortunately, comprehensive GMC guidance is available on their website to cover many eventualities. These include:
- Reporting concerns about patients to the DVLA or the DVA.
- Disclosing records for financial and administrative purposes.
- Reporting gunshot and knife wounds.
- Disclosing information about serious communicable diseases.
- Disclosing information for insurance, employment and similar purposes.
- Disclosing information for education and training purposes.
- Responding to criticism in the press.
Following GMC guidance does not absolve clinicians from using their own clinical judgement in individual circumstances. When in doubt, one's medical defence organisation can be most helpful.
Other examples of circumstances in which the safety of a third party may override patient confidentiality are in the arenas of child protection and drug dependence.
When talking with relatives, the default position is to obtain the patient's express consent. This may be verbal but, even so, such consent should be recorded in the patient's notes. If relatives wish to raise concerns with clinicians, the GMC advises that no guarantee should be given that such a discussion will not be reported to the patient.
Where a patient does not have the mental ability to make an informed decision about whether information should be disclosed (ie 'lacks capacity'), the GMC recommends that the clinician should:
- Make that patient's interests their first concern.
- Protect their privacy and dignity.
- Encourage them to become involved in such a decision as far as their abilities will allow.
To facilitate an assessment of the patient's best interests, a clinician may need to share information with the family, friends or carers or anyone authorised to represent the patient, but this does not mean allowing free access to all information. Further guidance on mental capacity can be found in the separate article Mental Capacity Act.
The questions of loyalty to society and breach of confidentiality about a serious crime have already been mentioned but there are other occasions when loyalty may be divided.
Doctors who practise in occupational health are paid by the employer to look after the employees. There may be times when it would be in the interest of the employer to know something and in the interest of the employee to hide it. If this matter affects health and safety it may be an important issue. As it says in The Bible, "A servant cannot have two masters" but it is important to find a compromise and perhaps to convince the patient that disclosure is the best course. The doctor may be in a very difficult position.
There may be divided loyalties with regard to medical care in prisons. Work as a police surgeon may bring problems.
It is not enough simply to obtain consent; that consent must be informed. This raises questions about how much information should be provided and how this can best be presented in a way that the patient understands. Informed consent applies to all medical interventions, including prescribing, and not just to procedures or operations. If a list of every possible complication were to be recited it is unlikely that anyone would ever take any drug or submit to any procedure. A list gives no indication of risk. It is a difficult balance to decide what to tell and what to omit. A very low risk can be omitted but it becomes more important if the adverse consequences are serious or fatal. Even facts and figures to quantify risk are useless if the patient does not understand percentages or the basis of risk. Avoid jargon, technical terms and abbreviations.
In difficult matters of consent where there may be legal issues including consent from minors, refusal of consent or obtaining consent from those who lack capacity, do not hesitate to seek advice. You are not an expert on the law and remember that it differs, often quite markedly, between Scotland and the rest of the UK.
An extremely important matter with regard to consent to treatment involves advance directives, also known as living wills. See separate article Advanced Directives (Living Wills).
Another very important issue with regard to consent, is consent to take part in medical trials or experiments. We have known clinical governance for many years but now there is also research governance.
Consent in minors
- When obtaining consent, the doctor must establish whether the child is legally competent (in legal terms, has capacity to give consent).
- All people aged 16 and over are presumed in law to have the capacity to consent to treatment unless there is evidence to the contrary.
- If the child is deemed not legally competent, consent will need to be obtained from someone with parental responsibility, unless it is an emergency.
- Emergency treatment can be provided without consent to save the life of, or prevent serious deterioration in the health of, a child or young person.
- The legal position differs, depending on whether the young person is aged over or under 16.
An assessment thus needs to be made as to whether a person under the age of 16 has the capacity to make an informed decision about their care. The courts have defined this as "sufficient understanding and maturity to enable them to understand fully what is proposed". This is known as Gillick competency. The concept initially arose in the case of Gillick v West Norfolk and Wisbech Area Health Authority in 1986 and it is also known as Fraser competency (Lord Fraser was the judge who ruled on the case). It is most commonly considered when the issue of underage contraception arises but can be relevant in any situation in which a person under 16 requires care.
If a person under 16 is not Gillick competent, then consent needs to be obtained from one person with parental responsibility. Ideally, as many people with parental responsibility should be involved as possible; frequently, this will be both of the child's biological parents.
The issue of Gillick competency normally arises when the question of contraception in an underage girl is considered but may be relevant in any patient under 16 who requires care. More details can be found in the separate article Consent to Treatment in Children (Mental Capacity and Mental Health Legislation).
Working as a team
Teamwork, once a new concept in general practice, is now vital to the process of delivering an effective service to patients. The GMC expects a reasonably competent GP to be a team player, a leader and a mentor. A balance needs to be struck so that each member is allowed to develop to their maximum potential without being delegated tasks which are beyond their competence.
Information sharing is an important part of team working but, again, a balance must be struck so that team members are allowed to access only those areas which are appropriate to them.
Removal of patients
There are many reasons why a general practitioner may terminate responsibility for the care of a patient. The most common is that the patient has moved outside the practice area and the doctor is no longer able to fulfil the obligation to visit if required. Other reasons to remove a patient, which the GMC would consider justifiable, include violence, theft or other unreasonable behaviour.
The GMC warns that patients should not be removed simply because they have made a complaint, because of resource implications or because they refuse to follow advice about lifestyle changes. Removal should always be a last resort and other options may be possible, such as having a meeting with the patient to discuss concerns or arranging for them to see another doctor in the practice. If you do decide to remove a patient, be prepared to justify your decision. Wherever possible, write to the patient to inform them of your decision and the reasons for it. This is a contractual obligation for the GMS contract; paragraphs 193 to 201 refer to it, and it is also outlined in paragraphs 6.29 and 6.30 of the linked Department of Health statement. Personal Medical Services (PMS) contracts vary but, since it is accepted that patients should not be put at a disadvantage by contractual differences, it would be sensible for PMS doctors to treat such obligations as contractual requirements.
The doctor as a patient
When the doctor becomes a patient there must be the same rights of confidentiality as for anyone else. That is why the GMC neither holds Health Committee hearings in public nor publishes the outcome. The GMC recommends that a doctor should not treat his family or himself. Obviously emergencies may arise where it may be sensible to do so but this guidance should be adhered to wherever possible.
Primum non nocere
The concept of "first do not harm" has been enshrined in medical ethics for centuries but one must bear in mind that there is no intervention that does not have some slight risk. Thus, although doing no harm should be one's first consideration, it must not prevent the clinician from avoiding all treatments which have some risk attached. Therapeutic nihilism is as unethical as negligent practice. When providing care, consider the risks and benefits and, where significant, discuss these with the patient and record the discussion in the notes.
The matter of risks and benefits must be judged on what was known at the time. The retrospective observation of an adverse incident does not necessarily mean that the decision was wrong.
Avoidance of pitfalls
- Ethics is about thinking. Do not be afraid to think.
- There may well be more than one correct answer. Do not be afraid to discuss ethical issues or to seek advice.
- Record ethical considerations just as you would clinical matters.
- Keep the welfare of your patient to the fore. Talk and communicate.
- Patients have the right to make bad decisions. They are permitted to follow adverse lifestyles and a sane person may refuse effective, even life-saving treatment
- Treat the Mental Health Act with respect. You are being asked to deprive a person who has not committed a crime of his or her liberty.
- Be broad-minded. Not everyone shares your views and values and they have a right to differ.
- You may not have the right to prevent a patient from acting in a way that you consider to be inappropriate but that does not mean that you condone it. You have a right to express your views but not to enforce them.
- Be prepared to justify your position.
- The GMC advises that, if you are concerned about a colleague's conduct, performance or health, the safety of patients must be your first priority. You should submit an honest appraisal of your concerns, to an appropriate person from your contracting or employing authority. If this fails to resolve the issue or there is no local system, you should contact the relevant regulatory body (the GMC, in the case of GPs). You may want to discuss your concerns with an uninvolved colleague, a professional organisation or your defence body before taking this step.
Further reading & references
- Consent, Dept of Health
- Medical Ethics Committee, British Medical Association, 2010; Links to BMA ethics resources, many free to non-members
- Good Medical Practice, General Medical Council
- The Hippocratic Oath. Translation of the original
- List of Ethical Guidance, General Medical Council
- Child protection - Confidentiality and record keeping in the context of child protection, CKS Knowledge Plus
- Confidentiality and information sharing, National Treatment Agency for substance misuse
- Consent guidance, General Medical Council
- Research Governance, Dept of Health
- Investing in General Practice. The new GMS Contract, Dept of Health
|Original Author: Dr Laurence Knott||Current Version: Dr Laurence Knott|
|Last Checked: 21/01/2011||Document ID: 2445 Version: 25||© EMIS|
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