Medical Ethics

Ethics involves thinking. It is not simply a matter of complying with the dicta of the GMC, nor is it political correctness or religious zeal. It involves comprehension of issues that may be far from clear.

Ideals and the Hippocratic Oath have been covered in another article but it is worth repeating the summary given in that article.

All of medical ethics can be distilled into the words, Treat the patient at all times as you would wish others to treat you if you were the patient.

Much has been written about medical ethics and it would be impossible to cover everything here including the use of stem cells and primates in research or euthanasia, but this is an attempt to cover some of the aspects that are more pertinent to General Practice. This includes such basic issues as research ethics and consent.

Treat everyone as a person. In hospital medicine it helps to refer to them by name rather by diagnosis. This tends to be less of a problem in Family Practice, but there are still heart-sink patients. The doctor should try to do what is in the best interest of the patient and not the Trust, the NHS or Society. This does not mean resuscitating the terminally ill. That is not kindness. We might ask if an intervention is really in the best interest of the patient. Are we prolonging life or prolonging death?

Not everyone is likable but we must try to avoid discrimination. Some people have a life-style that is not to our liking. Perhaps they are smokers, obese, travellers, drug addicts, unwashed, with a sexual orientation of which we disapprove, or perhaps they hold strong religious or political opinions that disturb us. If their life-style is such that it is deleterious to their health we may and should discuss the errors of their ways. Try to be helpful rather than judgemental. We should not refuse treatment purely on those grounds unless evidence-based practice shows that the intervention is useless unless they change their ways.

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 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 practice evidence-based medicine would be commendable if EBM were always available. A more realistic compromise would be to practice it wherever possible.

Good clinical practice also means being conscientious and devoting enough time to the patient. The doctor who is lazy or cares nothing for patients is far more unethical than one whose private life may meet with disapproval, providing that the private life does not impinge upon practice.

The notion of confidentiality is enshrined in the Hippocratic Oath¹ but it is not inviolable. A court may compel a doctor to break confidence as only a lawyer has client confidentiality enshrined in law, but a judge would give the matter grave consideration. A policeman does not have the right to pry into confidential matters and should be sharply rebuked if he tries. Guidance states that a doctor should breach confidentiality if it relates to a serious crime.² Thus if a doctor knows or suspects that a patient is a terrorist planning to kill many people his duty of care is to prevent this from happening. The problem is what constitutes a serious crime. If in doubt seek advice first. A doctor is also under obligation to breach confidence if the welfare of children is a stake.³ Doctors who deal with drug abusers may find problems about confidentiality and the public good.⁴ If a patient with epilepsy continues to drive despite warnings, the doctor should inform the DVLA as someone may be killed. Breach of confidentiality is not to be taken lightly and it may have serious consequences for the doctor/patient relationship⁵ and the doctor's reputation.

Confidentiality must also be respected when talking to relatives. Patients have the right to know about their condition and the right of access to their medical records. Parents or guardians have this right on behalf of minors but many people feel that they have similar rights for their elderly relatives. A person may be old, frail, dependent and ill but if he is of sound mind he has every right of confidentiality and this must not be breached. Consent must be sought before discussing medical matters, even with a spouse, but this can be informal. Verbal consent is usually adequate.

If the patient is unconscious or mentally incapable of consent the situation is more complex. Ask yourself what is in the best interest of the patient and what he would want if he were capable of giving consent. If in doubt, seek advice. In England, Wales and Northern Ireland relatives are unable to give consent for an incompetent adult but it is good practice to discuss options with them.

Communication with relatives is nearly as important as communication with patients but much neglected. Sometimes relatives make unreasonable requests including keeping a diagnosis of cancer from the patient.

Ask, "If it were you, would you wish to know or would you want me to hide it from you and tell your relatives instead?" Perhaps they would. Agree to probe the patient gently and to act in accordance with his wishes. It is the patient who must decide.

Divided Loyalties

The questions of loyalty to society and breach of confidentiality about a serious crime has already been mentioned but there are other occasions when loyalty may be divided.

Doctors who practice 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 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.

In the armed forces, the individual is both a doctor and an officer. In the past, there are many cases in which a member of the forces has admitted to a doctor about homosexuality and as a result faced court marshall and dishonourable discharge. The rules about this have changed but divided loyalties have not.

There may be divided loyalties with regard to medical care in prisons. Work as a police surgeon may bring problems.

Consent is not enough. It must be informed.⁶ This raises the question of how informed is adequate bearing in mind the intellect of the patient, how much is wanted and how much is desirable? 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 or 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 the vulnerable, 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 directive, also known as living wills. The subject has merited its own article.

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.⁷

When a young person under 16 comes alone to see the doctor, this creates problems of consent to treatment. The problem is validity of informed consent. If a 14 years old comes alone with impetigo few would have any reservations about issuing a prescription for an antibiotic. If the problem requires operative intervention, including minor surgery in the practice, most would want parental consent.

A relatively common problem is a girl under 16 who requests contraception. It is morally wrong and a criminal offence to have sexual intercourse with a minor. Some have argued that to supply contraception in these circumstances is to be an accessory to a crime. This is untrue as the crime does not require the prescription. The doctor does not facilitate the crime but is engaged in a harm reduction exercise to assure that underage sex is not compounded by underage pregnancy.

Victoria Gillick went to the High Court for a ruling that bears her name although it is not what she wanted. The 16th birthday is no longer regarded as a milestone at which a person suddenly transforms from incompetence to competence to make personal decisions. If the doctor is satisfied that the individual understands the implications and has sufficient maturity to comprehend, then treatment may occur.⁸ Similarly a person over 16 with learning disabilities may be incapable. This applies not just to contraception but to all forms of treatment.

Expert advice is that the doctor should try to convince the girl that she should involve a parent. If this would dissuade her from seeking contraception but not from sexual activity, it should not to be pursued. Some would argue that there are some things that are best kept from parents and that to make them give consent for contraception is inappropriate emotional manipulation.

The girl may be under pressure from an older boyfriend and while she does not want sexual intercourse she is afraid to refuse for fear of loosing him. If he does love her he will be prepared to wait but if he leaves her for this reason he did not love her but wanted to use her and she is better without him. This logic is usually lost on immature girls.

Many young people believe that GPs do not offer them confidentiality and this needs to be addressed. If it is true, it must be rectified. If it is untrue, the truth must be disseminated. Parents may ask about their offspring seeking medical advice and the answer must always be, "We have a practice policy that we do not confirm or deny if a consultation has taken place." If parents get to know that "No" means "No" and "I cannot tell you" means "Yes" there is no confidentiality.

Nowadays even a single-hand GP is part of a team. We must contribute to this team and afford professional respect and autonomy as necessary. We also need to share information with the team. All members of the team must share the tenets of confidentiality that have governed our profession for so long but this may need to be explored. It is not essential that everyone knows everything, and particularly where other professions may have a slightly different tradition, some sensitive information may be best withheld, provided that it does not compromise patient care.

The National Programme for IT (NPfIT), more recently called Connecting for Health, proposes that different levels of information may not be fully available for all health care professionals. Hence, a psychiatric history may not be available to a chiropodist or a GUM clinic visit to a nursing aid.

There are many reasons why a general practitioner may abdicate 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 are legion but most can be summarized as an irreconcilable breakdown of the doctor/ patient relationship.

Whilst patients may change doctors at a whim, the relationship is not mutual. Doctors should not remove a patient from the list because they refuse to take advice or change their lifestyles. Adherences to alternative practitioners or refusal to have a child given the MMR vaccine are not regarded as acceptable reasons. Making a complaint about a doctor or even litigation are not regarded as due cause to remove a patient from the list although many would argue most cogently that this would cause an irreconcilable breakdown of the doctor/ patient relationship.

Violence, the threat of violence or abusive behaviour are another matter and the NHS advocates a policy of "zero tolerance", a term that means the inability to think about individual circumstances. Violence, threats and bad language should not be tolerated but the circumstances need to be examined. Severe emotional distress may be seen as a mitigating factor. There may have been mental illness such as paranoid schizophrenia or physical illness such as hypoglycaemia. These can be treated with considerable leniency but being under the influence of alcohol or drugs is not a valid excuse.

It may be that formal removal is not necessary and that the best action is to suggest that the relationship is so damaged that it would be better to see another doctor, perhaps at a different practice. Try to appear reasonable and not punitive however you may feel.

It is good practice to write to the patient to explain the decision and this is enshrined in the new GMS contract, paragraphs 193 to 201. It is outlined in paragraphs 6.29 and 6.30 of the linked DoH statement.⁹ When a patient chooses to leave a doctor there is no reciprocal requirement. Be dispassionate and never commit in writing anything that could subsequently embarrass you.

When the doctor becomes a patient there must be the same rights of confidentiality as for anyone else. That is why the GMC does not hold Health Committee hearings in public or publish the outcome. The GMC recommends that a doctor should not treat his family or himself. This is basically sound but few of us would not treat our child who was crying in the night with otitis media or ourselves for a simple illness. Doctors should never treat themselves for depression or other mental disorders but nor should they go untreated.

Everyone in the country should be registered with a General Practitioner and that includes doctors. GPs would be wise to register with another practice. There may be problems of mental illness or abuse of drugs or alcohol that one would wish to keep from partners or there may be conflict of interest such as return to work after an illness.

Let your family have the benefit of treatment by one who is less emotionally involved than you.

The concept of "first do not harm" has been enshrined in medical ethics for centuries but it needs revision. It was fine when interventions were of dubious value and it was necessary to avoid doing harm but now there can be no intervention that does not have some slight risk attached and hence on the basis of "primum non nocere" we should never do anything. A much better dictum would be to ascertain that the chance of benefit significantly outweighs the risk of adverse outcomes. This is a question of balancing the risk of benefit or harm or the degree of benefit or harm. Thus it is not acceptable to prescribe oral chloramphenicol for an infection when a safer antibiotic exists although the risk of aplastic anaemia is very small. On the other hand quadruple therapy for a lymphoma may include doxorubicin that has a significant risk of causing myocardial damage but the risk of serious myocardial damage is outweighed by the benefit of effective treatment of the lymphoma.

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.

• 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 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.
• If you feel that a colleague is behaving badly or is practising below standard you should take up the matter with the individual or the appropriate authority but be discrete. Never be disparaging about others in public, to patients or in documents that may come to public attention.