Chapter Two - Physicians and Patients: Compassionate Doctor
Chapter Two - Physicians and Patients: Compassionate Doctor
Chapter Two - Physicians and Patients: Compassionate Doctor
CHAPTER TWO
PHYSICIANS AND PATIENTS
Compassionate doctor
Jose Luis Pelaez, Inc./CORBIS
Objectives
After working through this chapter you should be able to:
explain why all patients are deserving of respect and equal
treatment;
identify the essential elements of informed consent;
explain how medical decisions should be made for patients
who are incapable of making their own decisions;
explain the justification for patient confidentiality and
recognise legitimate exceptions to confidentiality;
recognize the principal ethical issues that occur at the
beginning and end of life;
summarize the arguments for and against the practice of
euthanasia/assisted suicide and the difference between
these actions and palliative care or forgoing treatment.
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Case Study #1
Dr. P, an experienced and skilled surgeon,
is about to finish night duty at a mediumsized community hospital. A young woman is
brought to the hospital by her mother, who
leaves immediately after telling the intake
nurse that she has to look after her other
children. The patient is bleeding vaginally
and is in a great deal of pain. Dr. P examines
her and decides that she has had either a
miscarriage or a self-induced abortion. He
does a quick dilatation and curettage and tells
the nurse to ask the patient whether she can
afford to stay in the hospital until it is safe
for her to be discharged. Dr. Q comes in to
replace Dr. P, who goes home without having
spoken to the patient.
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A person who
is afflicted with AIDS
needs competent,
compassionate
treatment.
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treat them well. They may feel unable to resist sexual advances of
physicians for fear that their treatment will be jeopardized. Moreover,
the clinical judgment of a physician can be adversely affected by
emotional involvement with a patient.
This latter reason applies as well to physicians treating their family
members, which is strongly discouraged in many medical codes of
ethics. However, as with some other statements in codes of ethics,
its application can vary according to circumstances. For example,
solo practitioners working in remote areas may have to provide
medical care for their family members, especially in emergency
situations.
Communication and Consent
Informed consent is one of the central concepts of present-day
medical ethics. The right of patients to make decisions about their
healthcare has been enshrined in legal and ethical statements
throughout the world. The WMA Declaration on the Rights of the
Patient states:
The patient has the right to self-determination, to make free
decisions regarding himself/herself. The physician will inform
the patient of the consequences of his/her decisions. A mentally
competent adult patient has the right to give or withhold consent
to any diagnostic procedure or therapy. The patient has the
right to the information necessary to make his/her decisions.
The patient should understand clearly what is the purpose of
any test or treatment, what the results would imply, and what
would be the implications of withholding consent.
A necessary condition for informed consent is good communication
between physician and patient. When medical paternalism was
normal, communication was relatively simple; it consisted of the
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Competent patients
have the right to refuse
treatment, even when
the refusal will result in
disability or death.
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Decision-making for
incompetent patients
Many patients are not competent to make decisions for themselves.
Examples include young children, individuals affected by certain
psychiatric or neurological conditions, and those who are temporarily
unconscious or comatose. These patients require substitute decisionmakers, either the physician or another person. Ethical issues arise
in the determination of the appropriate substitute decision-maker
and in the choice of criteria for decisions on behalf of incompetent
patients.
When medical paternalism prevailed, the physician was considered
to be the appropriate decision-maker for incompetent patients.
Physicians might consult with family members about treatment
options, but the final decisions were theirs to make. Physicians have
been gradually losing this authority in many countries as patients
are given the opportunity to name their own substitute decisionmakers to act for them when they become incompetent. In addition,
some states specify the appropriate substitute decision-makers in
descending order (e.g., husband or wife, adult children, brothers
and sisters, etc.). In such cases physicians make decisions for
patients only when the designated substitute cannot be found, as
often happens in emergency situations. The WMA Declaration on
the Rights of the Patient states the physicians duty in this matter
as follows:
If the patient is unconscious or otherwise unable to
express his/her will, informed consent must be obtained,
whenever possible, from a legally entitled representative.
If a legally entitled representative is not available, but a
medical intervention is urgently needed, consent of the
patient may be presumed, unless it is obvious and beyond
any doubt on the basis of the patients previous firm
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In certain limited
circumstances it is not
unethical to disclose
confidential
information.
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can conflict with the respect for human rights that underlies medical
ethics. Therefore, physicians should view with a critical eye any
legal requirement to breach confidentiality and assure themselves
that it is justified before adhering to it.
If physicians are persuaded to comply with legal requirements to
disclose their patients medical information, it is desirable that they
discuss with the patients the necessity of any disclosure before it
occurs and enlist their co-operation. For example, it is preferable
that a patient suspected of child abuse call the child protection
authorities in the physicians presence to self-report, or that the
physician obtain his or her consent before the authorities are notified.
This approach will prepare the way for subsequent interventions. If
such co-operation is not forthcoming and the physician has reason
to believe any delay in notification may put a child at risk of serious
harm, then the physician ought to immediately notify child protection
authorities and subsequently inform the patient that this has been
done.
In addition to those breaches of confidentiality that are required
by law, physicians may have an ethical duty to impart confidential
information to others who could be at risk of harm from the patient.
Two situations in which this can occur are when a patient tells a
psychiatrist that he intends to harm another person and when
a physician is convinced that an HIV-positive patient is going to
continue to have unprotected sexual intercourse with his spouse or
other partners.
Conditions for breaching confidentiality when not required by law
are that the expected harm is believed to be imminent, serious (and
irreversible), unavoidable except by unauthorised disclosure, and
greater than the harm likely to result from disclosure. In determining
the proportionality of these respective harms, the physician needs
to assess and compare the seriousness of the harms and the
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Beginning-of-life Issues
Many of the most prominent issues in medical ethics relate to the
beginning of human life. The limited scope of this Manual means
that these issues cannot be treated in detail here but it is worth
listing them so that they can be recognized as ethical in nature and
dealt with as such. Each of them has been the subject of extensive
analysis by medical associations, ethicists and government advisory
bodies, and in many countries there are laws, regulations and
policies dealing with them.
Contraception although there is increasing
international recognition of a womans right to control her
fertility, including the prevention of unwanted pregnancies,
physicians still have to deal with difficult issues such as
requests for contraceptives from minors and explaining the
risks of different methods of contraception.
Assisted reproduction for couples (and
individuals) who cannot conceive naturally there are various
techniques of assisted reproduction, such as artificial
insemination and in-vitro fertilization and embryo transfer,
widely available in major medical centres. Surrogate or
substitute gestation is another alternative. None of these
techniques is unproblematic, either in individual cases or
for public policies.
Prenatal genetic screening genetic tests are
now available for determining whether an embryo or foetus
is affected by certain genetic abnormalities and whether it
is male or female. Depending on the findings, a decision
can be made whether or not to proceed with pregnancy.
Physicians need to determine when to offer such tests and
how to explain the results to patients.
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