Doctor and Medical Ethics

IDI CABANG SURAKARTA

The oldest code of medical ethics : Hippocratic Oath

“To consider dear to me, as my parents, him who taught me

this art; to live in common with him and, if necessary, to
share my goods with him…”
“Nor will I give a woman a pessary to procure abortion;”
“I will not cut for stone, even for patients in whom the
disease is manifest; I will leave this operation to be
performed by practitioners, specialists in his art.”
“First, do no harm”
 Ethics : What is right?

Moral - comes from Latin ‘mos’(mores)

Ethics - comes from Greek ‘ethos’
Both have meaning of customs or generally accepted
social norm
But ‘What is right’ is not just a matter of social norm (e.g.
slavery was a social norm at one time)
Professional norm is not always right, it does revise over
time
What is legally permitted is not always right
Ethical principles

Commonly quoted ethical principles :

– Autonomy
– Beneficence
– Justice
– Nonmaleficence
These are useful but by themselves are
not adequate for ethical decision making
 WHO : Patient rights understood as
one aspect of basic human rights
World Health Organisation :

Formalized in 1948, the Universal Declaration of Human Rights

recognizes “the inherent dignity” and the “equal and unalienable rights
of all members of the human family”. And it is on the basis of this
concept of the person, and the fundamental dignity and equality of
all human beings, that the notion of patient rights was developed.
In other words, what is owed to the patient as a human being, by
physicians and by the state, took shape in large part thanks to this
understanding of the basic rights of the person.

http://www.who.int/genomics/public/patientrights/en/
 WHO : Patient rights can vary in
different countries
World Health Organisation (WHO) :

Patients' rights vary in different countries and in different

jurisdictions, often depending upon prevailing cultural and social
norms.
Different models of the patient-physician relationship—which can
also represent the citizen-state relationship—have been
developed, and these have informed the particular rights to
which patients are entitled.

http://www.who.int/genomics/public/patientrights/en/
 Doctor - patient relationship based on
medical ethics

Some doctors are worried that the physician-patient

relationship, a special humanism motivated by
tradition and governed by the ethics of medicine, may
be fouled up by the fiscal and economic constraints
likely to occur in the health care system
Alvan Feinstein, MD, professor of medicine, Yale University School of Medicine, New
Haven, Conn.
 William C. Hsiao :
William C. Hsiao, PhD, Department of Health Policy and Management,
Harvard School of Public Health, Boston, Mass. "We have promoted the
diffusion of some technologies that may not be cost-effective and
encouraged their overuse…"
"Furthermore, we undercompensate primary care physicians,
discouraging them from rendering their services, and likewise (fail to
encourage) the young medical school graduates to pursue a career in
family care.
"Instead of trying to align the economic incentives to improve cost-
effectiveness, we are creating an administrative organization that will
intrude on this very personal relationship between doctor and
patients, between the caring physician with the technical expertise
and the patient,"
"Is that the best we can do to preserve this unique relationship?"

Marwick, Charles. Preservation of Physician-Patient Relationship Seen as Integral to Health Care System Reform
JAMA The Journal of the American Medical Association. Volume 271(12), 23 March 1994, pp 892-893
Models of Doctor-Patient Relationship

There are three different kinds of models :

1. PATERNALISTIC
2. CONTRACTUAL
3. FIDUCIARY
http://www.carroll.edu/~msmillie/bioethics/modelsdocpatrelation.htm
 Paternalistic model :
Strengths and Weaknesses

Paternalistic model : The doctor is the professional.

He/she gives the order, the patient obeys.
Strengths : Emphasizes the expertise and knowledge of
the doctor
Weaknesses :
– Ignores the autonomy of the patient
– Ignores non-health related but morally legitimate values of
the patient
 Contractual model :
Strengths and Weaknesses
Contractual model : The doctor and patient "contract"
for each other's mutual benefit; the patient determines
or agrees to the doctor’s decisions.
Strengths :
– Highlights the autonomy of both patient and physician
– Acknowledges cooperative/shared aspects of medical
decision-making
Weaknesses :
– No "contracts" developed or signed in real doctor/ patient
relationships
– Model doesn’t allow for at trusting relationship
 Fiduciary model :
Strengths and Questions
Fiduciary model : The patient confidently entrusts his/her health care
to the doctor, who takes on the obligation of working for the benefit of the
patient (Fiduciary: relates to a holding of something in trust for another)
Strengths :
– Preserves the freedom and autonomy of both patient and physician
– The legitimate role of physician knowledge
– The important role of trust in the doctor/patient relationship
Questions raised by skeptics :
1. Patient trust may be manipulated for further economic gain.
2. Patient trust may undermines consumer’s awareness of need for self-
protection
3. Serious illness and fear of death diminish patient autonomy and power
to contract any relationship.
A few cases for thought
 Case 1 : Refusal of treatment

A is prescribed for an elderly cancer patient by

the attending doctor, but he refuses. Must the
physiotherapist insist on carrying out the
treatment plan?
Is it unethical to go against the patient’s wish
(to refuse)?
 Dealing with refusal of treatment

When mentally competent and properly informed, the

patient’s refusal must be respected. [Principle of
respect for autonomy]
Assess mental capacity
Provide adequate and appropriate information
Treatments can be provided to mentally
incapacitated persons
based on ‘best interests’principle [Principle of
beneficience]
 Case 2 : Autonomy and family member

A patient’s son insisted that the doctor should

not tell his mother that she has been diagnosed
with chronic leukemia, otherwise he will take her
home against medical advice.
The mother seems to be generally passive and
submissive to the son’s decisions related to her
health care
How should the patient’s right be addressed?
 Resolving ethical dilemma related to
autonomy – advice for clinicians
Listen carefully – do not jump to conclusion of “patient
not cooperative” too easily
Gather more information relevant to the case situation
Consider your own bias and assumptions
Explore reasonable options of compromise
Involve carers and friends trusted by patient as
appropriate
 Case 3 : Demand of medical treatment

A patient with mental illness demanded to be

treated with the newest psychiatric drugs
The doctor assessed and found that the patient
was not suffering from significant side effect
from the existing drug, which is also one of the
newer drugs that had passed the patent period
(cheap generic drug is locally available)
What is the extent of patient right in this case?
Thank you for your attention