Category Archives: Ethics

GIRFEC

Getting it right for every child. A framework for dealing with children and young people, looking at a range of values (SHANARRI).

Children and Young People (Scotland) Act 2014 made provision for Named Person and Child’s plan, but after review in 2019, amid privacy concerns (brought by Christian Institute, among others), government decided not to pursue legislation. Supreme court found that “duty to share information”, although well intentioned, was potentially at odds with article 8 of European convention on Human rights (“Privacy and family life”).

[https://www.gov.scot/publications/getting-right-child-practice-development-panel-report/]

Remote consultations – use of images

Clinical images are part of the medical record. Especially when they are being used to make clinical judgments, they should be retained, which means discussing transfer, storage and use of images.

Transfer – not subject to information governance and data protection rules until received! Whatsapp automatically uses end to end encryption.

Storage – needs to be deleted from your phone/device. NB Whatsapp has option to automatically save to phone. Arrange storage with NHS approved service, or else ask family to retain.

Use – needs specific consent to reproduce in any form, for specified purpose.

Document verbal consent.

If patients are unsure of sharing images, you could try sending illustrative images of the suspected condition.

Doctor-patient communication

Consultations – patient’s opening chat is interrupted by their doctor after mean 18 secs.  Patient talk for 40% of total consultation time, estimated by doctor at 60%.

Wayne et al 2011 – less info given to poorer and minorities, more dialogue and more informative with better educated, more literate patients

Neumann 2011 – decline in medical empathy: significant through medical school,  further declines through residency.  “Hidden” curriculum? Hardening/cynicism?

Rosenthal 2011 – humanism and professionalism student module, no decline in 3rd year student empathy.

Chen 2012 empathy associated with women, non-technological specialty preference, high debt!

Roter and Hall 2006 – doctors like to retain authority but poor at managing confrontation eg eye contact, picking up emotional cues of distress

Psychodynamic approach – counter transference (disgust, judgemental), counter resistance (non-compliance)

Narrative as diagnosis!  William Osler – the diagnosis is in the story.

Communication and teamwork “skills” underestimates complexity, the affective component.  Only learned if valued, rather than as something to be acquired

Heroic individualism valued in medicine, cf dialogue

Students struggle to make conversation with patients!  Fear of intrusiveness, failure to connect medical issues with psychosocial elements.

Best – learn through active reflection on work based learning (cf how artificial PBL etc are).  Think about values, how they shape communication.  Modelling of democratic values.  Appreciation of complexity of communication.

[ Alan Bleakley, Peninsula medical school – Homer as evidence of honour/shame/face directed behaviours, cf feminine, guilt directed behaviours etc]

Safety Nets

Top tips for safety-netting

  • Be specific in the advice given – ‘If xxxx happens, please ring the surgery or out of hours provider immediately.’
  • Provide a likely timescale for when you believe symptoms should have resolved – ‘Your cough should clear up soon if it’s due to the chest infection. If it’s still there in two weeks, please book an emergency appointment to see me.’
  • It can be helpful to book an appointment for follow up yourself. Telling a patient you’d like to book them in to review their progress in a couple of weeks is safer than just saying, ‘book an appointment if it’s not better.’
  • Consider giving written information and patient leaflets to reinforce verbal advice.
  • Document the specific advice, given rather than simply saying ‘advice given’.
  • Check that patients are aware of how to access advice if you’re not available, such as by giving the number of the Out Of Hours provider.
  • Bear in mind the need to re-assess if symptoms are not settling, or if there is no response to the treatment you have given. Be prepared to reconsider an earlier diagnosis.

[Sarah Jarvis, MDU]

LGBT issues

Sexual orientation vs sexual practices vs gender identity.

“Coming out”  means primarily acknowledging your own lesbian, gay, bisexual or transgender identity to yourself.  Coming out to others is not a one-off experience, LGBT people have to make decisions on whether to (or not) disclose, often on a daily basis. This can be an ongoing source of stress and distress.  Heterosexism – assumption of heterosexuality, +/- judgment of its superiority in terms of moral value.

Harassment in the workplace can lead to the organisation and/or the individual being found liable and having to pay compensation.

The umbrella term transgender includes transsexual people and transvestites.

A trans-man is someone who transitions from a female label at birth to a male gender identity.  When the transition is complete, their trans identity could be considered a part of their past medical history, rather than an on-going identity.

Trans vestites (medicalized? “Cross-dressers” better?) have no desire for any permanent transition but enjoy aspects of the opposite gender and may have a temporary identity including a different name.

Trans sexual protected under Equality act by EU gender directive 2007.

It is the impact on the individual that determines whether bullying, harassment or discrimination has occurred, not the intentions of the perpetrator.

Gender recognition act 2004 allows trans sexual people to apply for full legal recognition of their acquired gender (evidence must be provided).  It is also a crime to disclose previous gender without express permission.

Under legislation it is also illegal to discriminate against someone on the basis that they are heterosexual!

[Good LGBT practice in NHS document, Stonewall Scotland]

Parenting and permanence orders

Permanence order is mechanism for local authority to apply for parental rights and responsibilites to be removed from parents.

Not specifically detailed in law (2007) but “threshold test” must be satisfied:

  1. living with parent poses threat of serious detriment to welfare of child
  2. the need to safeguard and promote welfare of child is paramount consideration
  3. that it is better for the child that the order be made, than that the order not be made

Supreme Court decision In the matter of EV (A Child) (No 2) (Scotland) 2017 –

Not duty of parents to prove parenting ability, but for social work to prove lack of ability with full assessment (or adequate records and sworn evidence of non-engagement).

Also, although allegations of harm may be sufficient reason to place child in care, not sufficient for seeking “permanence order”.  Given that this may mean waiting on criminal proceedings to be completed, children may be stuck in hearing system for longer than before.

[https://andersonstrathern.co.uk/news-insight/supreme-court-permanence-order-decision-lessons-learned/]

 

Bawa Garba case

High Court ruling regarding Dr Hadiza Bawa-Garba following the tragic death of a 6-year-old boy in 2011. Subsequently convicted of manslaughter. Removed from the GMC register, although Medical Practitioners Tribunal Service (MPTS) decision was to suspend for a year.  GMC appealed, saying it had not taken into account the manslaughter conviction.

High Court then overturned erasure, saying that tribunal did not commit any errors in its procedures, and therefore its conclusions were valid.

The trust acknowledged systemic failures, so why the vindictiveness? Its report into the death (“no single error responsible for death”) was not brought before jury, as being beyond scope of the trial! Not lazy or under influence, rather, took on extra duties in overstretched hospital with very little supervision.

And since when was gross negligence manslaughter law the right way to deal with errors made by doctors in training?

Why not corporate manslaughter case against trust?

Concern about reflective notes being used in court – despite being confidential? Used in support of Dr Bawa-Garba to show remediation efforts.

Twitter response from consultants was to emphasise “WE are responsible – so long as you tell us what’s going on”.

Subsequently 2 reviews –

  • Marx review by GMC
  • Williams review by government into medical gross negligence.
    • Suggested that GMC lose right to appeal Tribunal decisions.  Most of these appeals have been regarding sexual misconduct cases.  Professional standards Authority would still be able to appeal.
    • Suggested that GMC not be allowed to access reflective notes eg portfolio.  Could still be used as evidence in prosecution, however, not clear whether would help defence or prosecution more
    • Touched on high rate of cases involving black or minority ethnic doctors, but did nothing other than suggest BAME representation in investigations
    • Recommends explanatory note for gross negligence law, to improve consistency.  Law remains the same, however

Insurance and genetic testing

You have to answer truthfully any question you are asked when applying for insurance.  You do not need to volunteer information not asked for!

The Government and the ABI have a policy framework (‘Concordat’) for cooperation that includes a voluntary Moratorium on insurers’ use of predictive genetic test results (NOT diagnostic tests) until 1 November 2019, (to be reviewed in 2016).  So for most tests, companies cannot force test before providing cover, customers do not need to disclose result while insurance in place, and do not need to disclose results of blood relatives.

Only one exception currently, for cover above £500 000 and Huntingdons.  Certainly no need for time limited policies eg travel, private medical care; really just for life insurance, critical illness and income protection. Recognition that increased risks of a small minority can be mitigated by larger population of policies [2014]  Evidence from US is that significant proportion conceal their diagnosis.

Asymmetry of information—when the customer knows more than the insurer—is the industry’s nightmare.  Testing positive for ApoE4, a mutation of a gene related to increased risk of Alzheimer’s, would be a good reason to get life insurance before symptoms develop.

See also ethics.

Death certificates (Scotland)

New system from 2015.  Medical Certificate of Cause of Death (MCCD) provides a permanent legal record of the fact of death and enables the family to register the death, make arrangements for the disposal of the body, and settle the deceased’s estate. In addition, a MCCD provides a record of causes of death for public health reasons.

Electronic system available but paper copy remains legal, and family  needs it to register death.

Ideally consultant responsible for patient completes or is at least involved in completion.  This should be recorded in notes.

New system of reviews:

  • In the shorter level 1 review cause of death checked, reviewer will speak to the certifying doctor about anything unusual. If the certifying doctor is unavailable or incapacitated, the Medical Reviewer will discuss the MCCD with the consultant in charge of the case or another member of the team who knew the deceased and / or has access to the clinical records.
  • A level 2 review is similar to a level 1 in that the Medical Reviewer will check the MCCD and speak to the certifying doctor. However, in addition, the Medical Reviewer will also consider relevant documents associated with the death, including health records and results of investigations. They may also wish to view the body.

These review types will be conducted through a random selection process, will be available on request in certain circumstances from interested persons, or may be targeted by Medical Reviewers in response to any emerging pattern that requires further checks.

The last type of review is the “Interested Person” review – provides further reassurance. Includes relatives, any person present at death, healthcare professional involved with deceased etc.  Must be within 3yrs of death, and can only take place if not already reviewed randomly.  Request to medical review service.

Tips for Certifying Doctors

Contact the Death Certification Review Service (DCRS) by phone or email for help, open Monday to Friday 08:30-17:30. There is an on-call medical reviewer available out of hours.

Consider whether there is any reason to report to or discuss the case with the Procurator Fiscal (guidance here) e.g. trauma has been identified as a cause or contributor to death, there is a complaint about the care provided prior to death etc.

If you have discussed a case and agreed with the Procurator Fiscal that the case does not need to be formally reported, then do not tick the “PF” box.

Your writing should be in CAPITALS using BLACK ink throughout when completed by hand.

The time of death is the time that to the best of your knowledge and belief you think the patient died and NOT the time that death was verified.

Use business telephone numbers; do not include personal mobile numbers.

You must not include any abbreviations except HIV or Aids which are both permissible.

The causes must make sense both medically and chronologically. If you use more than one line in section 1 then what is entered in 1a MUST be caused by what is in 1b which MUST be caused by what is in 1c etc. Durations likewise should be sequential.

Sites and organisms in infections, including resistance and routes of infection are important and should be entered if known.

If you wish to enter a cause of death that you believe is the case but you have no confirmatory evidence, you can qualify it with “Probable” or “Presumed”.

If obesity has significantly contributed to the death it should be included.

None of the form is optional and all parts and questions on both sides should be considered and answered as appropriate.

It is the statutory duty of the doctor, who has “attended” the deceased during the last illness, to issue the MCCD. There is no clear legal definition of “attended”, but it is generally accepted to mean a doctor who has cared for the patient during the illness or condition that led to death and so is familiar with the patient’s medical history, investigations and treatment. It is not unlawful to complete a certificate if you have not personally attended the patient but you have to be in a position to certify to the best of your knowledge and belief and willing to be personally accountable having had access to the appropriate records.

If you cannot issue an MCCD you should contact a colleague who can, or discuss/report to the Procurator Fiscal.

[HIS tips – Support around Death (SAD) website]

 

Hospitality

It is acceptable for staff to receive small tokens of gratitude from a relative or carer in appreciation of care and treatment received. These are typically cards, chocolates or biscuits. Where staff are offered gifts of greater value these must be politely refused. [bottles of wine?  Whisky?]  If this is difficult they must refer the matter to their line manager.

Hospitality

It is acceptable for staff to receive small promotional items, e.g. pens, calendars, diaries. However,

  • staff must not accept any offer of a gift or hospitality from any individual or organisation which stands to gain or benefit from a decision NHS Lanarkshire maybe involved in determining, or who is seeking to do business with NHS Lanarkshire.
  • staff must not accept any offer, by way of gift or hospitality, which could give rise to a reasonable suspicion of influence on their part to show favour, or disadvantage, to any individual, organisation or company.
  • staff should consider whether there may be a reasonable perception that any gift received by their spouse or partner or by any company in which they have an interest, or by a partnership of which they are a partner, can or would influence their judgement.

Note – the term ‘gift’ includes benefits such as provision of services at a cost below that generally charged to members of the public.

Modest hospitality may be acceptable provided it is normal and reasonable in the circumstances e.g. lunches in the course of a working visit. Any hospitality accepted should be similar in scale to that which the NHS as an employer would be likely to offer.

All other offers of hospitality should be declined.

Staff should register with their line manager all such modest hospitality which they wish to accept, using the hospitality register declaration form (Appendix 3). In cases of doubt, staff should seek advice from their line manager.

If the nature of the event dictates a level of hospitality which exceeds this, then the individual should ensure that their line manager is fully aware of the circumstances and approves their attendance. An example of such an event might be an awards ceremony involving a formal dinner. If the line manager grants approval to attend, the individual should declare their attendance in the register of hospitality held by their line manager. The approving manager must ensure that this will not result in any future conflict of interest.

If the individual is invited to an event in a private capacity (e.g. as result of their qualification or membership of a professional body), they are at liberty to accept or decline the invitation without referring to their line manager. The following matters should however be considered before an invitation to an individual acting in a private capacity is accepted.
a) The individual should not do or say anything at the event that could be construed as representing the views and/or policies of NHS Lanarkshire.
b) If the body issuing the invitation has (or is likely to have, or is seeking to have) commercial or other financial dealings with NHS Lanarkshire, then it could be difficult for an individual to demonstrate that their attendance was in a private and not an official capacity. Attendance could create a perception that the individual’s independence had been compromised, especially where the scale of hospitality is lavish. Individuals should therefore exercise caution before accepting invitations from such bodies and
must inform their line manager.
c) Where suppliers of clinical products provide hospitality it should only be accepted in association with scientific meetings, clinical educational meetings or equivalent, which must be modest, normal and reasonable in the circumstances and in line with what the NHS would normally provide. Any such hospitality should be held in appropriate venues conducive to the main purpose of the event. 

Sponsorship [should be] clearly disclosed in any papers relating to the meeting; products discussed should be described in relation to the Scottish Medicines Consortium, Formulary and the active promotion of clinical products is restricted to those in the Board’s Formulary and equivalent clinical product catalogues.

Any educational meetings hosted by suppliers must be approved by the line manager.

Before accepting an offer of hospitality the individual concerned should fill in a Registering Hospitality Declaration Form (attached as appendix 3) and have it approved by their line manager. A copy of the request form will be held as part of a Hospitality Register which will be available for scrutiny by the
NHS Board, Corporate Management Team, members of the public or press should they request such information.