Category Archives: Ethics

Fairness

Ethics, Generic

Raanan Gillon campaigned successfully for fairness to be added to the World Medical Association’s International code of medical ethics (with respect to both patients and professionals).

It therefore joins beneficence, non-maleficence and respect for autonomy as one of the cardinal principles (Beauchamp and Childress).

What fairness means is debatable, however. And these different principles can conflict.

But it still has value as a way of analysing ethical problems. Hopefully in advance of the problem becoming real for someone.

Aristotle’s theory of justice or fairness is a good place to start – “equals should be treated equally” is straightforward, but it also includes “unequals should be treated unequally, in proportion to their inequalities). In other words, some people may need to be treated differently (“unequally”) because they need the treatment more.

Circumcision

Ethics, General paediatrics, Neonatology, Sociology, Surgical

Still routine practice in many parts of the world, including the USA. Last figures I can find suggest 56% of US boys circumcised, with higher rates among non-Hispanic white boys, which is down from previous decades.

The Royal Dutch Medical Association declared in 2010 that male circumcision as routine practice or for religious reasons is medically unjustified and therefore an abuse of the rights of the child.

In 2013 the Children’s ombudsmen of the Nordic countries proposed a ban. In Sweden it is illegal in the first 2 months of life, following a death from complications in 2001 (an attempt at an outright ban was watered down).

In the UK there have been legal cases where parents have disagreed on their son having the procedure.

Trials in Africa suggested that circumcision might help prevent spread of HIV (38-66% reduced risk). South African president Jacob Zuma made a point of getting circumcised, to encourage others.

Risks are low in neonates cf adults.

Muslim and Jewish cultures see it as part of cultural identity, of course.

Faye Hawkins case

Clinical governance, Ethics, General paediatrics, Generic

A consultant paediatrician who received a formal warning from the GMC for missing a case of fatal appendicitis.

Found that she failed to consider possible underlying serious cause for fever, and that lethargy and mildly elevated heart rate are “red flags”. But actually, they are not – common and poorly predictive, and not in NICE Fever in under 5s table. Patient was 5 already, anyway. Did not flag on Sepsis tool.

Also found that she failed to examine again or look for other possible red flags when she discharged Elspeth from hospital; failed to adequately advise parents on how frequently they should monitor her temperature and pain symptoms; and failed to record the advice given in the notes.

British association for general paediatricians complained that the pressure of the acute unit were not taken into account, but GMC response was that tribunal (which is independent from GMC) took this into account, although they could not agree on what standards for a “reasonably competent clinician” could be applied!

Medical Professionalism

Ethics, Generic, Patients

“We teach good communication skills because we accept not everyone has them. But we also need to teach professionalism… We’re happier to challenge poor clinical skills, or to point out a gap in knowledge, than to have a conversation about behaviour or attitudes.”

“We expect learners to improve and progress.  So, by implication, they’re not perfect professionals: they can make mistakes.  It gives people permission to say, “That doesn’t look professional”.”

“We need to work on accepting  constructive feedback for unprofessional behaviours… We want a positive culture, where we teach people to speak up to promote professionalism.”

[Sheona MacLeod, BMJ 2020;368:m768]

Easier to spot when people are being unprofessional than to teach professionalism!

Which makes me think the issue is conflicting values/priorities rather than not knowing what is “good medical practice”.

So dress codes become an issue when someone’s need to express their individuality or fit in with their peer group clashes with public perceptions of what a health care professional should look like.

Or someone complaining about their work place on social media is wanting to assert their independent spirit even as an employee, perhaps also their right to self expression and to attract “likes”.

And professionalism is clearly performative. We can swear all we want in our heads, but to swear out loud (in most cases) would be considered inappropriate. Which also potentially makes class an issue.

Expectations (of the public but also our peers) change over time. Consider suits, white coats, ties, scrubs. Consider also #medbikini twitter controversy – an article by men describes social media posts of women doctors in bikinis as potentially unprofessional.

Rosenthal 2011 – humanism and professionalism student module included blogging about clerkship experiences, debriefing after significant events, and discussing journal articles, fiction, and film. Main focus however was on empathy.

Scott Oliver and Kathleen Collins described differences in attitudes between medical school students which appeared to suggest a hidden curriculum. Students with more knowledge focus failed to identify potential issues of confidentiality, ethics or trust. Students who had not explored such issues struggled to know how to approach such issues even if they did recognise them.

Definition is probably best medical practice but also the duties and responsibilities of being an employee. High level morals/values (as in GMC good medical practice) are uncontroversial but also hard to then produce policies from (and which can then be defended in court when issues arise).

Clearly some personalities can be more playful, or disagreeable, which are not necessarily negative (cf engaging, whistleblowing) so perhaps more about defining the outer limits rather than homogenizing behaviour.

Surveillance capitalism; social dilemma documentary (mental health declines with higher use; disinformation campaigns; extremism encouraged by algorithms)

Social media is performative (Erving Goffman – the presentation of self (name of his book), life as theatre (metaphorically- although some say actual)). 

MedTwitter – now X of course 

Human face vs personality cult and influencers

Social media hygiene. 

Modelling in absence of “official” voices. 

Self curation of brand. Bordieu’s social capital. 

How to teach?

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]

“We teach good communication skills because we accept not everyone has them. But we also need to teach professionalism… We’re happier to challenge poor clinical skills, or to point out a gap in knowledge, than to have a conversation about behaviour or attitudes.”

“We expect learners to improve and progress.  So, by implication, they’re not perfect professionals: they can make mistakes.  It gives people permission to say, “That doesn’t look professional”.”

“We need to work on accepting  constructive feedback for unprofessional behaviours… We want a positive culture, where we teach people to speak up to promote professionalism.”

[Sheona MacLeod, BMJ 2020;368:m768]

Medical Humanities

Communication, Ethics, Generic, Patients

In education, Johanna Shapiro has done interesting work, for example including relevant poems into objective structured clinical examinations (Female, by Ingrid Hughes, about a woman facing a probable diagnosis of breast cancer; Dear Left Knee by John Davis; Back Pain, by Ingrid Hughes; Night on Call, by Dr Rita Iovino). A large proportion said they felt it increased empathy, and had a significant effect on how they might present bad news, on the ultimate treatment plan. Most felt the Night on call poem helped gain perspective. [Medical Education 2005]

In the same paper, adding some readings led students to say (in 1/3 to 2/3 of cases) that they would be more likely to take into consideration psychosocial insights, or that it increased some dimension of empathy for the patient, including helping them take the patient more seriously.

Themes written by doctors or medical students are commonly about the rewards and stresses, relationships, role models, death, the meaning of life – things not directly addressed in the curriculum.

The quality is less important that the utility to a particular audience.

[BMJ 2010]

Racism in Medicine

Ethics, Generic

Infant mortality for black babies in US double that of white babies.

Newborn mortality in Florida for black babies under care of black doctors 58% lower than those under white doctors. No difference for white babies. Still not as good as white mortality though.

Participatory medicine

Communication, Ethics, Generic, Health Literacy, Patients

Patient led campaign for better involvement of patients in their own care.

Manifesto has 5 principles:

  • Share and listen – acknowledge patients are experts in their own lives and bodies, use plain language.
  • Respect one another
  • Share information responsibly – help patients access the information they need, and respect confidentiality
  • Promote curiosity – be clear even when it is difficult to explain, encourage patients to do their own research and get involved in patient communities
  • Be a teambuilder – treat patients as collaborators, respect their goals, values and preferences

These are shared responsibilities, the patient has their own duty to be honest, ask questions, advocate themselves.

Institute of Medicine describes a continuously learning system (in respect of healthcare in the US), the second feature of which is Patient-clinician partnerships. This is explained as “engaged, empowered patients – a health care system anchored on patient needs and perspectives, and promoting the inclusion of patients, families and other care givers as vital members of the team“.

Unclear this happens on any significant level, especially when it comes to communication outside the hospital or clinic room. Studies have found that when patient portals or messaging systems are used, patients often respond with further questions or comments, which suggests unmet need and desire to engage further. Other studies have found that only a tiny minority of messages in such systems are initiated by the health care team, which suggests a reactive rather than active contribution to the partnership.

History of Medical Failures

Ethics, General paediatrics, Generic, Medical, Teaching and training

Where to start!? Leaches, blood letting, pretty much everything doctors did in the pre-modern period…

Thalidomide and birth defects, of course. But unforeseen.

X-rays for pregnancy monitoring. Took years before people paid attention to the alarms. X-rays were also used for tinea capitis – not just brain tumours, strokes and ischaemic heart disease about 30% higher too.

Ribavirin (via SPAG machines) for RSV. Not harmful, just useless and expensive.

Iron supplements for preterm babies – increased sepsis.

GIRFEC

Community, Ethics, General paediatrics

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

Ethics

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.