ETHICAL ROUNDS:

PRINCIPLES AND PRACTICE

SIVALINGAM NALLIAH
PROFESSOR
OBSTETRICS & GYNAECOLOGY
INTERNATIONAL MEDICAL UNIVERSITY

THEORIES AND
PRACTICE
UTILITARIANISM
DEONTOLOGY
APPLIED ETHICS
VIRTUE THEORY

Theories
UTILITARIANI
SM
Right
consequences
DEONTOLOG
Y
Right principles
APPLIED
ETHICS
Rights and
duties
Virtue theory

Autonomy
Self determination
Protection
Non-maleficence
Beneficence
Equity
Justice
Fairness
Respect

www.newscorpse.com

MEDICAL EDUCATION 2010; 44: 11171147

http://www.medscape.com/features/slideshow/public/ethic
s2012#1 n=24000 physicians

WHY DO WE NEED ETHICIAL ROUNDS?

Clinics with no patience

2010/02/08 NST

Annie Freeda Cruez

KUALA LUMPUR: A total of 457 medical establishments
nationwide failed to comply with the Private Healthcare
Facilities and Services Act 1998 and remained
unregistered with the Health Ministry.

Dr Conrad Murray
Charged with Manslaughter
-Michael Jackson
09-02-2010
California

GREED, VALUES AND

PROFESSIONALISM

GREED LEADING TO INCREASING HEALTH COSTS (NST 23RD MAR 2006)

NEED TO INSTILL MORAL AND HUMANISTIC VALUES AND ASPECTS IN

MEDICAL CURRICULUM
INCREASING ADVERSE COMMENTS

BRIDGET MENZES
(COLUMN WRITER IN SERENDIPITY -NST 14TH JUNE 2003)

ROGUES IN WHITE COAT

SUSPENSION OF 100 DOCTORS BY THE FOREIGN WORKERS MEDICAL
EXAMINATION MONITORING AGENCY (FOMEMA)
IF DOCTORS ARE DEEMED TO BE JOINING THE ROGUES GALLERY IN DROVES, HOW DO
WE KEEP SOCIETYS FAITH IN THIS RESPECTED PROFESSION?
ROCKYS BRU
AHIRUDIN ATTAN
SUNDAY PEOPLE 13TH NOV. 2005

ROGUES IN WHITE COAT

NOTHING WILL PROMOTE THE INTEGRITY OF THE PROFESSION WHICH , OF

LATE , HAS ALREADY BEEN HIT BY THE UNBECOMING BEHAVIOUR OF SOME
OF ITS PRACTITIONERS GREEDY GPS SELLING MEDICAL CHITS TO LAZY
WORKERS FOR A FEW RINGGIT, YOUNG DOCTORS TURNING THEIR BACKS
ON THE COUNTRY..

ROCKYS BRU
AHIRUDIN ATTAN
SUNDAY PEOPLE NOV 13, 2005

ETHICAL DILEMMA

FRAGMENTATION
SUBSPECIALIZATION
MEDICAL TECHNOLOGY
MANAGED CARE
PATERNALISM
DEFENSIVE MEDICINE
TERMINAL ILLNESS
MEDICAL INSURANCE

DECISION TO GIVE CHEMOTHERAPY

TO PATIENTS WITH ADVANCED
METASTATIC SOLID TUMORS SHOULD
CONSIDER PATIENTS
PERFORMANCE STATUS
ONLY GIVEN TO THOSE WHO CAN
ATTEND CLINIC UNAIDED!
BRODY H NEJM
www.nejm.org/doi/full/10.1056/nejmp0911423

ETHICAL DILEMMA
COLONY STIMULATING FACTORS
(CSM) SHOULD BE AVOIDED OR USED
IN LOW DOSE AS NO IMPROVED
SURVIVAL IS SEEN
PATIENTS WITH PROGRESSIVE
CANCER SHOULD BE SWITCHED TO
PALLIATIVE CARE AS CHANCE OF
SUCCESS IS MINIMAL
Smith T & Hillner
Need for overhaul of cancer treatment
Massey Cancer Centre NEJM ;364;2060

Self determination

Consent to progress

Distributive justice

VALUE OF ETHICAL ROUNDS

OPPORTUNITY FOR ETHICAL
DISCOURSE
EXPLORE OWN PERSONAL SETS OF
VALUES
BALANCE THIS WITH PROFESSIONAL
SET OF VALUES
CONSIDER MORAL FABRIC OF BOTH
INSTITUTE AND COMMUNITY
(SOCIETY)
HELP DISCUSS DIFFICULT TOPICS
AND ADDRESS HIDDEN CONFLICTS

RESOLVING INTERNAL CONFLICTS

USING ETHICS DECISION MODELS
CORRECTLY ADDRESS ETHICAL
DILEMMAS

THE BIGGER PICTURE

ETHICAL PRINCIPLES GOVERN
PRACTICE
CONSIDER NATURE OF PRACTICE AND
PROFESSIONAL PRACTICE ( VALUE OF PRACTICE
GUIDELINES-EBM)
OBLIGATIONS OF INDIVIDUALS (VALUE BASED
PRACTICE)

TO PATIENT ( AS PRIORITY?)

COMMUNITY AND SOCIETY

THE LIVERPOOL CARE PATHWAY

www.cdc.gov.

TRUST
THE RELATIONSHIP IS NOW
EGALITARIAN AND
PATERNALISTIC
PHYSICIAN-PATIENT RELATIONSHIP
LEGAL CONCEPT
PHYSICIAN-PATIENT RELATIONSHIP ARE
IN A FIDUCIARY RELATIONSHIP
INCORPORATES SPECIAL OBLIGATIONS
OF TRUST AND CONFIDENTIALITY
THE THERAPEUTIC ALLIANCE
PATIENT IS MY PRIORITY

TRUST ME BECAUSE I KNOW WHAT IS

BEST FOR YOU!
TRUST ME , BECAUSE I HAVE
SHOWN THAT YOU CAN TRUST ME

PRACTICE GUIDELINES COULD

CONFLICT WITH THESE NEW
DEVELOPMENTS IN CLINICAL
CARE
IN INDICATED CASES

ETHICS AND FUTILITY IN

MEDICINE

American Medical Association:

The right of the patient to choose

does not imply the right to demand care beyond
appropriate options based on medical judgment and
accepted standards of care . . .
(Council on Judicial Affairs, 1992).

Hence there is no professional or moral

obligation to offer or provide treatment that is
determined to be futile according to the
standard

OPPONENTS OF MEDICAL FUTILITY

IT IS ABOUT POWER
WHO KNOWS BEST?

ENHANCING THE AUTHORITY OF THE

MEDICAL PRACTITIONER, PLAYING A
DOMINANT ROLE IN DECISION MAKING

FUTILITY
(SUSAN RUBIN)

Evaluative futility
(based on evaluative
judgment)
Treatment is not appropriate
and not worth it

Factual Futility
(based on fact judgment)
Treatment is ineffective ,
does not work

RESOLVING THE DILEMMA

Physician
Authority

Patient and
Surrogates
Views

DoctorPatient
Relationship

Shared Decision Making

A WORKING MODEL
(VEATCH R, 2005)

Demanded treatment, physiologically futile

Physician
should refuse
this

Evaluate against
existing health
delivery system

Social Dialogue

Competing for scarce resources

Treatment likely to achieve patients goals though

physician feels it is valueless

THE WAY FORWARD

There is a need to REGULATE medical futility
due to escalating health costs and scarce
resources

Factors to consider are medical facts,

normative values, socio-economic status
Consider societal interest and opinions of
patient and family

DIALOGUE TO BE ESTABLISHED

Patient
Autonomy

Doctors
Paternalism

DIALOGUE TO BE ESTABLISHED

GOOD CLINICAL PRACTICE

EVIDENCE BASED PRACTICE
PRACTICE GUIDELINES
EXPERT OPINION
HOSPITAL PROTOCOL

VALUE BASED PRACTICE

ETHICAL ISSUES ARISE WHEN THERE
ARE CONFLICTS OF VALUES OR
SOMETIMES AIMS

GOOD CLINICAL PRACTICE

EVIDENCE BASED PRACTICE
PRACTICE GUIDELINES
EXPERT OPINION
HOSPITAL PROTOCOL

VALUE BASED PRACTICE

ETHICAL ISSUES ARISE WHEN THERE
ARE CONFLICTS OF VALUES OR
SOMETIMES AIMS

Ethics committee and ethical ward round.

ARE THEY MANDATED IN YOUR INSTITUTE?.

EXPERTS
TARGETED ETHICS ROUNDS
ETHICS GRAND ROUNDS FOR
EDUCATION AND INTERACTION
RESOURCE CENTER
NEW EMPLOYEE ORIENTATION

http://www.medcrunch.net/w

 EXPERTS
THEORIES AND
PRINCIPLES

TARGETED ETHICS
ROUNDS

THE ETHICS COMMITTEE

ETHICS GRAND ROUNDS

FOR EDUCATION AND
INTERACTION

RESOURCE CENTER
NEW EMPLOYEE

REFERENCE

Nelson, L.J. and Nelson, R.M. 1992. Ethics and the Provision of
Futile, Harmful, or Burdensome Treatment
to Children, Critical Care Medicine, Vol. 20, pp. 427-433
Rubin, S. 1998. When Doctors Say No: The Battleground of
Medical Futility, Indiana University Press.

Doctor 2008 wordpress