Ethical principles quiz

Navigate the ethical maze

The following dilemmas are typical of the scenarios that confront doctors in their working lives. In each case there are two responses but only one demonstrates that the doctor has considered their legal and ethical obligations. What would you do? asks Dr Mike Roddis.

A 13-year-old patient has an aggressive brain tumour. The majority of doctors in the multi-disciplinary team treating him believe that further aggressive treatment is futile and would cause unnecessary distress and they want to begin palliative care. His parents, who have no other children, are distraught and have questioned whether the hospital is giving up on their son. What should the doctors do?

A

The doctors know they are not obliged to provide any treatment which is not to the patient's overall benefit. However, they recognise the distress felt by the parents and hold a further meeting with them and their son to explore their concerns. When this does not result in consensus, they consult the trust's legal team about seeking a court order.

B

The team reluctantly agree to the parents' demands for a further round of chemotherapy treatment. Sadly the patient does not respond well and dies a few months later. His parents say they are grateful to the hospital for everything they have done.

A 17-year-old consults a cosmetic surgeon because she wants breast implants. She says that her small breasts make her self-conscious and she has been teased about them by her friends and family. Her parents have offered to pay for the surgery for her 18th birthday and she wants him to increase her cup size from a B to a DD. Should the surgeon agree?

A

The surgeon is deeply reluctant to operate on such a young patient. He is also concerned she is being pressured to have treatment by others and that her expectations are unrealistic. He explains his concerns to the patient and refers her to a counsellor. 

B

The surgeon decides that the patient would only go elsewhere if he refused to carry out the procedure and goes ahead after explaining the risks of damage to her breasts and other possible complications. 

An elderly patient who has had a second stroke has been deteriorating in hospital and is now unconscious. Her husband wants everything possible to be done to keep her alive until their daughter arrives back from Australia the next day. He says mother and daughter were close and his wife had been determined that her daughter should be able to say goodbye, expressing her wishes in writing. Should life be prolonged until the daughter returns, even if there is a risk that resuscitation would be unsuccessful and cause the patient pain?

A

Having been told of the patient's previously expressed wishes the team agree not to record a DNACPR decision in her notes at this stage. However, they tell the patient's husband that they need to keep the situation under review and this may change when their daughter returns. They explain that in some circumstances, it may not be clinically appropriate or to her overall benefit to attempt CPR and the doctor in charge of her care will need to make an appropriate decision if this happens. 

B

The care team decides CPR would cause the patient pain and has no realistic chances of success. However, they do not tell her husband that a DNACPR decision has been made because they do not want to cause him further distress.

A 15-year-old girl is brought into A&E after being found slumped in the street. She has been drinking heavily and has cuts and bruises but refuses to be treated or give her name and address. She is later seen to leave hospital with an older man but forgets her purse which contains an ID card. Should her details be reported to social services without her knowledge or consent?

A

The doctor in charge consults the trust's named doctor for child protection who agrees the local authority should be told. When the patient refuses consent, the doctor explains that he is so concerned about her safety that he has to pass on the information. He tells her what is likely to happen next and gives her the details of an independent advice organisation for teenagers.

B

The doctor in charge determines the patient is at risk and contacts the local authority straight away without seeking the patient's consent. He passes on the patient's contact details, the reason she was admitted and the treatment she received. He does not tell the patient what he has done.

Mostly A's

Congratulations, you recognise the ethical principles underlying good medical practice and always try to apply them to your day-to-day practice.

Mostly B's

It may be tempting to take the line of least resistance when managing a patient or dealing with relatives but this can backfire. 

For example, in bowing to parental pressure in the first case, the medical team lost sight of their duty to consider the risks, potential benefits and burdens to the patient. By reluctantly agreeing to carry out a breast enlargement on an unsuitable patient, the surgeon was not acting in her interests and could be vulnerable to a complaint or claim in future. Even if the doctor's action can be justified, such as a DNACPR decision on a very sick patient or disclosing a patient's details when they are at risk of harm, avoiding a tough conversation with the relative or the patient is not an ethical response.

Taking an ethical approach means being able to assess each situation dispassionately and recognise the principles of Good Medical Practice that apply. Where there are conflicts, such as between a patient's right to confidentiality and the public interest, it requires judgment to balance the arguments on each side and decide which carries more weight. And it means being prepared to communicate sensitively with patients, relatives and colleagues, even if they disagree with you.

Of course, if you are in doubt about your medico-legal obligations in a particular case, it always helps to seek an impartial opinion. MDU advisers are on hand 24 hours a day to talk to members about the dilemmas they face and discuss the ethical and legal implications.

And for a more detailed exploration of the principles underpinning medical ethics, you might also find it useful to look at the MDU's online CPD module in ethics and law which is available on the MDU website.

Dr Mike Roddis is a joint director of Healthcare Performance. With his colleague Dr Emma Sedgwick he runs the MDU's practical workshops including sessions on medical ethics and law. For more information on courses, visit the Learn and Develop section of the MDU website.

This article originally appeared in the printed edition of the MDU journal April 2013 entitled "Can you navigate the ethical maze?"

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This guidance was correct at publication . It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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