PPVE Year 1

Professionalism

Set of values, behaviours and relationships that underpins the trust the public has in a doctor

GMC purpose

Provide current code of conduct for medical professionals

Ensures that all doctors are fit for practice

Hippocratic oath

Outlines the main moral and ethical obligations of doctors doctors and requires them to uphold certain ethical standards.

sworn agreement requires doctors to uphold certain ethical standards (not a law)

GMC ethical guidance

set out the professional values, knowledge, skills and behaviours expected of all doctors

Consequentialism

Moral worth of an act should be judged by net benefits of its consequences (results based ethics)

Utilitarianism

Greatest balance of good over evil for as many people as possible

Deontology

Requires that we abide by certain absolute guiding rules regardless of consequences = duty based

Duties are absolute (some rules shouldn't be broken EVER eg stealing or killing even it causes harm etc)

Autonomy > beneficence

Judges morality based on rule

Rights based deontology

Obligation to respect rights (autonomy beneficence, non-maleficence, truth and fairness, justice and integrity)

Rule based deontology

Compares moral to a set of rules to determine if it is right or wrong (focus on reasoning not feelings)

Virtue ethics

Concentrates on a person's character

Doing the right thing is only right if it is what a virtuous person would do

A virtuous person is one who exercises the virtues

Virtue = traits human needs to flourish

private healthcare

made up of hospitals and clinics

which are run independently from the NHS normally by a commercial company sometimes charities

Duty of care

The obligation of one party to take care and prevent harm to another party

Usually owed to patients by healthcare staff

legal requirement ⇒ Negligence/breach of civil law if not met

autonomy

Capacity to think, decide and act on the basis of thought and make decisions freely and independently

Free from controlling influence or coercion

Paternalism

Doctor decides what is right and makes decisions with minimal consent / overrides patients wishes

Beneficence

'Doing good' → providing benefit to patient ⇒ act in patient's best interests

Balancing benefits of treatment against risk and cost

Respect autonomy as to what is perceived to be a benefit (mastectomy good for one woman but not another)

Non-maleficence

'Do no Harm' -minimising harm→ never absolute

Requires balance with beneficence as all treatment involves some form of harm

Harm should never outweigh benefits of a treatment

Justice

The fair treatment or allocation of people and resources

Distributive justice

fair allocation of resources (in relation to cost)

legal justice

respect for morally acceptable laws

rights based justice

respect of patients human rights (don't discriminate)

Prima facies

Principle that says that duties are absolute until one conflicts with another

when conflict between duties arises, you have to pick between them

4 ethical principles - prima facie

Right

A moral or legal entitlement to have or do something

rights protect the right-holder by making obligations towards them

Everyone equally entitled to human rights without discrimination

Human rights

rights inherent to all human beings

regardless of nationality, place of residence, sex etc

Universal human rights

often expressed and guaranteed by law

international human rights law lays down obligation of governments to act in certain ways or refrain from certain acts in order to promote and protect human rights

Interests

The feeling of wanting to know

Things that make our lives go well

Interests can conflict between individuals

Absolute right

can never be limited / unqualified can legally be enforced

Limited rights

rights with exceptions- can lawfully be restricted e.g. right to liberty (prison)

Qualified right

government can interfere if it is lawful and necessary

eg national security

legal rights

Rights justified by law

Civil laws that enforce what can and cant be done

Needs to be certain and absolute

Changed deliberately by parliament

moral rights

Rights justified by moral principles

IMPLIES duty on others to do or not do something

CANNOT be deliberately changed → evolves slowly so more flexible and variable

positive rights

an obligation to provide something to the right holder

requires someone to do something for you

Negative rights

A duty to do nothing and not interfere → nothing has to be provided for this right to be exercised

Requires others to refrain from doing anything to prevent you for enjoying this right eg freedom of speech

statute law

Laws passed by parliament

Statutes = laws created by acts of parliament ⇒ ALWAYS BINDING

Common Law and precedent

Built on case law and precedence (previous legal rulings) as opposed to statutes

Court has to follow a previous decision if there was a previous ruling from a higher court (parliament can still overrule)

Public law

made up of both statute and common law

Case law

A judge has made a legal decision on a case

provides legal precedence in other cases = the law set by cases

precedence = what has been decided in previous law (not necessarily binding)

Civil law

2 independent parties

deals with tort / contract law (private law)

Aims to fairly compensate

Criminal law

One independent party against the state

Broken the law of the state

Used to decide if and what punishment should be delivered and carried out

Tort law

a civil wrong that inflicts harm or loss upon a person

covers battery (unlawful physical contact)

and negligence in medical practice = failure to provide adequate medial treatment

Distributive justice

How medical goods are split up fairly

Fair allocation of resources

Lay def of dignity

The quality of being worthy of esteem or respect Who decides this? ⇒ subjective

Medical Definition of dignity

Ability to feel important and valuable, and being able to communicate this in relation to others, and to be treated as such in threatening contexts.

implied by the principle of medical ethics → Dignity =

The need to obtain voluntary, informed consent

The requirement to protect confidentiality

The need to avoid discrimination and abusive practices

Respect to the individual

Respect for autonomy

Virtue ethics

A framework that focuses on the character of the moral agent rather than the rightness of an action

Cardinal Virtues

Courage

Prudence

Temperance

Justice

Theological virtues

Faith

Hope

Charity

Domino transplant

Patient needs new lungs but has healthy heart

Patient gets new lungs AND heart from a (same) cadaver same cadaver = decreased chance of rejection

Patient A's Heart available for transplant to another person

Consent required for both clinical procedures and to the donation of other organs removed in the course of the treatment

Live donation

Altruistic donation from healthy donors

Paired and pooled donation

Donor and recipient are incompatible

They are are paired up with one or more other couples

Each exchange organs

Altruistic non directed donation

Donation of blood, gametes or bone marrow by strangers = commonplace

sometimes donation is offered to a stranger

Permissable under the 2004 act

needs to be reviewed by 3 panel members of the HTA

Property

Describes a thing

the relationship between a person and a thing

Rules of rights in relation to property

If a person owns something, they have property rights to it :

The right to use the property

The right to sell / rent / transfer the property

The right to exclude others from using it

POSITIVE RIGHT

Privacy

Article 8 of the human rights act 1998

Based on principle of human dignity

A state by which one is not observed or disturbed by other people

rights to privacy and property - terms of body ownership

Both rights to privacy and property would prohibit removal of a persons bodily material

without their consent

Paris method

Dissecting in front of people

was the main method of teaching anatomy

Murder act 1752

Any sentenced murder should be executed 2 days after sentencing

any criminal that was hanged could have their body dissected (seen as double punishment) ⇒ allowed medical schools to legally dissect

Led to an increase in crimes that were punishable by hanging

Done to keep up with growing demands for corpses for dissection

Capacity

The ability to use and understand information to make a decision and communicate any decision made

All adults are presumed to have sufficient capacity to decide on their own medical treatment unless theres significant evidence to suggest otherwise

Lack capacity

If an individuals mind is impaired or disturbed in some way

Affects ability for that individual to make a decision

TIME SPECIFIC, CIRCUMSTANCES CAN CHANGE SO CAPACITY NEEDS TO BE REASSESSED

Advanced desicion

A decision to refuse particular medical treatments for a time in the future when you may be unable to make such a decision (CPR)

aka living will

need to be 18 years old or above

-have capacity at time

-only refuse not demand treatments

-written down

-signed by individual + witness

Lasting power of attourney

Legal recognition of proxies in mental capacity act 2005 (previously only allowed to handle legal and financial affairs)

Third parties able to make decisions on behalf of an individual if they lack capacity

Once lack of capacity is registered and individual is registered as LPA, they are charged with representing a patients best interests

Mental Capacity Act 2005

Applies to those who are 18 and over and have a disorder of the mind / brain

Aimed to protect and restore power to these individuals

Informed Consent

A doctor is under a duty to take reasonable care to ensure that the patient is aware of any material risks involved in any recommended trearment and any reasonable alternatives and variant treatments

Doctor must explain all risks and benefits even if it alters the patients choice to one that is not in their best interest (autonomy)

Battery

Touching without consent, regardless of harm

Direct physical contact is required to be charged with battery

There does not need to be any harm intended or occurring as a result

Civil offence (PERSON VS PERSON)

Assault

Does not require physical contact

Requires threat of harm

Criminal offence (STATE VS PERSON)

Tort of Negligence

failure to provide adequate medical treatment

A breach of duty of care that results in SERIOUS harm

Duty of Care

obligation to prevent harm to another

Bolam Test

Establishes whether a medical professional has breached their duty of care

Doctor must be able to show their opinion / action had a logical basis prevent being found NOT guilty if acted in accordance to proper practice

IF DOCTOR REACHES STANDARD OF A RESPONSIBLE BODY OF MEDICAL OPINION = NOT NEGLIGENT

Gillick competence

patient although under 16 can understand medical information sufficiently

The doctor cant persuade the patient to inform/gain permission for the doctor to inform the young patients guardian

In cases where young patient is seeking contraception, patient is very likely to have sex with or without contraception prescription safer to give

Young patients mental / physical health are likely to suffer if the treatment is not given

It is in the patients best interest for the the doctor to treat without parental consent

Fraser Guidlines

application of gillick competence is specific cases where girl under 16 is requesting contraception

●They understand all aspects of the advice and its implications

●You cannot persuade the young person to tell their parents or allow you to tell them

●In relation to STI's and sex, the young person would otherwise have unprotected sex

●The young persons mental or physical health is likely to suffer if they don't receive treatment

●It is in the best interests of the young person to receive the advice and treatment without parental knowledge or consent

Informed refusal

Healthcare team should ensure that the patient has based their decision to refuse of accurate information and any misunderstandings have been corrected

All options should have been discussed and weighed up by patient though they are not obliged to justify their refusal

Confidentiality (general def)

The state of keeping, or being kept a secret

Confidentiality (medical def)

A legal obligation

derived from case law

Prohibits a doctor/medical practitioner from revealing anything said to them by their patients during consultation or treatment

Profession

An occupation whose core element is work based upon the mastery of a complex body of knowledge and skills - LEARN

A vocation in which the knowledge of science or learning or the practice of an art is used in the service of others

Proffesionalisation

the action or process of giving an occupation, activity or group professional qualities

typically by increasing training or raising required qualifications

Proffesional Judgement

Professional can make a decision or judgements

based on expertise and skill

As a result of training

Specialisation

Increasing expertise within one field

with more specific training,

more autonomy and

higher prestige

Diversification

Expanding the professional boundaries within a particular discipline,

so when new techniques / tasks come along that no one is specifically trained for,

you can absorb that into your own discipline

expansion of the role of a particular discipline, that was previously owned by a particular disciplinary group. Identifying new markets, new technologies and new philosophies

Vertical Substitution

Delegation of tasks across levels of expertise / people / disciplinary boundaries

eg. advanced nurse practitioners can now prescribe

Horizontal Substitution

Delegation of tasks across SIMILAR levels of training and expertise

but from different disciplinary backgrounds

eg role overlap between occupational therapists and physiotherapists

Proletarinisation

predicts the decline of medical power

as a result of deskilling and the salaried employment of medical practitioners (other disciplines specialise and become more skilled = less of a difference between doctor and other HCP)

De-professionalisation

a loss of professional occupations of their unique qualities

particularly their monopoly over knowledge, public belief in their service ethos and expectations of work autonomy and authority over clients

Post-professionalisation

loss of exclusivity over knowledge that is experienced by existing professions

arises due to rise in tech and increased access to information and the differences in the way that knowledge is applied through increasing specialisation

Complementary Medicine

when a non mainstream practice is used together with conventional medicine

Alternative Medicine

when a non mainstream practice is used instead of conventional medicine

Medical dominance (3 parts)

refers to the medical professions control over the content, terms and conditions of its own work (autonomy), control over other health occupations and the health division of labour (authority), control over clients and control over the broader context of healthcare (sovereignty)

4 Domains of GMC

Knowledge, skills and development

Patients, partnership and communication

Colleagues, culture and safety

Trust and professionalism

Data Protection Act 1998 (Medical Records)

Patient has right to access own medical records. And find out classes of people whom it will be disclosed to. Also entitled to a copy in an understandable form

Access to medical reports act 1990 (Medical Records)

Relates specifically to medical reports for insurance or employment purposes that are written by the patient's own doctor and give rights of access to them; the GMC advises doctors to offer to show patients any reports they write about them.

Human Rights Act 1998 (Medical Records)

access to medical records was part of the right to respect for private and family life under article 8 of the ECHR - European Commission on Human Rights.

Access to Health Records 1990 (Medical Records)

pertains to the information of the deceased; the medical records are permissible to the patient's representative and to any person who may have a claim arising out of the patient's death.

DROIT Framework for protecting Patient Rights

Dignity = human right that recognises the worth of every person.

Respect is an affirmative acknowledgement of individual circumstances.

Obligation to act in the best interests of the patient is fundamental to medical professionalism.

Information is the foundation of healthcare decisions for patients and doctors.

Trust is the competence and ability of the doctor is a prerequisite for confidence.

Examine how anatomical knowledge was acquired historically

14th century Europe dissection of publicly executed felons was introduced

Lasted until 19th century- This was eventually stopped due to people dying alone and being dissected without giving consent.

'Body snatching'- early 19th century, medical schools were filled with stolen cadavers, due to a shortage of legally obtained cadavers.

Lay knowledge at this time was that they would be like frankinstein- anatomists could have prevented this lay belief, and it would have prevented objections towards dissection.

Explore if and how the treatment of people and bodies alter in life and death

Human tissue act 2004

-Regulation of removal, storage and use of human tissue

-'DNA theft' was established, meaning you cannot take tissue for DNA analysis without the consent of the person you took it from.

-Selling and trafficking organs was made illegal

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-Under this act, it became legal to take the first steps to preserve the organs of the deceased until we know the wishes of the individual/ consent of someone in a qualifying relationship.

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Live donations- domino, paired or pooled. Need to have counselling before undergoing the donation

Consider the moral, legal, historical and ethical perspectives on body ownership in life and death (1)

Are our bodies property?

For :

- It is possible to place value on property beyond the material e.g. wedding rings, or things with sentimental value.

- So we should be able to regard our bodies as property as long as it's not the only way they are valued. It may be possible to cl aim intellectual property on bodily material.

- If we assert owner ship over our bodiæ we have control over our body parts when removed, can seek the return of that body part if wrongfully taken and seekcompensation if profit is made of our body part/human tissue (Moore v University of California).

Against :

To say the body is property is demeaning- it is too precious to be owned. We should focus on autonomy and right to dignified treatment instead of right to own . Our reationship with our body isone of "existing" not "having" Bodies cannot be regarded as property in terms of property law because they are not transferable or divisible. Recognising property rights to a person's body couId hinder medical research and may lead to patient's "shopping around" to find the best pr ice for their body parts/human tissue.

Consider the moral, legal, historical and ethical perspectives on body ownership in life and death

Duties to the living:

-Unclaimed bodies can legally be used as cadavers, but these usually belong to the poor- exploitation?

-It goes against the religious and spiritual beliefs of some to utilise the body of the deceased

Duties to the living person who is now dead:

- Autopsy is carried out to find out the cause of death

Duties to the dead in terms of body use:

-Formal- abide by the explicit wishes of the deceased

-Substantial- respectful treatment of the dead is universal

For Consent to be valid it must be:

C- capacitous

O- ongoing

V- voluntary

I- informed

Negligence

breach of duty of care that results in SERIOUS harm

Battery

direct physical contact, not necessarily with harm

Capacity in terms of the mental capacity act:

-Understand the information

-Retain it

-Use or weigh it

-Communicate the decision in any means

When can you breach confidentiality?

-The patient consents

-Within healthcare teams

-If acting in the patients best interests

-If acting in the publics best interests

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Sharing within the healthcare team is deemed to be implicit consent, sharing to a third party would need explicit patient consent.

Discuss the reasons why complementary and alternative medicine has increased in popularity with patients and healthcare professionals

Reasons why people are shifting to it:

-Dissatisfied with conventional medicine

-Little to no side effects with CAM

-Patients are able to convey symptoms and concerns more effectively

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Arguments against it:

-It is not evidence based

-Lack of knowledge behind the practitioners

-Potentially harmful as patients not seeking the correct medical care