Ethical considerations

Introduction

The cornerstone of a good relationship between doctor and patient is trust. In primary care, this relationship (often in the context of caring for the whole family) may be built up over several years, but in hospital practice or in an emergency, the patient and the doctor may be meeting for the first time. Patients expect a high standard of behaviour and care when they seek medical help. This includes the following expectations:

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  They will be consulted about decisions bearing on their treatment.

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  They will be informed about their illness.

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  They will be informed about the likely outcome of any treatment offered.

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  Their right to confidentiality will be respected.

Always assume that a patient is able fully to understand the nature of the medical problem and its implications, regardless of your impression of educational level. Some patients like to discuss what they would like to know early in a consultation and many will say clearly what information they would like to be given to the family. Occasionally, family members may feel that the patient would not be able to comprehend medical information or ask that he be ‘protected’ from the full details of a serious illness. Patients may insist that they do not wish the family to know about their medical problems or, sometimes, that they themselves do not wish to know the diagnosis. In all such instances, the needs and rights of each individual patient should be considered paramount, over and above those of the family, in the event of conflict.

Autonomy

The fundamental principle underlying medical ethics is autonomy: patients have the right to decide their own medical destiny. This gives rise to the concept of seeking the patient’s consent for medical interventions, for research and for teaching. Only in the case of a minor or a mentally disturbed person may consent be sought from the patient’s lawful parents or guardians. Assent, but not consent, may be sought from relatives, such as in the case of an unconscious patient in an intensive care unit. The doctor therefore has a duty not only to advise but also to explain. This principle crosses all religious and cultural boundaries.

Consent

The patient’s consent should be sought for any treatment, however minor, even when that consent might appear implicit as, for example, by attendance at an emergency unit with injury. Sometimes assessment of a minor symptom discloses a separate, more serious issue. In such circumstances, consent to investigate the new problem is required.

To give consent, a patient must have sufficient, accurate information about the illness in order to make an informed judgement about whether its investigation and treatment are justified. There are four requirements of the doctor discussing an intervention with a patient:

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  The procedure itself must be described, including the technique, its implications and the intended benefit of doing it.

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  Information about the risks and complications must be given, which usually means all the risks, as well as some information about the consequences of any complication.

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  Associated risks (e.g. from anaesthesia or from other drugs that may be necessary) should be described.

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  Alternative medical or surgical investigations or treatments should be discussed, so that the reasons for the specific advice given are clear. In addition, the implications of the ‘do nothing’ option should be discussed.

Confidentiality

The fact that all aspects of the encounter are confidential forms the foundation for the consultation, because it allows the patient freedom of expression in the knowledge that disclosures made within the confines of the consulting room will not be made available to others.

The principle of confidentiality applies also to the medical records. These are held by the doctor or the group practice or, in the case of hospital records, by the hospital itself. Medical records are not available to anyone other than the medical and nursing staff treating the patient and are immune from police powers of search. They are made available, however, with the permission of the patient and, once disclosed, may be used as evidence in court in both civil and criminal cases. Patients have the right to inspect their own medical records after making a written application. In the UK, the principle of confidentiality is rigorously supported by the General Medical Council and its breach is regarded as a serious matter.

The main situations in which confidentiality can be relaxed include the following:

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  When the patient or the patient’s legal adviser allows it.

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  When it is in the patient’s interests.

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  If there is an overriding duty to society as a whole.

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  In cases of statutory disclosure.

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  Sometimes after death.