Everyday Medical Ethics and Law E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 615

Veröffentlichungsjahr: 2013

Beschreibung

Everyday Medical Ethics and Law is based on the core chapters of Medical Ethics Today, focussing on the practical issues and dilemmas common to all doctors. It includes chapters on the law and professional guidance relating to consent, treating people who lack capacity, treating children and young people, confidentiality and health records. The title is UK-wide, covering the law and guidance in each of the four nations. Each chapter has a uniform structure which makes it ideal for use in learning and teaching. "10 Things You Need to Know About..." introduces the key points of the topic, Setting the Scene explains where the issues occur in real life and why doctors need to understand them, and then key definitions are followed by explanations of different scenarios. The book uses real cases to illustrate points and summary boxes to highlight key issues throughout. Whilst maintaining its rigorous attention to detail, Everyday Medical Ethics and Law is an easy read reference book for busy, practising doctors.

Leseprobe

Table of Contents

BMA

Title page

Copyright page

Medical Ethics Committee

List of case examples

Chapter 2: The doctor–patient relationship

Chapter 3: Consent, choice and refusal: adults with capacity

Chapter 4: Treating adults who lack capacity

Chapter 5: Treating children and young people

Chapter 6: Confidentiality

Chapter 7: Management of health records

Chapter 8: Prescribing and administering medication

Preface

1: A practical approach to ethics

Does medical ethics help and how?

Medical law and healthcare law

Ethical decision making

Approaching an ethical problem

A final word on problem solving

2: The doctor–patient relationship

Setting the scene

Responsibilities for patients and the duty of care

Patient autonomy and choice

Truth-telling and good communication

Keeping patients’ trust

Recognising boundaries

Treating oneself, friends and family

Providing a safe service

A last word on the doctor–patient relationship

3: Consent, choice and refusal: adults with capacity

Setting the scene

The importance of information

Refusal of treatment

Seeking consent

Documenting the decision

Implementing the decision

A last word about patient consent and refusal

4: Treating adults who lack capacity

Setting the scene

The law concerning treatment and non-treatment of adults lacking capacity to consent

Assessing patients’ capacity

Providing care and treatment for adults lacking mental capacity

The role of proxy decision makers

Decisions needing special safeguards

A last word on caring for adults who lack capacity

5: Treating children and young people

Setting the scene

Consent to examination and treatment

Consent or refusal on behalf of babies and young children

Involving older children in decisions

Assessing competence in children and young people

Consent and refusal by competent young people

Research involving children and young people

Consent and refusal in exceptional circumstances

Child protection

Advisory services and involving the courts

A last word on treating children and young people

6: Patient confidentiality

Setting the scene

What is confidential?

Keeping information secure

Informing patients about possible uses of their health information

The law on confidentiality and disclosure

Use of patient information for purposes directly related to care

Uses of patient information for purposes indirectly related to care

Disclosures unrelated to health care

Disclosures to identify and address poor health care

Disclosures related to crime prevention, detection or prosecution

Disclosures in the public interest

The confidentiality owed to deceased patients

A last word on confidentiality

7: Management of health records

Setting the scene

Defining medical records

Making a health record

Changing medical records or adding to them

Primary and secondary uses of records

Giving access to patient records and reports

Security of data

Retention and destruction of records

A last word about records management

8: Prescribing and administering medication

Setting the scene

Talking to patients and obtaining consent

Choosing the right product for the patient

Shared prescribing and continuity of care

Prescribing for different patient groups

Conflicts of interest

Administering medication

A last word about prescribing and administering medicine

Index

Information about major developments since the publication of this book may be obtained from the BMA’s website or by contacting:

Medical Ethics Department

British Medical Association

BMA House

Tavistock Square

London WC1H 9JP

Tel: [phone]

Email: [email protected]

Website: bma.org.uk/ethics

This edition first published 2013, © 2013 by BMA Medical Ethics Department.

BMJ Books is an imprint of BMJ Publishing Group Limited, used under licence by Blackwell Publishing which was acquired by John Wiley & Sons in February 2007. Blackwell’s publishing programme has been merged with Wiley’s global Scientific, Technical and Medical business to form Wiley-Blackwell.

Registered office: John Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK

Editorial offices: 9600 Garsington Road, Oxford, OX4 2DQ, UK

The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK

111 River Street, Hoboken, NJ 07030-5774, USA

For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell

The right of the author to be identified as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.

Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought.

The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by physicians for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom.

Library of Congress Cataloging-in-Publication Data

Sommerville, Ann.

Everyday medical ethics and law / British Medical Association Ethics Department ; [project manager], Veronica English ; [written by] Ann Sommerville ; [editors], Sophie Brannan . . . [et al.] ; [director of professional activities], Vivienne Nathanson.

p. ; cm.

Includes bibliographical references and index.

ISBN 978-1-118-38489-3 (pbk.)

I. English, Veronica. II. Brannan, Sophie. III. British Medical Association. Medical Ethics Department. IV. Title.

[DNLM: 1. Ethics, Medical–Great Britain. 2. Jurisprudence–Great Britain. 3. Patient Rights–legislation & jurisprudence–Great Britain. 4. Physician-Patient Relations–ethics–Great Britain. 5. Professional Practice–ethics–Great Britain. W 50]

174.2–dc23

2012047947

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

Cover design by Rob Sawkins for Opta Design. Image #617669 from Istockphoto.com © 2005 Clayton Hansen

Medical Ethics Committee

A publication from the BMA’s Medical Ethics Committee (MEC). The following people were members of the MEC for the 2011/12 session.

Dr Anthony Calland, Chairman – Generalpractice (retired), Gwent

Dr JS Bamrah – Psychiatry, Manchester

Dr John Chisholm (deputy) – General practice, Bromley

Dr Mary Church – General practice, Glasgow

Professor Bobbie Farsides – Medical law and ethics, Brighton

Claire Foster – Medical ethics, London

Professor Ilora Finlay – Palliative medicine, Cardiff

Professor Robin Gill – Theology, Canterbury

Professor Raanan Gillon – General practice (retired) and medical ethics, London

Dr Zoe Greaves – Junior doctor, South Tees

Dr Evan Harris – Former MP and hospital doctor, Oxford

Professor Emily Jackson – Medical law and ethics, London

Dr Surendra Kumar – General practice, Widnes

Professor Graeme Laurie – Medical law, Edinburgh

Dr Lewis Morrison – General and geriatric medicine, Lothian

Dr Ainslie Newson – Biomedical ethics, Bristol

Professor Julian Savulescu – Practical ethics, Oxford

Dr Peter Tiplady (deputy) – Public health physician, Carlisle

Dr Frank Wells – Pharmaceutical physician (retired), Ipswich

Dr Jan Wise – Psychiatry, London

Ex-officio

Dr Hamish Meldrum, Chairman of BMA Council

Professor David Haslam, President of BMA

Dr Steve Hajioff, Chairman of BMA Representative Body

Dr Andrew Dearden, BMA Treasurer

Thanks are due to other BMA committees and staff for providing information and comments on draft chapters.

List of case examples

Throughout this book points are illustrated with the use of case examples. Some of these are cases that have been decided by the courts (these have the case name, in italics, in the title) while other case examples are based on enquiries to the BMA or on material published by other organisations, including some disciplinary cases heard by the General Medical Council.

Chapter 2: The doctor–patient relationship

Duty of Care: Barnett

Case example – continuing duty of care

Case example – managing expectations

Case example – failure to discuss

Reporting errors: Froggatt

Case example – accepting a bequest

Case examples – maintaining professional boundaries

Case example – personal relationships

Case example – personal beliefs

Case example – religious beliefs

Case example – deregistration on grounds of cost and disability

Case example – removal without warning

Case example – doctors working outside their sphere of expertise

Case example – out-of-hours cover

Case example – writing references

Chapter 3: Consent, choice and refusal: adults with capacity

Case example – exceeding consent during surgery

Case example – problems conveying information accurately

Case example – advance decision made on the basis of incomplete information

Duty to warn about risks: Sidaway

Duty to warn about risks: Pearce

Duty to warn about risks: Chester

Refusal of life-sustaining treatment: Re B

Case example – valid refusal of treatment following a suicide attempt

Refusal and undue influence: Re T

Case example – a pretence of refusal

Alleged influence from a health professional: Mrs U

Treatment without consent: Patrick McGovern

Failure to make a formal advance decision: Re M

Request for treatment: Burke

Documentation of advance refusal: XB

Chapter 4: Treating adults who lack capacity

Valid refusal of treatment by a mentally ill patient: Re C

Refusal of treatment due to phobia: MB

Case example – need for safeguards on powers of attorney

Giving experimental treatment: Simms

Bone marrow donation: Re Y

Withdrawal of artificial nutrition and hydration: Bland

Case example – powers of restraint

Deprivation of liberty: Bournewood

Chapter 5: Treating children and young people

Parents requesting treatment considered inappropriate: Re C

Courts insisting on continuing treatment for a young child: MB

The unpredictability of prognosis in some young children: Charlotte Wyatt

Parental refusal: Re T

Consent by people under 16: Gillick

Case example – requests for contraception by underage patients

Young person’s refusal of a heart transplant: Re M

The power to override a young person’s competent refusal: Re W

Overriding a young person’s refusal of a blood transfusion: P

Case example – Hannah Jones’s refusal of a heart transplant

A young person’s refusal of treatment in Scotland: Houston

Circumcision and a child’s best interests: Re J

Involving the court: Glass

Case example – judging who should act and when

Case example – Victoria Climbié

Case example – Baby P

Chapter 6: Confidentiality

The use of anonymised data: Source Informatics

Case examples – breaches of confidentiality

Case examples – failure to keep data secure

Case example – retention of information

Confidentiality and the Human Rights Act: Campbell

Case example – information fraudulently requested

Case example – inappropriate discussion

Clinical information and the media: Ashworth

Case example – police request for too much information

Patients’ rights to object to disclosure: TB

Case example – disclosure to the police

Disclosure in the public interest: Egdell

Case example – contacting the DVLA

Case example – patient with a serious communicable disease

Freedom of Information requests: Bluck

Chapter 7: Management of health records

Case example – whether unsubstantiated allegations should be recorded

Case example – tampering with records

Case example – publication of an identifiable case

Case example – disposing of private records

Case example – third-party information in medical records

Case example – separated parents applying for access to a child’s record

Case example – misplaced records

Case example – unauthorised access by staff

Case example – accessing records after the duty of care has ended

Chapter 8: Prescribing and administering medication

Case example – patients insisting on having antibiotics

Case example – media reports generating demand

Case example – failure to tell patients about lack of evidence

Case example – demand for inappropriate repeat prescriptions

Case example – request for past prescribing to continue

Case example – drugs to improve exam performance

Case example – failure to prescribe correctly

Case example – pressure from employers

Case example – Viagra

Case example – prescribing off-label on cost grounds

Case example – shared care

Case example – failings in internet prescribing

Case example – Annie Lindsell and double effect

Case example – the influence of financial investments

Case example – meeting with pharmaceutical company representatives

Case example – lack of protocols for administering medication

Case example – covert medication of people with capacity

Preface

The BMA is a doctors’ organisation which, among other activities, provides ethical and medico-legal advice. Other health professionals are increasingly exploring similar dilemmas to those facing doctors and BMA guidance has broadened out to reflect that. This book also summarises best practice standards, legal benchmarks and the advice published by a range of other authoritative organisations throughout the UK. This book may be useful for other health and social care professionals as well as for doctors, although naturally, they are our main audience.

Traditionally, medical ethics applied to the standards and principles that governed what doctors do but now often describes the obligations of all health professionals. Some people prefer a broader and, arguably, more inclusive term such as healthcare ethics, but we have stuck with the term medical. While recognising that good patient care consists of a range of skilled personnel working cooperatively, sharing the same basic values and with very similar ethical duties, our experience is primarily concerned with advising doctors. This book focuses on the daily ethical and medico-legal problems doctors face. We know what these are because, for several decades, the BMA has run an advisory service through which members can receive prompt advice on specific dilemmas. Very often, the recurring problems involve aspects of confidentiality and patient consent, such as whether an unmarried father can legally access his child’s medical records or who can consent to treatment for young people. Patterns of queries alter to reflect high-profile cases reported in the media and the very significant growth of case law (judge-made law) and statute. Now many of both the mundane and the more tricky questions are covered by law, which can differ significantly across the four nations of the UK. This is reflected in the following chapters.

Case examples are also included in the text. Some of these are cases which have gone through the courts and illustrate specific points of current good practice. Others are based on dilemmas doctors have raised with us. We have summarised and anonymised real cases, but some of the examples are amalgams of many very similar scenarios, rather than one specific case. The aim is to capture the very common niggling worries that should have easy answers but often do not.

Above all, our approach is practical rather than abstract or theoretical. As each chapter is based on the problems raised with us by BMA members, many of the fascinating topics of more abstract ethical debate, beloved of philosophers and examiners – such as the moral status of the embryo and whether assisted dying should be perceived as a human right – are entirely absent from this volume. The BMA has, of course, explored all these issues in considerable depth. Readers who wish to see the full range of topics should consult the third edition of our detailed ethics handbook, Medical Ethics Today. A range of guidance notes are freely available to all health professionals and patients on the ethics section of the BMA’s website and members can also talk through specific dilemmas either by telephone, letter or email.

1: A practical approach to ethics

Picture this . . .

A senior police officer is asking for details of all patients on a certain drug. It could be in connection with a serious crime or an unidentified corpse, but the facts are vague. What do you think? Is patient confidentiality trumped by serious crime and, if so, how serious does the crime have to be? In another part of the building, an irate father is demanding to see his daughter’s record. Can he do that as a divorced dad without custody rights? Should the mother or the 12-year-old daughter herself be asked first? Another headache is that you are new to the area and keen to meet people. Surely there’s no problem in going to a local barbecue? You’ve already had a few flirty emails from one of the organisers who wants to be your Facebook friend and happens to be a patient. It seems quite innocent or is it? On top of that, a senior colleague wants to do some research involving a change of medication for your patients with early-stage dementia. It may do them some good, but doesn’t someone need to consent on their behalf or can they do that themselves? Also there’s a man who always stands far too close and keeps accidentally brushing against you. He’s booked in for a prostate examination and asked specifically for you to do it. Do doctors really still need chaperones? It sounds so Victorian and what if the patient objects? And you’re worried about the patient with the fractured ribs who makes a habit of falling downstairs but refuses to let you tell the police that or about the cigarette burns on her arms. She has young children who don’t look too good either. Shouldn’t you do something? The teenager waiting for stitches in his hand also gives an odd account of the accident. Aren’t you supposed to report all knife wounds even if, as he says, he was just showing off his chef’s chopping technique to his mum in the kitchen?

Common enough questions but the answer may not always seem immediately obvious. That is the point of this book. In the following chapters, we pull together some of the recurring queries that doctors raise. Many dilemmas appear relatively mundane, but some touch on life-changing decisions that need to involve the courts. In fact, all health professionals are likely to face situations in which they have to pause and consider. Their initial gut reaction is not always the right one and, if challenged, they need to be able to offer a reasonable justification for the decisions taken.

Does medical ethics help and how?

When professionals have to work through a problem and feel justified about the options they take or recommend, they need some consistent benchmarks. Traditionally, codes of ethics helped by setting out a framework of duties and principles. Modern medical ethics still provides the framework but also needs to take account of professional regulation, law and quasi law. Frustratingly, ready-made answers are seldom available. Careful analysis and reasoning about the particular circumstances is usually needed, so that superficially similar cases may prompt different responses. This is because an ethical decision is not just about providing the best clinical outcome for the patient but may also include accommodating that person’s own wishes and values. It involves a search for coherent solutions in situations where different people’s interests or priorities conflict. It is often as concerned with the process through which a decision is reached as with the decision itself.