Doing right a practical guide to ethics for medical trainees and physicians

380 Pages·2014·4.926 MB·English

by  Hébert, Philip Charles

D oing Right
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D oing Right
A Practical Guide to Ethics for
Medical Trainees and Physicians
Philip C. hébert
Third EdiTion
1
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1
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Library and Archives Canada Cataloguing in Publication
Hébert, Philip C., author
Doing right : a practical guide to ethics for medical trainees
and physicians / Philip C. Hébert. – Third edition.
Revision of: Doing right : a practical guide to ethics for medical
trainees and physicians / Philip C. Hébert. – 2nd ed. – Don Mills, Ont. :
Oxford University Press, [2008], c2009.
Includes bibliographical references and index.
ISBN 978-0-19-900552-9 (pbk.)
1. Medical ethics. I. Title.
R724.H39 2014 174.2 C2013-908208-5
Cover image: Fuse/GettyImages.com
Oxford University Press is committed to our environment.
This book is printed on Forest Stewardship Council® certified paper
and comes from responsible sources.
Printed and bound in Canada
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Contents
Cases viii
Preface x
Acknowledgments xii
Introduction: A Revolution in Learning xiv
1 Ethics Matters: Doing Ethically Sound Medicine 1
I. Ethical Reasoning and Principles in Medicine 1
II. Three Ethical Principles and Questions 8
III. “Resolving” Ethical Dilemmas 13
IV. “ Doing Right”: A Decision-Making Procedure for Clinical
Ethics 14
V. Applying the Ethics Decision-Making Procedure 19
2 The Almost Revolution: Autonomy and
Patient-Based Care 27
I. The Autonomy Principle 27
II. The Case of Mrs Malette and Dr Shulman 34
III. Choices: The Good, the Bad, and the Ugly 36
IV. Reduced Autonomy 43
3 No Man an Island: Confidentiality and Trust 50
I. Rights of Privacy, Confidential Duties 50
II. Professional Regulations 56
III. Limits to Confidentiality 62
IV. To Warn and to Protect 67
V. The Digital Age 71
4 The Power to Heal: Truth and Deception in
Clinical Practice 76
I. On Not Telling the Truth 76
II. The Truthtelling Task 80
III. Modern Law and the Profession 86
IV. The Changing Practice of Medicine 87
V. Truthtelling’s Exceptions 89
5 The Power to Choose: Due Care and Informed Consent 98
I. The Essence of Informed Consent 99
II. Ethical Consent 101
III. The Doctor Who Didn’t: The Case of Mr Reibl versus
Dr Hughes 102
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vi Contents
IV. The Essential Elements of Consent: When, Who, What,
How? 104
V. Exceptions to Consent 116
6 The Waning and Waxing Self: Capacity and Incapacity
in Medical Care 123
I. Attending to and Assessing Capacity 123
II. Substitute Decision-Makers (SDM) 134
III. Treatment of the Vulnerable 137
IV. When Not to Rescue 139
V. Failure to Care for Self 142
VI. Cases Involving Minors 144
7 Helping and Not Harming: Beneficence and
Non-Maleficence 149
I. The Principles of Beneficence and Non-Maleficence 150
II. The “Duty to Rescue” the Patient 157
III. Endangering One’s Self 159
IV. In the Best Interests of Minors 164
V. Parental Requests for Treatment 169
8 Conduct Becoming: Medical Professionalism and
Managing Error 176
I. Professionalism in Healthcare 176
II. Professionals and the Drug Industry 183
III. Boundaries and Crossings 186
IV. The Error of Our Ways 192
9 Beyond the Patient: Doing Justice to Justice 204
I. Justice in Everyday Medicine 204
II. Distributive Justice 208
III. Medically Necessary Treatment 209
IV. The Role of Practice Guidelines 219
V. The Health Professional’s Master 223
10 Labour Pains: Ethics and New Life 230
I. Birthing and Reproductive Choice 230
II. In the Interest of the Child: Being Born and Living Life 237
III. The New Age of Reproduction 240
IV. Desperately Seeking Stem Cells 248
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Contents vii
11 A Dark Wood: End-of-Life Decisions 254
I. Allowing Death: Refusals by the Patient 254
II. Advance Directives 262
III. Who is the Patient? 263
IV. Lost Souls 266
V. Physician-Accelerated Death (PAD) 271
12 Questions of Culture, Genetics, and Science 280
I. Cultural Connections 280
II. All in the Genome? 289
III. Ethical Regulation of Research 293
IV. Some Questions and Answers Regarding Research 300
Conclusion: Going from Here 308
Notes 313
Index 347
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Cases
1.1 To Prescribe or Not to Prescribe? 1
1.2 A Risky Teaching Tool 5
1.3 Desperate Hopes 12
1.4 To Feed or Not to Feed? 19
2.1 The Patient’s Agenda 27
2.2 Patient Knows Best? 32
2.3 Ligation Litigation 36
2.4 Don’t Touch My Arm! 38
2.5 Tranquillizer Trap 40
2.6 A Man Should Die at Home! 41
2.7 A Hypnotic Request 43
2.8 A Wish Not to Hear 44
2.9 This Lady’s Not for Turning 45
3.1 Don’t Tell! 50
3.2 Self Secrets 54
3.3 A Casualty of War 57
3.4 A Risky Record 60
3.5 The Pose that Pauses 72
3.6 Trainee Trouble 73
4.1 The Worrier 76
4.2 Not to Worry 82
4.3 A Dark Secret 83
4.4 Mirror, Mirror on the Wall 89
4.5 “I’m So Stupid” 90
4.6 “What’s Up, Doc?” 94
5.1 A Simple Process 98
5.2 The Undisclosed Side Effect 104
5.3 “You Have No Right to Touch Me!” 106
5.4 More Surgery Wanted! 109
5.5 “Stop the Test!” 114
5.6 An Unstated Risk 118
6.1 “Talk to Me, Not My Daughter!” 123
6.2 Beyond Help? 127
6.3 Still Capable 129
6.4 “I’ve Seen Worse!” 131
6.5 Re-examining “No” 133
6.6 “I Can’t Let Her Die!” 134
6.7 Risky Business 136
6.8 A Fractured Hip, A Broken Mind 137
6.9 Do Not Go Gently into a Good Nursing Home 142
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Cases ix
7.1 A Theatre Performance 149
7.2 No Surgery Wanted 153
7.3 Too Much of a Good Thing? 155
7.4 Not Like Himself 158
7.5 No Fools Allowed 159
7.6 An Illicit Request? 162
7.7 Fasting Unto Death 168
7.8 E (Mrs) versus Eve 170
7.9 The Pillow Angel 171
8.1 An Unexpected Death 176
8.2 Belly Up 179
8.3 Time and Wounds 180
8.4 Supping with the Devil 183
8.5 Drug Redux 185
8.6 A Boundary Too Far 187
8.7 An Uncomfortable Revelation 190
8.8 “I’m Just So Tired!” A Missed Result 192
9.1 Time Well Spent? 205
9.2 To B12 or Not to B12? 207
9.3 “Misfortune Begetting Injustice” 210
9.4 Transplantation Tourism 217
9.5 Terms of Entitlement 220
9.6 An Expensive Proposition 224
10.1 A Trivial Matter? 230
10.2 A Right to Be Tested? 236
10.3 Fetus at Risk 238
10.4 Whose Baby Is It Anyway? 241
10.5 The Saviour Child 249
11.1 A Death Not Foretold 256
11.2 A Shocking Shot 258
11.3 No Crap versus No CPR 260
11.4 The Longest Goodbye 267
12.1 A Clash of Generations 281
12.2 A Natural Cure 284
12.3 Far From Home 285
12.4 A Dispute Over Death 287
12.5 All in the Family? 290
12.6 Poles Apart 295
12.7 An Unexpected Association 298
12.8 Are You Coming Home Soon, Dad? 302
12.9 An Unfair Trial 304
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Preface
It has now been over 15 years since the first edition of Doing Right was
published. The reasons for this newest edition are many. As with the
second edition I have updated the book with recent cases in the bioethics
and jurisprudence literature that help provide directions to clinicians. I
have included more material on disability, research, and cultural aspects
of care. All chapters have been rewritten and revised to reflect this.
As with previous editions I have included cases that affect all health-
care professionals, not just physicians. The cases and issues are shared
alike by all healthcare professionals—whether medical trainees, physi-
cians, nurses, nurse practitioners, or physician assistants. Allied health-
care professionals may also find some of the cases useful and relevant for
their practices. I will, in general, shy away from thinking of those we serve
as “consumers,” “customers,” or “clients” of healthcare and instead refer
to them as “patients,” “partners,” or “participants” in care. Call me old-
fashioned, but I think the latter “p-words” better capture than the former
what healthcare is all about. Those we serve are often unwell and deserve
protection as well as promotion; in the country of illness, they do not need
to be boondoggled and cajoled as if in a market or a souk.
The perspective is that of the well-intentioned healthcare professional,
the “good clinician,” in general. Although different healthcare profession-
als will have different degrees of agency and responsibility for handling
dilemmas in clinical practice, the “right way” of doing so should reflect a
common “professional point of view”—best arrived at by consensus, crit-
ical interprofessional discussion—and by those with an abiding commit-
ment to the healing enterprise. There is an ongoing revolution in medical
education in favour of patients, multidisciplinary teams, and evidence-
based care, which this book, like its previous editions, mirrors, supports,
and encourages. Medicine is a difficult enterprise but need not be a lonely
one. When a troublesome issue must be addressed, three nostrums can be
recommended: (1) turn to the wisdom of others; (2) try to find someone to
help you; and (3) turn to your best resource, the patient beside you; he or she
may know more than you realize.
There is a renewed international approach to professional medical
ethics, spurred on by medical associations such as the British Medical
Association and the World Medical Association.1 Despite many large dif-
ferences in culture, religion, and politics (differences that should not be
minimized), the healthcare professions throughout the world share sim-
ilar goals: the prevention of premature death and the treatment and pre-
vention of illness and human suffering more generally. These are the good
ends that the virtuous clinician strives to achieve in “doing right.” These
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