Medical ethics

The four principles

• Justice in practice means treating similar cases alike and allocating care by need, not by wealth, status or connections. Equity (fairness according to need) differs from equality (identical shares for all).
• Supporting duties: veracity (truthfulness), fidelity (keeping promises), confidentiality, respect for dignity, and probity (honesty in all professional dealings).
• Paternalism (overriding a capable person "for their own good") conflicts with autonomy.
• Ethical theories: duty-based (deontological) ethics judges the act itself; consequentialism (utilitarianism) judges outcomes, aiming at the greatest good for the greatest number; virtue ethics asks what a good doctor would do.

Doctrine of double effect

• An act with a good intended effect and a foreseen but unintended harmful effect is acceptable if the act itself is not wrong, the harm is not the means to the good, and the good outweighs the harm (proportionality).
• Example: increasing morphine to relieve severe pain in a dying patient is acceptable even if it might shorten life, because the intention is relief of suffering.

Valid consent

• Three requirements: capacity, adequate information and voluntariness (free choice without coercion). Consent is a continuing process and may be withdrawn at any time.
• Information: diagnosis, nature and purpose of the procedure, material risks (those a reasonable person in the patient's position would want to know, including rare serious ones), benefits, alternatives including doing nothing, and who will do it.
• Ideally the operator takes consent, or a colleague trained in the procedure. A signed form only records the discussion; it is not itself consent. Consent can be written, verbal or implied (offering an arm for blood).
• Emergency: if the patient lacks capacity and treatment cannot wait, give treatment that is immediately necessary in their best interests (doctrine of necessity).
• A valid and applicable advance refusal made while capable must be respected. A capable adult Jehovah's Witness may refuse blood even if death results; for a child, life-saving transfusion is given in the child's best interests, with legal authority sought where time allows.

Capacity

• Presume capacity. It is decision-specific and time-specific.
• A person has capacity if they can understand the relevant information, retain it long enough, use or weigh it, and communicate a decision.
• An unwise decision is not proof of incapacity. Mental illness, old age or disorientation do not by themselves remove capacity, but they prompt formal assessment.
• Help the person decide (interpreter, simple language, better timing, treat reversible confusion).
• If capacity is lacking: act in best interests, considering the person's past and present wishes, consulting family and carers, choosing the least restrictive option, and waiting if capacity may return and delay is safe.
• A disoriented elderly patient with acute appendicitis who refuses surgery: assess capacity first. If delirium removes capacity and surgery is urgent, proceed in his best interests after involving his wife and documenting the assessment; if he has capacity, his refusal stands.

Children and young people

• Parents consent for young children, but involve the child as far as possible.
• Gillick competence: a young person under 16 can consent if they have enough maturity and understanding of the proposed treatment.
• Fraser guidelines for contraception without parental knowledge: she understands the advice; cannot be persuaded to involve parents; is likely to have sex anyway; her health would suffer without it; it is in her best interests. So a 15-year-old who understands the risks and benefits can receive contraception after the doctor assesses her maturity, while encouraging parental involvement and checking for exploitation.
• Refusal of life-saving treatment by a minor may be overridden by parents or the courts. Local law (age of majority 18 in Pakistan) and hospital policy apply.

Truth-telling and family requests

• A capable patient is entitled to information about their own condition. If a relative asks you not to tell the patient:
• Explore the family's concerns (often fear of causing distress) and explain your duty to the patient.
• Ask the patient how much they want to know and who they want involved; some prefer not to know, and that wish is respected.
• If the patient asks directly, tell him honestly and sensitively. Deceiving a capable patient breaches autonomy and trust.
• Withholding information is justified only if disclosure would cause serious harm (not merely upset), which is rare.

Confidentiality

• The duty continues after death. Sharing with the direct care team is acceptable on implied consent; audit and research need anonymised data or consent.

• Disclose only the minimum necessary to the appropriate authority, tell the patient first where safe, and record the reasons.
• Epileptic pilot or driver asking for secrecy: explain the danger and advise him to stop and inform the licensing or aviation authority. If he refuses and continues, the doctor may disclose to that authority, after telling him.
• HIV and partner notification: encourage the patient to tell partners; disclosure to a partner at serious risk can be justified if the patient refuses.
• A psychiatrist who does not share a patient's details with relatives without consent is upholding confidentiality.

End of life and brainstem death

• Euthanasia and assisted suicide are illegal in Pakistan and the UK. Withholding and withdrawing futile treatment are ethically equivalent. DNACPR is a clinical decision discussed with the patient and family.
• Brainstem death (before organ donation) requires preconditions (deep apnoeic coma of known irreversible cause, with drugs, hypothermia and metabolic or endocrine causes excluded), then testing by two experienced doctors on two occasions:

• Spinal reflexes may persist and do not exclude brainstem death.

Probity and professional conduct

• Medical certificates and reports must be true: refuse to write a sick note for days the patient was not ill.
• Impaired or unsafe colleague (for example operating while smelling of alcohol): patient safety comes first. Act promptly through proper channels, speaking to the clinical lead or medical director, and to the regulator (PMDC or GMC) if needed; do not ignore it or gossip.
• Duty of candour after errors; no relationships with patients; declare conflicts of interest; careful use of social media.
• Negligence needs duty of care, breach, causation and harm. The Bolam test asks whether a responsible body of medical opinion would support the practice; Bolitho adds that the opinion must be logical.

Research ethics

• Nuremberg Code (voluntary consent), Declaration of Helsinki, Belmont Report (respect for persons, beneficence, justice).
• Ethics committee approval, informed consent with the right to withdraw, confidentiality, equipoise, protection of vulnerable groups. Misconduct: fabrication, falsification, plagiarism.

Remember Valid consent needs capacity, information and free choice; an unwise decision is still the patient's decision.

Exam trap Family members cannot veto what a capable patient is told: explore their worry, then ask the patient what he wants to know.

Exam trap Breach confidentiality only for consent, law or serious risk to others, and disclose the minimum.

How FCPS asks about this

• Requirements of valid consent: capacity, adequate information and voluntariness.
• Brother asks you to hide cancer; capable patient asks what is wrong: tell him honestly and sensitively.
• 15-year-old wants contraception and understands: assess maturity (Gillick, Fraser); she can consent.
• Epileptic pilot asks for secrecy: advise him to inform the authority; disclose if he refuses, telling him first.
• Morphine that may hasten death in terminal pain: doctrine of double effect; foreseen harm accepted if proportionate.
• Brainstem death: absent brainstem reflexes and a positive apnoea test, with reversible causes excluded.
• Colleague operating under the influence of alcohol: raise it through proper channels.