Medical Ethics Today

The BMA's Handbook of Ethics and Law

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• Publisher: BMJ Books
• Year: 2012
• Print ISBN: 9781444337082
• eBook ISBN: 9781444355642
• Edition: 3
• Topic: Medicine
• Subtopic: Ethics in Medicine

This is your source for authoritative and comprehensive guidance from the British Medical Association (BMA) Medical Ethics Department covering both routine and highly contentious medico-legal issues faced by health care professionals. The new edition updates the information from both the legal and ethical perspectives and reflects developments surrounding The Mental Capacity Act, Human Tissue Act, and revision of the Human Fertilisation and Embryology Act.

1

The doctor–patient relationship

The questions covered in this chapter include the following.

• Do doctors in different types of relationship with patients have different obligations?
• Can doctors choose their patients in the same way as patients choose their doctor?
• When does the ‘duty of care’ start and end?
• What, if any, responsibilities do patients have?
• Can patients choose not to have any information about their treatment?
• What happens when the doctor–patient relationship breaks down?

This chapter looks at how attitudes and some facets of the relationship between patients and their doctor have changed. It examines the rights and duties on both sides, while recognising that doctors have particular responsibilities to make the relationship work well. The emphasis is on doctors respecting patient autonomy, while doing more than providing a menu of options, but tensions arise when patients request treatments or procedures that doctors feel unable to provide. This may be due to the cost or the lack of evidence of efficacy. The likelihood of such problems becoming more prevalent for some doctors as the NHS undergoes significant change is among the factors flagged up here. Doctors are expected to be supportive of patients and offer them as holistic a type of care as possible, while ensuring that professional boundaries are maintained and that empathy does not result in inappropriate closeness or dependency. They should learn from their mistakes and those of colleagues so that services and patient safety are improved. They must not offer moral comment or make reference to their own personal views unless explicitly invited by patients to do that. Above all, they must act with integrity and be quick to spot any measure which might lessen their patients’ trust in them.

General principles

General principles that all doctors must observe are listed in the previous chapter, where the General Medical Council’s (GMC) guidance1 on the duties of a doctor is set out (see pages 6–7). In this chapter we focus more closely on the practical implications of the requirement that doctors be honest, open and act with integrity, that they respect patients’ dignity and treat them politely. Principles underpinning the doctor–patient relationship can be summarised as follows.

• Doctors owe special duties of care to their patients.
• All interactions involving doctors and patients should be characterised by honesty, politeness and respect on both sides.
• Effective communication requires both parties to listen, talk frankly and recognise uncertainties.
• Doctors have the main duty to make the relationship work but patients also have responsibilities.
• Establishing and maintaining appropriate boundaries is essential.

Changing expectations of the doctor–patient relationship

Patients expect more and different things from medicine than they previously did. Along with the increased life expectancy for most people has come a greater focus on medicine’s contribution to their quality of life (see the discussion of ‘health’ as an evolving concept in Chapter 20, pages 802–804). Through media such as the internet, patients tend to be better informed about what medicine can achieve. They rightly expect to share in deciding how different treatment options fit with their own preferences. Some use online technology to obtain advice, diagnoses or direct-to-consumer testing. They can switch between NHS and private providers and buy medicines over the internet, without discussion with their GP. (These issues are covered in detail in Chapter 19, pages 780–781.) Although this puts more tools within the grasp of patients, they still need professional expert advice when making treatment decisions. Part of the doctor’s role is to help people make the decisions that best suit them, in a fair and well-informed way. Listening to patients’ views and feedback about their experience is essential to the provision of a patient-centred service.

The strong emphasis on patient autonomy and choice, combined with the focus on doctors being trained to have good communication skills should ensure a better balance in the doctor–patient relationship than in the past, when access to information was more one-sided. Tensions arise, however, if there is a mismatch of expectations between what patients want and what doctors see as appropriate evidence-based solutions. Wider awareness of newly evolving treatments, including elective, cosmetic or alternative therapies, can also create tensions between differing interpretations of ‘wants’ and ‘needs’. The use of consumerist language also raises patients’ expectations. The growth of a range of ‘lifestyle’ drugs, for example, can contribute to misperceptions about the primary focus of medicine. Examples include patient demand for amphetamine-type appetite suppressants, steroids to improve sporting performance or cognitively enhancing drugs to aid concentration. (These are discussed in Chapter 13, pages 547–549.) Part of the doctor’s role in maintaining a workable relationship is to try to ensure that patients are aware of any risks attached to the medicines or interventions they seek and also the limits on what doctors can provide. The NHS is a bureaucratic organisation through which patients can find it difficult to navigate. Doctors see themselves simultaneously as patient advocates, helping patients obtain appropriate and timely care, and custodians of NHS resources, with an important role in containing costs fairly.

Changing expectations about what medicine can provide coincide with some patients no longer having a sense of continuity of care, provided by a doctor with whom they have had a long relationship. Different doctors or other healthcare professionals probably deal with some aspects of their routine care and locums provide out-of-hours cover. Patients also obtain health advice from various other sources, such as telephone helplines and walk-in clinics. Doctors’ expectations about some aspects of their role have also changed. Greater emphasis on medical appraisal, governance, audit and performance management can mean that they feel they have less scope for clinical discretion in individual cases. Health and social care are intended to be more joined up than in the past so that patient care is often provided by multi-disciplinary teams, which may include other professionals such as social workers. Proposed changes in how the commissioning of services will work in future is likely to mean that GPs face more conflicts of interest between trying to do the best for the individual and simultaneously trying to conserve NHS funds. Changes in hospital team structure mean that contact between individual clinicians and patients can be a more transitory experience, as opposed to the traditional model of one doctor having responsibility for continuity of the patient’s care. Other changes to NHS organisation, such as shorter hospital stays, more shift working following the implementation of the European Working Time Directive, GPs relinquishing ‘out-of-hours’ responsibilities, and the tendency for multi-practitioner primary care surgeries, can mean that contact is fragmentary. Some doctors know their patients less well as individuals.

Ethical guidance continues to emphasise doctors’ traditional duty to benefit patients and help them function well but what counts as ‘benefit’ has undergone significant reappraisal. Fundamental concepts of ‘harm’ and ‘benefit’ have changed greatly to reflect the wishes and values of the individual patient. Prolonging life at all costs was sometimes seen as a ‘benefit’ in the past whereas it is now recognised that ‘benefit’ and ‘harm’ must be judged in terms of what the individual patient would like. Imposing a treatment – even to save life – contrary to the wishes of an informed patient with capacity is now recognised as a ‘harm’ rather than a ‘benefit’. Expectations have also changed in relation to issues such as patient satisfaction and dignity. Healthcare is not only about preventing disease and trying to make people well, but also about providing the right treatment environment. As well as prompt access to good quality care, clean and safe premises are a high priority for patients.2 The focus on patient rights in ethical guidance, the law and in charters, such as the NHS Constitution, influences public perceptions about what doctors should provide and when.

Medicine is both an art and a science, although some think that the technological and scientific side has become more pre-eminent. While acknowledging the vital importance of technical competence, the British Medical Association (BMA) also emphasises the need to develop the personal characteristics of ‘a good doctor’ (see the introductory chapter, pages 4–6, and Chapter 18, pages 743–745). A former BMA President noted that:

Two hundred years ago, when little effective treatment was possible, the ability to comfort and help a patient to accept illness and death – in other words the art of medicine – was paramount. Today, when many patients with previously fatal diseases can expect from medicine an almost normal life span, science is vital. Even now, however, common complaints cause much misery, there is no cure for many serious diseases and the death rate for us all is one hundred percent in the end. So the old art is still a vital characteristic of the good doctor.3

Telemedicine and other forms of care at a distance

Face-to-face interaction between patient and doctor is acknowledged to be the best in most circumstances but providing medical advice and treatment by video, telephone or internet can be a useful addition. Telemedicine involves consultations carried out at a distance, using tools such as videoconferencing, multi-media communications, internet and intranet for a range of clinical purposes such as diagnosis, treatment and clinical education. It includes both live and time-delayed consultations. Live telemedicine usually involves a combination of patients, primary care practitioners and specialists communicating by means of an audiovisual link. At its best, it can improve communication because the patient and the doctor who knows the patient’s history can be present together when a specialist is consulted by videoconferencing. GPs can begin treatment following the advice of the specialist via the video link. Time-delayed telemedicine involves the electronic transmission of a previously recorded visual image of the patient, consisting either of a visual sequence, such as a video clip of an echocardiogram, or single pictures, for example of a skin abnormality. Among its advantages are cost reduction, the speeding up of referral for the patient, avoidance of unnecessary referrals, greater consistency in healthcare and improved contact between doctors. The number of broken appointments can be reduced and one specialist can provide services to a number of different locations.

Among the ethical considerations, principal concerns are accuracy of the image or text, security and confidentiality. Mistakes can be made and an erroneous diagnosis given by video link as in any other consultation, and teleconsultation cannot convey the same information as a physical examination. The accountability of doctors and their ethical duties remain the same. There are both advantages and drawbacks of consulting and prescribing electronically and over the internet (see Chapter 13, pages 567–569).

Routine telephone communications can also replace some consultations and provide rapid review of some patients. Such systematic monitoring of patients by telephone can be as effective as and less time consuming than face-to-face consultations as they can be more focused and more flexible in terms of time needed to talk to the patient than surgery consultations.

Background to changed expectations

Thomas Percival’s 1803 influential text on medical ethics4 set the benchmark for the traits of a good doctor which, he said, should be a balance of compassion and authority. He advised that doctors should be sensitive to patients’ fears and anxieties by shielding them from disturbing information. Generations of doctors were taught to keep up patients’ hopes and spirits by withholding bad news which would depress them. The duty of beneficence was interpreted as an obligation to be reassuring rather than honest. From the 1950s, this interpretation became discredited and, by the 1980s, paternalism was seen as completely outmoded. All current ethical guidance, including that from the BMA, sees patients themselves as the most suitable arbiters of their own best interests. This entails them being given all the relevant information about their condition. Throughout this book, we emphasise the key importance of patient autonomy and the need for health professionals to help patients to make the decisions that are best for them rather than assuming that they have similar goals or values as their doctor. In a multi-cultural society such as the UK, values and expectations can differ considerably. Most patients are willing and able to know about the options open to them. Some may have other expectations and do not want full information or a list of options. They may not want to feel that they alone are responsible for making decisions or they may want others to take the decision for them. (This is discussed in more detail in Chapter 2, pages 70–71.)

Changing expectations of the do...

Table of contents

• Cover
• Series
• Title Page
• Copyright
• List of statutes and regulations
• Directives and conventions
• List of cases
• Where to find legal references online
• Medical Ethics Committee
• Acknowledgements
• Preface to the third edition
• Bridging the gap between theory and practice: the BMA’s approach to medical ethics
• Chapter 1: The doctor–patient relationship
• Chapter 2: Consent, choice and refusal: adults with capacity
• Chapter 3: Treating adults who lack capacity
• Chapter 4: Children and young people
• Chapter 5: Confidentiality
• Chapter 6: Health records
• Chapter 7: Contraception, abortion and birth
• Chapter 8: Assisted reproduction
• Chapter 9: Genetics
• Chapter 10: Caring for patients at the end of life
• Chapter 11: Euthanasia and physician assisted suicide
• Chapter 12: Responsibilities after a patient’s death
• Chapter 13: Prescribing and administering medication
• Chapter 14: Research and innovative treatment
• Chapter 15: Emergency situations
• Chapter 16: Doctors with dual obligations
• Chapter 17: Providing treatment and care in detention settings
• Chapter 18: Education and training
• Chapter 19: Teamwork, shared care, referral and delegation
• Chapter 20: Public health dimensions of medical practice
• Chapter 21: Reducing risk, clinical error and poor performance
• Appendix a
• Appendix b
• Appendix c
• Index