Ethical Issues

Also known as Kantism, Deontology is the ethical study of duties, rights and obligations focusing on the rightness and wrongness of the actions and not the consequences. It is important to note, though, that Immanuel Kant’s theory did not extend to persons lacking capacity by which he meant children and those with mental impairment or illness (Clark 2000, p.145). Deontology takes many forms some of them are: rights, contactualism, divine command ethics, monistic deontology and duty. (Glossary Of Technical Terms, 2007) * Rights are actions that are morally right which respect all rights and freedoms to which all humans are entitled. * Contactualism is the theory that actions are morally right if they respect the rules that everyone accept in a social relationship. (Darwell, Deontology, 2003) * Divine command ethics is the theory that actions are morally right when they agree with the rules and duties established by God. * Monistic deontology is the theory that actions are morally right when it coheres with a set of agreed duties and obligations. (Wolf, 1993) .

According to Rachels 1999, A deontologist’s actions are defined by the difference between acts of duty and acts of belief; obligation is what ought to be done as oppose to what we believe we should do. Rationality: humans are capable of rational thought, rational thought is what makes morality possible, therefore, we are able to override our beliefs and preferences. Kant believed the key to all moral judgements with rationality core to his beliefs. Consequentialism

Consequentialism is results-based ethics. Consequentialism Also known as Utilitarianism is based on two principles. The first principle is whether an act is right or wrong depends only on the results of that act. The second is the better the consequences an act produces the better the act. (Glossary of Technical Terms, 2007) * Consequentialism gives guidance when faced with a moral dilemma. This guidance is; a person should choose the action that maximises good consequences. * It also gives general guidance on how to live. This guidance is; people should live so as to maximise good consequences. (Smith, 1995) Different forms of consequentialism differ over what the good thing is that should be maximised. Two forms of consequentialism are; utilitarianism and hedonism.

* Utilitarianism states that people should maximise human welfare or well-being. * Hedonism states that people should maximise human pleasures. (Darwell, 2003) Norman, 1998 believed the most important aspect of living was to be happy, therefore, actions must be assessed in terms of consequence to happiness or wellbeing: * Always act in the way that will directly lead to the greatest happiness/wellbeing for the greatest number. * Follow the rule that offers the best consequences in terms of overall happiness/wellbeing. * It is the outcome rather than the intention that is important. * No differentiation is made between persons or species.

Ethical Principles
The four moral principles are central to biomedical ethics:
Respect for autonomy
Respect for autonomy is respecting the decision-making capacities of autonomous people; enabling individuals to make reasoned informed consent. (Bartter, 2001) (S. Fry, 2010)

* Respect the capacity of individuals to make informed decisions about their own lives.
* Consider decisions in a cultural/religious context but without discrimination in regard to race, religion or sexuality.

Beneficence
Beneficence is the consideration of balance of maximising
* Benefits of treatment against the risk and costs;
* The healthcare professional should act in a way that benefits the patient * Directly or indirectly improving care or best practice. Determining what action is in a patient’s best interest is challenging to health professionals if practitioner and patient have conflicting views. Non malfeasance

Non malfeasance is avoiding the intention of harm; the healthcare professional should not harm the patient. All treatment involves some harm; even if minimal, but the harm should not be disproportionate to the benefits of treatment. (Bartter, 2001) (S. Fry, 2010) * Health practitioners have a greater obligation not to harm the patient than to do them good. * Any medical or social intervention has the potential to cause harm as well as benefits. * Decisions must always be made that benefit the patient or how likely it is that harm may be caused, benefit must outweigh risk. Justices

Justices is concerned with the benefits, risks and costs fairly; the notion that patients in similar positions should be treated in a similar manner. (Bartter, 2001) (S. Fry, 2010) * Solidarity in health and social care;

* Those with high risk of disease or mental health problems have an equal right to healthcare compared to those of low risk. * Managing competing claims fairly.
* Healthcare workers must be clear about their motivation behind particular actions that may benefit one client over another. Two Ethical Issues from Nurses Code of Practice
For consent to be valid it must be informed, voluntary and competent and professionals have a duty to the patient to provide any information to them about their condition, treatment and prognosis (Halstead and Vernon 2000). There are many legal and ethical implications with the main issue being that of consent. As McHale (1997) states, when a nurse touches a patient weather it is to examine them or give an injection, valid consent must first be obtained. Valid voluntary consent

* A patient consents freely; consideration should be made to patients not competent or too vulnerable to refuse; those under pressure from health professionals or family. * Adults are assumed to be competent unless demonstrate otherwise. * means that the patient must not be under any duress or influence from the professional (Booth 2002). Informed consent

Consent to treatment is usually informal except in the case of surgery (Fortes Mayer, 2002). Before undertaking any procedure, health professionals need to explain to the patient what is going to happen and why. The Human Rights Act 1998 (HMSO, 1998) states that everyone has * the right to freedom of thought, conscience, opinion and expression. * NMC (2002a) also publishes that nurses must respect the patients’ rights to decide whether or not to undergo any procedure. There are currently no laws in England that specifically cover adult consent in health care, but there are many laws and acts that may help protect the patient against suffering from poor consent issues, such as the professional running the risk of committing trespass or negligence, or not fulfilling their duty of care to a patient. Those proceeding without consent, or in the face of a valid refusal, risk committing battery or assault (Halstead and Vernon 2000).

Capacity to consent:
* A patient has capacity to fully understand the circumstances and give consent. * If opposed by a relative or spouse opposition is unlikely to be upheld. Consent by proxy:
* The views of the patient must be considered whatever their age or capacity. * In the case of children and vulnerable adults, a parent, guardian or advocate can consent on their behalf if consent is seen to be in the best interests of the patient.

Ethics and confidentiality
A duty of confidence when one person discloses information to another in a situation where it is reasonable to expect confidentiality. The Confidentiality Model: (VCTU, 2009)
* Protect:
* A legal obligation to protect personal information with regard to physical security of records and appropriate disclosures. * In compliance with NHS Code of Practice (2003) implemented following the Caldicott Report (1997) * In compliance with Data Protection Act (1998)

* Inform:
* Ensure patients know how their records will be used (for their personal medical care, teaching or research) * Provide choice:
* Allow patients to decide whether or how their information is to be used or disclosed.

In line with the NHS code of practice (2003) and the Data Protection Act (1998) breaches of confidentiality may lead to legal action.

Exceptions to the rules of confidentiality
* Control of Diseases Act (1984) and Public Health (Infection) Regulations (1998)
* All notifiable diseases must be reported.

* To prevent a client or patient from serious, foreseeable danger:
* A patient is considered at risk of serious self injury or suicide.
* To safeguard an identified person at risk:
* A child at risk of neglect.

Confidentiality is a value that is a part of the ethical code of practice of most professions. Nurses, lawyers, doctors, and accountants all have code of ethics that impose a duty of confidentiality on practitioners. Confidentiality is an important value that should be a constant consideration for health and social care workers in their interactions with their colleagues and with service users, their friends and relative, (British journal of nursing, 2000, vol 9, no 8) Disclosing Confidential Information

There are times when care practitioners have to reveal what they have been told, or have seen, to a more senior person at work or to an external organisation. Clients’ request that you keep what they tell you a secret can be overridden if:

* What they reveal involves them breaking the law or planning to do so. * They tell you that they intend to harm themselves or another person. * They reveal information that can be used to protect another person from harm. If an offence that could have been prevented by your revealing the confidence is committed, you could be brought to court to face charges. Care workers should never promise a client that what they say will be absolutely confidential. They should explained to that, depending on what they are told or observe, there are times when they may have to share information with their colleagues and other authorities. In all care settings the standard of confidentiality that care practitioners are able to provide should be communicated to service users at the first point of contact. Ethical issues in professional practice

Passive euthanasia occurs when a patient dies because the medical professionals either don’t do something necessary to keep the patient alive, or when they stop doing something that is keeping the patient alive. Examples of this might be; * Switching off life-support machines.

* Disconnecting a feeding tube.
* Not carrying out a life-extending operation.
* Not giving life-extending drugs.
Arguably, euthanasia should not take place in the absence of * The consent of the person concerned.
* Passive euthanasia can more readily occur in the absence of consent. Clearly, there are ethical issues or dilemmas surrounding the matter as to whether or not the individual is able to give informed consent. Also does a depressed or physically/mentally disabled person have the ability to make a sensible, informed decision or does this case just highlight the kinds of issues we would be making on an everyday basis if euthanasia was to be legalised? If we look at the case of Gemma Jones who was an 85 year old lady being kept alive by feeding her through a syringe following a series of strokes. She had no ability to communicate. Her children and her doctor took a decision not to feed her and so she starved to death. If there was no consent the from the family the GP would of been charged with murder and struck off. Withholding an ANH

* Artificial feeding and hydration (ANH):
* Is withholding ANH a form of passive euthanasia?
* Beneficence/Double Effect: Drug induced unconsciousness confers a pain free death and emotional relief to the family. Key Issues regarding ANH
* Beneficence; acting in the best interest of the patient: * Using sedation selectively, carefully and according to a patient’s needs. * Autonomy; Knowing and understanding the wishes of the patient and family: * The increase of psychological and physical suffering.

* Justice; balancing those wishes with the legal, ethical and moral obligations of the health professional: * Suicide Act (1961) decriminalised suicide but created a new offence of ‘Complicity’ with a custodial sentence of 14 years for those who are ‘complicit’ in bringing about the death of another. (OPSI) * The Assisted Dying Bill (2006) reviewed the ethical implications of assisted dying; assistance remains illegal but each case will be considered individually and with discretion (BBC Ethics).

The first thing we have to consider is that the view of the doctor and the family was that the quality of Gemma’s life was not worth living. Many people accept euthanasia on the basis that it would be better to be dead other than sick or disabled. We could argue that such a view devalues a human life. However some people regard death as bad thing as it is the worst possible violation of the wishes of the person who does not want to die. This links to euthanasia in the sense some people die involuntarily. Possibly, individuals might hold either of these perspectives as a result of their own life experiences. It is difficult to be sure as to which the correct perspective might be. Ironically, Gemma was unable to voice her own opinion and it is not known if she had left a Living Will. But, it was Gemma who died a slow and painful death. And behind that lies the idea that human beings are independent biological entities, with the right to take and carry out decisions about themselves, providing the greater good of society doesn’t prohibit this.

Allied to this is a firm belief that death is the end. Finally, an ethical issue involved in Euthanasia is that it will happen anyway so isn’t it better to regulate it in some way. If you accept this as the basis for your ethical code then the arguments above are perfectly sensible. Those in favour of euthanasia think that there is no reason why euthanasia can’t be controlled by proper regulation, but even they fear that regulations won’t deal with people who want to implement euthanasia for bad motives. Nonetheless, people worry that whatever regulations are put into place they won’t stop, particularly vulnerable, patients being pressured to choose death when they would rather live for a few more weeks.

For safeguards to be meaningful and effective, they have to involve investigations of the patient’s psyche, their family dynamics and the financial implications of their death, among with more obvious things such as the patient’s medical condition, and the likely course of the disease. In order to ensure that requests are properly considered, both by the patient, the family, and the authorities, regulations need to build in a time-period for reconsideration. If we apply the teleological ethical theory to this we could argue that in the long run the death of the person, where it has been intended, is for the best. It reduces suffering of not only the patient but the family. When considering the teleological theory we do not need to consider the means in which the person came to die, so people who believe in the teleological theory would say that the final outcome is the same as if the person had died of natural causes.

Overall as a principle I fail to understand why euthanasia is a bad thing as people will die anyway. People have been taking their own life since we had life to take, and the whole concept of euthanasia actually strikes me as an act of compassion, but people tend to make it out to be some horrible murderous act. Despite this I think euthanasia has to many complications to allow it be to be legalised.