Ethical Guidance for Doctors

While pondering what it means to be a good or immoral person, a philosopher may  conclude there are not always right or wrong answers to questions of ethics. For a doctor, nonetheless, there are well-established ethical frameworks which must be followed to ensure patient safety and maintain trust in the medical profession. This article will provide you with a brief overview of the medical code of ethics and NHS ethics guidelines. 

 

The 4 Pillars of Medical Ethics

Respect for autonomy, beneficence, non-maleficence, and justice – referred to as the four pillars of medical ethics – are likely the first ethical principles you may have come across before or during your medical education. This is for good reason; these principles form the basis of clinical judgement and decision-making when confronted with moral problems in the medical field.

Nevertheless, whilst they offer a common moral code relevant to ethical issues in a healthcare setting, they do not provide specific rules or guidelines which doctors can refer to. For this reason, various medical associations and organisations, principally the General Medical Council (GMC), have articulated a comprehensive ethical system which all licensed doctors must adhere to and consult when facing an ethical dilemma.

 

Good Medical Practice

This is the overarching ethical guidance for doctors in the UK, outlining core ethical values and attributes. It is split into four domains:

1) Knowledge, skills, and behaviours

2) Safety and quality

3) Communication, partnership, and teamwork

4) Maintain trust

It is important all licensed doctors are well-versed in what Good Medical Practice entails for their medical care. This document also sets out what standards patients, colleagues and managers should expect of doctors.

Furthermore, Good Medical Practice forms the foundation of and should always be referred to when thinking about your annual appraisals and revalidation.

 

Confidentiality and Health Records

Confidentiality is an essential and recurring subject in medical ethics and is sometimes even considered the fifth pillar. GMC guidelines include an extensive section on confidentiality and health records when handling patient information. However, the main purpose of the guidance can be summarised by the following eight core principles as articulated by the GMC:

1. Use the minimum necessary personal information. Use anonymised information if it is practicable to do so and if it will serve the purpose. 

2. Manage and protect information. Make sure any personal information you hold or control is effectively protected at all times against improper access, disclosure or loss. 

3. Be aware of your responsibilities. Develop and maintain an understanding of information governance that is appropriate to your role. 

4. Comply with the law. Be satisfied that you are handling personal information lawfully. 

5. Share relevant information for direct care in line with the principles in this guidance unless the patient has objected. 

6. Ask for explicit consent to disclose identifiable information about patients for purposes other than their care or local clinical audit, unless the disclosure is required by law or can be justified in the public interest. 

7. Tell patients about disclosures of personal information you make that they would not reasonably expect, or check they have received information about such disclosures, unless that is not practicable or would undermine the purpose of the disclosure. Keep a record of your decisions to disclose, or not to disclose, information. 

8. Support patients to access their information. Respect, and help patients exercise, their legal rights to be informed about how their information will be used and to have access to, or copies of, their health records.

 

There are, however, certain circumstance where you may disclose patient information without breaching confidentiality: 

1. The patient consents, whether implicitly or explicitly for the sake of their own care or for local clinical audit, or explicitly for other purposes.

2. The patient has given their explicit consent to disclosure for other purposes.

3. The disclosure is of overall benefit4 to a patient who lacks the capacity to consent.

4. The disclosure is required by law, or the disclosure is permitted or has been approved under a statutory process that sets aside the common law duty of confidentiality.

5. The disclosure can be justified in the public health interest.

 

Additional supporting pieces on confidentiality, designed for specific purposes – such as disclosing information about fitness to drive, serious communicable diseases, or gunshot/knife wounds – are readily available on the GMC page. 

 

Decision-Making and Consent

Good Medical Practice promotes a holistic and patient-centred approach in healthcare. The patient’s involvement and their consent regarding care and treatment are hence crucial themes in a doctor’s everyday practice.

As with confidentiality, there are numerous legal and ethical factors you must consider when making decisions about a patient’s care. The seven core principles decision making and consent in healthcare articulated by the GMC are as follows:

1. All patients have the right to be involved in decisions about their treatment and care and be supported to make informed decisions if they are able.

2. Decision making is an ongoing process focused on meaningful dialogue: the exchange of relevant information specific to the individual patient.

3. All patients have the right to be listened to, and to be given the information they need to make a decision and the time and support they need to understand it.

4. Doctors must try to find out what matters to patients so they can share relevant information about the benefits and harms of proposed options and reasonable alternatives, including the option to take no action.

5. Doctors must start from the presumption that all adult patients have capacity to make decisions about their treatment and care. A patient can only be judged to lack capacity to make a specific decision at a specific time, and only after assessment in line with legal requirements.

6. The choice of treatment or care for patients who lack capacity must be of overall benefit to them, and decisions should be made in consultation with those who are close to them or advocating for them.

7. Patients whose right to consent is affected by law should be supported to be involved in the decision-making process, and to exercise choice if possible.

 

The GMC has also set out guidance specific to bioethics, i.e. seeking consent to research, which you may wish to look into.

 

Leadership and Management

Part of a doctor’s job description is leading teams and supervising colleagues for the purpose of providing safe care to patients. Therefore, they are required to adhere to the following, no matter what role they are in:

1. Engage with colleagues to maintain and improve the safety and quality of patient care. 

2. Contribute to discussions and decisions about improving the quality of services and outcomes. 

3. Raise and act on concerns about patient safety. 

4. Demonstrate effective team working and leadership. 

5. Promote a working environment free from unfair discrimination, bullying and harassment, bearing in mind that colleagues and patients come from diverse backgrounds. 

6. Contribute to teaching and training doctors and other healthcare professionals, including by acting as a positive role model. 

7. Use resources efficiently for the benefit of patients and the public.

 

Maintaining Professionalism

As a doctor you are part of the professional culture present in healthcare. Developing professionalism is a process; from an early stage in your medical education, you are consistently required to demonstrate attributes, values, and behaviours expected of a physician until you come to think, act, and feel like a physician.

Doctors regularly face a variety of situation where they must remain professional, which is why the GMC offers a range of guidance to help you maintain appropriate boundaries, including on social media.

 

Children and Young People

Doctors must consider additional ethical and legal factors when dealing with children. The GMC, the BMA, as well as the Medical Defence Unit (MDU) have developed guides to help you explore and act in the best interest of a child or young person. Comprehensive guidance for all doctors on 0 to 18 years old patients can be found on the GMC’s webpage.

 

Good Practice in Prescribing

As you are responsible for your signed prescription, it is in your best interest to ensure you are prescribing safely, particularly when prescribing controlled drugs. Do not prescribe for yourself or friends and family. Additional guidance can be found on the GMC webpage.

 

End-of-Life Care

This is a very sensitive and complex subject and you should consult the detailed guidance on end-of-life care provided by the GMC. Overall, you must be aware of the Human Rights Act 1998 and its main provisions, as your decisions are likely to engage the basic rights and principles set out in the Act.

In accordance with the pillar of justice, you must give patients who are approaching the end of their life the same quality of care as all other patients. You must treat patients and those close to them with dignity, respect and compassion, especially when they are facing difficult situations and decisions about care. You must respect their privacy and right to confidentiality.

 

Candour and Raising Concerns

All doctors have a duty to raise concerns where they believe patient safety or care is being compromised as well as encourage a culture in which staff can raise concerns openly and safely.

Concerns may stem from numerous sources, such as patients’ complaints or colleagues’ concerns. Upon receiving such information, you are obliged by medical law to act promptly and professionally by putting the matter right (if that is possible), investigating and dealing with the concern locally, or referring the matter to senior management or the relevant regulatory authority. More detailed guidance on raising concerns can be found on the GMC webpage.

 

References

1. Ethical Guidance. General Medical Council. Available from:

https://www.gmc-uk.org/ethical-guidance

2. Ethics. British Medical Association. Available from:

https://www.bma.org.uk/advice-and-support/ethics

      3.  Gillon R. Medical ethics: four principles plus attention to scope. BMJ 1994;309:184–184. doi:10.1136/bmj.309.6948.184