Doing Right: A Practical Guide to Ethics for Medical Trainees and Physicians

Contents
Cases ix
Preface xii
Acknowledgements xiv
Introduction: A Revolution in Learning xvi
1 Ethics Matters 1
I. Great Expectations: Healthcare Professionals and Ethics 1
II. Four Ethical Principles and Questions 2
III. The Principles and Ethical Reasoning in Medicine 5
IV. Beyond Principles 9
V. The Hidden Curriculum 10
VI. Overcoming Obstacles to Ethics 12
2 Broadening the Horizon: What Law
and Ethics Say 15
I. What the Law Says 16
II. What Ethics Says: Virtues, Rules, and Consequences in
Medicine 17
III. Expanding the Horizons of Ethics 23
IV. Professional Ethics 28
3 Managing Medical Morality 33
I. Managing Ethical Dilemmas 33
II. Really Hard Choices Are Not Always about Ethics 34
III. “Doing Right”: A Process for Managing Ethical Choice 37
IV. The Ethics Process in a Little More Detail 38
V. Applying the Ethics Process 43
4 The Times are Changing: Autonomy and
Patient-Based Care 50
I. The Autonomy Principle 51
II. Autonomy as the Patient’s Preference 54
III. The Case of Ms Malette and Dr Shulman 56
IV. Choices: The Good, the Bad, and the Ugly 58
5 Reasonable Persons: The Legal Roots of
Informed Consent 69
I. Medical Consent 69
II. Informed Consent: A Brief Legal History 71
III. Informed Consent: The Canadian Context 74
IV. Significance of Reibl v Hughes: The Modified Objective
Standard 79
6 Informed Choice and Truthtelling:
The Centrality of Truth and Trust 85
I. Disclosure and Truthtelling 85
II. The Elements of Informed Choice 89
III. Consent as Trust 95
IV. Other Special Circumstances 97
V. Special Circumstances and Limits on Truthtelling 101
7 Keeping Secrets: Confidentiality and
Privacy in the Electronic Age 108
I. Confidentiality and Privacy 108
II. Privacy, confidentiality, and Trust 110
III. New Risks to Privacy 115
IV. Limits to Confidentiality 121
V. To Warn and Protect 128
8 The Waning and Waxing Self: Capacity and
Incapacity in Medical Care 131
I. Incapacity and Its Discontents 131
II. Assessing Capacity 134
III. Capacity and Consent 136
IV. Treating and Protecting the Vulnerable 137
V. Substitute and Assisted Decision-Making 139
VI. Mental Illness and the Right to Refuse 142
VII. Children’s Right to Refuse 145
9 Helping and Not Harming: Beneficence and
Nonmaleficence 151
I. The Principles of Beneficence and Nonmaleficence 151
II. A Duty to Attend? 156
III. Risks to the Professional 158
IV. Endangering One’s Self 160
V. Parental Refusals of Treatment 165
VI. Parental Requests for Treatment 169
10 Conduct Becoming: Medical
Professionalism 175
I. Maintaining the Connection 175
II. A New Professionalism 177
III. Conflicts of Interest 181
IV. Professionals and Industry 183
V. Boundaries Large and Small 186
VI. Fitness to Practise Medicine 191
11 The End of Forgetting: Ethical and Professional
Issues with Social Media 197
I. Friends, Boundaries, and Privacy in the Age of Social Media 197
II. The Personal and the Private 201
III. Patients Using Social Media 204
IV. Photographs and Patient Privacy 206
V. Internet Etiquette and Telling Others’ Stories 209
12 The Error of Our Ways: Managing
Medical Error 214
I. Medical Error 214
II. Error and Being Responsive to Patients 222
III. How to Disclose Error 223
IV. Apologies 224
V. Large-Scale Adverse Events 225
13 Beyond the Patient: Doing Justice to
Justice 230
I. Justice in Everyday Medicine 230
II. A System of Mutual Recognition 234
III. Distributive Justice 239
IV. Squeezing the Balloon 242
V. Guidelines and Rationing 245
VI. Justice for All? 247
14 Labour Pains: Ethics and New Life 254
I. Birthing and Reproductive Choice 254
II. Termination and Choice 260
III. The New Age of Reproduction 262
IV. Desperately Seeking Stem Cells 272
15 A Dark Wood: End-of-Life Decisions 276
I. Allowing Death: Refusals by Patients 276
II. Competent Decisions, Living Wills, and Advance Directives 281
III. Decisions to Withhold or Withdraw Life-Sustaining Treatment 284
IV. Persistent Vegetative States and Prognostic Error 287
V. Unilateral Decisions Regarding Life-Sustaining Treatment 289
VI. Palliative Sedation 292
16 Medical Assistance in Dying: The Triumph of
Autonomy 296
I. Assisted Death: Terminology and Other Jurisdictions 298
II. Medically Assisted Death in Canada: A Brief History 300
III. Legislating Medical Assistance in Dying: Bill C-14 302
IV. MAID: Minors, Advance Requests, and Mental Illness 304
V. MAID and Issues of Conscience 313
17 Nature and Culture: Of Genes and Memes 319
I. All in the Genome? 319
II. Cultural Connections 327
III. Worlds Apart? 331
IV. Culture and Defying Death 332
V. Transcending Culture 335
18 The Ethical Regulation of Research 340
I. Medicine’s Legacy 340
II. The Purpose of Research 341
III. Consent for Research 344
IV. The Tissue Issue 347
V. Some Questions and Answers Regarding Research 350
Conclusion: Setting our Sights 358
Notes 362
Index 406