Dara Gantly examines a selection of the submissions made during the public consultation stage of drafting the new Ethical Guide
Some two-and-a-half years in the making, the Seventh Edition of the Guide to Professional Conduct and Ethics was unveiled by the Medical Council on November 12 last. It was produced following some 25 meetings of the Council’s Ethics Working Group and after extensive consultations with numerous outside bodies.
Irish Medical Times has learned that more than 6,500 submissions were also made during the drafting process, the overwhelming majority of which were identical in nature and essentially constituted a petition by pro-life/anti-abortion campaigners.
Patient Focus
While IMT decided against pursuing all 6,500 documents through the Freedom of Information Act, it was given access by the Medical Council to a selection of the submissions. One of these was from the patient lobby group Patient Focus, which had urged the Medical Council to substantially change the Sixth Edition of the Guide. It believed the document had taken up an uncomfortable position, ‘straining to stand firm but failing to do so’.
In a hard-hitting critique, Patient Focus suggested its failings might be down to respect for the uncertainty of medical ethics, the evolution of Irish social morality, or concern about the legal implications of making more didactic statements.
“The resulting document is weakened, and possibly lacks impact and influence among a profession which most certainly needs and oftentimes demands guidance in the areas of ethical conduct and professional behaviour. Because of this, we urge the reviewing committee to consider substantial change to the entire document rather than a basic section-by-section review,” the patient group recommended.
It added that the aim of the Council should be to provide a guide that ‘redefines professionalism’, and which uses examples, where possible, to illustrate the application of its principles in the day-to-day activities of doctors.
“The Guide may be the only document available to a medical professional facing a difficult situation or clinical dilemma. It has to be specific, demanding and didactic in critical areas, and we believe the review must replace ‘should’ with ‘must’ in many instances relating to corrective behaviour.”
Patient Focus believed the Guide should be ‘mandatory reading’ for every professional and feature in the curriculum for education and Continuous Professional Development (CPD) at every level. The Council intends to introduce a new ‘tick box’ system from July on the annual retention notices and new registrations, whereby doctors will have to indicate that they have both read and understood the document.
In the area of Fitness to Practise, Patient Focus wanted patients to be able to know if a doctor had been sanctioned ‘at any time’ by the Council and if any restrictions had ever been placed on their practice.
The professional responsibilities of a doctor, it believed, also included a duty to ‘blow the whistle’ when there was any reasonable concern about the clinical competence or health of a professional colleague. “This duty has been suppressed in the past due to a lack of appropriate investigative mechanisms,” the submission stated.
“As the ‘blame culture’ rapidly disperses, and with the advent of competence assurance and a health committee with the Medical Council, it is a duty which should now be expressed and become a professional reality.”
Change in the area of advertising was also addressed. “While we agree that allowing advertising can be distasteful and allow exploitation of vulnerable patients, these same patients need to be permitted to make informed choices about who they attend. This does not just apply to general practice, but to specialists in both the public and private sectors as well,” the group noted.
Advertising limits
“Clearly a decree that ‘information is acceptable, but advertising is not’ would be ineffective, but it is possible to define some type of information, and some methods of making that information available, for which benefit outweighs risk,” the group added.
While the style of the material was a matter for individuals, Patient Focus was adamant that all qualitative statements, inducements, incitements, and testimonials from previous patients, as well as information about business levels, practice activity or turnover must be ‘banned’.
As reported in this week’s news section, the Department of Health (DOH) had wanted the Medical Council to consider strengthening the requirements on doctors to treat public and private patients equally. In his submission, DOH Secretary General Michael Scanlan also suggested creating new mechanisms that could allow doctors to demonstrate an ‘adherence’ to this principle of equitable treatment.
In a separate submission, the Office of the Data Protection Commissioner recommended that where personal information was being collected on doctors’ websites, a privacy statement should be present on the site. This was incorporated into the new Guide (paragraph 54.8).
The Council also heeded the Commissioner’s suggestion that doctors be careful that information supplied to insurance companies was ‘specific’ to the episode for which the report had been requested, and that in no circumstances should medical files be furnished to an insurance company.
On the subject of referrals, the Commissioner questioned the validity of paragraph 12.2 of the old guidelines (Sixth Edition), which stated that in the exceptional circumstances when a consultant saw a patient without referral, that patient’s GP should be informed of the consultant’s findings and treatment.
“We cannot see why the original doctor would be informed of the outcome without the consent of the patient. Perhaps the patient would not want that doctor to know and that should be respected,” the submission pointed out.
To address this concern, the Seventh Edition states that in such instances the patient’s general practitioner should be kept informed of the patient’s progress, ‘unless the patient specifically objects’.
The Women’s Health Council (WHC) in its submission on the Ethical Guide wanted the provision on ‘conscientious objection’ to be strengthened by the Medical Council. It believed that after having secured consent from the patient, the referring doctor should establish an official link with the ‘receiving’ doctor to ensure a minimum of continuity of care, and also to check that the receiving doctor did not share his or her conscientious objection, thus exposing the patient to additional and unnecessary distress and costs. These arrangements, the WHC said, were particularly crucial in cases of crisis pregnancy.
Contraception
The WHC felt the guidelines were ‘unclear’ regarding the issues of confidentiality and consent where the treatment of young people was concerned. This was particularly the case when considering the prescription of contraception to teenagers. “While we realise that the current lack of clarity in this area places practising doctors in a difficult position, it is still vital that health professionals make their views on confidentiality and treatment clear when dealing with patients who are minors so to avoid any potential for later distress and perceived breach of confidentiality.”
In the area of reproductive medicine, the WHC believed it was unclear what position the Medical Council took on freezing and storing embryos for future implantation; what its stance on surrogacy was; or whether it believed non-married or same-sex couples should be considered eligible for fertility treatment.
The body said the ‘ambiguity’ was not helpful to doctors practising in the field. “Until such time when a statutory regulatory agency is established, in line with the recommendation of the CAHR [Commission on Assisted Human Reproduction], it is the duty of the Guide to provide clear, unambiguous advice for doctors. Moreover, ethical concerns over the health of women undergoing fertility treatment should be just as critical as those governing the handling of embryos.”
As for the Medical Council’s position on abortion, the WHC said the guidelines needed to be clarified in accordance with the X case ruling, so as to recognise the risk of suicide by the mother as a medical ground for the termination of a pregnancy. The new Ethical Guide has done this in paragraph 21.1.
The WHC also called for the use of the phase ‘the child in utero’ to be reconsidered [“It is standard practice to refer to a ‘foetus’ while in utero”].
The organisation believed the introduction of nurse prescribing would also pose new and additional ethical challenges for doctors. “While this new practice will certainly bring many benefits, working relationships within health service delivery settings might be affected,” the WHC envisaged.
Pro Life Campaign
One of the most extensive submissions came from the Pro Life Campaign (PLC). In its 34-page document, complete with two pages of contents, the lobby group dealt with five major issues: abortion, abortion assistance, euthanasia and the withdrawal of feeding, and the protection of human embryos.
In reference to the X case, the PLC stated that deliberately induced abortion had ‘no place in the treatment of any maternal condition, either physical or psychological’. Included in a set of six recommendations on abortion was the statement that medical ethics ‘do not follow each change in the law and mere legality is not equivalent to ethical practice’.
Addressing the issue of euthanasia, the PLC wanted the Seventh Edition of the Ethical Guide to include a statement that any ‘complicity of a medical practitioner in the withdrawal of feeding from a chronically ill patient with the intention or purpose that the patient will die as a result is unethical’.
Addressing end-of-life care, the new Guide (par 22.2) states that there is no obligation on the part of a doctor to start or continue a treatment, or artificial nutrition and hydration, that is ‘futile or disproportionately burdensome, even if such treatment may prolong life’. “You should carefully consider when to start and when to stop attempts to prolong life, while ensuring that patients receive appropriate pain management and relief from distress,” it adds.
IVF therapy also came under the scrutiny of the Pro Life Campaign. The group believed it was disingenuous to justify the storage or freezing of human embryos on the basis that it was either ‘pro life’ or represented a ‘pro life strategy’.
“Apart from the very dramatic lessons that can be learned from the British experience in this regard, the storage of a human embryo is not ‘pro life’ — it merely tolerates the existence of the unborn human involved without respecting its rights to life and in circumstances where there is no guarantee that its right to life will ever be respected.”
Among a number of recommendations in this area was the call for a prohibition on embryo research or the use of human embryos as a source of stem cells for research or therapy.
The lobby group was clear in its belief that an opposition to induced abortion should logically apply also to abortion assistance and referral.
“There is a clear ethical and logical, if not legal, dichotomy between having abortion in Ireland unethical and at the same time allowing medical practitioners to actively assist having unborn children aborted outside the State.”
In its conclusion, the PLC stressed that some rights were nonnegotiable, and first among these was the right to life. “If the Guide to Ethical Conduct lacked clarity regarding that most basic right, it would undermine the basis for all other self-evident rights we cherish.”
Running to more than 60 pages (compared to just 37, excluding appendices, in the previous sixth edition), the Seventh Edition of the Ethical Guide contains a number of expanded sections on adverse events, reporting abuse, locum cover, healthcare resources and more open communication with patients.
Further guidelines
According to Council President Prof Kieran Murphy, it clarifies, in particular, issues surrounding consent, confidentiality, end-of-life care, the provision of information to the public, prescribing practices and referral of patients. “If there are certain issues that more detailed guidance is required on, then we will publish those as we get through them,” said the President at the launch of the publication. He singled out human assisted reproduction and doctors’ relationship with industry as two key areas that will be addressed in future.
“The process of developing an Ethical Guide is really a rolling agenda. We hope over the term of the remainder of the Council to develop further comprehensive guidelines based on assisted human reproduction,” added Prof Murphy.
If the above submissions are anything to go by, further recommendations in this area will be examined with great interest.
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