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Practising ethical medicine

27 May 2016

Dara Gantly further reflects on the new Guide to Professional Conduct and Ethics

The arrival of a new Ethical Guide is always a special event in the medical calendar, and even more so when it has been nearly seven years since the last edition was released. Is this not too long a gap? The previous Ethical Guide (7th edition) was produced within 16 months of a new Council taking up office, in November 2009. This time around, the Council has been in place for nearly three years before an 8th edition emerged.

Yes, the Council did re-circulate the 7th edition in early 2014 with an update to paragraph 21, dealing with abortion, following the commencement in January of that year of the new Protection of Life During Pregnancy Act. But nothing else changed over the past six-and-a-half years — despite pledges made back in 2009 that the Guide would undergo “rolling” changes, particularly on the thorny areas of assisted human reproduction and stem cell therapy; two areas still not advanced in the new document. To be fair, IMC President Prof Freddie Wood remarked in 2014 that a fully updated Guide would only emerge after an “extensive consultation process” with the public and profession. And that consultation was worthwhile.

During that process, it emerged that the profession was looking, in particular, for guidance on how to navigate through budget cuts and challenges to its role as patient advocate. And much of this has been taken on board. On advocacy, the new Guide stresses the need to “balance your duty to do your best for each individual patient with the wider need to use finite healthcare resources efficiently and responsibly” (Section 24.2). However, if doctors find themselves working in a facility that is not suitable for patients or for the treatment provided, “you have a responsibility to advocate on behalf of your patients for better facilities” (24.1).

The Guide also clarifies that doctors should act as an advocate for their patients in two ways: by speaking on behalf of individual patients to make sure they receive appropriate healthcare, but also by “promoting the fair distribution of limited resources and fair access to care” (4.5).

In the new section on ‘Doctors in management roles’, the Guide stipulates that doctor managers have a responsibility to advocate for appropriate healthcare resources and facilities “if insufficient resources are affecting or may affect patient safety and quality of care” (63.1.1). A new whistleblowing provision also states that “you should not start disciplinary measures against a staff member for raising concerns that they believe to be true” (63.1.3).

Another new section on open disclosure states that doctors have a duty to “promote and support this culture [of candour] and to support colleagues whose actions are investigated following an adverse event” (67.1). And : “Patients and their families, where appropriate, are entitled to honest, open and prompt communication about adverse events that may have caused them harm.” (67.2) But the Guide does not require them to inform patients of serious adverse events. The wording is quite different to the stance taken by the General Medical Council in the UK, which clearly states doctors “must be open and honest with patients if things go wrong”. Overall, the input of NALA has been positive, but perhaps more work still needs to be done.

Thankfully we have gotten down to just 44 pages, excluding appendices, from the 60-page 7th edition, and that’s with all these other new sections on social media, equality and diversity, doctors in leadership and management roles and doctors as trainers. That is an achievement. As is the new format under the three ‘Pillars of Professionalism’: partnership, practice, and performance. This does make a simple ‘compare and contrast’ exercise with the previous Guide a bit more difficult ­— but then, perhaps it will make more of us read it from cover to cover.

The expanded section dealing with relationships with colleagues — addressing the scourge of bullying and the newly tackled issue of sexual relationships between supervisors and their trainees — might generate some headlines (‘IMC tackles sexual politics’, IMT, May 20, 2016), but there is plenty of other material to chew over; like the new paragraph (34.2) indicating that in “exceptional circumstances” doctors may take images of patients using their personal mobile device, or the revised section on telemedicine, in which the Council advises that doctors should “inform the patient’s general practitioner of the consultation”.

Equally important are the changes appearing in the section on physical and intimate examinations, which has been expanded to stress the need to “respect patients’ dignity by giving them privacy to undress and dress, and keep them covered as much as possible” (35.2). And while the offer of a chaperone was already recommended in the 2009 Guide, the new document adds that this offer needs to be noted in the patient’s records (35.3). Furthermore, it is specifically noted that doctors must not carry out intimate examinations on anaesthetised patients unless the patient has given written consent to this in advance (35.4).

Parsing a new Ethical Guide is always interesting, and the 8th edition is no different. I just hope we don’t have to have until 2023 for some badly needed guidance on some of those other outstanding ethical concerns facing both the profession and their patients.

Dara Gantly

Click here to view the full article which appeared in Irish Medical Times: Opinion