What should a GP do when he or she believes that a patient with dementia is no longer safe to drive, or is faced with a mother asking what took place in a recent consultation with her 15-year-old daughter who came in requesting a termination of pregnancy?
These are the sorts of dilemmas that a typical GP can expect to encounter regularly. To be able to practise effectively, safely and on the right side of the law requires a good understanding of the basic principles of ethics and of the law relating to medicine.
Consent to Treatment
Before performing any procedure involving a patient, even a simple blood test, the GP must ensure that an adult patient has the mental capacity to give consent (see Figure 10a), that their decision is free from coercion and that they have been given sufficient information to make the decision. Without proper consent such procedures could result in a charge of battery.
Of these, assessing mental capacity can be the least straightforward. Since the Mental Capacity Act (MCA) came into force in 2007, doctors have a clear framework to work with. The Act covers adult patients in England and Wales.
To assess capacity the patient must be able to:
- Understand the information being given
- Retain the information in their mind
- Use or weigh the information in considering the decision
- Communicate the decision using any means (see Figure 10b).
The Act also covers the legal basis for decisions made for patients who lack capacity. These are summarised in Box 10.1.
Children under 16 Years
Although most consultations with children under 16 years will be with an adult, there are situations where the GP will be faced with a child requesting treatment in the absence of a parent or adult. This may be because the child does not wish his or her parents to be present, for example, a request for contraception.
Treatment relating to children is covered by the Children Act 1989. This defines those with ‘parental responsibility’ who may make decisions on behalf of a child patient. If, say, the child minder brings a child to surgery they would not be able to give consent for the child unless the parent has given their explicit permission. This means it is normally necessary to contact the parent before proceeding. In an emergency, if it is not possible to get hold of a parent, a child can be treated under the Act if it is ‘reasonable’ to do so.
In certain circumstances children can give consent without the need of a parent or adult. There is no age limit that determines this, instead it is determined by the child’s ability to demonstrate ‘sufficient understanding and intelligence to enable him or her to understand fully what is proposed’ (also known as ‘Gillick’ or ‘Fraser’ competence). Where the GP relies on the child’s consent in the case of contraception, the GP must also ensure that:
- He or she has sought to persuade the child to involve her parents
- That the child is likely to engage in sexual activity, and
- That the treatment is in her best interests.
Finally, although children with sufficient maturity may consent to treatment, even a competent child may have a refusal of treatment overturned by his or her parents or the courts in the case of life-saving treatment.
Confidentiality
Keeping information gained from patients secret has been a fundamental part of medical ethics as far back as Hippocrates. Doing so serves to protect patient autonomy and trust in the doctor–patient relationship.
In certain circumstances a GP may be permitted or even have a duty to breach patient confidentiality, if:
- It is required by law (e.g. notification of certain infectious diseases; Public Health Act 1984).
- It is justified in the public interest where others may be at risk of serious harm. For instance, a patient with epilepsy who insists on driving.
- The patient consents. Express consent is necessary if identifiable information is to be disclosed. Consent may be implied when sharing information within the healthcare team.
Data Protection
GP records hold large amounts of sensitive personal information and are regulated under the Data Protection Act 1998. GPs are responsible for ensuring that data are accurate, secure and accessible to patients.
Confidentiality and the Student
As a medical student you also carry confidential information from clerking and examining patients and from seeing the patient’s records. You should always take care to protect your patient’s confidentiality. Do not talk with colleagues about your patient in a public place (e.g. the hospital lifts). Do not write identifiable details in your patient clerkings (they might get left on the bus). Equally, beware of what you put on Facebook or other social networking sites.
Ethics
The ability to recognise, analyse and resolve ethical dilemmas in clinical practice is a crucial skill for any doctor. There are many tools or frameworks that can be used to help in this process. None are perfect but with a thorough understanding of the clinical issues, the non-medical factors and context of a case, these frameworks help resolve the ethical issues involved.
The Four Principles approach is widely used in medical ethics. Although it looks easy to apply, problems can occur when any of the principles conflict, which is all too common in practice. As the approach does not tell us how to resolve such conflicts one is still left with difficult decisions to make.
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