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Shared decision-making

Dr Nancy Boodhoo, MPS Head of Operations in the Caribbean and Bermuda, recently met with Professor Sir Errol Walrond to discuss the place of ethics, law and values in modern-day medicine

The biggest challenge that faces doctors in the Caribbean is trying to reconcile religious views and teachings with the law, and the wishes and rights of patients. Doctors should not  discriminate against any patient, even if they have strong religious views; however, even with the best will in the world, emotions spill over and some patients have less access to, or experience a delay in, treatment. A common example would be termination of pregnancy.
Doctors feel threatened, especially if they find it difficult to separate legal and ethical issues in their own minds

Another challenge facing doctors is the amount of information patients now have with regards to their own treatment and their legal rights. Doctors feel threatened, especially if they find it difficult to separate legal and ethical issues in their own minds.

One area where this comes out strongly is in the backlash in relation to rights of children and indeed older people. Some people take a simplistic view that an ill elderly person is incapable of making their own decisions about their treatment; a doctor may be lured into failing to carry out a formal consent procedure by a universal assumption that “doctor knows best”.

Other issues that have been raised relate to the age of consent for children to medical treatment. Minors feel that the age of consent should be reduced because 16 and 17-year-olds are able to do other things without parental consent; for example they can consent to sex, they can drive and they can work but they cannot go to the doctor without their parents.

Some doctors argue against this as they feel changing things will destroy the fabric of the family. But many of these families are already broken and we think that by insisting on including parents in the consent procedure, we will magically mend the family.

Changing attitudes

There is now a greater effort to formally bring ethics into the curriculum of medicine. I am optimistic about the future: young doctors will be more exposed to formal teaching although some will remain influenced by religion, and other societal issues.

We still do not have good measures to evaluate the success of teaching but the young are more interested if we can make it more relevant. We should not treat young people as vessels for facts but challenge them to think; and for me ethics is a way of thinking about situations. How do you think of one situation that looks similar to another, eg, consent, where ten cases will be different in terms of what is relevant to the patient?

I am optimistic about the future: young doctors will be more exposed to formal teaching although some will remain influenced by religion, and other societal issues

Therefore, treatment should not be determined by the law, but a doctor ought to know every patient will have different issues related to their illness and that situations will present different challenges. Young doctors should be encouraged to think about each situation.

Another thing that has changed is medical council reaction to complaints from the public. In the past, the medical councils have been accused of being professional clubs that look out for each other – but now, complaints are being taken much more seriously across the jurisdictions. This will concentrate the minds of some professionals who have hitherto not viewed their patients as partners in service.

The Hippocratic Oath

I am concerned that young doctors and healthcare professionals are using their own beliefs about what is in the Hippocratic Oath. They know they are entitled to their views, but patients are entitled to their rights under the law. Healthcare professionals sometimes exercise their own rights to the detriment of the patient. In the case of a conscientious objection to abortion, it should lead to the removal of a doctor from treating a patient rather than a doctor misusing his position when treating the patient. A doctor should not actively deny a patient their legitimate right to have treatment because of his own views.

The Hippocratic Oath has become a kind of flag, which no-one knows exactly the true meaning of. It is interesting to hold up a national flag and ask what it means; many could not say what the different parts of the flag represent. With the Hippocratic Oath, some doctors only seem to remember you should do good but do not remember you should not do harm. Some are unsure of what justice means. One reason is that the Hippocratic Oath is talked about and there are ceremonies for swearing in, but it is not dissected and put into modern terms – which religion, which god, etc.
A doctor should not actively deny a patient their legitimate right to have treatment because of his own views

Access to care

Issues surrounding resources are not new in the Caribbean, but are more in the spotlight because of access to care that people think they need, with greater barriers being thrown up by the current economic situation. In the Caribbean there is good access for everyone to primary and secondary care, and, to a lesser extent, tertiary care. However, there is a perception that if you can have private care you will have easier access and better treatment.

The future

There are basic issues surrounding the ethical development of society. For example, more awareness of government legislation, such as the Conventions on Human Rights, etc. These need to be put in reach of citizens by way of statutes. If this can be challenged positively it will be good – for example in Barbados and Guyana, the Medical Termination of Pregnancy Acts have included a wide remit for allowing terminations: they can be undertaken for social and economic reasons. This has revolutionised certain aspects of care for young women.

Ethics is used more seriously in teaching but in the wider society this should be explained: what does ethics mean, not only in medicine but in business and religion. There is still a cloud over many of these areas and these issues.

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