Mark Baxter has provided case notes and video links about various medical ethics topics. The videos were too large to upload, so screenshots and YouTube links were included along with accompanying case notes that discuss the legal and ethical issues raised, relevant objectives, and references. The case notes cover topics like organ donation, medical research, conflicts of interest, confidentiality, and whistleblowing.

1. Contact Details:
Mark Baxter
Email: markajbaxter@gmail.com
Unfortunately, our video content was too large to upload to the internet, so I have included a
screenshot of each video along with a youtube link and case notes to accompany each video.
Introduction to our Project
http://www.youtube.com/watch?v=iHwz5sSOeXk

2. Example Topic 1: Organ Donation
http://www.youtube.com/watch?v=EbObZ8zs82E&feature=player_embedded
Case Notes:
LEARNING OBJECTIVES
o The significance andlimitsof respectforpatientautonomy
o Proxyconsent
o Bestinterestsof patientswholackcapacity
o Local,national andinternational prioritizationinrelationtoclinical decisions
LEGAL ASPECTS OF CASE
A healthcare professional shouldtryandfindoutif a patienthasindicatedif theywishtodonate
theirorgans.Thiscan be done bycheckingthe Organ Donor Register,lookingforanorgan donor
card on the person,or checkingthe patient'smedical records.If thisisthe case,organdonationcan
thengo ahead,legally.
The Human Tissue Act2004 detailsthe guidelinesforwhichorgandonationcanoccur.
If the patienthasindicatedtheirwishfororgandonation,buttheirfamilyobjectstoit,thenlegally
under the Human Tissue Act 2004, the familycannot vetothis consent. In practice th ough,few
surgeonswouldconsidercarryingoutorgan retrieval overthe family'swishes.
If the patienthasnotindicatedtheirwishfororgandonationbefore theirdeath,consentcanbe
givenposthumously,byapersonina 'qualifyingrelationship'(HumanTissue Act 2004). The Human
Tissue Actactuallyrankspeople whocouldbe ina 'qualifyingrelationship'withthe patient,asto
whocan give consentfirst.

3. ETHICAL ISSUES RAISED
 In posthumousdonation,adeadpersonlackscapacityto consent.Soby giving'treatment'-
ventilatingthem,are youactinginthe patient'sbestinterests?Butdoesadeadpersonhave
any interestsanyway?
 Consentto'treatment'by anotheradultisnot allowedinall otherbranchesof medicine,
unlessthe patienthascreatedalastingpowerof attorney.Whyshoulditbe differenthere?
 Whichorgans are beingdonated?Shouldall the organsbe usedfordonationtomaximise the
benefitfromone donor?
IN CLINICAL PRACTICE
Organs and tissuessuitable fortransplantation:
 Organs: kidney,heart, lung,liver,pancreas,small bowel
 Tissues:cornea,bone,tendon,skin,heartvalve.
Familiesmustneverfeelunderanypressure toagree todonation,andmustbe assuredthat their
decisionwillbe respected.
The NHSBT (NHS Blood & Transplant) service has strict rulesforthe subsequentorganallocation.
Thissystemaimsto treatpatientsequally,toensure thatorgansare allocatedfairlyaccordingto
patients'needs,andtoachieve the bestpossible matchbetweendonorsandrecipients.
REFERENCES
1. Human Tissue Act2004
http://www.hta.gov.uk/legislationpoliciesandcodesofpractice/legislation/humantissueact.cfm
2. Organ DonorRegister
http://www.uktransplant.org.uk/ukt/how_to_become_a_donor/how_to_become_a_donor.js
p

4. Example Topic 2: Ethics of Medical Audit and Research
http://www.youtube.com/watch?v=o2_EOEdLp_o&feature=player_embedded
Case Notes:
LEARNING OBJECTIVES
o Confidentialityforpublications/casereports/audits
o The purposesand differencesbetweenresearchandaudit
o Ethical,professional andlegal considerationsinvolvedinmedical researchandaudit
o National/Local ethicscommittee
o Ethical and legal issuesinconductingandreportingclinical trials
LEGAL ASPECTS OF THE CASE
 It isvital to define researchadequatelytofollowthe appropriate guidelines.
 Informedconsentmustbe obtainedfromall participants.Thisincludesadequatelyproviding
informationof the benefitsandrisksinvolved.The onlyexceptiontothisisif the patienthas
impairedmental capacity.
 Clinical researchmustbe approvedatnational andlocal levelsbyethicscommittees.The NHS
site (R&Ddepartment) mustalsobe made aware of,and approve anyprojectsor
investigations.
ETHICAL ISSUES RAISED
 Doctors have a dutyto do good fortheirpatients:the principleof beneficence.Medical
research(involvingpatientsdirectlyorindirectly) isvital topromote andimprove existing
healthcare inthe presentandalsoindiscoveringtherapiesandtreatments.

5.  Patients'autonomymustbe respected.'The relationshipbetweenadoctorand a patientis
basedon trust,and the participants'rightstomake a decisionontheirinvolvementinany
researchmustbe protected'.[1]
Hence,anyparticipantsmustbe informedif they are tobe
involvedinanyresearch,inordertogetconsent.
 However,informedconsentisonlyvalidif patientsare givenhonestinformationaboutthe
researchand are informedfullyaboutall the benefitsandrisks.
 The principle of non-maleficence mustalsobe adheredto.Asmentioned,the primaryaimof
researchisnot intendedtodirectlybenefitthe currentparticipants,andsotheymay notget
any benefitsfromit.BUT, measure mustbe takento ensure thatall risksare minimised- and
again,patientsare informedof thiswhenyougetconsent.
IN CLINICAL PRACTICE
DefiningClinical Research
4 keydiscriminantsare,aslaidoutin'DefiningResearch(2010)'by the National ResearchEthics
Service (NRES):intent,treatment/service,allocationandrandomisation. [2]
i. Intent.The primaryaimof researchisto derive new knowledge2,whichisbeneficial to
future patientsandthe widerpopulation.Thisisdifferenttoservice evaluationsorclinical
audits,where the aimsare to judge andevaluate currentstandardsof care.
If a projecthasmultiple intentions,itmaybe harderto define whatitis.Inthiscase it may necessary
to seekclarificationandjudgement,eitherfromaResearchEthicsCommittee (NationalorLocal),or
eventhe ResearchandDevelopmentoffice locatedatthe NHS site where the projectistakingplace.
ii. Treatment/Service."Neitherauditnorservice evaluationusesaninterventionwithouta
firmbasisof supportin the clinical orhealthcommunity."(DefiningResearch,2010) [2]
iii. Allocation.Allocationof Treatmentfollowsprotocol andadefinedframeworkinresearch.
In auditsandservice evaluations,noallocationtakesplace.Treatmentischosenjointlyby
the patient/clinicianbeforeeithertake place.
iv. Randomisation.Researchmayuse randomisation.AuditsandService Evaluationsdonot.
Applyingfor Research Approval:
Afterthe projectisdesignedandinformedconsentisobtained,the followingprocedure needstobe
followedtoobtainapproval:
o Applicationsneedtobe made usingthe IntegratedResearchApplicationsSystem- IRAS
(https://www.myresearchproject.org.uk/).
o Applicationsthenneedtobe bookedinforreview withanappropriate REC,eithertovia
the central allocationsystem,ordirectlyviathe local allocationservice.Once abookingis

6. made,the applicationandsupportingdocumentsneedtobe submittedtothe allocated
REC within4 days.
o Once a validapplicationisreceived,the REChas60 days to returnan opiniononwhether
the researchcomplieswiththe currentethical regulations.
REFERENCES
1. General Medical Council: http://www.gmc-uk.org/guidance/ethical_guidance/research.asp
2. 'DefiningResearch':NationalResearchEthicsService, 2010.

7. Example Topic 3: Conflictsof Interestwith Financial Incentives
http://www.youtube.com/watch?v=5kXtecrSUuU&feature=player_embedded
Case Notes:
LEARNING OBJECTIVES
o Respectforthe role,responsibilitiesandrequirementsof the GMC andits primaryconcern
to promote the healthandsafetyof patients
o Importance of trust,integrity,honestyandgoodcommunicationinprofessional
relationships
o Acceptingpersonal responsibilityandbe aware of limitationsandseekingappropriate help.
o Professionalboundarieswithpatients.
o Conflictsof Interest
o Respondingtoclinical errorsandreportingadverse incidents
o Legal and ethical responsibilitiesforprotectingpatients
LEGAL ASPECTS OF THE CASE
NHS General Medical ServicesContract (2004)
 Schedule 5
A GP may notaccept a fee froman NHS patientforservicesunlesstheyare specificallyoutlinedin
the above document.Thisparticulararrangementisnotmentioned andthusthe doctormay not
demandpaymentforit.
 Schedule 6Paragraph 124
GPs mustkeepa registerof all giftsfrompatientsandoutside partiesabove the value of £100. This
registermustbe made available tothe PCTon request. Thusinthissituation, if he acceptsa
monetaryor non-monetarygiftof value greaterthan£100 for hisendorsement,itmustbe recorded.

8. GPPartnership Agreement
Each GP practice has a PartnershipAgreement(essentiallyaconstituition)outliningfinancial policy.
If,in this policy,extraearningsare sharedcommunallybetweenpartners,the GPmustensure that
hispartnersare happyto endorse the dvdas well because byacceptingpayment,theirendorsement
isimplied.
ETHICAL ISSUES RAISED
Is this GPqualifiedto assessthe qualityof the product?
From the GMC Good Practice Guidance [2] "64. youmust alwaysbe honest aboutyour experience,
qualificationsandposition.." Itisnotunreasonable toquestionthe expertise of aGP inthe areaof
sportsscience.Itisunlikelythat the GPwill have the appropriate depthof knowledge inthisarea.
Is there any clinical evidence supporting/opposingthe methodsinthe DVD?
GMC Good Practice Guidance [2] "65. Youmust do yourbest to make sure any documentsyou
write or signare not falseor misleading.Thismeansyoumust take reasonablesteps to verifythe
informationinthe documentsand that youmust not deliberatelyleave out relevant information."
The GP mustmake an informeddecisiononthe meritsof the exerciseprogramme.He must
differentiatebetweenamedical andpersonal endorsement - if there issupportingresearchitisa
medical endorsement,if notitisonlya personal endorsement.He musttake stepstoensure a
personal endorsementisnotmis-leadinglyportrayedasa medical one.Thisisfurthercompounded
by the GMC Good Practice Guideline "63.Youmust be honest andtrustworthy when writing
reports..."
Ethicallythe GPmust declare anyfinancial interesthe hasinan enterprise tohispatientswhen
recommendingthe product.
GMC Guidance [2] states "before takingpart in anydiscussionsaboutbuyingorsellinggoodsor
services you mustdeclare any relevant financial orcommercial interest that you or your family
mighthave in the transaction."
IN CLINICAL PRACTICE
Will the Dr-PatientRelationshipbyaffected?
By enteringintoafinancial agreementwiththe patientthe GPisputtinghisprofessionalrelationship
withthe patientat risk.
From the GMC Guidance "MaintainingBoundaries"(2006);."Inmostsuccessful doctor-patient
relationshipsaprofessional boundaryexistsbetweendoctorandpatient.If thisboundaryis

9. breached,thiscanundermine the patient'strustintheirdoctor,aswell asthe public'strustin the
medical profession."
Also,"The doctor-patientrelationshipmayinvolve animbalance of powerbetweenthe doctorand
the patient."Inthiscase,by acceptingpaymentfroma patientthe balance of powermayshift
towardsthe patient,whichcouldcause difficultiesforthe GPinthe future whendealingwith this
man,or hisfamily.Thisisof particularconcerninthisscenario,where the patienthaslong-standing
mental healthissueswhichthe GPissupportinghimwith.
Will the public'strustin the Dr be affected?
GMC Guidance states; "youmustmake sure that yourconduct at all times justifiesyourpatients
trust in you andthe publicstrust in the profession."
The GP shouldconsiderthatbyendorsingacommercial productof thisnature he may be seento be
"selling-out".Thismaycause patientstoquestionhisjudgmentandclinical decisionmaking.If inthe
future the DVDis provedtobe unsafe/inadequatethismayalsounderminepatientconfidence inhis
practice.
Wouldthisscenariobe more acceptable if the GP didnotreceive paymentforhisendorsement?
REFERENCES
1. NHS General Medical ServicesContract(2004)
2. GMC: Dutiesof a Doctor
3. GMC: Conflictsof Interest(September2008)
4. Medical Act (1983)
5. PublicInterestDisclosure Act(1998)
6. HealthService Circular(1999/198)
7. GMC: MaintainingBoundaries - Guidance forDoctors(November2006)

10. Example Topic 4: Dealingwith Authoritiesand Confidentiality
http://www.youtube.com/watch?v=IkA_YzEPvrQ&feature=player_embedded
Case Notes:
LEARNING OBJECTIVES
o Informedconsent,voluntarinessanddisclosure of diagnosis
o Recognitionof the legal andethical boundariesof the clinicaldiscretiontowithhold
information
o Whenit islegally,professionallyandethically justifiableormandatorytobreach
confidentiality(balance of publicinterests)
o Conflictsof interest
LEGAL ASPECTS OF THE CASE
GoodMedical Practice (2006) :-
 "Patientshave arightto expectthatinformationaboutthemwill be heldinconfidence by
theirdoctors"
 There are seriousrepercussionsforthe doctorwhodisclosesconfidential informationranging
fromdisciplinaryGMChearings,civil proceedingsandcriminal proceedings.
 The patient'sbasiccontact detailsisconfidential informationalongwith theirmedical
information.
Data ProtectionAct (DPA),section29, paragraph 3 :-
 Personal dataisexemptfromnon-disclosureprovisionsforpreventionordetectionof crime.
So the police canrequestforpersonal datato be disclosedincertaincircumstances.

11.  However,despite the factthatthe DPA releasesthe dataholderfromobligationtoprotect
data, itdoesnot require the holdertodisclose it.Inthiscase,the clinicianmustdecideif the
circumstancesare seriousenoughandinthe publicinterest todisclosethe information.
PreventionofTerrorism Act 2000 :-
 If the doctoris suspiciousthatanact of Terrorismmighttake place,itis hislegal dutytoreport
thisto the police.
ETHICAL ISSUES RAISED
 Under whatcircumstancesisitalrightfor a doctor to breachpatientconfidentiality?There are
guidelinesfromthe GMCwhichdefinesseriouscrimesasapossible reasontodisclose
information.Howevertheydonotlistwhattypesof crimesare involved.
 What shouldcome first:the doctor'sduty to an individual patient,orthe dutyto the public
and inthiscase,publicsafety?
 By withholdinginformation,isthe doctorpotentiallywithholdinginformationthatcouldhelp
protectsomeone else?Afterall,the police couldjustgetacourt order to requestthe
informationlateronanyway.
IN CLINICAL PRACTICE
 The clinicianhasobligationstotheirpatienttokeeptheirinformationconfidential,including
theircontact details.
 No one outside the healthcare teamshouldsee theirmedical files;norshould anythingabout
the patientbe discussedbyanyone outsidethe medical team,unlessthe patientconsents.
 The clinicianshouldattempttofollow the "CaldicottPrinciples",whichsetouta wayin which
the DPA can be followedwithinthe frameworkof the NHS.
 If the clinicianisunsure astowhat to do,theycan contact the NHSTrust CaldicottGuardian,
whocan advise insituationswhere confidentialityisatriskof beingbreached;oralternatively,
contact theirmedico-legal team.
REFERENCES
1. Data ProtectionAct1998, section29
2. CaldicottPrinciples
3. CaldicottGuardian

12. Example Topic 5: The Whistleblower
http://www.youtube.com/watch?v=XuugG0WWAAg&feature=player_embedded
Case Notes:
LEARNING OBJECTIVES
o The role,responsibilitiesandrequirementsof the GMC inwhistleblowing
o The importance of trust, integrity,honestyandgoodcommunicationinall professional
relationships
o The needto knowhowand where toseekappropriate help
Studentsshould be able to:
o Respondappropriatelyclinical errors
o Followproceduresforreportingadverse incidents
o Adhere tolegal andethical responsibilitiesthatprotectpatients
LEGAL ASPECTS OF CASE
Is Dr A legallyprotectedif she makes a complaint?
The PublicInterestDisclosureAct1998 (PIDA),statesthat"The disclosure mustrelate toraising
genuine concernsaboutriskstopatients,financial malpractice,orotherwrongdoingfromthe
followingcategories:
 a criminal offence;
 breachof any legal obligation
 miscarriage of justice

13.  danger(or potential danger) to the healthandsafetyof anindividual
 damage (or potential damage)tothe environment;and
 the deliberate concealingof informationaboutanyof the above."
PIDA givesrightnotonlyto full time staff butalsoto locums,studentsandcontractors.Thiswas
designedtoprotectemployeesbyprotectinganybodywhoinformedthe authoritiesfrombeing
victimisedordismissed.Therefore,inthiscase,the doctoris legallyprotectedasherregistrarmay
be endangeringhispatients.
What action can the GMCtake?
The GMC has a setout a listof what theycan andtheycan't take actionagainst.Theycan take and
have takenactionagainst:
 Misconduct
o E.g. misuse of alcohol/drugs,sexual advances,treatingwithoutconsent
 Deficientperformance
o E.g. notexaminingproperly,serious/repeatedmistakes
 A criminal conviction
 Physical ormental illness
 A decisionbyaregulatoryboardinthe BritishIslesoroverseas
Whenfitnesstopractice isfoundto be impaired,the possibilitiesincludesuspension,
removal/imposingconditionsof adoctorsregistration.A warningcanalsobe issuedif itis not
believedthatfitnesstopractice isnot impairedbutthere hasbeenasignificantdeparturefromthe
principlessetoutinthe GMCs Guidance forDoctors: Good Medical Practice.
In thiscase,the Registrar,isguiltyof misconductwithalcohol.Furtherinvestigationtoelucidateif
thiswas a onetime occurrence,orarecurringproblemisnecessary.His/herperformance shouldbe
evaluated,toensure patientcare hasnot beencompromised.
What is the correct reportingprocedure to follow?
The firstport of call inthissituationisthe consultant.Afterthis,the PCTshouldbe informed.
Ideallythe followinginformationshouldbe providedinwriting,sothatan investigationcan begin:
 The doctor's full name,orsurname,initialsandreference number
 The doctor's address,or the addressof the hospital/practice where theywork
 A full accountof the eventsorincidentsthatconcernyou,withdates,if possible
 Copiesof any relevantpapersand/oranyotherevidence youhave

14.  Detailsof anyaction youhave takenalready - for example,if youhave spokentothe doctor,or
made a complainttothe doctor'semployer
 Detailsof anyone else whowillsupportyourcomplaint.
If a doctor isconcernedthatby providinginformationtheywillbe breachingpatientconfidentiality
theymay wishtotake advice fromthe GMC or theirdefence organisation.
ETHICAL ISSUES RAISED
Is the Registrar putting hispatient'sinterestsfirst?
In thiscase,the Registrarwouldnotbe able to make hispatienthisfirstconcernsince alcohol will
impairhisdecisionmaking.The GMCGuidance alsostatesthat 57 "You mustmake surethatyour
conductatall times justifiesyourpatients'trustin you and thepublic's trustin theprofession."
Obviously,practisingmedicine whilstunderthe influenceof alcohol doesnotpromote publictrustin
the profession.
As the Consultantis not there,is the Registrar leadingthe team appropriately?
GMC Guidance:ManagementforDoctorssetsout what isexpectedof aDoctor ina positionof
leadership,whichinthiscase inthe absence of the Consultantisthe Registrar.Inparticularthe
followingare relevanttothiscase:20. "Whether you havea managementroleor not,yourprimary
dutyis to yourpatients.Their care and safety mustbeyourfirst concern."And21. "Management
involvesmaking judgementsaboutcompeting demandson availableresources."Inthiscase,by
drinkingthe Registrarisimpairinghisabilitytodoeitherof the above.
Is a Doctor responsible fora colleague'sperformance?
GMC Guidance:GoodMedical Practice 43. statesthat "If you haveconcernsthata colleaguemay not
be fit to practice,you musttake appropriatestepswithoutdelay,so thatthe concernsare
investigated and patientsprotected wherenecessary.Thismeansyou mustgivean honest
explanation of yourconcernsto an appropriateperson fromyouremploying orcontracting body,and
followtheir procedures".Inthiscase,if the reporting doctorignoresthisincident,she isneglecting
herduty and wouldbe inbreachof the GoodMedical Practice Guidelines.
Is the healthof the Registrar affectinghisability?
GMC Guidance:GoodMedical Practice 79. "...if yourjudgementorperformancecould beaffected by
a condition or its treatment,you mustconsulta suitably qualified colleague.You mustaskforand
followtheir advice aboutinvestigations,treatmentand changesto yourpracticethatthey consider
necessary.You mustnotrely on your own assessmentof therisk you poseto patients."Alsorelevant
here isGMC Guidance,ManagementforDoctors,58. "Doctorsshould also protectthosethey
managefromrisksarising froma colleagueshealth and respond constructively to signsthat
colleagues havehealthproblems,in particularmentalhealth problems,depression and alcoholand
drug dependence."
IN CLINICAL PRACTICE

15. Ever since the Bristol HeartCase,where anumberof operationswere performedonchildrenwith
sub-optimal results.Legislation hasbeenputinplace sothatpoor clinical practise canbe reported
withoutrepercussion.Currentlyitisthoughtthatthere are variousinequalitiesinhow
whistleblowersare treatedinthe NHS,as well asa lack of adequate protection.
AndrewLansley(HealthSecretaryof the UK) realisedthatthe NHSConstitutionshouldmore
accuratelyreflectwhistleblowingculture tocounteractthe culture of silence andfearwithinthe
workingenvironment.He hasestablishedaNHSConstitutionconsultationpaper.
The paper statesthat dismissal of awhistleblowerwouldbe consideredunfairif theyare dismissed
for makinga protecteddisclosureasdefinedbyPIDA 1998.
At the time of writingthis,the paperisstill undergoingreview.
REFERENCES
1. GMC Guidance:Good Medical Practice
2. NHS Departmentof Health:The NHSConstitutionandWhistleblowing(A paperfor
consultation)
3. AntecedentsandOutcomesof RetaliationAgainstWhistleblowers:GenderDifferencesand
PowerRelationshipsbyMichael TRegh,Marcia P. Miceli,JanetP.Near,JamesR.VanScotter in
OrganizationScience Vol.19,No.2, March-April 2008, pp.221-240
4. The keyto effective whistleblowingisinterprofessionalcollaboration.BMJ2009;339:b3055

16. Example Topic 6: A Case of Pre-Eclampsia
http://www.youtube.com/watch?v=0iC2Xbgm8p0&feature=player_embedded
Case Notes:
LEARNING OBJECTIVES
o Maternal-fetal conflictsof interest
o Ethical,legal andprofessional aspectsof terminationof pregnancy
o Human FertilisationEmbryoAct1998, Abortionact
LEGAL ASPECTS OF THE CASE
Under the AbortionAct 1967 :-
Justificationformedical terminationof pregnancyinclude:
 The pregnancydoesnot surpass24 weeks,andthatcontinuationof the pregnancywould
entail greaterrisk(tothe mental/physical healthof the pregnantladyoranyexistingchildren
of herfamily) thanif the pregnancywere terminated.
 Severe permanentinjurytothe physical ormental healthof the pregnancyladywouldbe
preventedbyterminationof the pregnancy.
 The risk to the life of the pregnancyladywouldbe greaterbycontinuationof pregnancythanif
it were terminated.
 if the childwere born,there isconsiderable riskthatitwill sufferfromphysical ormental
abnormalities,astobe significantlyhandicapped.
In thiscase point3 and 4 wouldjustifyterminationof pregnancy.

17. Under the HFEA 1990 Act,it amendsthe AbortionAct1967 to allow abortionswhere thereisa
seriousriskof foetal handicapuptobirth.
ETHICAL ISSUES RAISED
 The rights of the motherand the interestsof the foetustolife.
 The rights of that fatherand hiswishes.
 At whichpointdoesthe foetusattainshumanrights?
 Whichis more important,the life of the motherorthe life of the unbornfoetus?How doyou
decide?Inreality,the obstetricianismore concernedaboutthe lifeof the mother.However
the motherhas beentryingforso longto getpregnant,thisbabyisveryspecial toher,and
therefore she islesswillingtoterminate the pregnancy.
 Psychological traumatothe motherand herhusbandneedtobe consideredastheyhave to
choose betweenthe life of the motherandthe life of ababy.Alsoif she terminatesthe
pregnancy,she maynot be successful ingettingpregnancyagain.
IN CLINICAL PRACTICE
 Incidence of preeclampsiais5%(range 5 - 10%) of all pregnancies.Maternal complicationsof
preeclampsiainclude:-
o HELLP (10-20%)
o Pulmonaryoedema(2-5%)
o Acute renal failure (1-5%)
o Placental abruption(1-4%)
o Eclampsia(<1%)
 These risksincrease inthose <33wk gestation.
 The importance of recognisingearlystagesof pre-eclampsia.
 A recentstudyinthe UK amongstmedical studentshowedthat62% were pro-choice and33%
pro-life and7%wasundecided.Thiswascomparablyalowerpro-lifepercentage thanasimilar
surveyof GPs, the authorswere unsure whetherthiswasasocietal change toabortion,or
because doctorsbecome more pro-choice astheydevelop.
REFERENCES
1. AbortionAct1967
2. HFEA 1990 Act
3. Medical students'attitudestowardsabortion:aUK studyJ Med Ethics 2008;34:783-787

18. Example Topic 7: ChildProtectionand Non-Accidental Injury
http://www.youtube.com/watch?v=krEM-6_0-AQ&feature=player_embedded
Case Notes:
LEARNING OBJECTIVES
o Rightsand Interestsof children
o Capacityof youngpeople toconsenttoandrefuse treatment
o Role of parents/guardians/HCP/courtsindecisionsabouttreatmentof children
o Ethical & legal issuesinchildprotection
o Applicationof the dutyof confidentialitytoyoungpeople
LEGAL ASPECTS OF THE CASE
ChildrenAct 1989 and 2004 :-
 The Act outlinesthatthe child'swelfare isof paramountimportance whenmakingdecisions
 Basedon the ChildrenAct,local authoritieshave a"dutyto investigate...if theyhave
reasonable cause tosuspectthata childis ...likelytosuffersignificantharm"(section47)
 Medical practitionershave adutyof care towardstheirpatients,whichmeansthatwhen
abuse issuspected,there isalegal imperative toreportthissuspiciontothe relevant
authorities
 If a childstatesthattheyhave beenthe victimof abuse,these claimsshouldbe investigated.In
these cases,parental consentisnotrequiredtoconducta formal investigation
Protectionorders :-

19.  Protectionordersare givenoutwhenadoctor believesthatthe childrenisatriskof significant
harm.
 EPOs (Emergencyprotectionorders) are usedtopreventsignificantharmand/allow
investigation.
 If it is a true emergency,the police mayissue aPPO(PoliceProtectionOrder) whichlastsfor72
hours.
 If the childisnot at immediate riskthenanCAO (ChildAssessmentOrder) isgiven
ETHICAL ISSUES RAISED
 Whenchildabuse issuspected,itmaybe acceptable tospeakto and examine the child
withoutthe parents'consent.Thisisespeciallytrue of sexual abuseswhenthe perpetuators
may try andsilence the child.
 Shouldthe doctorbreakthe child'sconfidentiality?He is12. If confidentialityisbroken,the
childmaynot trust thisdoctor again.Causingpossibleevenmore harm?
 Again,comesbackto ChildrenAct1989 - takingintoaccountviewsof children,treating
themwithrespectandtakingtheirownwishesintoaccount.
 Doctors have a dutyof confidentialitytopatients.However,thiscanbe breachedinthe
publicinterest(whichincludespreventionof crime,includingabuse)
IN CLINICAL PRACTICE
 There islittle likelihoodthatdifferentclinical conclusionswouldbe foundinthiscase
 In general,childabuse shouldbe suspectedif presentationof injuryisdisproportionate toits
"history"
 In clinical situations,parentswouldlikelybe discussedwithbefore aprotectionorderis
issued
 Wouldhe be willingtotalkto the Police andmake a formal statementaboutthisissue.If not
...what shouldhappen?
 Issueswhichmightcome intoplayinclude childrenwithlearningdifficulties - are theyat
more riskof abuse?
REFERENCES
1. ChildrenAct1989 and 2004