Ethics and Professional Dilemmas

Four Pillars of Medical Ethics

1. Autonomy: respect the patient's right to make informed decisions about their own care; includes right to refuse treatment
2. Beneficence: act in the patient's best interest; duty to do good
3. Non-maleficence: do no harm; balance risks against benefits
4. Justice: fair distribution of resources; treat patients equitably regardless of background

When pillars conflict, there is no fixed hierarchy — the resolution depends on context and requires reasoned argument.

Confidentiality

• Duty of confidentiality: fundamental to doctor-patient relationship; enshrined in GMC Good Medical Practice
• Limits to confidentiality (disclosure may be justified):
  • With patient's consent
  • Court order or statutory requirement
  • Public interest (serious crime, risk to others)
  • Safeguarding children or vulnerable adults
  • Notification of communicable diseases
  • DVLA fitness to drive concerns (after encouraging patient to self-report)
• FGM mandatory reporting: legal duty to report to police if FGM identified in a girl under 18 (Serious Crime Act 2015)
• Fraser guidelines: can provide contraception to under-16s without parental knowledge if criteria met

Safeguarding

Child Protection

• Every doctor has a duty to act if concerned about a child's welfare
• Follow local safeguarding procedures
• Inform designated safeguarding lead
• Document concerns clearly
• Do not delay action by attempting to investigate yourself

Female Genital Mutilation (FGM)

• Illegal in the UK (FGM Act 2003, as amended)
• Mandatory reporting duty for professionals who discover FGM in under-18s
• Record on medical notes
• Offer appropriate referral and support

Domestic Abuse

• Screen for domestic abuse (NICE recommendation) at antenatal and postnatal contacts
• Ask sensitively and privately
• Document clearly
• Provide information about support services (MARAC referral if high risk)

Common Ethical Dilemmas in O&G

Jehovah's Witness Refusing Blood Products

• Competent adult has the right to refuse treatment, including blood transfusion, even if refusal leads to death
• Discuss in advance: which products are refused (some accept albumin, cell salvage, EPO)
• Document the discussion clearly
• Advance decision to refuse blood: legally binding if valid and applicable
• Cannot refuse treatment on behalf of another competent adult or a child
• For a child: if parents refuse blood on religious grounds and it is life-saving, seek emergency court order
• Optimise: iron supplementation, erythropoietin, tranexamic acid, cell salvage, meticulous surgical technique

Maternal Request Caesarean Section

• NICE (NG192): a woman's request for CS should be respected
• Explore reasons (fear of labour, previous traumatic birth, tokophobia)
• Offer support (psychological support, birth plan, debrief)
• If the woman still requests CS after discussion: arrange it
• If clinician is personally unwilling: refer to a colleague who will perform it
• Not appropriate to refuse solely on grounds of no medical indication

Conscientious Objection (Abortion Act 1967)

• Doctors and nurses can conscientiously object to participating in termination of pregnancy
• Does NOT apply in emergency (when life of the woman is at risk)
• Must refer the patient to a colleague who will help
• Cannot obstruct access to lawful treatment
• Does not extend to administrative tasks (e.g. making referrals)

Mental Capacity Act 2005

• Applies to adults (≥16 years) in England and Wales
• Five principles:
  1. Assume capacity unless established otherwise
  2. Support decision-making before concluding incapacity
  3. An unwise decision does not mean incapacity
  4. Act in best interests of incapacitated persons
  5. Choose the least restrictive option

Best Interests Decision-Making

• Consider: patient's past and present wishes, beliefs, values
• Consult: family, carers, welfare attorney, IMCA (Independent Mental Capacity Advocate) if no one else to consult
• Document the decision-making process

Duty of Candour

• Professional and legal obligation to be open with patients when things go wrong
• Professional duty (GMC): apologise, explain what happened, offer support, document
• Statutory duty (CQC regulation): applies to organisations; notify patient in writing of safety incidents causing moderate harm or above
• An apology is NOT an admission of liability (Compensation Act 2006)
• Failure to be candid can result in GMC sanctions or CQC enforcement action

Key Points Examiners Mark

• Identifies the ethical principles at stake
• Balances competing principles with reasoned argument
• Demonstrates respect for patient autonomy
• Knows relevant law (MCA, FGM Act, Abortion Act, Montgomery)
• Shows awareness of professional guidelines (GMC, RCOG)
• Suggests practical solutions (not just theoretical discussion)
• Remains non-judgemental
• Demonstrates clear, logical reasoning

Common Pitfalls

• Stating "beneficence overrides autonomy" without reasoned justification
• Forgetting that a competent adult can refuse treatment (even life-saving)
• Not mentioning the legal framework (Montgomery, MCA, duty of candour)
• Being judgemental about patient choices (e.g. Jehovah's Witness, maternal request CS)
• Confusing Gillick competence with Fraser guidelines
• Forgetting mandatory reporting duty for FGM in under-18s

Clinically reviewed by NHS obstetricians and gynaecologists

MRCOG AI is an independent educational tool. It is not affiliated with, endorsed by, or connected to the Royal College of Obstetricians and Gynaecologists (RCOG).