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Associate Professor Jane Turner

ETHICS AND PROFESSIONAL PRACTICE SEMESTER 1 CONTENTS 1. Overservicing and inappropriate practice 2. Challenge of Euthanasia 3. Clinical Ethical Reasoning 4. Consent to Medical Treatment 5. Informed Decision Making 6. Counter-transference and stereotyping 7. Refusal of Treatment 8. Self-induced disease 9. CAM Symposium 10.Patient Safety 11.Brain & Mind, Psychiatric Diagnoses 12.Looking after yourself SUMMARY (NEED TO KNOW) Involuntary treatment requirements under Elements of Consent MHA QLD (2000) 1. Authorization is voluntary/uncoerced ‘MIND AC/T 2. Patient must be competent Mental illness present 3. Patient adequately informed Immediate treatment required 4. Consent must cover actual procedure to be No less restrictive way to treat performed Damage/deterioration to themselves/others 5. Procedure must be legal in itself 6. Consent given to specific doctor Available treatment at mental health service/ Negligence authorized hospital C/T – Consent impossible (competence), or 1. Duty Of Care – Reasonable Forseeability, treatment unreasonably refused Proximity 2. Breach Of Duty Competency 3. Damage 1. Receive, Retain, Comprehend and recall 4. Causation information Hierachy of decision maker 2. Integrate information Guardianship & Administeration Act 2000 3. Evaluate against personal moral code and Power of Attorney Act 1998 (QLD) 4. Make a decision 1. Competent patient 5. Defend the decision 6. Adhere to the decision to the point of 2. Advanced Health Directive 3. Appointed Guardian treatment 4. Attorney under Enduring Power of Overservicing: Seeing one patient too many Attorney times or seeing too many patients for too little 5. Statutory Health Attorney (spouse, carer) time 6. Adult Guardian Fraud: Misrepresenting what occurred in a Trespass: Tort/civil wrong involving a wrongful, consult/procedure direct interference with a person, or with his land/property. Failure to satisfy elements of Medical Record - requires consent 1. Name of Patient Assault: Intentional or reckless act causing 2. Dated Entry for each attendance someone to be put in fear of harm 3. Adequate clinical information at each Battery: Intentional or reckless application of entry to explain services rendered physical force to some one without consent, with 4. Sufficiently comprehensible so another or without damage practitioner could undertake patient’s Three Standards for Disclosure/Informed care Decision Making Outcomes of Medicare Review 1. Professional Standard (Bolam) 1. Dismissal 2. Reasonable Person Standard 2. Negotiate settlement 3. Particular Person Standard 3. Referral to Professional Services Review Therapeutic Privilege: right not to disclose Outcomes of a Professional Service review information in circumstances where the doctor 1. Written reprimand 2. Counseling recommended considers that the disclosure itself would lead to 3. Repay benefits gained unjustly significant harm 4. Full/partial disqualification from Medicare for up to 3 yrs Doctor’s Role in relation to CAMs 5. Disqualification form PBS for up to 3 yrs 1. Must disclose available alternatives 2. Same standard of care for diagnosis and treatment if doctor is using CAMs Problems with Medical Records 3. Can be sued for referral to CAM 1. Inappropriate use of MBS attendance practioner if damage occurs items 2. Inappropriate use of MBS procedural 4. Standard of care from CAM practitioner is items not equivalent to that of a doctor 3. Inappropriate prescribing 4. Inappropriate use of diagnostic imaging or pathology Euthanasia – FOR 5. Corporate owners may have business  Ethically right – autonomy and rights plans based on billing a predetermined  No moral difference between killing and letting die – the result is the same number general practice management plans each week, irrespective of patient  Beneficence – promoting well-being of need. patients  It happens already Implications of Dx of Psychiatric Condition  A legitimate part of palliative care  Decision making and autonomy?  MHA  Death with dignity – low subjectivity legislation may restrict patients liberty  Subject to perceptions of Mental Illness – quality of life inferior, different, morally responsible,  Suicide is not illegal (in many western countries) so why shouldn’t assisted symptoms not real/organic, carry suicide be allowed? implications of social harm  Social Isolation Euthanasia - AGAINST  Labeled for insurance purposes,  Morally wrong – life is sacred increasing premiums  There is a moral difference between killing (caused by a person) and letting  Stereotyping: Attribution of a global set of characteristics on the basis of one or die (caused by disease) more observed characteristics  Hippocratic oath - integrity of medical profession  Transference: Positive or negative  The slippery slope – will lead to spread of feelings about the doctor, Potentially other killing practices e.g. non-voluntary problematic if result is dependency or premature termination euthanasia  Counter-transference: Positive or  Palliative care eliminates the need for euthanasia negative feels about the patient. Positive:  The value of human suffering (religious) good unless eroticized, Negative: deficient  Who can decide when someone’s life is clinical care not worth living? Movement to Patient Safety motivated by 1. Prominent individual and institutional Doctors Health  Sleep cases: Shipman, Bristol, Greenlane, Patel  Exercise and Diet 2. Failures in self-regulation (‘whistle- blowers’)  Social contact with partner, family, friends 3. Large studies of medical error revealing  Colleague support & opportunity for extent of problem debriefing 4. Increased litigation rates and awards  Having your own GP  Avoid alcohol & drugs as coping mechanisms 5. Increased education, dissatisfaction and calls for apologies and disclosure of error  Meditation practice by patients  Relaxing and enjoyable activities  No self diagnosis, treatment or prescribing Ways to Refuse Treatment  Holidays for recreation, study or conference 1. Verbally refuse treatment leave, sick leave of mental health days 2. Refuse treatment by signing a statement e.g. in the medical record  Spiritual well-being 3. Refuse treatment by direct action e.g. leaving the surgery or hospital Being a Good Patient for a GP  Accept and implement the role of patient; 4. Refuse in advance via an Advance Health don't be a doctor-patient, but a patient. Directive  Be prepared to request that your GP Role of Clinical Ethics Committees treats you as a patient, not as a doctor- 1. Provide Consultation patient, eg taking short-cuts in relation to 2. Education of staff, patients, families and the normal doctor-patient interaction. public  Ensure that you follow up appointments, 3. Recommend organizational policy tests etc.  Comply with treatment, once this is mutually agreed.  Ask for a long appointment if needed.  Attend regularly for checks & prevention, not just for acute care.  Indicate the problem prior to making an appointment/attending if it is acute/serious. OVERSERVICING AND INAPPROPRIATE PRACTICE Learning Objectives 1. Define inappropriate practice in the context of the Professional Services Review scheme. 2. Describe the roles of Medicare Australia & the Professional Services Review in monitoring doctors' practices under the Medicare system, and responding to inappropriate practice. MEDICARE  Instated in 1984 and provides medical insurance for all Australians, while in the early 1950s, the PBS was introduced by Earle Page, the Health Minister at the time. INAPPROPRIATE PRACTICE Defined in the Health Insurance Act as conduct “which would be unacceptable to the general body of general practitioners.” Over servicing  Seeing one patient too many times for a simple problem (i.e.: too many follow- ups)  Seeing far too many patients in a day, and spending too little time with each patient. Fraud  Misrepresenting what occurred in a consult/ procedure PATIENT RECORDS There are four conditions that must be satisfied for an adequate medical record: 1. Clearly identifies the name of the patient 2. Contains a separate dated entry for each attendance by the patient 3. Each entry needs to provide clinical information adequate to explain the type of service rendered or initiated 4. Each entry needs to be sufficiency comprehensible such that another practitioner, relying on the record, can effectively undertake the patient’s ongoing care. Common problems that arise with medical records are: 6. Inappropriate use of MBS attendance items e.g. Up-coding of consultation items, Inappropriate use of chronic disease management items 7. Inappropriate use of MBS procedural items e.g. Up- coding of skin cancer removal items, Inappropriate use of vascular diagnostic items 8. Inappropriate prescribing e.g. Excessive prescribing of lipid lowering drugs, narcotic and benzodiazepine drugs, Unnecessary/ inappropriate use of antibiotics 9. Inappropriate use of diagnostic imaging or pathology e.g. CT scans without clinical justification, Unnecessary repeated pathology testing, 10.Corporate owners may have business plans based on billing a predetermined number general practice management plans each week, irrespective of patient need. MEDICARE REVIEWS Outcomes of Medicare review of physician’s usage 1. The case may be dismissed 2. Medicare may enter into a negotiated settlement with the physician in question 3. The physician may be referred to a professional services review committee In regards to examining the services provided by a practitioner under review, he/ she must have:  Satisfied the requirements of the relevant items in the medicare benefits schedule  Provided services that were medically necessary  Provided an appropriate level of clinical input  Satisfied the requirements for prescribing under the PBS  Record was adequate for the continuing care of the patient by another practitioner Possible outcomes of a professional service review 1. The PSR may issue a written reprimand to a physician. 2. The PSR may suggest that the physician be counseled. 3. The physician may have to repay Medicare benefits they gained in an unjust fashion to the commonwealth. 4. The physician may receive full or partial disqualification from Medicare for up to three years. 5. The physician may be disqualified from the PBS for up to three years (as in their prescriptions are not qualified for coverage under the PBS). The Medical Board of Australia may also be involved in a professional services review.  These will often be in circumstances when a significant threat to the life of health of a patient is identified.  Issues commonly seen are: o Inappropriate prescribing of opiates and/ or benzodiazepines o Unconventional/ dangerous treatments o Personal issues affecting doctors that become apparent during the PSR process EUTHANASIA Learning Objectives 1. Outline the fundamental ethical arguments for and against active euthanasia (including considerations of medical practitioners' involvement) 2. Distinguish between euthanasia and the withdrawal of medical treatment 3. Describe national and international developments including the legal status of euthanasia Definition: Deliberate act intended to cause death, at the request of a competent patient, for what he/she sees as his/her best interest, usually in circumstances of terminal illness where the patient is experiencing physical and/or psychological suffering that is unacceptable, and cannot be relieved by means acceptable to the patient 1. Withdrawing ineffective life support systems; including advance directives to this effect 2. Giving increasing amounts of pain medication that may incidentally shorten one’s life 3. Respecting the patient’s right to refuse further treatment 4. Providing a person with the means, knowledge, to end their life Hippocratic Oath: “I will give no deadly drug, nor perform any operation for a criminal purpose, even if solicited, nor will I suggest any such council” IMPORTANT TERMS Consent  Voluntary euthanasia: conducted with the consent of the patient  Non-voluntary euthanasia (mercy killing): euthanasia on a patient who cannot consent (incompetent)  Involuntary euthanasia (murder): euthanasia against the expressed wish of a person Procedure  Passive euthanasia (letting die): withholding of life-sustaining treatment (e.g. respirator, medications)  Active euthanasia (killing): use of lethal substance or forces (usually by a doctor) to a person Non-euthanasia  Physician-assisted suicide: a person takes their own life with help from a doctor regarding o Prescription of lethal drugs o Advice – dosing, which drugs o Setting up equipment that a person activates to take their life  Terminal sedation: use of sedative drugs to induce unconsciousness in terminally ill patients. Includes withholding/withdrawing of artificial nutrition and hydration  Double effect: giving enough pain relief to control a person’s pain but also hasten death o Pain relief is intended, death is (ostensibly) foreseen but unintended ARGUMENTS FOR AND AGAINST EUTHANASIA Arguments For Arguments Against Ethically right – autonomy and rights Morally wrong – life is scared No moral difference between killing and letting There is a moral difference between killing die – the result is the same (caused by a person) and letting die (caused by disease) Beneficence – promoting well-being of patients Hippocratic oath - integrity of medical profession It happens already The slippery slope – will lead to spread of other killing practices e.g. non-voluntary euthanasia A legitimate part of palliative care Palliative care eliminates the need for euthanasia Death with dignity – low subjectivity quality of The value of human suffering (religious) life Suicide is not illegal (in many western Who can decide when someone’s life is not countries) so why shouldn’t assisted suicide be worth living? allowed? LAW Legality Worldwide  Euthanasia is legal in Holland (2001), Belgium (2002), and Luxembourg (2008)  Physician-assisted suicide is legal in some places. E.g. Germany, Switzerland, Oregon, Washington  Nether are legal in Australia (were once legal in NT). There are state bills in every state except QLD Northern territory 1995: Euthanasia was legalized. During 1995-7, four people were assisted to die. This was the first legislation in the world 1997: The legislation was overridden by the commonwealth government Queensland  Against euthanasia: The Queensland Criminal Code 1989 s284: the fact that a person consented to euthanasia is not a viable defence against a criminal charge s296: anyone who (by act or emission) hastens the death of another person shall be deemed to have killed that person s285: a person who has the duty to provide the necessities of life for another person who, due to age, ill health or disability cannot provide them for themselves, is criminally liable if they don’t provide them  Defenses for Euthanasia o But futile treatment cannot be construed as necessary o Also not liable if a competent patient requests to have treatment removed S282A (2003 amendment) – not criminally liable if reasonable palliative care is given in good faith, even if an incidental effect of the care is to hasten the death of the person  Lack of punishments for doctors o Physicians who have admitted to AVE/PAS usually don’t face punishment due to judicial mercy, community sympathy, the question of intention, predictability, causation STANCES ON EUTHANASIA  Australian Medical Association: Anti euthanasia; withholding treatment, refusing treatment, and pain relief (that may hasten death) may be justified  World Health Organization: Physician Assisted Suicide is unethical and must be condemned by the medical profession CLINICAL ETHICAL REASONING Learning Objectives 1. Describe the role and function of the Clinical Ethics Committee 2. Describe ethical decision making models 3. Apply these tools to ethically analyse clinical issues CLINICAL ETHIC COMMITTEE  Each institution has a responsibility to assure ethical treatment is provided to patients  Professionals trained and experiences in ethics may provide insight and assistance to those faced with ethical dilemmas  Roles o Provide consultation  advisory, not authoritarian o Education staff, patients, families, public o Recommend organizational policy General Ethical Decision Making Process  Identifying ethical issues and conflicts  Analyzing underlying values and sources of disagreement  Resolving, if possible, ethical dilemmas in clinical cases or health care policy PRINCIPALISM Autonomy Beneficence  Derives from patient’s capacity/desire for self-  Derives from fiduciary relationship to do good determination and act to help someone in need/vulnerable  Requires decision making capacity – lack patient should be proven not assumed  Imposes responsibility to act in the best  Respect the decisions of autonomous persons interests of patients, advance patient welfare, and protect persons who lack decision-making health interests capacity  Recognise the capacity of competent patients to think and make decisions independently, to act on the basis of their decisions and to communicate their wishes Non-Maleficience Justice I will use treatment to help the sick according to  Fair distribution of burdens and benefits my ability and judgement but never with a view to  What does fair mean? injury or wrongdoing  Equal?  General rules of human conduct that applies to  According to merit? everyone: Do No Harm to Others and Prevent  Taking account of initial disadvantages? Harm to Others  Non abandonment: obligation to provide ongoing care  Conflict of interest – do not engage in activities that conflict with or reduce patient’s best interest  Imposes responsibility to analyse the risks/burdens versus the benefits of treatment and to maintain the patient’s confidentiality UTILITARIANISM  An action is right when it increases the happiness or pleasure of people who are likely to be affected by the action and an action is wrong if it increases the unhappiness or misery of those who are likely to be affected by the action  Harm: harm to self is not sufficient to warrant inference with an individuals actions. Harm to others is the only reason to interfere with an individual’s actions Features of utilitarianism  Principle of utility: Maximise the good, minimize the bad  A theory of value: The standard of value  Consequentialism: Actions are right or wrong relative to their consequences, rather than by reference to any intrinsic moral features the actions may have, such as truthfulness or fidelity  Impartiality: Everyone is treated equally. Everyone’s happiness is equally good and everyone’s unhappiness is equally bad CONSENT TO MEDICAL TREATMENT Learning Objectives 1. Explain the ethical bases of consent to medical treatment, the ethical and legal requirements for valid consent, and the legal implications of failure to obtain consent CONSENT Definition: Authorization by competent person of an action, which affects the authorizing person  Failure to obtain consent = interference with the person without his authorization  Elements of consent 1. Authorization is voluntary/uncoerced 2. Patient must be competent 3. Patient adequately informed Competence Patient must comprehend, 4. Consent must cover actual procedure to be believe and understand performed information provided 5. Procedure must be legal in itself 6. Consent given to specific doctor TRESPASS  Failure to satisfy requirements above  Invalid consent  unauthorised invasion  trespass  Trespass is a tort or civil wrong involving a wrongful, direct interference with a person, or with his/her land or property  Trespass against a person is assault and/or battery  Assault: intentional or reckless act causing someone to be put in fear of harm  Battery: intentional or reckless application of physical force to someone without consent with or without damage o Criminal law  Results in prosecution  Medical assaults/batteries result from fraud, deception or physical force o Civil law  Results in recovery of damages/compensation  Most medical assaults/batteries are unintentional  reckless acts  Mallette v Schumann: 1990, court ruled that physicians must honor Medical alert cards signed by Jehovah’s Witnesses that forbid blood transfusion under any circumstances. o Treatment was competent and results were favourable (life was saved) o JW patient suffered ‘mentally and emotionally’ as a result of unconsented blood transfusion Example Trespass Negligence JW receiving blood transfusions  Patient can sue doctor in without consent trespass as there is an intentional action (battery) Patient consents to operation of  No consent for procedure left arm, doctor mistakenly  Patient may sue for trespass, operates on her right despite no intention for damage (reckless) Patient consents to operation of  Patient had adequate general  Patient was not informed of arm but complications follow understanding and legally all relevant risks during operation valid consent was obtained  Negligence  Would not be able to sue for  Breach in duty to disclose trespass risks TRESPASS V NEGLIGENCE Trespass Negligence Must have Must have  No valid consent 1. Duty of Care 2. Breach of standard of care Actionable per se: No need to establish any 3. Breach caused damage actual damage  Requires general adequate disclosure  Requires more stringent disclosure of risks for informed decision making STATUTORY PROVISIONS  Powers of Attorney Act Qld (1998) and Guardianship and Administeration Act Qld (2000) o Extend decision making powers of citizens by way of processes allowing advanced planning for a time when the person will be incompetent, for example by:  Writing an advance health directive  Appointing an attorney (family member) who can give or refuse consent for a number of health care matters  Appointing a default attornery (“statutory attorner” given the same powers (spouse, unpaid carer or close friend) o Some matters consent can be given by competent persons but not by attorneys acting for incompetent persons e.g. tissue donation, research, ECT, psychosurgery, sterilization  “Special Health Care” o The withdrawal of life-sustaining treatment, was initially a Special Health Care matter but now attorneys able to give consent under certain conditions  The substitute decision maker must consent to the withholding of treatment that is considered futile, because (1) medical treatment must be consented to and (2) withholding treatment is included in the definition of medical treatment o Doctors must inform substitute decision makers about treatment they will not commence and obtain consent for not commencing it. GIVING CONSENT  Current or advance e.g. advanced health directive  Explicit or implied  Verbal or written INFORMED DECISION MAKING Learning Objectives 1. Distinguish between consent & informed decision making 2. Critically appraise the contested ethical standards of information and risk disclosure in relation to informed decision-making for medical procedures 3. Describe current legal standards for disclosure, and the history of change in the standard in Australia 4. Explain how failure to warn or disclose, as a breach of the duty of care, can constitute medical negligence  To avoid legal suits of battery, doctors need to advise patients of the nature, benefits and risks of procedure in broad terms only  To avoid suits in negligence, they need to advise patients in greater detail, because risks of a specific nature may persuade a particular patient not to undergo a procedure STANDARD OF CARE FOR DISCLOSURE  Legally required standard of care: exercise of reasonable care to avoid foreseeable risks where reasonable care provided by a person in a specific area is that of the ordinary skilled person exercising and professing to have that special skill, and where foreseeability is limited by considerations of proximity  ‘Bolam Principle’: doctors cannot be found negligent if they act in accordance with what a responsible body of medical opinion deems proper at the time. Also known as professional practice standard.  Early 1980s, courts in Australia began to move away from the Bolam principle ( paternalism)  Rogers v Whitaker (1992): “a doctor has a duty to warn a patient of a material risk inherent in the proposed treatment, a risk is material is, in the circumstances of the particular case, a reasonable person in the patient’s position, if warned of the risk, would be likely to attach significance to it or if the medical practitioner is or should reasonably be aware that the particular patient, if warned of the risk, would be likely to attach significance to it. This duty is subject to the therapeutic privilege”  In relation to disclosure, there are three possible standards 1. Professional standard (Bolam) 2. Reasonable person standard 3. Particular person standard  Prior to R v W, state courts had moved onto the reasonable person standard, whereby doctors needed only to indicate serious or frequent risks or risks specifically asked about by patient  R v W: notion of a subjective or particular person standard  high standard, requires doctor to be aware of what his/her individual patient would be likely to attach significance to, not simply what they happen to ask about CAUSATION IN RELATION TO DISCLOSURE  Causation can be understood in objective and subjective ways  Objective (reasonable patient) o For procedures that are generally agreed to be necessary and important for patient welfare, negligence actions based on inadequate disclosure seldom succeed, since the patient will find it very hard to persuade the court that they would not have had the procedure had they been better informed. o I.e. they cannot demonstrate the causal link between the harm sustained and failure by the doctor to adequately inform them.  Subjective (particular patient) o When a patient sues a doctor for inadequate disclosure of information leading to harm which could have been avoided, it is open to the patient to show that he would not have had the procedure if he had been given more or different information, rather than having to demonstrate that any reasonable person would not have proceeded THERAPEUTIC PRIVILEGE  The medical profession’s right not to disclose information in circumstances where the doctor considers that the disclosure itself would lead to significant harm  Anxiety and stress insufficient to invoke therapeutic priviledge DISCLOSURE VS DIAGNOSIS & TREATMENT  In diagnosis and treatment: current professional practice strongly influences legal judgments concerning standard of care  In disclosure i.e. the extent to which a particular patient desires information: the medical expertise cannot be informative MEDICAL INDEMNITY CRISIS  2001: NSW passed legislation which restricted damages awards in personal injury cases  2002: QLD passed legislation which capped large claims, streamlined legal procedures and encouraged structured settlements in preference to lump sums  2002: Commonwealth Review of the Law of Negligence (Ipp Review) made recommendations that have been incorporated into legislation including QLD’s Civil Liability Act 2003 CIVIL LIABILITY ACT 2003 (QLD) Standard of care for professionals (1) A professional does not breach a duty arising from the provision of a professional service if it is established that the professional acted in a way that (at the time the service was provided) was widely accepted by peer professional opinion by a significant number of respected practitioners in the field as competent professional practice. (2) However, peer professional opinion can not be relied on for the purposes of this section if the court considers that the opinion is irrational or contrary to a written law.
 (3) The fact that there are differing peer professional opinions widely accepted by a significant number of respected practitioners in the field concerning a matter does not prevent any 1 or more (or all) of the opinions being relied on for the purposes of this section. (4) Peer professional opinion does not have to be universally accepted to be considered widely accepted. (5) This section does not apply to liability arising in connection with the giving of (or the failure to give) a warning, advice or other information, in relation to the risk of harm to a person, that is associated with the provision by a professional of a professional service.  This is a return towads the Bolam principle of determining standard of care, except that it includes an irrationailility condition (Clause 2).  Disclosure exempt from modified Bolam test (Clause 5), instead more or less equivalent to Rogers v Whitaker standard: Proactive and reactive duty of doctor to warn of risk
 (1) A doctor does not breach a duty owed to a patient to warn of risk, before the patient undergoes any medical treatment (or at the time of being given medical advice) that will involve a risk of personal injury to the patient, unless the doctor at that time fails to give or arrange to be given to the patient the information about the risk – (a) that a reasonable person in the patient’s position would, in the circumstances, require to enable the person to make a reasonably informed decision about whether to undergo the treatment or follow the advice; and (b) that the doctor knows or ought reasonably to know the patient wants to be given before making the decision about whether to undergo the treatment or follow the advice.  The subjective standard for causation is affirmed: If it is relevant to deciding factual causation to decide what the person who suffered harm would have done if the person who was in breach of the duty had not been so in breach -
 (a) the matter is to be decided subjectively in the light of all relevant circumstances, subject to paragraph (b); and
 (b)any statement made by the person after suffering the harm about what he or she would have done is inadmissible except to the extent (if any) that the statement is against his or her interest. INFORMED FINANCIAL CONSENT  Provision of information regarding fees for procedures, prostheses, etc  Reduces the incidence of patients discovering after the event that they may be considerably more out of pocket than they anticipated COACHING  Provides assistance to patients who lack confidence and/or skills to actively engage in doctor- patient consultations  Provides information and explanation, help clarifies values and wishes and supports deliberation and communication LOSS OF CHANCE  Negligence awarded on the basis of loss of chance of a better medical outcome than what occurred  Instead of balance of probabilities that the doctor’s action or omission caused the harm but by proving that the chance of a better outcome was a possibility STEREOTYPING AND COUNTERTRANSFERENCE Learning Objectives 1. Explain counter-transference & stereotyping in the doctor-patient relationship and their potential harmful consequences 2. Describe how to recognise and avoid stereotyping and judgmental behaviour in relation to patients Stereotyping Counter-transference  Attribution of a global set of  Intense emotional response to a person characteristics on the basis of one or more without obvious basis observed characteristics  Activated in clinical or other close  Culturally based interpersonal situations  May be positive but often negative  May be positive or negative STEREOTYPING  Defined as: the attribution of a probability that any subject in a whole population or an entire class will possess a feature that an observer has encountered in one, or a few early representatives of that class.  Early experience, particularly that encountered in childhood, is of the greatest importance in fixing stereotype  Stereotyping is about extrapolating from an individual to a class as a whole  Can be a vice: all back pain in Eastern European patients is malingering or hysteria  “Mediterranean back”  Can be a virtue: all tigers are dangerous STEREOTYPING IN MEDICINE  Every medical interaction in the doctor-patient dyad has the potential to involve individuals in stereotypic views Virtue of stereotyping in medicine  After eliciting a medical history, doctors start to stereotype as they begin the formulation of a differential diagnosis.  In one sense, the dynamic of generating a medical diagnosis is about extrapolating from the individual to an entire class o E.g. i
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