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Ethics Overview

Definition

• Ethics, or moral philosophy, is a branch of philosophy concerned with norms and values, rights and wrongs, and what ought or ought not to be done. It involves reflection, argument, and analysis to determine what actions one should take under specific circumstances.

Medical Ethics (Bioethics)

• Medical ethics, or bioethics, involves the study and critical analysis of ethical issues that arise in the interrelationships between law, medicine, life sciences, theology, and biotechnology.

Basic Theories of Right and Wrong Actions

1. Utilitarianism:

   • A moral theory that evaluates the consequences of an act.
   • The morality of an act is determined by its outcomes, exemplified by outcome measures for populations, such as vaccination.

2. Deontological or Rights-Based Theories (Kantianism):

   • Emphasizes that agents must act rationally and consistently to be moral.

3. Virtue Ethics:

   • Focuses on the character of the individual.
   • Includes feminist ethics, asserting that the rightness or wrongness of an action is embedded in the character of the individual.

4. Four Principles Approach:

   • A widely accepted framework in medical ethics, including principles like autonomy, beneficence, non-maleficence, and justice.

Utilitarian Vs Deontological Ethics

Ethics Comparison

Utilitarian Ethics	Deontological Ethics	Virtue Ethics
Definition: The greatest good for the greatest number of people.	Definition: Any act is intrinsically right or wrong and must be done (or not done) regardless of the consequences.	Definition: Considering what virtues make a good public relations professional.
Application: Making a decision based on what will benefit the majority.	Application: Identifying one’s duty and acting accordingly.	Application: Making a decision in light of those favored virtues.
Pros & Cons: – Cons: – Decision-makers are forced to guess the outcome of their choice. – Harming a minority and benefiting a majority doesn’t build mutually beneficial relationships. – It is not always possible to predict the outcome of a decision.	Pros & Cons: – Cons: – There may be disagreement about the principles involved in the decision. – The possibility of making a “right” choice with bad consequences. – The possibility of a conflict in duties. – Pros: Strongest model for applied public relations ethics.	Pros & Cons: – Cons: – Misses the importance of obligations to client and publics. – The possibility of a conflict in virtues.

Virtue Ethics

• (Plato) Four key virtues: wisdom, courage, temperance and justice.
• (Aristotle): when people acquire good habits of character, they are better able to regulate their emotions and their reason.
• Virtue ethicists thus think that right and wrong cannot be defined in terms of pre set moral principles or rules. The distinction is made between right and wrong by being sensitive to situations in a moral sense or expressing fundamentally good or admirable character traits.
• The motives and character of the agent are what counts. They help us reach morally correct decisions when we are faced with difficult choices.
• As a means of solving difficult ethical problems though it seems to have some disadvantages. How do we determine what is the “right” sort of character and how does just having the right sort of character ensure a correct decision? Similarly how do we distinguish or rank differing virtues. Perhaps as an ethical model it says more about the psychology of morality than the nature of moral truth.

Core Ethical Frameworks

Ethical Principles in Anaesthetic Practice

Principle	Definition & Core Idea	Practical Implications for Anaesthetists
Autonomy	The patient’s right to make informed, voluntary decisions about their care.	• Provide clear, jargon-free information. • Confirm understanding and consent, especially when capacity may fluctuate (e.g. delirium, hypoxia).
Beneficence	Obligation to act in the patient’s best interests, maximising benefit. Best Interests (when capacity is absent): Choose the option that best aligns with the patient’s values, welfare and previously expressed wishes	• Optimise peri-operative plans (enhanced-recovery, multimodal analgesia). • Balance benefits with comorbidities and stated patient goals. • Consult advance directives, family, cultural and religious factors. • Select the least restrictive option; document reasoning thoroughly.
Non-Maleficence	“First, do no harm”—avoid or minimise foreseeable injury.	• Prevent drug errors, limit unnecessary invasive lines, monitor for complications. • Proceed only if expected benefit outweighs potential harm.
Justice	Fair distribution of healthcare resources across patients and society.	• Prioritise theatre lists and ICU beds transparently. • Apply national triage tools in pandemics; avoid bias between private and public sectors.

Common Tensions

• Autonomy vs Beneficence: competent patient refuses life-saving treatment.
• Beneficence vs Justice: costly rescue therapy for one may deny care to many.
• Non-Maleficence vs Beneficence: high-risk surgery justified if benefits are substantial.
• The National Health Act permits immediate treatment without consent only to prevent death or serious, irreversible harm when no proxy is available.

South African Legal & Regulatory Landscape

• Health Professions Act 56 of 1974 & HPCSA Ethical Rules–overarching professional conduct.
• National Health Act 61 of 2003–defines informed consent and emergency treatment.
• Protection of Personal Information Act 4 of 2013 (POPIA)–governs all patient data, including electronic anaesthetic charts and intraoperative video.
• Medicines & Related Substances Act 101 of 1965 (as amended)–scheduling, dispensing, Section 21 access.
• Children’s Act 38 of 2005–“best-interests” standard for all paediatric decisions.

Medication-Related Ethics

Section 21: Unregistered Medicines

1. Eligibility: life-threatening or unmet clinical need.
2. Application: practitioner applies online, attaches motivation, protocol, peer-reviewed evidence.
3. Obligations: witnessed informed consent, adverse-event reporting within 15 d, six-monthly progress reports, single-patient import limited to 6 months’ supply.

Off-Label Prescribing

• Justifiable when supported by published evidence or strong consensus (e.g. tranexamic acid in obstetrics).
• Obtain explicit written consent; explain licensing status and alternatives.
• Document rationale and literature used; copy script with indication to pharmacy.
• Practitioner shares liability with manufacturer and dispenser.

Controlled Medicines & Prescriptions

Schedule	Script requirements	Dispensing notes
5–6	Valid 6 months; one repeat	May fax/email; original within 7 d
7	Triplicate handwritten/e-script with secure digital signature; no repeats	Pharmacy keeps original; supply ≤ 30 d
8	Ministerial permit or Section 22A(9); palliative exceptions	Daily register reconciliation

• Perverse-incentive prohibitions (HPCSA Booklet 11) forbid any financial gain tied to particular brands.

Digital Conduct, Social Media & AI

• HPCSA Booklet 16 (2023 revision)–share only the minimum necessary clinical detail; de-identify images; obtain written consent for any educational or marketing post.
• POPIA requires secure cloud storage and end-to-end encryption of theatre photos/videos.
• AI decision-support (HPCSA Booklet 20, 2024 draft): clinician remains accountable; disclose AI involvement to patient when its output influences care; carry out human plausibility check.
• Never crowdsource a diagnostic image on public platforms.
• Health practitioners may share confidential information with:
  • a) Other members of the health care team involved in the patient’s care.
  • b) Individuals who have the patient’s consent.
  • c) If it is justified in the public interest.
  • d) If failure to do so will result in harm to the patient.
• If the patient is under 12 years old, obtain written consent from a parent or guardian and assent from the minor
• The obligation to keep patient information confidential remains even after the patient dies.

Medico-Legal Risk Management

1. Act professionally at all times.
2. Keep meticulous records.
3. Know the guidelines and statements of your specialty and engage in Continuing Medical Education (CME).
4. Practice only the standards of care.
5. Adopt risk management and quality assurance protocols.
6. Understand your duties to the patient within the physician-patient relationship.
7. Take informed consent obligations seriously.
8. Never coerce a patient into accepting a given anesthetic plan.
9. Examine the patient and document preexisting conditions.
10. Know the patient’s history and medication regimen.
11. Examine all laboratory data preoperatively, such as coagulation status.
12. Practice only those techniques in which you are fully trained and proficient.
13. Carry adequate malpractice insurance.
14. Avoid vicarious liability.
15. Respond appropriately when an incident occurs, including inter-disciplinary consultations and following up with the patient.

Environmental Ethics

• SASA 2024 Position Statement on environmental protection urges:
  • Minimum-fresh-gas-flow inhalational practice.
  • Sevoflurane over desflurane where clinically equivalent.
  • Preference for TIVA when cost-neutral.

Research & Publication Ethics

• Prior ethics-committee approval for all human research (National Health Act S71 regulations).
• Clinical trial registration before first patient.
• Disclose conflicts of interest; avoid duplicate publication.

Rapid-Review Summary for Key Ethical & Legal Instruments (SA Context)

Instrument	Definition / Core Idea	Anaesthetic Relevance–‘Need-to-Know’ Points
Children’s Act 38 of 2005–s129 (Consent to Treatment)	Sets legal rules for when minors may consent to their own care.	• ≥ 12 yr & mature → may consent to medical treatment alone; needs parent/guardian for surgical procedures.• < 12 yr or ≥ 12 yr but not mature → parent/guardian/caregiver consents to medical; only parent/guardian to surgical.• “Child parents” ≥ 12 yr can consent for their own child’s medical care; surgical needs adult co-signature.• Written consent for surgery on Form 34; if parent is a minor, additional Form 35 signature required.
Geneva Declaration (WMA Physician’s Pledge, 2017)	Modern physician oath emphasising patient-centred care, non-discrimination and human-rights.	• Primary duty: patient health & confidentiality—even after death.• Reject discrimination on any ground.• Never use medical knowledge to violate human rights (relevant to dual-use research, torture).
HPCSA Rule 23 (Preferential Use of Medicines/Devices)	Bars clinicians from promoting products that are not clinically appropriate or cost-effective.	• Prescriptions must follow accurate diagnosis and indication.• Inform patients of all suitable options; no financial inducements.• Breach may trigger professional-conduct inquiry.
National Patients’ Rights Charter (1999)	Enumerates fundamental patient rights in SA health facilities.	• Informed consent & participation in decisions.• Right to refuse treatment or seek second opinion.• Confidentiality, continuity of care, transparent costs, formal complaints pathway.
Batho Pele Principles (“People First”)	Public-service code aimed at service quality and accountability.	• Consultation, equal access, courtesy, full information.• Openness/ transparency in resource use.• Redress when standards not met; value for money; reward service excellence.

Children’s Act 38 of 2005–Consent to Health-Care

Topic	Key Provisions	Anaesthetic Application / Pitfalls
Foundational aims	Protect child autonomy while ensuring welfare; harmonise with Constitution (§28) and National Health Act.	Assent ≠ consent: even where legal consent comes from an adult, seek the child’s assent for GA/RA to reduce distress and improve compliance.
Section 129 (medical & surgical treatment)	• ≥ 12 yr & “sufficient maturity” → child may consent to medical treatment; surgical procedures still require a parent/guardian co-signature. • < 12 yr or ≥ 12 yr but lacks maturity → parent/guardian/caregiver consents to medical treatment; only parent/guardian may consent to surgery. • Child-parents ≥ 12 yr: may consent to medical tx for their own infant; surgical tx needs additional adult with parental responsibility.	1. Assess maturity—document understanding of risks, benefits & alternatives. 2. In emergencies the doctrine of necessity applies: treat immediately, then inform guardian ASAP. 3. HIV testing, male circumcision, virginity testing, contraceptive advice have separate clauses—check before elective lists.
Written surgical consent	• Form 34—completed by operating practitioner in language child understands; co-signed by child (if ≥ 12 yr&mature) and parent/guardian. • If parent signing is a legal minor, Form 35 captures grand-parent/guardian assent.	Have blank Forms 34/35 in theatre block; delay start until paperwork complete—common OSCE station.
Capacity assessment cues	Age, cognitive ability, emotional state, and situational complexity.	Use “teach-back” method: ask child to restate procedure and risks.
Documentation	Include capacity discussion, who signed, interpreter use, and time of consent.	Failure to document knocks out medicolegal defence even if

Geneva Declaration (WMA Physician’s Pledge 2017)

• Essence–Modern restatement of the Hippocratic oath emphasising patient-centred care, human rights, collegiality and non-discrimination.

Clause	Practical Meaning in Theatre	Mnemonic
“The health of my patient will be my first consideration”	Prioritise patient safety over pressures to turn over lists or cost-cut.	H = Health first
Confidentiality even after death	Do not reveal peri-mortem airway video on social media education channels without consent.	C = Confidentiality
Respect teachers & colleagues	Constructive feedback in M&M; no public “blame and shame.”	R = Respect
No discrimination	Provide equitable analgesia regardless of HIV status, substance use or ability to pay.	E = Equality
No use of medical knowledge to violate human rights	Decline involvement in coercive interrogations or non-consensual research.	H = Human rights

• (Mnemonic “HeCReH”)–Health, Confidentiality, Respect, Equality, Human-rights and civil liberties, even under threat.
• Oath Commitment: I make these promises solemnly, freely, and upon my honor.

Summary

• Patient-Centered Approach: Prioritize patient health and respect their confidentiality.
• Respect: Show respect to teachers and uphold the noble traditions of the profession.
• Equality: Treat everyone equally, without discrimination.
• Human Rights: Never violate human rights or liberties.
• Collegiality: Consider colleagues as sisters and brothers.

HPCSA Ethical Rule 23–Preferential Use of Medicines & Devices

1. Core directive–A practitioner must not “accept any commission, fee or reward” for prescribing a specific product nor favour a product that is not clinically appropriate or cost-effective.
2. Three tests before preference
   • Accurate diagnosis–evidenced in notes.
   • Clinical indication–guideline or peer-review support (e.g. sugammadex vs neostigmine).
   • Patient information–discuss options and relative costs.
3. Implications
   • Disclose any industry funding when teaching about devices (e.g. videolaryngoscopes).
   • Hospital formularies may override personal preference; document rationale if deviating.
   • Kickbacks (incentive trips, “educational grants” tied to volume) breach Rule 23 and POPIA.
4. Defence checklist (keep in theatre note)
   • Relevant guideline citation (e.g. SASA Difficult Airway 2023).
   • Comparative cost sheet if using high-price single-use airway device.
   • Written patient discussion for off-label or Section 21 drugs.

National Patients’ Rights Charter (1999)

Right	Implications in Anaesthesia
Access to care	Public-sector anaesthetist must not refuse analgesia for after-hours C-section because “list is full”.
Informed consent	See Autonomy principle; translate consent forms; use pictorial aids.
Refuse treatment & seek second opinion	Stop elective list if competent patient withdraws consent on table before induction.
Confidentiality	Do not project patient details on shared Zoom M&M without anonymisation.
Complaint mechanism	Direct patient/family to hospital Quality Assurance Officer; document.

Batho Pele (“People First”) Principles in Peri-operative Services

Principle	Theatre-Block Example
Consultation	Pre-list huddles include nurses, porters and cleaners to plan flow.
Service Standards	Display target “knife-to-skin by 08h15” and infection-rate dashboard.
Access	Prioritise weekend trauma overflow lists in district hospitals lacking ICU.
Courtesy	Greet patients in preferred language; introduce self and role.
Information	Provide postoperative analgesia leaflet in isiXhosa/Afrikaans/English.
Openness/Transparency	Publish waiting-list criteria online.
Redress	Apologise and arrange expedited date after unplanned cancellation.
Value for Money	Use low-flow sevoflurane and pulse oximeters with reusable probes.
Leadership	Consultant leads WHO checklist and models professionalism.
Innovation & Excellence	Pilot AI scheduling to cut late starts; reward staff through recognition programme.

Links

• Practice management
• Practice guideline
• Research ethics
• Consent
• Impaired capacity

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References:

1. Lawson, A. (2011). What is medical ethics?. Trends in Anaesthesia and Critical Care, 1(1), 3-6. https://doi.org/10.1016/j.cacc.2010.02.009
2. Health Professions Council of South Africa. Guidelines for Good Practice in the Healthcare Professions: Booklet 1 (rev 2021). Available from: https://www.hpcsa.co.za/
3. Health Professions Council of South Africa. Booklet 16: Ethical Guidelines on Social Media (2019, rev 2023). Available from: https://www.hpcsa-blogs.co.za/
4. Health Professions Council of South Africa. Booklet 20: Ethical Guidelines on the Use of Artificial Intelligence (draft 2024). Available from: https://ethiqal.co.za/downloads-and-documents/
5. South African Health Products Regulatory Authority. Guideline for Section 21 Access to Unregistered Medicines (May 2025, version 4). Available from: https://www.sahpra.org.za/
6. South African Society of Anaesthesiologists. Adult Procedural Sedation and Analgesia Guidelines (2020). Available from: https://www.sasaweb.com/
7. South African Society of Anaesthesiologists. Position Statement on the Environmental Impact of Inhalational Anaesthetics (2024). Available from: https://www.sasaweb.com/Republic of South Africa. National Health Act 61 of 2003. Available from: https://www.gov.za/
8. Republic of South Africa. Protection of Personal Information Act 4 of 2013. Available from: https://www.justice.gov.za/
9. American Society of Anesthesiologists. Guidelines for the Ethical Practice of Anesthesiology (October 2024). Available from: https://www.asahq.org/
10. Jenkins KJ, Raynes‐Greenow CH, Samuels M et al. Paediatric emergency front-of-neck airway: ethical and legal issues. Br J Anaesth 2023;130:904-10. Available from: https://www.bjanaesthesia.org/
11. Chandrakantan, A. and Saunders, T. A. (2016). Perioperative ethical issues. Anesthesiology Clinics, 34(1), 35-42. https://doi.org/10.1016/j.anclin.2015.10.004

Summary or mindmap:

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