15-minute reading · Slides (PDF) · Български
How to work
Read the preparation material first, then work in groups of three or four. The reading takes 15 minutes and the tasks 75 minutes — one 90-minute class. Choose a discussion lead, a note-taker and a spokesperson, and rotate the roles between tasks. Open each self-check answer only after you have written down your own reasoning.
All persons, events and circumstances are fictional and do not describe a real patient. Work with the information given and say what else you would like to know. You are assessed on naming the kind of “ought” you use (ethical, legal, professional), citing the correct Bulgarian rule, and reaching a decision you can justify publicly — not on memorising the self-check answers.
Task 1. Legal but unethical? — 10 minutes
A physician obtains a signed consent form after a hurried explanation that the patient did not understand. A classmate calls this “legal but unethical”. Is that right? Then give a true example of conduct that is lawful but ethically poor.
It is neither. The Health Act (Arts 88–89) requires substantive information given in good time and in an understandable form, so a signature without understanding is not valid consent — the conduct is unlawful as well as unethical. A signature shows that a form was signed, not that the patient was informed.
A true example of lawful but ethically poor conduct: valid consent obtained in a dismissive, uncompassionate way; or the class example — a generously paid “advisory board” place with almost no real work, formally declared, followed by prescribing the company’s product.
Task 2. Two kinds of utilitarianism — 10 minutes
Explain the difference between act and rule utilitarianism, using medical confidentiality as the example. Then say what a deontologist would add.
Act utilitarianism judges each act by its consequences, so a single breach of confidentiality might look beneficial in one case. Rule utilitarianism judges rules by the consequences of their general observance: a rule of confidentiality kept in all ordinary cases preserves trust and the patient’s willingness to disclose, so it gives better results even when one breach would seem useful.
A deontologist would add that confidentiality is a duty of fidelity owed to this patient and that the patient must not be used merely as a means; for Ross, it is a prima facie duty that can be outweighed only by a stronger duty in the concrete situation, such as preventing serious harm to another person.
Task 3. Prima facie, specification and balancing — 15 minutes
What does “prima facie” mean in principlism? Explain specification and balancing, and apply both to the class’s worked example: an adult Jehovah’s Witness with capacity who is bleeding after surgery and refuses blood.
Each principle binds unless it conflicts with an equal or stronger obligation in the concrete case; the principles are not ranked in advance. Specification narrows a principle for a context — “respect for autonomy includes the right of an adult with capacity to refuse life-sustaining treatment”. Balancing decides which obligation weighs more here; the infringement must be necessary, minimal and openly justified.
In the example, beneficence pulls towards transfusion, but the refusal is informed, voluntary, repeated and current, so respect for autonomy weighs more. A capable adult may refuse at any time (Health Act, Art. 90(1)); the refusal is documented with signatures (Art. 90(2)); the team uses the options the patient accepts and does not abandon him. Urgency alone does not cancel a clear, specific and current refusal (Pindo Mulla v. Spain, ECtHR, 2024). The head of the establishment’s power under Art. 90(4) is a different situation from a patient who cannot consent (Art. 89(2)) — see Class 2.
Task 4. Oviedo and the Bulgarian Medical Association — 15 minutes
- Where does the Oviedo Convention stand in Bulgarian law? (b) A patient complains that a physician breached the Code of Professional Ethics. Who examines the complaint, who imposes the sanction, what sanctions are possible, and does this exclude other liability?
Bulgaria deposited its ratification on 23.04.2003, and the Convention entered into force for Bulgaria on 01.08.2003. Under the Constitution, Art. 5(4), a ratified, promulgated treaty in force is part of domestic law and takes precedence over conflicting domestic legislation.
The ethics commission of the regional college of the Bulgarian Medical Association examines it (Act on the Professional Organisations of Physicians and Dentists, Art. 39). The penal decree is issued by the chair of the college’s board (Art. 40(3)). The sanctions are a reprimand, a fine of one to five minimum monthly wages, or removal from the register for 3 months to 1 year (Art. 38). Criminal, civil and labour-disciplinary liability remain possible alongside it (Art. 42(1)).
Task 5. Two cases from the class — 20 minutes
Half the groups take case A, half case B. Use the eight-step method and present in two minutes.
Case A: the last intensive-care bed
During a severe influenza season one ICU bed remains. Patient A, 82, has advanced COPD; patient B, 45, previously healthy, father of three, has severe post-influenza pneumonia. With intensive care, the (hypothetical) probability of survival to discharge is 30% for A and 80% for B; without it, both are likely to die. Patient A arrived ten minutes earlier. Which criteria of justice are relevant — need, expected benefit, age, “social value”, order of arrival? What do the hospital and the doctor owe the patient who does not get the bed?
Case B: a double dose without established harm
A junior doctor notices that his consultant prescribed twice the recommended dose of an intravenous antibiotic; two doses have been given. Renal function is normal and the patient has no symptoms. The consultant says: “No harm done. Don’t document it and don’t tell the patient.” Which principles and virtues are at stake? Is there a duty to tell the patient? Does the hierarchy excuse silence?
Case A. Both patients are in need, so need alone does not decide. Expected benefit is a relevant clinical criterion; “social value” (being a father of three) is not — it would rank people by their worth to others. Age by itself is not a fair criterion, and the Health Act requires care regardless of age (Art. 85); age may matter only through its effect on the probability of benefit, assessed individually. Order of arrival is at most a tie-breaker for comparable cases. A utilitarian would give the bed to B and may overlook what is owed to A; a rigid “first come, first served” rule ignores that the bed would do much more good for B. Whatever is decided, the criteria must be transparent and applied consistently. Patient A is owed the best care available outside the ICU, honest information, reassessment and relief of suffering — not abandonment.
Case B. At stake are non-maleficence (correct the prescription, assess and monitor the patient), the patient’s right to clear information (Health Act, Art. 86(1)), and the honesty and conscientiousness that the Code lists among the physician’s values (Art. 2). An error that caused no established harm should still be documented and disclosed honestly: the patient has a right to know what was done to her, and hidden errors prevent learning. The hierarchy does not excuse silence. The junior doctor acts clinically first, speaks to the consultant again, and if that fails uses the hospital’s reporting route or the head of the department.
Individual final task — 5 minutes
Answer briefly without opening the answers:
- Give one example each of an ethical argument, a legal rule and a professional rule that apply to the same clinical decision.
- Name what the Hippocratic Oath lacks compared with modern medical ethics.
- Why is “sharing a decision” with the family not the same as “taking it away” from the patient?
Feedback criteria
A complete answer distinguishes morality, ethics, law and medical deontology; applies the theories to the facts instead of naming them; treats the principles as prima facie and shows specification and balancing; cites the correct Bulgarian sources (Constitution, Art. 5(4); Health Act, Arts 84–94; Act on the Professional Organisations, Arts 38–42; Code of Professional Ethics); and ends with a decision that could be explained publicly. Listing principles without applying them does not complete the task.