Medical Ethics Board Review

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					Medical Ethics
          Medical Ethics
     [vs. Professional ethics]
w Ethical dilemma is a predicament in which
  there is no clear course to resolve the
  problem of conflicting moral principles
w Autonomy
w Beneficience
w Nonmaleficence
w Justice
w Freedom to influence course of
  – Requires the person to be competent in
    decision making capacity
    Preservation of Autonomy

w Living Will
     • Takes effect when terminally ill and lacking
       decision making capacity
w Surrogate Decision Makers
  – Represents patients interest
    Preservation of Autonomy
w The primary responsibility of the physician
  is to serve the patients interest
  The patient self determination
           act of 1990
w At the time of admission information re:
  the patients’ right to refuse care or create
  an advance directive must be dispensed
            Informed Consent
w Patient is presented all alternatives so they can
  make a decision. Must be competent
w Requirements
   – Decision making capacity
   – Volutariness
   – Reasonable person standard
w Present all alternatives f/b recommendation
w Respect refusal
w All surgical and experimental procedures
          Implied Consent
w Invoked when in emergency situations
  when harm would result without urgently
  needed intervention
w Truth telling on part of physician is an
  integral part of patient autonomy
w Justifiable if patient at risk of significant
  preventable harm, paternalistic action will
  prevent harm, benefits outweigh risks and
  the least autonomy-restrictive course of
  action is used
w Obligation of physician to maintain information
  in strict confidence
w Breaching patient confidentiality may be merited
   – When ordered by court of law – a court case
   – Where statutory requirement – public health laws
   – Where required in health professional’s defense –
     malpractice suit
   – Where necessary for appropriate patient care-
     speaking to another provider in the medical care
w The percentage of patients who would like to be
  told their diagnosis if it is a:
                    Metastatic cancer               Terminal
European Americans          87%                                69%
African Americans           88%                                63%
Mexican Americans           65%                                48%
Korean Americans            47%                                35%
Ethiopians (can you guess?)??%                                 ??%
                          Source: Blackhall LJ, et al. (1995) JAMA 274: 820-5.

w The more traditional the culture … the less truth
  telling regarding patient condition
w Obligation to preserve life, restore health,
  relieve suffering and maintain function
w To do “good”
w Nonabandonment – obligation to provide
  ongoing care
w Conflict of interest – must not engage in
  activities that are not in patients best
w “Do no harm”
w Allocation of medical resources must be
  fair and according to need
w Physicians should not make decisions
  regarding individuals based upon societal
w DNR orders affect CPR only
w Other therapies should not be influenced
  by DNR order
w Should be reviewed frequently
w Rationale should be in medical record
    Persistent Vegetative State

w Uncnsciousness/ loss of self awareness
  lasting more than weeks
w Supreme court draws no distinction
  between artificial feeding, hydration vs.
  mechanical ventilation
w Irreversible cessation of circulatory and
  respiratory function
w Irreversible cessation of all brain function
  (including brainstem)
           Ethical Dilemas
w Euthanasia
  – Legally prohibited in the US except in Oregon
    which permits MD assisted suicide
w Destroying Frozen Embryos
             Case Studies
w Lake, your 36-year-old patient, has just
  tested positive for HIV. He asks that you
  not inform his wife of the results and
  claims he is not ready to tell her yet.
             Case Studies
w 22 year-old woman, is admitted to the
  hospital with a headache, stiff neck and
  photophobia but an intact mental status.
  Lab tests reveal contagious meningitis. She
  refuses treatment for it.
w A 25 year old woman victim of a single car
  MVA enters a persistent vegetative state.
  After four years, her parents petition to
  have her feeding tube removed. The
  hospital insists on a court order, and the
  victim’s closest friend and parents testify
  that she would not have wanted to have a
  feeding tube.

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