Professional Issues I Ethical Considerations Chapter ETHICS Principles of ethical

Professional Issues I Ethical Considerations – Chapter 8 ETHICS • Principles of ethical and moral conduct that govern the behavior and conduct of health professionals. • What is right or wrong • Specify what should be done from a moral standpoint • Enforced by peers BIOETHICS • Moral issues and problems that affect a patient’s life • Many arise due to the advances of modern medicine • Biotechnology – Applied biological science Principle-Centered Leadership • Are you continually learning? • Are you serviceoriented? • Do you radiate positive energy? • Do you believe in other people? • Do you lead a balanced life? • Do you see life as an adventure? • Are you synergistic – Able to work for the whole • Do you exercise for self-renewal? Ethical Power • Purpose – Why am I doing this? • Check questions – Is it Legal? – Is this the best approach? – How will I feel about myself? – Will my family, employer, or coworkers be proud of my decision • • • • Pride Patience Persistence Perspective Ethics Something may be legal and still be unethical BUT If it is unethical it usually is illegal AAMA Code of Ethics • Render service with full respect for the dignity of humanity • Respect confidential information obtained through employment unless legally authorized or required by responsible performance of duty to divulge such information • Uphold honor & high principles of the profession and accept its disciplines • Seek to continually improve the knowledge and skills of medical assistants for the benefit of patients and professional colleagues • Participate in additional service activities aimed toward improving the health and well-being of the community. AMA Code of Ethics • Dedicated to providing • competent medical service with compassion and respect for human dignity • • Deal honestly with • patients and colleagues, strive to expose those physicians deficient in character or competence • or who engage in fraud or deception • Respect the rights of patient, colleagues, other health professionals Continue to study Be free to choose whom to serve, unless in emergencies Participate in activities contributing to an improved community Respect the law and recognize a responsibility to seek change Advertising • Legal and Ethical • Description of the practice • Kinds of services • Names of participating physicians • Testimonials - NOT Media Relations • Don’t talk to the press • Public Domain: – – – – Births Deaths Accidents Police Records Confidentiality • Must not reveal unless: – PT threatens another person and you believe them – Knife & gunshot – Suspected Child Abuse – Communicable diseases – Subpoenaed Medical Records • Reveal no information without patients consent unless required by law • Cannot be withheld due to unpaid bill Professional Fees & Charges • Based on those customary • Reflect difficulty of services • NO – Fee Splitting • May charge for missed appointments – if previous notified • Submission of insurance forms • Not written down – don’t charge Rights of the Patient • Consult the phys. of his / her choice. • Receive respectful / considerate care • Expect confidentiality / privacy • Receive info regarding the condition, diagnosis, treatment & prognosis • Make decisions regarding medical care • Refuse treatment • Refuse to participate in research projects. • Expect continuity of care • Copies of med. records Responsibilities of the Patient • Provide phys. with accurate data about the duration and nature of symptoms • Provide complete / accurate past med.history. • Follow phys. instructions for diet, exercise, medications, and follow-up appointments. • Compensate the physician for services rendered ( Payment) Physician has the right to: • Accept / decline new pt. into the practice • Accept / decline former pt. with new problems. • Designate the type of services he/she will provide • Specialize • Select office hours, vacations, and time available • Relocate the office • Select substitute physician coverage in his/her absence Responsibilities of Physician • Respect pt. confidential information • Provide reasonable skill, experience & knowledge • Continue treating pt. until contract has been withdrawn • Inform patients • Provide competent coverage during any absence. • Obtain INFORMED CONSENT. • Caution against unneeded treatment The Physician is not bound to: • • • • • • • • • Treat every patient who seeks service Restore pt. To his / her original health Possess the highest skills possible To effect a recovery Skilled as a specialist Correct diagnosis in every case Free from mistakes / infallibable judgment Continue after discharged Guarantee successful treatment / operation Physician Obligation • Use due care, skill • Stay informed • Perform to the best of ability • Perform to the best of ability • Exercise best judgment • Customary treatment • Abstain from experiments • Furnish complete information • Take every precaution to prevent the spread of infection • Advise patient against needless operations Abuse • Physician should routinely inquire about physical, sexual and psychological abuse • Physicians must comply with reporting laws • If the patient is mentally competent adult, physician must not disclose an abuse diagnosis to spouses or any 3rd party without patient permission. Bioethical Dilemmas Allocation of Scarce Medical Resources • Consider: • Physicians must – Likelihood of place patient benefit benefit above – Urgency of need policies. – Change in quality • Physicians should of life not make • Duration of benefit allocation – Amount of resources required decisions. for successful treatment Allocation of Limited Medical Resources • NEVER TO BE CONSIDERED: – Age – Sex – Social worth – Perceived obstacles to treatment – Patient’s contribution to illness – Past use of resources – Ability to pay Transplantation Guidelines • Primary concern health of patient • Death determined by at least 1 physician other than recipient’s physician • Procedure fully discussed with the donor / recipient • Recipient determined according to guidelines • Procedures performed by physicians with appropriate knowledge / competence • Organs considered a national resource • Single list for each organ Xenotransplantation Animal to human transplant of parts Baby Roe – Baboon heart Mandated Choice and Presumed Consent • Required to express their preferences concerning donation • Consent to donate is presumed unless refusal is indicated • Macroallocation – Congressional Decisions • Microallocation – Local level Abortion . • Physicians have the right to refuse to participate in abortions – but no one has the right to judge • Physicians must know the laws in their states as it applies to minors and pregnancy: • If the law states that parental involvement is not required – the physician is not obligated to demand the minor tell the parent Mandatory Parental Consent to Abortion • Encourage minors to discuss their pregnancy with their parents or with other trusted adults. • Physicians should not feel compelled to require them to involve their parents before making the decision to undergo an abortion • Physicians must know the law in their state regarding parental involvement Teenagers • Parents have a right to decide what medical care their young children receive. Mature Minors • Individuals in their mid-to late teens who, for health care purposes, are considered mature enough to comprehend a physician’s recommendations and give informed consent. Fetal Research Guidelines • Part of a competently designed program • Properly performed clinical studies on animals / nongravid humans should precede and fetal research • Follow all federal / state laws • Fetal material should not be purchased • Competent peer review to protect against possible abuse • Written informed consent Genetic Engineering • Supervised by DNA Advisory Committee and FDA – Gene splicing – Recombinant DNA Research – Chemical Synthesis Genetic testing of children? • Offered or required if a child is a risk for genetic conditions that could be prevented • Parents should decide about genetic testing for which preventive measures are not available • Should not be done if they are at risk for a genetic condition with adult onset • Carrier Status should be delayed until maturity • Not performed for the benefit of the family unless substantial harm to the family member could be prevented by the testing. Genetic Tests Include: • Cystic Fibrosis • Down’s Syndrome • Fragile X Disease – Mental retardation • Huntington’s Chorea • Mucopolysaccaridosis – Metabolic-skeletal deformities • Gaucher’s Disease – Fat Metabolism • Phenyketonuria – PKU – Metabolic-retardation • Hemochromatosis – Iron storage disorder • Spinocerebellar Ataxia – Destroys cerebellum • Sickle Cell • Breast, Ovarian, Colon Cancer • Tay-Sachs – Lipid metabolism – Jewish Descent Genetic Testing is Used For: • • • • • Crime Scenes Determining Parentage Determine Inherited Diseases Amniocentesis – Fetal Abnormalities Confirm / Rule out disease causing gene. Genetic-Related Issues Gene Therapy • Replacement / modification of genetic variant to restore or improve cellular function. • Somatic Cell Therapy – Human Cells Altered • Germ Line Therapy – Replacement gene is inserted into human germ cells resulting in new gene Genetic Counseling / Testing • Screening prospective parents for genetic disease before conception • Analysis of preembryos before implanting • In utero testing after conception – – – – – Ultrasound Amniocentesis Fetoscopy Chronic Villus Sampling Genetic Discrimination Differential treatment of individuals based on their actual or presumed genetic differences Artificial Insemination • Donor / recipient are married-child will have same rights as naturally conceived • Unmarried – recipient will be considered the sole parent unless agreed upon previously • If semen is frozen and donor dies – should not be used or donated for purposes other than those intended – No instructions the remaining partner may use semen Artificial Insemination by Anonymous Donor Histories Checks Include: • Infectious / inheritable diseases • Frozen is preferable • Consent of husband is ethically appropriate • May be offered to single / homosexual couple Permanent Records • Exclude those who test positive for infectious / inheritable diseases • Limit # of pregnancies • Notify donors of screening results • Disorders Surrogate Mothers • Becomes pregnant, usually by artificial insemination or surgery and bears a child for another woman • Usually agrees to terminate all parental rights to the sperm donor’s wife. • Birth mother should have the right to void the agreement within a reasonable period of time following birth • Zygote when of donated egg + sperm not genetically related to the surrogate mother In Vitro Fertilization • IVF-Fertilization takes place outside of the body-all fertilized ova are not for implantation. ? Medical research • Frozen Preembryos – Fertilized IVF and stored • Preembryo Splitting – IVF that are engineered to form multiple genetically identical siblings. Rights of Children Parens Patriae Legal doctrine that gives the state the authority to act in the child’s best interest Best Interest of the Child • When all options are weighed, what is in the child’s best interest to safeguard the child’s – Growth – Development – Health – Least Harmful Quality of Life Quality vs Quantity Euthanasia • Administration of a lethal agent by by person to a patient for the purpose of relieving intolerable / incurable suffering • AMA – In compatible with the physician’s role as healer • Emotional support, comfort care, adequate pain control, respect for autonomy instead of Euthanasia WITHHOLDING/ WITHDRAWING TREATMENT • WITHHOLDING TREATMENT: Certain treatment may not be initiated • WITHDRAWING TREATMENT: Termination of treatment that has already begun • ADVANCE DIRECTIVE: Wishes of a patient concerning specific medical treatment in a written form Institutional / Judicial Role in Withdrawing Life-Sustaining Medical Treatment • There are no available family members willing to decide • Dispute between family members – Advanced Directive does not designate one • HCP believes family’s decision is not what patient would want • HCP believes decision is clearly not in patient’s best interest. Futile Care • Not ethically obligated to deliver care that will not benefit patients • Denial of treatment should be based on ethical principles and acceptable standards of care Cost • Should not prescribe unnecessary services Medical Futility in End-ofLife Care • Shift to comfort care • Due process approach: – Joint decision making among physician, patient, proxy. – Negotiate when disagreements rise – Involve institutional ethics committee when possible – Transfer to another physician when disagreements cannot be resolved Physician –Assisted Suicide Physician-aware of patient’s desire to commit suicide – Provides necessary means and or information for the suicide to occur Incompatible with physician’s role as healer Do-Not-Resuscitate Written at the request of patients or their authorized representatives that authorized representatives that CPR not be used to sustain life in a medical crisis. HIV Testing Patients must give informed consent for HIV T If pt. is putting others at risk the physician is ethically obligated to : •Attempt to persuade infected to stop endangering 3rd Person •If persuasion fails – notify authorities •If authorities take no action – notify 3rd party Other Testing •If HCP is exposed to HIV from patient, Pt. maybe tested without giving consent. •Unethical to refuse to treat HIV+ pt. •If diagnosis of HIV status is critical , physician may transfer care if patient refuses testing. Cloning • Organisms are created asexually from a single cell of the parent organism • Cattle, Goats, Mice, Monkeys, Pigs • What’s Next ? Stem Cell Research • Early embryonic cells that have the potential to become any type of body cell. • Cells that don’t know what they want to be when they grow up