"Exhaustive Durable Power of Attorney"
Ethical Principles اصول چهارگانه و ابزارهاي تحليل اخالق دکتر واشقانی فراهانی گروه اخالق پزشکي دانشگاه علوم پزشکي تهران A 78 y.o. male with COPD When hospitalized with pneumonia one year earlier, signed AD, no ventilator. Has worked with respiratory therapist for one year to improve breathing effort. Was admitted through the ER for breathing difficulties & placed on a ventilator in ICU. Primary care doc cites AD, spouse wants everything to be done to prolong his life. 25 y.o. female in premature labor Married woman, desired pregnancy, well educated, at 27 weeks gestation, in labor. Admitted for tocolytic therapy to stop labor. Requests that “nothing be done” to resuscitate or support if infant born prematurely due to risk of morbidity. What should be done? 30 y.o. with C-4 fracture 30 y.o. longshoreman, injured in dock accident, fracture & spinal cord injury C-4. Following surgery & post-op recovery is transferred to rehab unit. Requests the ventilator be turned off on 8th day in rehab ward (26 days post accident.) Primary family & fiancee is in the area. Case to Discuss Managers of a health provider discover that one of their nurses is infected with HIV but has told nobody. Should they release the nurse's name to the media? Should they notify all those who may have been treated by the nurse even though the chances of anybody being infected are vanishingly small? The Case of Dax Cowart An unmarried, 25 year-old man named Dax Cowart was in a terrible accident and received second and third degree burns over two-thirds of his body. Now, one year after the accident, Dax is blind in both eyes, though with delicate surgery, partial vision may be restored to one eye. The burns have not healed completely, and Dax must be immersed daily in an antiseptic solution to keep the burns from getting infected. Each day after the bath the burns must be bandaged; both procedures are extremely painful to Dax. Dax has had several operations on his hands and arms, but has recently begun to refuse any additional surgery o them. Dax’s hands are, as of now, useless. The doctor’s feel, however, that further surgery could restore some useful function to Dax’s hands. Dax’s upper torso – particularly his arms, face, and neck – is severely scarred. Dax is very intelligent and articulate, and before the accident he led a very active life. He has repeatedly asked that his treatment be discontinued and that he be allowed to go home and die. Doctors attending Dax say that if his treatment were discontinued he would most certainly die from infections to his open wounds. Contaception and Minors 1. Jane aged 15 yrs requests the OCP 2. Her mum phones you the next day 3. Several weeks later she tells you Case to Discuss A infertility specialist writes to ask if a patient of his can select the gender of a child because he has a patient who want a girl to balance their family. What Are Ethical Principles, and How Do They Help With Decision Making? Major Ethical Theories Utilitarianism Deontology Natural Law Virtue Rawl’s theory of justice Gilligan’s theory of caring- relationships DEONTOLOGICAL THEORIES Some principles are intrinsically right - regardless of resulting consequences. CONSEQUENTIALIST THEORIES Consequence alone determines right and wrong. - greatest happiness of the greatest number. Principles in Bioethics Respect for Autonomy Nonmaleficence Beneficence Justice Veracity Theduty to tell the truth. Truth-telling, honesty. Privacy/Confidentiality Respecting privileged knowledge. Respecting the “self” of others. Respect for Autonomy Self-Rule Self-Determination Patient‟s unique set of: values goals desires experiences Respect for Autonomy This principle requires respect for patients' and caregivers' deliberated choices made in accordance with their own values, consciences, and religious convictions. Autonomy Autonomy implies competence Legal age of decision making Minors and autonomy – the age of assent – exceptions for reproductive decisions The ability to understand medical information and to relate this to one‟s life plan and priorities Logical consistency with one‟s goals Problems related to incompetence Incompetence: a legal definition Incapacity: a clinical definition – patients‟ capacity may wax and wane – capacity for this decision at this time? Creates a need for a surrogate – substituted judgement – best interest principle Problems in assessing autonomy Patients with C-3, C-4 spinal cord trauma 90% asked to d/c the respirator, post accident Is this an autonomous decision? Problems in assessing autonomy Following rehabilitation, 95% of the patients were glad to be alive and no longer wished to have their respirators turned off NEJM Vol. 328, No. 7 Feb. 18, 1993 Components of Autonomy 1) Intentionality 2) Understanding 3) Freedom from External Constraints 4) Freedom from Internal Constraints Intentionality What is the patient‟s intent when consenting to a medical procedure or treatment? What is the physician‟s intent? Understanding How much is sufficient? Exhaustive versus Material Information External Constraints Prisoners Economic Status Geographic Location Internal Constraints Alcoholism & Drug Addiction Mental Illness Chronic Pain Fear Autonomy 1. Capacity to think, decide, take action 2. Mental incompetence= no autonomy 3. Autonomy –v-Paternalism When patient not autonomous –no clash. When patient autonomous- questionable procedure Decisional Capacity A patient has decisional capacity to consent to or to refuse treatment when the patient has: 1) the ability to comprehend information relevant to the treatment being offered, and 2) the ability to deliberate in accordance with his/her own values and goals, and 3) the ability to communicate with care givers. Nonmaleficence Do no harm Avoid harm Prevent harm Nonmaleficence This principle requires that health care providers not The Gross Clinic, 1875 attempt to harm their patients. The infliction or risking of harm to patients in the context of medical practice can only be justified by the pursuit of other moral values - principally benefits to the patients sufficient to outweigh the harm. “First Do No Harm” “The very first requirement in a hospital is that it should do the sick no harm.” Florence Nightingale Nonmaleficence Medical Error An estimated 44,000 to 98,000 patients die annually as a result of medical errors. Medication errors alone are estimated to account for over 7,000 deaths annually. I.O.M. To Err Is Human, 2000 Beneficence Act in such a way as to provide a benefit for the patient According to the usual goals of medicine In terms of the patient‟s value system Beneficence This principle requires that The Agnew Clinic, 1889 health care providers attempt to benefit their patients and to do so with minimal harm. The Principle of Beneficence The Principle of Beneficence asserts the duty to help others In the medical context, failure to benefit others when in a position to do so violates the professional relationship that is institutionally established between health care professionals and patients Paternalism – Weak Paternalism – Strong Paternalism 3 constraints on Beneficence 1. Need to respect autonomy-patient and doctor may differ re. Management 2. Need to ensure health is not brought at too high a price 3. Need to consider rights of others Justice “Give to each that which is due.” According to: – merit – need – equally – potential for contribution Justice This principle requires that health care providers act justly or fairly to others in the context of respecting each other's rights, in the context of obeying morally acceptable laws, and in the context of the distribution of scarce resources. Ethical Principles PRIMA FACIE DUTY ACTUAL DUTIES – principles are broad, – principles are applied general statement’s of in the unique duty circumstances of an – they are ethical ideals actual clinical situation in a sense, since they – it is presumed that the are articulated apart weighting of the from a particular principles will become context self-evident in context. Ethical Principles Serve as practical moral guidelines for assessing one’s duty in a particular case Provide continuity and uniformity in assessing policies in health care Limitations of Principles Risk of oversimplification Risk of playing one principle as “trump” Requires balancing several principles There is no formula for prioritizing They do not provide an account for the “casuistic” nature of moral analysis Ethical Principles Provide an approach to constructing or assessing one’s moral duty in a particular sense. Assume that the moral agent embodies a virtuous character with a predisposition to do the right thing. Principles and Virtues PRINCIPLES VIRTUES – Autonomy – Respect for others – Nonmaleficence – nonmalevolence – Beneficence – benevolence – Justice – fairness, empathy 69 y.o. in PVS with feeding tube 69 y.o. woman suffered MI and arrest. EMT‟s arrived & resuscitated after 10 min. In hospital recovery from coma to PVS Breathes spontaneously, requires tube feeding, no self-awareness nor of others. Husband requests feeding tube be clamped after 3 months in this condition. روش تجزيه و تحليل Caseهاي اخالق باليني Decision Making Model: (ADPIE) Diagnose Assessment Planning On-going Evaluation On-going Implementation Implementation On-going Planning Evaluate On-going Diagnosis On-going Assessment Husted’s Formal Ethical Decision Making Model Husted, G.L., & Husted, James H. Ethical Decision Making In Nursing, 1991, Mosby St. Louis, MO, pp. xi. Casuistry An ethical method which resolves cases of conscience by applying general rules of morality to particular instances in which circumstances alter cases or in which there appears to be a conflict of duties. Casuistry A form of analysis which assumes there are paradigm cases about which we can all agree as to the right or wrong resolution, even if we have different reasons for our positions. Current cases are analyzed based on their similarities and differences with the paradigm case. Casuistry “…the analysis of moral issues, using procedures of reasoning based on paradigms and analogies, leading to the formation of expert opinions about the existence and stringency of particular moral obligations, framed in terms of rules or maxims that are general but not universal or invariable, since they hold good with certainty only in the typical conditions of the agent and circumstances of action.” (Jonsen & Toulmin) Two Types of Moral Reasoning Formal Arguments – Particular conclusions are deduced from universal principles. – Truth and certainty flow downward from universal principles to specific instances. – The universal starting point underpins the particular end point. Practical Arguments (Casuistry) – Conclusions about specific instances are based on how closely they resemble earlier precedent cases. – Truth and certainty established in precedent cases pass sideways to provide resolutions for later problems. – The outcomes of experience serve to guide future action. Formal Argument Model Universal Principle (Major Premise) Minor Premises Specifying The Present Instance The Necessary Conclusion About The Present Instance Practical Argument Model General Warrant (based on similar precedents) Particulars Of The Provisional Conclusion Present Case About the Present Case May Be Challenged By Exceptional Circumstances Common Uses of Casuistical Reasoning in Medicine Case Law Medical Diagnosis and Treatment Prioritizing prima facie principles during the analysis of specific cases brought to medical ethics committees – especially when those principles create conflicting obligations A Paradigm for the analysis of ethics cases From Clinical Ethics, 4th Edition Four Box Method Medical Indications Preferences of the for Intervention Patient Quality of Life Contextual Issues MEDICAL INDICATIONS What is patient‟s medical problem, diagnosis, prognosis? Is it acute, chronic, critical, reversible? What are the goals of treatment and probabilities of success? In case of therapeutic failure, what plans? How can benefit be provided- harm avoided PATIENT PREFERENCES What preferences for treatment has the patient expressed? or refused? Does the patient understand the risks and benefits and has the patient given consent? Is the patient competent, is there evidence of incapacity to make decisions? Are there Advance Directives, surrogates? QUALITY OF LIFE What are the prospects, with or w/o treatment, for a return to normal life? Any biases that might prejudice provider‟s evaluation of the patient‟s quality of life? What physical, mental, and social deficits may remain, even if treatment succeeds? Might the patient consider continued life to be judged as undesirable for self? CONTEXTUAL FEATURES Family issues influencing treatment choice? Physician-Nurse issues influencing? Financial, economic, scarcity issues? Religious, cultural factors? Institutional, professional or legal issues? Any justification to breach confidentiality? Or to act contrary to the patient‟s wishes? The Principle of Autonomy A person is autonomous if and only if that person is self-governing All things being equal, autonomous actions and choices should not be constrained by others The Principle of Autonomy lies behind Informed Consent and Refusal of Treatment – The issue of informed decision-making implies that subjects and patients with the capacity to „consent‟ may likewise opt to refuse The Principle of Nonmaleficence As a principle, it has become associated with the dictum, above all, do no harm As a prima facie rule, it includes the following: “Don‟t kill”, “Don‟t cause pain”, and “Don‟t disable” The AMA House of Delegates holds that cessation of treatment is morally justifiable when the patient and/or immediate family, in consultation with medical staff decide to withhold or stop the use of “extraordinary means to prolong life when there is irrefutable evidence that biological death is imminent” But while the physician is always morally prohibited from killing, he or she is not morally bound to preserve life in all cases. Thus, in certain circumstances, the physician is morally permitted to Two Types of Ethical Theory Utilitarianism (Consequentialism) – Act Utilitarianism – Rule Utilitarianism Deontology – Kant‟s Theory – Multi-Rule Deontology (e.g., Ross) Euthanasia – Hospital Policy Intervention with the solitary intent of causing death is prohibited It is ethically permissible to provide pain medications to a terminally ill patient, even if such medications may hasten the death of a terminally ill, consenting patient – Does not apply to a non-terminally ill patient – Does not effect the right of a competent patient to refuse medical treatment (forgoing treatment) Neither merciful intent nor autonomous request by a patient form a justifiable basis There are ethical differences between active euthanasia and physician assisted suicide Ethical Principles Conflict is inevitable. Ethical principles provide the framework/ tools which may facilitate individuals and society to resolve conflict in a fair, just and moral manner. MDU Beneficence Non-maleficence Justice Autonomy Case to Discuss A doctor working in an NHS trust thinks it wrong that his patients will be denied a new treatment for cancer (the hospital formulary committee had decided that it should not be prescribed). Should he contact the local media? Should the trust punish him if he does? Case to Discuss A health maintenance organisation in the United States considers investing in improvements in its system for caring for patients with AIDS.The vice president for marketing warns that such improvements may lead to selective enrolment of unprofitable membersnamely, those with HIV infection. Is the organisation ethically bound to improve its HIV care, even if that may reduce its financial viability? Ethical Principles Autonomy/Freedom Veracity Privacy/Confidentiality Beneficence/Nonmaleficence Fidelity Justice Autonomy The right to participate in and decide on a course of action without undue influence. Self-Determination: which is the freedom to act independently. Individual actions are directed toward goals that are exclusively one’s own. Beneficence/Nonmaleficen e The principle and obligation of doing good and avoiding harm. This principle counsels a provider to relate to clients in a way that will always be in the best interest of the client, rather than the provider. Fidelity Strict observance of promises or duties. This principle, as well as other principles, should be honored by both provider and client. Justice The principle that deals with fairness, equity and equality and provides for an individual to claim that to which they are entitled. – Comparative Justice: Making a decision based on criteria and outcomes. ie: How to determine who qualifies for one available kidney. 55 year old male with three children versus a 13 old girl. – Noncomparative Justice: ie: a method of distributing needed kidneys using a lottery system. Principles 1. Beneficence 2. Non-Maleficence 3. Autonomy 4. Truth telling 5. Confidentiality 6. Preservation of Life 7. Justice Beneficence and Non- Maleficence Questions: 1)Is the patient your only concern? (possible conflict with utility) 2)Do we always know what is good for the patient? (patient‟s view may differ from ours) Autonomy 1. Capacity to think, decide, take action 2. Mental incompetence= no autonomy 3. Autonomy –v-Paternalism When patient not autonomous –no clash. When patient autonomous- questionable procedure Truth Telling “In much wisdom is much grief:and he that increaseth knowledge increaseth sorrows” (Ecclesiastics 1,18) Truth telling (cont) If you override it you endanger doctor/patient relationship(based on trust) You offend against the principle of autonomy(Dr.C Mooreland) At times there are good reasons for overriding the truth telling principle The case for deception is founded on three fallacies 1. Hippocratic obligations 2. Not in a position to know the truth 3. Patients do not want the truth if the news is bad Confidentiality Act against this principle and you destroy patient‟s trust Clash –when keeping confidentiality would harm others eg child abuse Should patients have access to their notes? Against Layman unable to cope with data Opinions not facts cause anxiety Third party information Defensive medicine For Data belongs to patient Accuracy improved by sharing Access to Records Data Protection Act (1998) What records are covered? Does it matter when the record was made? Who can apply? Are their exemptions? Must copies be given if requested? Access to records of deceased patients? Exceptions to Medical Confidentiality Pt gives written and valid consent To other participating professionals Where undesirable to seek patients consent info can be given to a close relative Statutory requirements Ordered by Court Public interest Approved Research Preservation of Life At what stage does human life begin?- coil, pill Can we assess another persons quality of life?-Jehovah's Witness Other Moral doctrines Acts and Omissions Doctrine-held by those who believe that passive euthanasia is not killing(killing is an act,and an omission is not an act) Doctrine of Double effect-makes a distinction between what I intend and what I merely foresee Living Wills Patient unconscious\severely mentally disabled , and two docs agree it unlikely he will be able to communicate treatment decision Refuse treatment if prolongs life with no further benefit to patient Justice How to allocate scarce healthcare resources? 1. Medical need 2. Medical Benefits 3. Social worth-discriminates against underprivileged 4. Merits/contribution to society-very contentious 5. Desert 6. Market Forces 7. A lottery Lord Fraser’s reccomendations the The doctor should assess whether patient understands his\her advice The doctor should encourage parental involvment The doctor should take into account whether the patient is liekly to have sexual intercourse without contraceptive treatment The doctor should assess whether the patient‟s physical\mental healthare likely to suffer if she does not receive advice\treatment The doctor must consider whether the patient‟s best interestsrequire him\her to Duties of a Doctor Please apply ethical principles to the above list as described in “Good Medical Practice” Truth Telling Video clip 1. How much information should be given to patients preoperatively? 2. When/how should we relay information to a postoperative patient? 3. What lessons can be learned from this tape? Ethical principles in public health in Bulgaria Main ethical principles which are the basis for ethical evaluation: Basic Principles – Autonomy/Keeping Promises Fidelity is basic principle of business ethics. Assumption that contracts (promises) will be honored, both written and oral. Healthcare is a trust-based business. Ethics obligation to employees, community, board of directors. – Ethics in Health Administration - Morrison Basic Principles – Do No Harm/Beneficence Fundamental concern is that whatever harm is causes is outweighed by the benefits provided. Intersections with ethical and legal considerations. Critical issues: starting/withdrawing life support. Beneficence: patients assume we will act in their best interest. Beneficence/Nonmaleficence extends to staff, community, employees. – Ethics in Health Administration - Morrison Basic Principles – Justice Patient Justice – patients expect they will be treated fairly and needs met in a reasonable time. Distributive Justice – the appropriate and fair distribution of benefits provided by society. – Utilitarian theory – Market theory Staff Justice – concept of fairness and equity for employees – Ethics in Health Administration - Morrison Ethics – Outside Influences Federal and state agencies regulate reimbursement and structure of healthcare as well as business activities. Legal system Healthcare specific organizations and agencies: JCAHO, AMA, AHA, etc. Staff Competency/Incompetence Ethics – Other Outside Influences Market Forces/Economics Technology – Information Technology – Clinical Technology Managed Care Social Responsibility – Quality Assurance – Public Health Ethics -Inside Influences Organizational Culture – No Margin, No Mission Organizational Culture – Patient Relations, Staff Relations Patient Billing and Charity Care Corporate Compliance – Fraud and Abuse – Conflicts of Interest Resource Allocation Personal Ethics Character Development/Moral Integrity – Education – Experience – Self assessment – Decision making Codes of Ethics and Administrative Practice Guidelines – Not well publicized – Vague – No enforcement Four Box Method Medical Indications Preferences of the for Intervention Patient Quality of Life Contextual Issues Ethical Problem Solving Modern health care gives rise to many value ladened issues for which medicine alone cannot provide an adequate answer. Patients may seek a solution – that maximizes possibilities for a good outcome – or, that fulfills their sense of duty to self- others – or, that follows a rule or principle such as Principles in Health Care Ethics Respect the autonomy of the patient Nonmaleficence: do no harm Beneficence: seek to provide a benefit for the patient in terms of the patient‟s goals Justice: treat persons fairly, without regard to irrelevant factors Consider how these may apply in following: AMA’s Code of Medical Ethics 1847 Edition 2001 Edition Introduction: Setting the Context Medical Ethics (1): Levels &Types Individual level clinical ethics (patient-centred) professional ethics (physician-centred) Institutional level organizational ethics (integrating clinical, professional & business ethics) Societal level shared conceptions of health-related quality of life & resource allocation priorities; social values Medical Ethics (2): Four Principles Autonomy Non-maleficence Beneficence Justice Medical Ethics (3): Evolving with Society Hippocratic Era - Non Maleficence – Beneficence Contemporary Era - Above constrained by autonomy & justice Distinctive features of the Contemporary Era Autonomy of individuals Plurality of viewpoints Widespread cost (profit)- consciousness Ethical issues in Geriatric Care Intervention-related matters - informed consent (decisional capacity) - matters of death & dying - life sustaining treatment - quality of life (QOL) - euthanasia & assisted suicide Policy-related matters - rationing & managing health care costs Ethical issues in relation to Four Principles Autonomy Decisional capacity Nonmalefience – Beneficence Life sustaining decisions, QOL, euthanasia & assisted suicide Justice rationing & managing health care costs Substantive Issues in Geriatric Ethics Informed Consent Three components: Competence (decisional capacity) Disclosure Voluntariness Decision-Making Capacity (DMC) Three questions: Who needs assessment? How is assessment to be done? If DMC is impaired, who will then make decision and on what basis? DMC: Who to assess? Those making apparently unreasonable choices ( e.g. rejecting high benefit – low burden options or choosing low benefit – high burden options) Those exhibiting shift in long-standing values or preferences Those with problems in cognition or psychological states (e.g. depression) DMC: How to assess? Ascertaining psychopathology Assessing functional abilities in decision-making - expressing choice - showing understanding - having appreciation of context - demonstrating reasoning Evaluating consequences of decision Making Decisions for Incompetent Patients (1): Who? Patients themselves (advance directives) - Decisional directives (living wills) - Proxy directives (durable power of attorney) - Combined directives Family members - hierarchy: spouse, adult children, parents, adult siblings etc. Courts - committee-of-person/estate Making Decisions for Incompetent Patients (2): How? Explicit patient choice - via advance directives Substituted judgment - selecting choices that patients themselves would have made, based on the best knowledge of patients Best interests of patient - when above standards cannot be determined - Best interest of the person as a whole and not best medical interest alone (patient‟s QOL important) Life-Sustaining Treatment (1) To treat or not to treat? Traditional distinctions: all morally untenable - withholding & withdrawing treatment - extra-ordinary & ordinary treatment - artificial feeding & technological modalities Important moral distinction: obligatory vs. optional treatment - benefits vs burden of treatment - patient‟s quality of life central to decision-making Artificial Hydration and Nutrition – Some Special Points Current legal consensus: artificial feeding amounts to medical treatment and care (as opposed to basic, non-medical care) Increasing medical consensus: stopping artificial feeding leads to sedation, diminished awareness and increased pain threshold. Life-Sustaining Treatment (2) To discuss before deciding Autonomous patients: as per informed decision (within limits of society‟s just allocation) Non-autonomous patients: - Advance directives - Substituted judgment - Best interests (to discuss benefits & burdens of treatment in relation to patient‟s QOL) Quality of Life Assessment (1) Inevitable when best interests are being analysed One definition of minimal threshold of QOL: - Extreme physical debilitation & complete loss of sensory and intellectual activity - Qualities fundamental to human interaction (ability to reason, experience emotions, enter into relationships) irreversibly lost Quality of Life Assessment (2) QOL assessments highly subjective Studies show physicians and even family members rate patients‟ QOL lower Nevertheless, QOL still plays a vital role in life-sustaining treatment decisions Shared decision-making vital Physician – Patient/Surrogate Disagreement Both sides to re-examine values & basis of disagreement & to re-discuss Physicians are not ethically obliged to give futile treatment; If disagreement persists, to ask for institutional review and/or transfer locus of care; (but till takeover, patient is still physician‟s responsibility) Points for Reflection (1) Important for more public education on matters of - Life, ageing and death - Health-related quality of life - Principles of medical decision-making Role of professional groups in facilitating public education Euthanasia & Assisted Suicide Morally, distinction between letting die & assisted dying is untenable. (What is important is the moral justification of the act) However, sanctioning euthanasia & assisted suicide as a policy is problematic: - fears of progressive erosion of moral restraint especially against the frail & disabled - insufficient consideration for good alternatives (palliative care and community support services) Points for Reflection (2) If society is unwilling to sanction euthanasia & assisted suicide requested by suffering patients, society must then also ensure that suffering is reasonably minimised by - Good palliative care services - Good community support services Justice in Health Care (1) Considerations: – Equal opportunity to have - access to health care - good quality health care – Society‟s resources are limited and justice also demands that the health care system runs efficiently – Insufficient resources allocated to health care will lead to an unjust system – balancing efficiency against equity Justice in Health Care (2) – Ethical justification exists for a two-tiered system with equal rights of access to first tier (decent minimum standard of health care) and with no social subsidies for second tier – Age, race, gender, social worth etc are no barriers to first tier access – Fundamental challenge is specifying the decent minimum in health care - a social and political decision. Regular review and revision of such standards vital. Justice in Health Care (3) – Once specified, patients & physicians must operate by the rules of the two-tier system – Compromises to both access and quality of health care can also arise from policies of health care organizations which may only advance business interests alone. The need thus for institutional or organizational ethics. Points for Reflection (3) A just health system will not compromise decent “bedside” quality of health care (including effective communication time) A just health system however does not mean there will be no medically-based rationing at “bedside” Educating administrators and accountants about medical ethics is vital so that they can make resource-related health care decisions more validly Summing Up Individual Clinical Encounter (1) Within a just health system... Neither absolutist nor relativist stand toward principles are valid Context is vital: especially that of benefits vs. burden of treatment (to be assessed by autonomous patient) with guidance and help from medical profession General Decision-Making Model in Clinical Ethics Autonomous Patient (competent, informed, free) weighs benefits & burden physician of intervention guidance (benefits that patient wishes & burden that patient is willing to take) support Makes Decision Individual Clinical Encounter (2) Benefit must precede burden Benefit can be defined by medical profession, but they must ultimately be sanctioned by autonomous patient Burden is also what autonomous patient knowingly accepts Individual Clinical Encounter (3) When patients lack decision-making capacity: advance directive substituted judgment best interests Best interests: understanding benefit and burden of intervention in relation to patient‟s QOL All other ethical issues in geriatric care to be approached with this general format Medicine & Learning Clinical medicine (continuing) Clinical epidemiology (role of uncertainty, chance and bias; care in making conclusions) Clinical ethics Usefulness of Clinical Ethics (1) Clarifies complex issues in clinical management which cannot be resolved by technical knowledge alone Implies decisional agreement on these issues can be ultimately arrived at (despite plurality in society) by due process of analysis and communication Legal sanctions: last resort The Four Prima Facie Principles of Medical Ethics 1. Respect for Autonomy 2. Beneficence 3. Nonmaleficence Tom L. Beauchamp 4. Justice Principles of Biomedical Ethics, 1st Edition, 1978 5th Edition, 2001 James F. Childress Principles Based On “Common Morality” “…the set of norms that all morally serious persons share….” Common Morality does not include: – “moral ideals that individuals and groups voluntarily accept”; – “communal norms that bind only members of specific moral communities”; or – “extraordinary virtues.” Borrowed From W.D. Ross Prima Facie Duties W.D. Ross, The Right and the Good (1930): “first face” or “at first glance” evident without proof conditional obligations or duties Ross‟s categories: 1) fidelity 2) reparation 3) beneficence 4) nonmaleficence 5) justice 6) self-improvement The Four Prima Facie Principles of Medical Ethics 1. Respect for Autonomy 2. Beneficence 3. Nonmaleficence Tom L. Beauchamp 4. Justice Principles of Biomedical Ethics, 1st Edition, 1978 5th Edition, 2001 James F. Childress Surrogate Decision Making Hierarchy 1. autonomously executed advance directive 2. substituted judgment (“don the mantle of the incompetent”) 3. best interests of the patient Edmund Pellegrino Autonomy & Trust Autonomy-driven models of the doctor- patient relationship tend to be legalistic and based more on distrust than trust. “There is no way to circumvent the physician‟s character or her construal of what autonomy means in actual practice.” “…there is no evidence that a relationship based on mistrust is any more protective of patient autonomy than one based on trust, that is on a covenant rather than a contract.” Beneficence & Paternalism They are not synonymous! Paternalism Mapes & Degrazia Definition: “the interference with, limitation of, or usurpation of individual autonomy justified by reasons referring exclusively to the welfare or needs of the person whose autonomy is being interfered with, limited or usurped.” Types of Paternalism Based on Restrictions of Liberty: – Extreme Paternalism: liberty is restricted to benefit the patient – Paternalism: liberty is restricted to prevent harm to self or others Based Autonomy Status – Weak Paternalism patient has limited autonomy patient has temporary loss of autonomy – Strong Paternalism: patient is autonomous Paternalism Edmund Pellegrino “Paternalism…assumes that the physician knows better than the patient what is in the patient‟s best interests, or that even a mentally competent patient cannot possible know enough about the choices to be able to make intelligent decisions.” “Or, less benignly, the physician may assume that it is her prerogative as the privileged proprietor of medical knowledge and skill to dispense it as she sees fit, without the patient‟s interference.” Paternalism Edmund Pellegrino “Paternalism, whether benignly intended or not, cannot be beneficent in any true sense of that word.” “Beneficence and its corollary, nonmaleficence, require acting to advance the patient‟s interests, or at least not harming them.” “It is difficult to see how violating the patient‟s own perception of his welfare can be a beneficent act.” Edmund Pellegrino “True Beneficence” “…is a compound idea consisting of an ascending hierarchy: 1) what is medically good…restoration of physiological functioning and emotional balance; 2) what is defined as good by the patient in terms of his perception of his own good; 3) what is good for humans as humans and members of the human community; 4) what is good for humans as spiritual beings.” Examples of Health Care Errors • Medication errors/adverse drug events • Falls • Hospital acquired infections • Failures to diagnose/incorrect diagnoses • Use of inappropriate or outmoded diagnostic tests or treatments • Burns • Wrong site surgical errors • Restraint-related strangulation Justice When we grant others rights, we accept duties for ourselves. Distribution of Scarce Medical Resources – “Baby Boomers”: – Primary Care Providers – ICU Beds – Total Joint Replacements – Immunizations Casuistry The Devil Is in the Details Casuistry Historical Roots Penitential Books, the Venerable Bede, 735 C.E. Confessional Books, 12th Century Jesuits, 1534 St Ignatius of Loyola Founder of the Jesuits in 1534 Albert Jonsen & Stephen Toulmin The Abuse of Casuistry, 1988 both involved in the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, 1975-1978 congressional legislation, 1974 aftermath of Roe v. Wade, Scandinavian fetal research and the Tuskegee syphilis study National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research purpose – review federal regulations about research with an eye to the protection of the “rights and welfare” of human subjects – study ethical issues arising in research using vulnerable subjects – develop a general statements of ethical principle to guide the future development of biomedical and behavioral research produced the Belmont Report – the foundational guideline for Institutional Review Boards (IRBs) National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research 11 commissioners representing: men, women, blacks, whites, Catholics, Protestants, Jews, atheists, medical scientists, behaviorist psychologists, philosophers, lawyers, theologians, public interest representatives unable to agree on “principles” as a first step used agreement on specific cases and instances to develop their statement of principles in the Belmont Report 1) respect for persons 2) beneficence 3) justice National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research “Members if the commission were largely in agreement about their specific practical recommendations; they agreed what it was they agreed about; but the one thing they could not agree on was why they agreed about it. So long as the debate stayed on the level of particular judgments, the eleven commissioners saw things in much the same way. The moment it soared to the level of „principles,‟ they went their separate ways. Instead of securely established universal principles, in which they had unqualified confidence, giving them intellectual grounding for particular judgments about specific kinds of cases, it was the other way around.” (Jonsen & Toulmin)