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					‫‪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)

				
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