ETHICS COMMITTEES AND ETHICS CONSULTATION FUTILITY

1. ETHICS COMMITTEES AND ETHICS CONSULTATIONFUTILITY Yulia Peeva, Chief Assistant Professor at Public Health Department, Faculty of Public Health, Medical University - Plovdiv

2. Why it’s necessary? • In many countriesmost hospitals are now required to have an ethics committee. • Ethical committees have been organized to medical and dental associations in Bulgaria (Bulgarian Physician Union and Bulgarian DentalUnion).

3. Justice • Term that defines fair, equitable, and appropriate treatment in light of what is due or owed to persons. Typically refers to distributive justice in medical ethics, which is the distribution of all rights and responsibilities in the society.

4. Virtue Ethics approach to ethics that de-emphasizes rules, consequences and particular acts and places the focus on the kind of person who is acting. What is primary idea dependswhether the person acting is expressing good character or not. Aristotle (384-322 B.C.E)the name of the founder of virtue ethics

5. The goals are: • to promote the rights of patients; • to promote shared decision making between patients (or their surrogates if decisionally incapacitated) and their clinicians; • to promote fair policies and procedures that maximize the likelihood of achieving good, patient-centered outcomes; and • to enhance the ethical tenor of health care professionals and health care institutions.

6. Hippocratic oath • a documented example of virtue ethics in action • Engraving of Hippocrates by Peter Paul Rubens, 1638

7. English translation, version 2 • I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement: • To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art; and that by my teaching, I will impart a knowledge of this art to my own sons, and to my teacher's sons, and to disciples bound by an indenture and oath according to the medical laws, and no others.

8. I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone. I will give no deadly medicine to any one if asked, nor suggest any such counsel; and similarly I will not give a woman a pessary to cause an abortion. But I will preserve the purity of my life and my arts. I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art. In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or men, be they free or slaves. All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal. If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all humanity and in all times; but if I swerve from it or violate it, may the reverse be my life.

9. Modern use and relevanceof Hippocratic Oath The Oath has been modified multiple times, in several different countries. One of the most significant revisions is the Declaration of Geneva, first drafted in 1948 by the World Medical Association. …In France, it is common for new medical graduates to sign a written oath. The oath was first used in 1938, and the current version has been in use since 1954.

10. Who becomes a member of an ethics committee? • Ethics committee members usually represent major clinical services and other stakeholders in health care delivery. Thus, it is not uncommon for committee members to include clinicians (physicians and nurses) from medicine, surgery, and psychiatry, a social worker, a chaplain, and a community representative.

11. All members of the ethics committee take responsibility for learning techniques of ethical analysis and the arguments, surrounding most of the ethically charged issues in clinical practice.

12. Ethical committee • committee made up of individuals who are involved in a patients care, including health care practitioners, family members, clergy and others, with the purpose of reviewing ethical issues in difficult cases

13. The basic ethical principles: • Autonomy - the condition of being self-governing; independence; personal freedom from choice • The first fundamental principle is respect for people • Beneficence- doing what is good • Nonmaleficence- doing no harm • Justice- fairness

14. What is the difference between an ethics committee and an ethics consultant? • An ethics consultant is an expert in clinical ethics who either provides ethics consultations or serves as an educator to the committee.

15. New model for ethics committees • Proactive (not just reactive), Organizationally integrated (not isolated), accountable according to measurable outcomes (not just good intentions), oriented by institutional values (not just pt rights)

16. Medical Futility Yu. Peeva, PhD Medical University

17. Futility • feeling of being ineffective, uselessness, hopelessness • medical futility – medical care that has not benefit.

18. MEDICAL FUTILITY Futile treatment is any course of treatment that provides no beneficial outcome or is medically ineffective or even harmful to the patient. It is usually contrary to generally accepted standards of care. A treatment may have an effect on the patient but may not benefit the patient. Treating the disease and not treating the patient. Treating the numbers and not treating the patient.

19. Definition of Medical Futility • Quantitative Definition - The expectation of success empirically is so unlikely that its exact probability can’t be calculated. • Qualitative Definition - Any treatment that merely preserves permanent unconsciousness or total dependence on intensive medical care.

20. MEDICAL FUTILITY • Quantitative futility The likelihood that an intervention will benefit the patient is exceedingly low (less than 1/100) • Qualitative futility The quality of benefit an intervention will produce is exceedingly poor (Goals/Definition of recovery)

21. Questions • What is the process by which standards are devised and quantitative judgements made? • Society for Critical Care Medicine - 1990 Consensus report on the ethics of forgoing life support • Medicaid stipulates that recipients are to receive “medically necessary” care but does not stipulate standards

22. Questions • What is the process by which standards are devised and quantitative judgements made? • The Pepper Commission in 1990 tried to define minimum health benefits. • The State of Oregon combined public values, professional judgment, cost-effectiveness data to rank procedures covered under the state Medicaid program.

23. Questions • Who decides when treatment is futile? • Healthcare providers • Patients and their surrogates • The courts

24. Determining Futility • Determination of futility combines technical considerations, clinical judgments, and patient values. • Determination requires shared decision making.

25. Making Judgments • How do we make judgments that combine factual and normative (moral) ingredients? • Values can influence how one recognizes and interprets facts. • We must make a sharp distinction between scientific knowledge and moral and political judgments.

26. Making Judgments • Scientific data provide probabilities not certainties. • Probabilities can not always be kept free of values. • The use and interpretation of scientific data for moral or political purposes will be a function of the values we bring to bear on the data.

27. Questions • How do we determine medical futility for patients who are in a comma, in a persistent vegetative state or who are suffering from multi-organ failure or severe dementia? • When if ever does cost become a consideration?

28. Tension • Physicians must have the right to act on their values and sense of integrity just as patients must be allowed to act on theirs. • The physician is the expert but may act paternalistically. • The patient and family want autonomy and want to follow a democratic process. • How do we resolve the inherent tension between doctors and patients?

29. Questions • If patients and their surrogates insist on continuing treatment that is considered futile, who should pay for the treatment? • If health care providers discontinue treatment against the wishes of patients and their surrogates, will this cause the public to lose trust in the health care system?

30. Questions • If the physician accedes to family wishes to continue futile care, is he/she sending the family a mixed message of false hope? • Does the physician have an obligation to protect the patient’s interest? • How does the physician determine what is in the best interest of the patient?

31. Questions • In the absence of laws, are the family members best qualified to decide whether treatment is futile? • When if ever are physicians justified in refusing to continue futile treatment? • Should the potential costs to the provider (hospital) and to the public of futile care be a consideration?

32. MEDICAL FUTILITY PHYSICIAN AUTONOMY INTEGRITY OF MEDICAL PROFESSION VS PATIENT/SURROGATE AUTONOMY TYPICALLY A CONFLICT SITUATION

33. MEDICAL FUTILITY Physicians have no obligation to offer treatments that do not benefit their patients. Although respect for patient autonomy entitles them to choose a medically acceptable treatment option, it does not not entitle the patients to receive whatever treatments they ask for. Futility determination should conform with professional standards of care.

34. julipeeva@abv.bg

35. QUESTIONS?