Medical Ethics and Professionalism Part 2

2. Medical Ethics and ProfessionalismPart 2 Richard L. Elliott, MD, PhD, FAPA Director, Medical Ethics and professionalism Professor, Community Medicine Mercer University School of Medicine Adjunct Professor Mercer University School of Law

3. Follow-up on Health Care Delivery

4. Abortion and the ACA – kff.org • Abortion excluded from 10 Essential Health Benefits • Federal funds may be used for abortion if related to rape or incest or if mother’s life is in danger • HR7 limits tax credits to plans offering abortion • Some states permit riders for private insurance plans that cover abortions, some do not (Utah) • 50% women legally residing in U.S. will have access to plans that permit abortions • 30-35% women will have access only to plans that restrict abortions to rape/incest/danger to mother

5. Residency slots in Georgia • According to AAMC, there will be a shortage of 45,000 primary care physicians, 46,000 specialists by 2020 • Georgia HB 922 • Almost $7 million requested to support new residency positions, fellowships, other training positions • Cost per resident per year $150,000-200,000

6. Uninsured with and without Medicaid expansion • The Uninsured After Implementation Of The Affordable Care Act: A Demographic And Geographic Analysis • http://healthaffairs.org/blog/2013/06/06/the-uninsured-after-implementation-of-the-affordable-care-act-a-demographic-and-geographic-analysis/ • Georgia 1.8 million pre-ACA uninsured • 1.54 million uninsured with Medicaid opt-out • 924,000 uninsured with Medicaid expansion

7. Death Panels • Medicare payment for end-of-life counseling • Patient-Centered Outcomes Research Institute • Independent Payment Advisory Board

8. www.kaiserhealthnews.org

9. Goals • What is medical ethics? • Medical ethics and professionalism at MUSM • Expectations for Community Medicine I • What is an ethical dilemma? • What are the principles of medical ethics? • How to analyze an ethical problem • Introduction to informed consent and confidentiality • Introduction to surrogate decisionmaking • Introduction to professionalism

10. Optional review after lecture

11. When the Patient is Incompetent • Karen Ann Quinlan • 1954-85 • 21 yo, Valium and ETOH • PVS, ventilator • Parents sued to remove ventilator • 1976 New Jersey Supreme Court decided on right to privacy • “Right to die”

12. When the Patient is Incompetent • Nancy Cruzan • 1983 MVA • PVS, feeding tube • 1987 parents sued to remove tube • Court liberty interest in being free from unwanted intrusions • Loosely “right to die” • Patient Self-Determination Act 1990

13. Patient Self-Determination Act • 1990 after Cruzan • Written notice upon admission to the health care facility of decision-making rights • The right to accept or refuse medical treatment • The right to make an advance health care directive • Facilities must ask whether the patient has an advance health care directive • Facilities must educate staff about advance health care directives.

14. When the Patient is Incompetent • Guardian • Probate court • Guardian of person or estate or both • Advance directive • Specifies what is to be done in the event patient is unable to make a decision • Durable Power of Attorney for Health Care • Who will make decision • Living Will • Specifies particular decisions, e.g., ventilators • Georgia Advance Directive for Health Care includes both Power of Attorney and Living Will provisions (posted on ethics site, First Year)

15. Georgia Advance Directive for Health Care • GUIDANCE FOR HEALTH CARE AGENT • When making health care decisions for me, my health care agent should think about what action would be consistent with past conversations we have had, my treatment preferences as expressed in PART TWO (if I have filled out PART TWO), my religious and other beliefs and values, and how I have handled medical and other important issues in the past. If what I would decide is still unclear, then • My health care agent should make decisions for me that my health care agent believes are in my best interest, considering the benefits, burdens, and risks of my current circumstances and treatment options.

16. Substituted Judgment v Best Interests • Substituted judgment – for persons who have been competent to express a choice but who presently lack capacity • Dementia • Delirium • Severe mental illness • Best interests standard – for persons never competent to have decided • Children • Mentally retarded/developmentally disabled

17. Georgia Advance Directive for Health Care • PART TWO will be effective if I am in any of the following conditions: • A terminal condition, which means I have an incurable or • irreversible condition that will result in my death in a relatively short period of time, and/or; • A state of permanent unconsciousness, which means I am in • an incurable or irreversible condition in which I am not aware of myself or my environment and I show no behavioral response to my environment. • To be determined by personal and second physician

18. Georgia Advance Directive for Health Care • Try to extend my life for as long as possible, using all medications, machines, or other medical procedures that in reasonable medical judgment could keep me alive. If I am unable to take nutrition or fluids by mouth, then I want to receive nutrition or fluids by tube or other medical means, OR; • Allow my natural death to occur. I do not want any medications, machines, or other medical procedures that in reasonable medical judgment could keep me alive but cannot cure me. I do not want to receive nutrition or fluids by tube or other medical means except as needed to provide pain medication, OR;

19. Georgia Advance Directive for Health Care • I do not want any medications, machines, or other medical procedures that in reasonable medical judgment could keep me alive but cannot cure me, except as follows: • [Initial each statement that you want to apply to option (C).] • If I am unable to take nutrition by mouth, I want to receive nutrition by tube or other medical means. • If I am unable to take fluids by mouth, I want to receive fluids by tube or other medical means. • If I need assistance to breathe, I want to have a ventilator used. • If my heart or pulse has stopped, I want to have • cardiopulmonary resuscitation (CPR) used.

20. Default Surrogate Decisionmakers I • § 31-9-2. Persons authorized to consent to surgical or medical treatment • (a) any one of the following persons is empowered to consent: • (1) Any [competent] adult, for himself or herself, whether by living will, advance directive for health care, or otherwise; • (1.1) Any person authorized to give such consent for the adult under an • advance directive for health care or durable power of attorney for health care • (2) In the absence or unavailability of a living spouse, any parent, whether an • adult or a minor, for his or her minor child; • (3) Any married person, whether an adult or a minor, for himself or herself • and for his or her spouse;

21. Default Surrogate Decisionmakers II • (4) Any person temporarily standing in loco parentis, whether formally • serving or not, for the minor under his or her care; and any guardian, for his or • her ward; • (5) Any female, regardless of age or marital status, for herself when given in • connection with pregnancy, or the prevention thereof, or childbirth; or • (6) Others • (A) Any adult child for his or her parents; • (B) Any parent for his or her adult child; • (C) Any adult for his or her brother or sister; or • (D) Any grandparent for his or her grandchild. • (E) Grandchild • (F) Niece, nephew, aunt, or uncle • Treatment which the patient would have wanted had the patient understood the circumstances under which such treatment or procedures are provided.

22. Medical Consent in Minors • Under the age of 18 may consent to: • Treatment for drug abuse • HIV testing • Prevention of pregnancy • Treatment during pregnancy and childbirth • Treatment for STD • Abortion with parental notification

23. Informed Consent • Not just a piece of paper • Informed consent is a means of engaging a patient in important health care decisions • There is therapeutic value to true informed consent

24. Exceptions to Informed Consent • Emergency exceptions to informed consent • Consent is implied in emergency when patient is lacks capacity and surrogate unavailable • Therapeutic privilege

26. Confidentiality • What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself • Hippocrates

27. Confidentiality • Confidentiality is the obligation on the physician not to reveal what has been learned during the course of treatment • Privilege is the right of a patient, established only by statute, whereby a patient may prevent his physician from testifying. Privilege is a legal right belonging only to the patient and not to the physician.

28. Health Insurance Portability and Accountability Act (HIPAA) 1996 • Title II: Preventing Health Care Fraud and Abuse; Administrative Simplification; Medical Liability Reform • Intent to restrict release of information to only that necessary to achieve the purpose • Patients are guaranteed access to their medical records and may amend • Not “psychotherapy” notes • What about disclosing information to a family member in an emergency? • Consent not required if disclosure necessary for treatment • Notification of family may be necessary for treatment

29. Subpoena Duces Tecum • Immediate response: Reply, don’t comply • Check with patient • Get legal advice if needed • Release minimum information necessary

30. Breaking Confidentiality • Reporting child abuse or neglect • Abuse of seniors • Abuse of disabled • Residents of long term care facilities • Reporting HIV to state • Notifying sexual partners of HIV • “Tarasoff” warnings • “protective privilege ends where the public peril begins”

31. Review • Four principles of medical ethics • Three elements of informed consent • Ethical principle - basis for informed consent • Karen Ann Quinlan • Nancy Cruzan • Tatiana Tarasoff

32. What does it mean to be professional? • As a preclinical student? • Prepared • On time • Respectful • As a clinical student? • Appearance • Prepared • On time • Respectful • Nurses • Extra duty

33. Some Characteristics of a “Professional” • Self-regulating • Specialized education, training, knowledge • Competence • Behaviors • Dress • Timeliness • Preparedness • Courtesy • Hard working

34. On Entering a Profession • An oath is taken pledging to uphold the standards of that profession

35. The Oath of Geneva AT THE TIME OF BEING ADMITTED AS A MEMBER OF THE MEDICAL PROFESSION: I SOLEMNLY PLEDGE myself to consecrate my life to the service of humanity; I WILL GIVE to my teachers the respect and gratitude which is their due; I WILL PRACTICE my profession with conscience and dignity; THE HEALTH OF MY PATIENT will be my first consideration; I WILL RESPECT the secrets which are confided in me, even after a patient has died; I WILL REMAIN by all means in my power, the honor and the noble traditions of the medical profession; MY COLLEAGUES will be my brothers and sisters; I WILL NOT PERMIT considerations of religion, nationality, race, party politics or social understanding to intervene between my duty and my patient; I WILL MAINTAIN the utmost respect for human life from its beginning, even under threat, and I will not use my medical knowledge contrary to the laws of humanity; I MAKE THESE PROMISES solemnly, freely and upon my honor.

36. “Consecrate My Life” • I SOLEMNLY PLEDGE myself to consecrate my life to the service of humanity

37. “Respect and Gratitude” • I WILL GIVE to my teachers the respect and gratitude which is their due

38. “Conscience and Dignity” • I WILL PRACTICE my profession with conscience and dignity

39. “My First Consideration” • THE HEALTH OF MY PATIENT will be my first consideration

40. “Confided in Me” • I WILL RESPECT the secrets which are confided in me, even after a patient has died

41. “Traditions” • I WILL REMAIN by all means in my power, the honor and the noble traditions of the medical profession

42. “Brothers and Sisters” • MY COLLEAGUES will be my brothers and sisters

43. No Other Considerations • I WILL NOT PERMIT considerations of religion, nationality, race, party politics or social understanding to intervene between my duty and my patient

44. “Respect for Human Life” • I WILL MAINTAIN the utmost respect for human life from its beginning, even under threat, and I will not use my medical knowledge contrary to the laws of humanity

45. “Promises” • I MAKE THESE PROMISES solemnly, freely and upon my honor.

46. The Oath of Geneva • Challenges to professionalism – But what about . . .?

47. Consecrate My Life • I SOLEMNLY PLEDGE myself to consecrate my life to the service of humanity • What does it mean to “consecrate?” • Are you ready when you come to class/rounds? • Do you do just the minimum work required (e.g., number of patients)? • Resident work hours – what to do when you’ve reached the limit and patient continuity of care or a learning might be compromised? • Will you take responsibility for your continuing education, attending meetings, reading journals, obtaining consultations?

48. Respect Teachers • I WILL GIVE to my teachers the respect and gratitude which is their due • An attending asks you to suture a deep facial wound. You have little experience with this and express your concern. The attending tells you “Well, this is how you learn” and leaves.

49. Conscience • I WILL PRACTICE my profession with conscience and dignity • A woman approaches you for advice about an elective abortion, to which you are opposed for religious reasons. Should you refer her to a colleague who performs abortions?

50. Health of My Patient • THE HEALTH OF MY PATIENT will be my first consideration • Your patient comes to you for an exam prior to traveling to Greece for his wedding. You discover him to have TB and express your concern over his trip.