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Medical Ethics

Preface. For the health care provider, deciding the right thing to do is often a split second event; deliberation is a precious luxury. Stress, trauma and human limitations in the face of the great adversities in medical care delivery can hinder finely tuned skills that have taken a lifetime of se

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Medical Ethics

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    1. Medical Ethics

    2. Preface For the health care provider, deciding the right thing to do is often a split second event; deliberation is a precious luxury. Stress, trauma and human limitations in the face of the great adversities in medical care delivery can hinder finely tuned skills that have taken a lifetime of service to develop. Thinking through some of the ethical principles and issues related to health care, in advance, can help keep health care "ethical" amid the complexities and turmoil of caring for hurting people.

    3. Terms in Medical Ethics Ethics - from Greek e[qo" meaning: character, habit Morality - from Latin mores meaning: custom, character or habit Common Morality - refers to social conventions about right and wrong human conduct so widely shared that they form a stable communal consensus

    4. Medical Ethics = Bioethics A. “Clinical” derives from the Greek word klivniko" or “bedside” B. “Problem” - two meanings in Greek 1. problevma, meaning “obstacle”. 2. proballeivn, meaning “projection” or “to throw forward.”

    5. Prima Facie Obligations - W.D. Ross an obligation that must be fulfilled unless it conflicts on a particular occasion with an equal or stronger obligation. (A prima facie obligation is binding unless overridden or outweighed by competing moral obligations)

    6. Rights Definition: Justified claims that individuals and groups can make upon others or society. (Just like prima facie duties, any right can be legitimately exercised and can create actual duties on others only when the right overrides rights that compete with it) Rights claims are also prima facie claims

    7. Rights - Cont’d Violation: Unjustified action against a right. Infringement: Justified action overriding a right. Positive Right: A right to other person’s positive actions (for every positive right I have, someone else has a duty to DO something.) Negative Right: A right to other persons’ omission or forebearances (for every negative right I have, someone else has a duty to REFRAIN from doing something)

    8. Balancing and Overriding Polio Vaccine Research Richard McCormick – (Catholic Theologian) Alright to use children in non-therapeutic research Theory: Utilitarianism (greatest good for the many) Paul Ramsey – (Methodist Theologian) We should never use any child in non-therapeutic research Theory: Deontology (persons are ends not means)

    9. Two Primary Concerns in Medical Ethics 1. What ought I/We to DO - Concerned about Acts and Actions 2. What ought I/We to BE - Concerned about Actor or Agent

    10. Primary Ethical Theories Virtue Ethics- A character based theory Aristotle (384-322 B.C.E.) Virtue (Gk.) arete = Excellence Character (Gk) hexis = Disposition to Virtue THESIS: “The agent has certain characteristics as he performs it (action). First of all, he must know what he is doing; secondly he must choose to act the way he does, and he must choose it for its own sake; and in the third place, the act must spring from a firm and unchangeable character.”

    11. Primary Ethical Theories Utilitarianism - a Beneficence-based theory (John Stuart Mill - 1863) Thesis: An action or practice is right if it produces the greatest balance of good over evil for a group of people. We promote human welfare by minimizing harms and maximizing benefits.

    12. Oregon Health System Project One issue identified while putting together a state health plan was how to deal with medical coverage in areas where there were critical shortages of resources. An example of this dilemma was in the area of Kidney Dialysis. The identified need for dialysis was more than 5 times their capability and the cost per patient and per dialysis machine was very high. Knowing they could not significantly increase their capability, the discussion centered around which selection criteria and method would be used to decide who would get dialysis….

    13. Patient Selection Decisions Some Utilitarian options available: 1. Let no-one get dialysis (Egalitarian) 2. Social worth/status of individuals (Greatest Good for greatest number) 3. Use objective criteria (e.g., age, sex) 4. Cast lots

    14. Primary Ethical Theories - Cont’d Kantianism an Obligation-based theory Immanual Kant - Father of Deontology Deontology (gk. devon = ought, duty) - the study of moral obligation Teleontology (gk. tevlo" = end, conclusion) - the study of the final issue or result of a state or process Persons must not be treated exclusively as a means to our ends - persons are ends in themselves

    15. Case Penicillin Shortage In 1950, Rabbi Feinstein (Hadassah Hospital) had three wards full of children with Bacterial Meningitis. There was a significant shortage of penicillin in the entire region. He had enough to fully treat 6 children with no hope of resupply in the next week or so. Who gets the penicillin when not everyone can get it? What selection criteria would you use?

    16. Case Penicillin Shortage In WWII, in North Africa, doctors were faced with a limited quantity of penicillin. There were thousands of venereal disease stricken soldiers who were otherwise healthy that were desperately needed in combat. They also had some very seriously wounded soldiers who needed large doses of penicillin. Who should get the penicillin and Why? What selection criteria would you choose for making your decision?

    17. Some Selection Criteria Consequentialist (greatest good for the greatest number) 1. Likelihood of medical success 2. Immediate usefulness under the circumstances 3. Conservation 4. Parental Role (largest responsibility to dependents) 5. General social value of the patient

    18. Selection Criteria - Cont’d Egalitarian principles (all treated equally) 1. Principle of saving no one at all 2. Medical neediness (the greatest medical needs) 3. General neediness (help the most helpless) 4. Queuing (first come first served) 5. Random selection (based on chance)

    19. Ethical Principles Governing Patient Care Respect for Autonomy (Self-Rule) - a norm of respecting the decision making capacities of autonomous persons Beneficence (Do Good) -a group of norms for providing benefits and balancing benefits against risks and costs Nonmaleficence (“First, do no harm”) -a norm of avoiding the causation of harm Justice (Fairness) -Latin = Jus, “standard, due measure” -a group of norms for distributing benefits, risks and costs fairly

    20. Autonomy (Gk) auto nomos = meaning self rule Two conditions are essential: Liberty: Independence from controlling influence. Agency: Capacity for intentional choice

    21. Autonomy (cont.) Moral Rules: -Tell the truth -Respect the privacy of others -Protect confidential information -Obtain consent for interventions with patients -When asked, help others make important decisions

    22. Autonomy (cont.) Informed Consent: Autonomous authorization of a medical intervention or participation in research -Competence -Disclosure -Understanding -Voluntariness -Consent

    23. Beneficence (Lat.) bonus = good facare = to do Defined: A moral obligation to act for the benefit of others. -Good outcomes determined by balancing benefits with risk for harm or cost. -Supererogation: Acting above and beyond the call of duty

    24. Beneficence (cont.) General Rules: -Protect and defend rights of others. -Prevent harm from occurring to others. -Remove conditions that will cause harm to others. -Help persons with disabilities. -Rescue persons in danger (minimal risk).

    25. Beneficence (cont.) Kew Gardens Principle: Kitty Genovese -Need (cause to intervene) -Proximity (near enough physically or relationally) -Capability (able to do) -Last Resort (no one else capable) -Proportionate Good- weigh need vs. risk of competing claim

    26. Non-Maleficence Primum Non Nocere- “Above All [or first] Do No Harm” Hippocrates - Epidemics Definition: Refraining from actions which may thwart, defeat or set back a parties interest or place them at risk of harm.

    27. Non-Maleficence (cont.) Supported Rules: -Do not Kill -Do not cause pain or suffering -Do not incapacitate -Do not cause offense -Do not deprive others of the goods of life

    28. Non-Maleficence (ex.) LIFE: Two Intuitions -Life is a fundamental good -Life is not an absolute good

    29. Non-Maleficence (ex.) Limits of Obligation to Preserve Life -Integrity -Conflict between two lives -Autonomy -Quality of Life -Considerations of futility

    30. Justice (Lat.) Jus = standard or due measure Definition: Fair, equitable and appropriate treatment in light of what is due or owed persons Distributive Justice: Fair, equitable and appropriate distribution of all rights and responsibilities in society (ex: goods and services, political and civil rights)

    31. Justice (cont.) Formal Principle: Aristotle -Equals must be treated equally -Unequals must be treated unequally Material Principle -Specify the relevant characteristics for equal treatment -Identify substantive properties for distribution

    32. Justice (cont.) Commonly Held Material Principles: -To each person an equal share -To each person according to need -To each person according to effort -To each person according to contribution -To each person according to merit -To each person according to free-market exchange.

    34. Case Studies

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