1. Introduction to Medical Ethics Practice Edward L. Queen, Ph.D., J.D.equeen@emory.eduequeen@emory.edu Director, D. Abbott Turner Program in Ethics and Servant Leadership Director of Research, Institute of Human Rights Faculty Member Department of Religion Jewish Studies Associated Faculty Center for the Study of Law and Religion © Edward Queen 2008

3. What is Ethics? The formal study of:  What is right and wrong.  The study of the bases or principles for deciding right and wrong.  The analyses of the processes by which we decide what is right and wrong.

4. Ethics is not: Merely obeying the law Compliance Although in many instances laws are statements of considered ethical positions and most of the time obeying the law is an element of ethical behavior.

5. Medical Ethics a field of applied ethics, the study of moral values and judgments as they apply to medicine. As a scholarly discipline, medical ethics encompasses its practical application in clinical settings as well as work on its history, philosophy, theology, sociology, and anthropology. Based on definition of “Medical Ethics” http://en.wikipedia.org/wiki/Medical_ethicshttp://en.wikipedia.org/wiki/Medical_ethics

6. Medical Ethics Long history  Third Dynasty (Egypt) 2700 BCE  Code of Hammurabi (Babylon) 1750 BCE: If the physician succeeds, he gets paid. If he fails, at worst he loses his hands.  Oath of the Hindu Physician (Vaidya’s Oath) 15 th cy. BCE  Hippocratic oath (Hippocrates, ca 460-370 BCE)  The Oath of Asaph and Yohanan (ca 6 th cy. CE)  Advice to a Physician (Persia) 10 th cy. CE  Oath of Maimonides 12 th cy. CE  Ming Dynasty (China) 14 th cy. CE  Seventeen Rules of Enjun (Japanese Buddhist Physicians) 16 th cy. CE) Drawn from Codes of Medical and Human Experimentation Ethics by Victoria Berdon and Jennifer Flavin viewable at http://wisdomtools.com/poynter/codes.htmlhttp://wisdomtools.com/poynter/codes.html

7. History cont. Percival's Code (England) 1803 basis for first AMA Code of Medical Ethics. Beaumont's Code (United States) 1833: experimental treatments when all else fails. Get voluntary, informed consent. Stop experiment at subject’s request. American Medical Association (AMA) Code of Medical Ethics 1847 Claude Bernard (France) 1865 Walter Reed (United States) 1898: Introduces written consent “contracts”. Allows healthy human subjects in medical experiments. Berlin Code, or Prussian Code (Germany) 1900: No medical experiments when subject not competent to give informed consent, in the absence of unambiguous consent, or when information not properly explained to subject. Reich Circular (Germany) 1932 Concerned with consent and well- being of the subjects. Drawn from “Codes of Medical and Human Experimentation Ethics” by Victoria Berdon and Jennifer Flavin viewable at http://wisdomtools.com/poynter/codes.htmlhttp://wisdomtools.com/poynter/codes.html

8. Modern Issues and statements Nuremberg Code (1947)  Medical research Declaration of Geneva, W.M.A. (1948, 1968, 1984, 1994, 2005, 2006) World Medical Association International Code of Medical Ethics AMA revision (1957) Declaration of Helsinki, application to medical research (1964, rev. 1975, 1983, 1989, 1996, 2000) Belmont Report (1979) AMA revision (2001) Drawn from “Codes of Medical and Human Experimentation Ethics” by Victoria Berdon and Jennifer Flavin viewable at http://wisdomtools.com/poynter/codes.htmlhttp://wisdomtools.com/poynter/codes.html

9. As Practical Ethics, Medical Ethics focuses on: The process of deciding what is the most appropriate (right) course of action in a particular situation given these facts given my skills and abilities operating with finite knowledge in real time and then effecting that course of action.

10. Ethical Theory and Decisionmaking Ethics involves applying a set of rules or principles to a given set of facts  Questions?  What are the facts of this situation?  What rules or principles apply?  How should they be ranked/ordered?  How do they apply?  Does it matter what the consequences are? Can something be good if it does not (cannot) work? Does individual skill and ability change what a “right” answer or decision might be? Prudence

12. Process of making ethical decisions Awareness—Is there a moral issue here?  What is its nature? How important? What are the facts? What are the issues? What rules or values apply here? To whom or what do I owe a duty? How should they be applied? Who needs to decide and act? Who ought to? To what am I obligated because of role/position? What are the consequences? What are the options?!

13. To whom or what do you owe an obligation or a duty? Often dealt with in terms of stakeholders Can also be values or principles Need to be identified Need to be ranked  Ranking may be context specific

14. Duties—Sources Legal Obligations  HIPPA  Emergency treatment  Reporting duties Institutional Obligations  Practices of hospital Professional norms and obligations  Inhere with being a physician

15. Duties to whom or what? Individuals  Patients  Patients’ families/guardians  Colleagues  Co-workers  Self Groups  Profession  Society  The weak Ideas/Principles  The Law  Truth  Justice  Individual value

16. Belmont Report Foundational Document for Medical and Biomedical Research Ethics Guided by Four Principles 1. Respect for Persons 1. Autonomy 2. Those with diminished capacity/status deserve protection 2. Beneficence 1. Act in best interest of patient 3. Non-maleficence 1. Do no harm 2. Maximize benefits/minimize harm 1.Issue of double effect 4. Justice 1. Giving every person her or his due 2. Injustice occurs when a person entitled to a benefit is denied it without sufficient reason or when an undue burden is imposed. The Belmont Report, “Ethical Principles and Guidelines for the Protection of Human Subjects of Research.” The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. April 18, 1979. Viewable at http://www.esteve.org/FEsteve/content/publicaciones/docInteres/1074785709.67/1093864680.57/endoc.pdfhttp://www.esteve.org/FEsteve/content/publicaciones/docInteres/1074785709.67/1093864680.57/endoc.pdf

17. Principles become expressed in policies and practices 1. Informed Consent 1. Information 2. Comprehension/understanding 3. Voluntary 2. Privacy/Confidentiality 3. Refusal to allow one individual make complex decisions about treatment/care 4. Ethics committees 5. Ethics consults

18. Ethical Problems Problems caused by fact of having to choose between goods or things to which we owe an obligation Bad rankings of goods Failure to grasp facts  Ignorance  Incompetence  Willful blindness Bad factual analysis  Often caused by personal or institutional distortion

19. Organizational Problems General organizational culture Ego and narcissism Overly punitive responses Lack of a culture of responsibility Failure to acknowledge information distortion Bad communication flows High transaction costs for doing the “right” thing

20. Ethics Committees and Consults Designed to minimize some of the challenges to making good decisions.

21. What Ethics Committees/Consults (Should) Do Gather Relevant Data, through:  discussions with involved parties  examination of medical records other relevant documents Identify Values and Principles Implicated in Case  e.g. autonomy, informed consent, confidentiality, etc.) Identify Related Normative Issues  Social norms  laws  institutional policies Identify and analyze Range of Morally Acceptable Options for the Case Building Agreement on Act to extent Possible  Ensure that involved parties have their voices heard (patients, families, surrogates, health care providers)  Assist involved individuals in seeing range of values they hold that are involved  Help facilitate (to extent possible) building of morally acceptable shared commitments or understandings within the context Adapted from “Core Competencies for Health Care Ethics Consultation.” American Society for Bioethics and Humanities. 1998. Thanks to Lindsay Zausmer for identifying this source for me.

22. Ethical Challenges in Medicine are of several types 1. Issues related to treatment of a particular patient 2. Issues related to wider practices that could distort treatment decisions 3. Issues related to one’s personal behavior toward colleagues, hospital/medical staff, and patients.

23. Ethical challenges in contemporary medicine Some current macro-challenges  Attitude toward and response to patients  Code of silence—the unethical, incompetent or impaired health provider  Inducements and financial distortions  Abuse of power  Futility  Institutional distortions  Experimentation  Withdrawal of treatment  Placing form of ethics over substance  Conflicts over patient choice

24. Appendices  Hippocratic Oath original  The Oath of Asaph and Yohanan (6th c.?)  Oath of Maimonides  17 Rules of Enjun  AMA 9 Principles of Medical Ethics (2001)  Declaration of Geneva (amended 2006)

25. Hippocratic Oath original I swear by Apollo the physician and AEsculapius, and Hygiea, and Panacea, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation-- to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion. With purity and with holiness I will pass my life and practice my Art. I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work. Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further, from the seduction of females or males, of freemen and slaves. Whatever, in connection with my professional service, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret. While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times. But should I trespass and violate this Oath, may the reverse be my lot.

26. The Oath of Asaph and Yohanan (6th c.?) (From: Sefer ha-Refuot, The Book of Medicines) This is the pact which Asaph ben Berakhyahu and Yohanan ben Zabda made with their pupils, and they adjured them with the following words: Do not attempt to kill any soul by means of a potion of herbs, Do not make a woman [who is] pregnant [as a result of] of whoring take a drink with a view to causing abortion, Do not covet beauty of form in women with a view to fornicating with them, [Do not divulge the secret of a man who has trusted you, Do not take any reward [which may be offered in order to induce you] to destroy and to ruin, [Do not harden your heart [and turn it away] from pitying the poor and healing the needy, Do not say of [what is] good; it is bad, nor of [what is] bad: it is good, Do not adopt the ways of the sorcerers using [as they do] charms, augury and sorcery in order to separate a man from the wife of his bosom or a woman from the companion of her youth, [You shall not covet any wealth or reward [which may be offered in order to induce you] to help in a lustful desire, You shall not seek help in any idolatrous [worship] so as to heal through [a recourse to idols], and you shall not heal with anything [pertaining] to their worship, But on the contrary detest and abhor and hate all those who worship them, put their trust in them, and give assurance [referring] to them, For they are all naught, useless, for they are nothing, demons, spirits of the dead; they cannot help their own corpses, how then could they help those who live? Now [then] put your trust in the Lord, your God, [who is] a true God, a living God, For [it is] He who kills and makes alive, who wounds and heals, Who teaches men knowledge and also to profit, Who wounds with justice and righteousness, and who heals with pity and compassion, No designs of [His] sagacity are beyond His [power] And nothing is hidden from His eyes. Who causes curative plants to grow, Who puts sagacity into the hearts of the wise in order that they should heal through the abundance of His loving-kindness, and that they should recount wonders in the congregation of many; so that every living [being] knows that He made him and that there is no saviour [other] than He. For the nations trust in their idols, who [are supposed] to save them from their distress and will not deliver them from their misfortunes For their trust and hope is in the dead. For this [reason] it is fitting to keep yourselves separate from them; to remove yourselves and keep far away from all the abominations of their idols, And to cleave to the name of the Lord God of spirits for all flesh, And the soul of every living being is in His hand to kill and to make live, And there is none that can deliver out of His hand. Remember Him always and seek Him in truth, in righteousness in an upright way, in order that you should prosper in all your works And He will give you help to make you prosper in [what you are doing], and you shall be [said to be] happy in the mouth of all flesh. And the nations will abandon their idols and images and will desire to worship God like you, For they will know that their trust is in vain and their endeavor fruitless, For they implore a god, who will not do good [to them], who will not save [them]. As for you, be strong, do not let your hands be weak, for your work shall be rewarded, The Lord is with you, while you are with Him, If you keep His pact, follow His commandments, cleaving to them, You will be regarded as His saints in the eyes of all flesh, and they will say: Happy the people whose [lot] is such, happy the people whose God is the Lord.... And they continued to charge them, and said: The Lord God, His saints and His Torah [bear] witness, that you should fear Him, that you should not turn aside from His commandments, and that you should follow His laws with an upright heart, You shall not incline after lucre [so as] to help a godless [man in shedding] innocent blood. You shall not mix a deadly drug for any man or woman so that he [or she] should kill their fellow-man, You shall not speak of the herbs [out of which such drugs are made]. You shall not hand them over to any man, And you shall not talk about any matter [connected] with this, you shall not use blood in any work of medicine, You shall not attempt to provoke an ailment in a human soul through [the use of] iron instruments or searing with fire before making an examination two or three times; then [only] should you give your advice.* You shall not be ruled - your eyes and your heart being lifted up - by a haughty spirit. Do not keep [in your hearts] the vindictiveness of hatred with regard to a sick man, You shall not change your words in anything, The Lord our God hates [?] [this?] being done, But keep His orders and commandments, and follow all His ways, in order to please Him, [and] to be pure, true and upright.

27. Oath of Maimonides " The eternal providence has appointed me to watch over the life and health of Thy creatures. May the love for my art actuate me at all time; may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty aim of doing good to Thy children. May I never see in the patient anything but a fellow creature in pain. Grant me the strength, time and opportunity always to correct what I have acquired, always to extend its domain; for knowledge is immense and the spirit of man can extend indefinitely to enrich itself daily with new requirements. Today he can discover his errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today. Oh, God, Thou has appointed me to watch over the life and death of Thy creatures; here am I ready for my vocation and now I turn unto my calling.“

28. 17 Rules of Enjun 1. Each person should follow the path designated by Heaven (Buddha, the Gods). 2. You should always be kind to people. You should always be devoted to loving people. 3. The teaching of Medicine should be restricted to selected persons. 4. You should not tell others what you are taught, regarding treatments without permission. 5. You should not establish association with doctors who do not belong to this school. 6. All the successors and descendants of the disciples of this school shall follow the teachers' ways. 7. If any disciples cease the practice of Medicine, or, if successors are not found at the death of the disciple, all the medical books of this school should be returned to the School of Enjuin. 8. You should not kill living creatures, nor should you admire hunting or fishing. 9. In our school, teaching about poisons is prohibited, nor should you receive instructions about poisons from other physicians. Moreover, you should not give abortives to the people. 10. You should rescue even such patients as you dislike or hate. You should do virtuous acts, but in such a way that they do not become known to people. To do good deeds secretly is a mark of virtue. 11. You should not exhibit avarice and you must not strain to become famous. You should not rebuke or reprove a patient, even if he does not present you with money or goods in gratitude. 12. You should be delighted if, after treating a patient without success, the patient receives medicine from another physician, and is cured. 13. You should not speak ill of other physicians. 14. You should not tell what you have learned from the time you enter a woman's room, and, moreover, you should not have obscene or immoral feelings when examining a woman. 15. Proper or not, you should not tell others what you have learned in lectures, or what you have learned about prescribing medicine. 16. You should not like undue extravagance. If you like such living, your avarice will increase, and you will lose the ability to be kind to others. 17. If you do not keep the rules and regulations of this school, then you will be cancelled as a disciple. In more severe cases, the punishment will be greater.

29. AMA 9 Principles of Medical Ethics Preamble The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. As a member of this profession, a physician must recognize responsibility to patients first and foremost, as well as to society, to other health professionals, and to self. The following Principles adopted by the American Medical Association are not laws, but standards of conduct which define the essentials of honorable behavior for the physician. Principles of medical ethics I. A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights. II. A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities. III. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient. IV. A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law. V. A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated. VI. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care. VII. A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health. VIII. A physician shall, while caring for a patient, regard responsibility to the patient as paramount. IX. A physician shall support access to medical care for all people. Adopted by the AMA's House of Delegates June 17, 2001. Viewable at http://www.ama-assn.org/ama/pub/category/2512.htmlhttp://www.ama-assn.org/ama/pub/category/2512.html

30. Declaration of Geneva (amended 2006) At the time of being admitted as a member of the medical profession: I solemnly pledge to consecrate my life to the service of humanity; I will give to my teachers the respect and gratitude that is their due; I will practise my profession with conscience and dignity; The health of my patient will be my first consideration; I will respect the secrets that are confided in me, even after the patient has died; I will maintain by all the means in my power, the honour and the noble traditions of the medical profession; My colleagues will be my sisters and brothers; I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient; I will maintain the utmost respect for human life; I will not use my medical knowledge to violate human rights and civil liberties, even under threat; I make these promises solemnly, freely and upon my honour.