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Chapter 7 contextual features

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1 Chapter 7 contextual features

2 Although clinical ethics concentrates on the medical indications, patient preferences, and quality of life in a particular case of patient care, physicians and patients have various responsibilities and obligations to the larger world .

3 In almost all clinical circumstances, medical decisions are not individual choices made by the physician and the patient, but choices that are influenced and constrained by contextual and external social, political, economic, and family considerations.

4 Today, the encounter between patient and physician occurs in more complex institutional and economic structures than ever before. Doctors have multiple relationships with other physicians, nurses, allied health professionals, health care administrators, third-party payers, professional organizations, and agencies, in addition to their own families.

5 Similarly, patients stand in relationships with family and friends, other health professionals, health care institutions, and third-party payers.

6 Physicians and patients also are subject to the varying influences of community and professional standards, legal rules, governmental and institutional policies about financing and access to health care, computerized methods of storage and retrieval of medical information, regulations governing research, teaching concerns, economic considerations, religious belief, and other factors.

7 New way of organizing and paying for health services and the complex relationships between medicine and the pharmaceutical industry create conflicts of interest for physicians.

8 What is the import of these multiple responsibilities on the relationship between patient and physician? The ethical task is to determine how correctly to assess these contextual features.

9 Justice is the ethical principle governing the fair and equitable distribution of burdens and benefits to the participants in social institutions. Justice also determines how the rights of various participants are realized within those social institutions.

10 The multiple responsibilities of physicians
It is clearly unethical for a physician to do anything to a patient that is not intended to benefit thae patient but rather to benefit the physician or some other party. For example, a physician who performs diagnostic or therapeutic procedures that are not indicated, under pretense of caring for the patient but with the intent only of collecting a Medicaid fee, clearly acts unethically.

11 At the same time, physicians also have certain responsibilities beyond their patients. As citizens have an obligation to the common good of the society. The ethical problem appears when duty to one’s patient is in direct conflict with duties to others.

12 The medical profession
The medical profession has long stated its commitments in oaths and codes of ethics. A renewed interest in the social and personal implications of being members of a profession has led major medical organizations to formulate the physician’s charter.

13 This document states three fundamental principles of professionalism: the principle of primacy of patient welfare, the principle of patient autonomy, and the principle of social justice.

14 Fiduciary duty It is often said that physicians have, under law, a fiduciary duty to their patients. Fiduciary have specialized expertise and are held to high standards of honesty, confidentiality, and loyalty.

15 Above all, fiduciary must avoid financial conflicts of interest that could prejudice their clients’ interests. Physicians, lawyers, accountants, engineers, and architects typically are considered fiduciaries.

16 Physician’s duty to self and family
Every physician, like every human being, has certain moral duties to self and to those who constitute immediate family. Duties to self include adherence to one’s values, cultivation of one’s talents, and preservation of one’s own health.

17 Duties to family include especially stringent obligations to promote their welfare and protect them from harm.

18 Case Dr. O.S., a 36-year-old orthopedic surgeon in private practice, instruct his office staff to “screen” prospective patients by looking for personal characteristics that suggest they might be in a high-risk group for human immunodeficiency virus(HIV) infection.

19 They are to inform such persons that Dr. O. S
They are to inform such persons that Dr.O.S. is unable to accept new patients at this time. He also includes HIV tests on the panel of tests performed for all new patients. He defends his actions by asserting his right, and the right of his wife and any future child, to protection from infection.

20 Comments: (a)the danger of HIV infection by contact with a patient is low but not negligible.
(b)various protective procedures have been devised that, if properly used, appear to be an effective barrier to infection. (c)Medical tradition praises those who care for patients at the risk to themselves.

21 (d)Toleration of the practice of excluding HIV-positive patients would lead to the exclusion of many persons in serious need of care and the exclusion of many who are incorrectly identified as infected. (e)Dr.O.S is using methods that are inappropriate, inefficient, and unethical, even though he has the laudable motive of protecting himself, his wife, and his family from infection. HIV testing without consent is clearly unethical.

22 Family, Relatives, and Friends of the Patients
The good physician understands and works with those personal relationships as he or she works with the patient. They providing emotional or living support, providing information, serving as interpreter of the patient’s values, or paying the bills.

23 At times, the family’s interests may conflict with the patient’s interests:final concerns or interfamilial disputes may spill into clinical care.

24 The cooperation of relatives should be sought and encouraged; when families pose problems about the care of the patient, it is necessary to seek and understand the reasons for their behavior and to attempt conciliation, if possible. On rare occasions, resorting to legal steps may be necessary to protect the patient.

25 Case A Japanese-American family brings their maternal grandmother to their primary care physician. Grandmother is 72 years old, came to the United States 10years ago, and speak no English. She complains of weakness, weight loss, nausea, and fever of several moths’ duration.

26 Her grandson, a computer engineer, tells the doctor, “In case you find cancer, we prefer that she not be told. That is the way with our older people. But we do want her to have full treatment.” Studies reveal acute lymphocytic leukemia with renal failure, a condition that has a 5% chance for clinical response to aggressive and prolonged chemotherapy.

27 Comment: many cultural traditions grant to the family as a group the role of making important decisions about one of their members. Also, in some traditions, this authority is granted to the leader or elders of the family. These customs, which contrast with strong reliance on patient autonomy, should be accommodated in clinical care to the extent possible.

28 Recommendation: in this case, we recommend that the patient be informed, through a reliable translator, that she is very sick, that decisions must be made about her care, and then asked whether she wishes to make these decisions for herself or prefers to have them made by another.

29 An authorized delegation of decisional authority instead of simple acceptance of the culture’s purported customs is an appropriate compromise.

30 Confidentiality of medical information
The Hippocratic Oath states,” What I may see or hear in or outside the course of treatment which on no account must be spread abroad, I will keep to myself, holding such things shameful to speak about.”

31 Modern medical ethics bases this duty on respect for the autonomy of the patient, on the loyalty owed by the physician, and on the possibility that disregard of confidentiality would discourage patients from revealing useful diagnostic information and encourage others to use medical information to exploit patients.

32 Confidentiality has been treated rather carelessly in modern medical care. Providers may speak about patients in public places, such as hospital elevators or cafeteria.

33 Cell phone conversations can broadcast confidential information
Cell phone conversations can broadcast confidential information. Records may not be well secured and may be accessible to many persons, including some who are not health professionals.

34 Confidentiality must be protected, but efforts to protect it may conflict with other social needs, including the ability of health professionals to exchange information when caring for a patient, the right of parents to sensitive health information concerning their children, and the use of data for research, public health, or audit purpose.

35 Confidentiality is stringent, but not unlimited, ethical obligation
Confidentiality is stringent, but not unlimited, ethical obligation. The ethical issue, then, is determining what principles and circumstance justify exception to the rule.

36 The ethical justification of limiting confidentiality are based on principle of respect for autonomy, assuring that the privacy of a person is protected, and also on the principle of justice, assuring that others are not endangered because they are ignorant of a threat posed by another.

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