1. Ethics HINF 371 - Medical Methodologies Session 18

2. Brain Storming Session - 15 minutes Brain Storming Session - 15 minutes What are my expectations from my healthcare provider? What are my expectations from my healthcare provider?

3. Objective To review ethics concepts and principles in healthcare To review ethics concepts and principles in healthcare To discuss controversial areas that are challenging ethics To discuss controversial areas that are challenging ethics

4. Reference Molckovsky A and Pirzada K S (eds) (2004) Introduction to the Ethical, Legal and Organizational Aspects of Medical Practice, The Toronto Notes, Toronto Notes Medical Publishing. Molckovsky A and Pirzada K S (eds) (2004) Introduction to the Ethical, Legal and Organizational Aspects of Medical Practice, The Toronto Notes, Toronto Notes Medical Publishing.

5. Ethics Definition Ethics: a field of inquiry dealing with the principles and values that help define what is right and wrong, and with the rights, duties and obligations for individuals and various groups Ethics: a field of inquiry dealing with the principles and values that help define what is right and wrong, and with the rights, duties and obligations for individuals and various groups Ethical principles of autonomy, beneficence, non-maleficence, and justice govern ethical decisions in healthcare Ethical principles of autonomy, beneficence, non-maleficence, and justice govern ethical decisions in healthcare

6. Key Principles Autonomy Autonomy Decision making respecting, reflecting, and promoting and individual’s personal values Decision making respecting, reflecting, and promoting and individual’s personal values Recognition self determination based on personal beliefs and values Recognition self determination based on personal beliefs and values Beneficence Beneficence Acting in the patient’s ‘best interests’ Acting in the patient’s ‘best interests’ Minimize harms or burdens and maximize beneficial outcomes Minimize harms or burdens and maximize beneficial outcomes Autonomy overrides acting in the patient’s ‘best interest’ Autonomy overrides acting in the patient’s ‘best interest’ Non-maleficence Non-maleficence Avoid harm and wrong- doing – “Primum nil nocere” Avoid harm and wrong- doing – “Primum nil nocere” Sometimes considered under beneficience Sometimes considered under beneficience Justice Justice Concept of fairness or what is deserved by the patient Concept of fairness or what is deserved by the patient Respects rules of fair play and basic human rights Respects rules of fair play and basic human rights

7. CMA Code of Ethics Aims to set a standard of ethical behaviour expected of physicians Aims to set a standard of ethical behaviour expected of physicians A quasi-legal document. If law sets a moral standard, the code ratchets up these standards A quasi-legal document. If law sets a moral standard, the code ratchets up these standards Developed based on Developed based on Hippocratic Oath Hippocratic Oath Development in human rights, Development in human rights, Recent bioethical discussions Recent bioethical discussions May set out different standards than law May set out different standards than law Statements are general in nature Statements are general in nature Supported by Policy Statements exist to address ethical issues Supported by Policy Statements exist to address ethical issues I swear by Apollo, 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. 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 I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone. To please no one will I prescribe a deadly drug nor give advice which may cause his death. Nor will I give a woman a pessary to procure 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 with 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 men and in all times; but if I swerve from it or violate it, may the reverse be my lot.

8. Confidentiality Basis of the fiduciary physician-patient relationship Basis of the fiduciary physician-patient relationship Patient autonomy should be respected (patient has the right to control his/her information) Patient autonomy should be respected (patient has the right to control his/her information) Personal information will be protected from unauthorized access by others Personal information will be protected from unauthorized access by others Physicians have some obligation to ensure that patient records remain private and confidential Physicians have some obligation to ensure that patient records remain private and confidential Subsidiary to the obligation to not to harm others Subsidiary to the obligation to not to harm others No physician-patient privilige No physician-patient privilige Confidentiality may be ethically breached in certain circumstances (when public interest overrides the patient rights such as child abuse or neglect, fitness to drive a vehicle, communicable diseases, improper conduct of other physicians or health professionals, vital statistics, reporting to coroners) Confidentiality may be ethically breached in certain circumstances (when public interest overrides the patient rights such as child abuse or neglect, fitness to drive a vehicle, communicable diseases, improper conduct of other physicians or health professionals, vital statistics, reporting to coroners)

9. Consent The autonomous authorization of a medical intervention by an individual patient The autonomous authorization of a medical intervention by an individual patient Determined by the mental capacities of the person, a valid consent requires; Determined by the mental capacities of the person, a valid consent requires; Disclosure: relevant information by physician and comprehension by the patient Disclosure: relevant information by physician and comprehension by the patient Capacity: ability of the patient to understand the relevant information and appreciate the consequences of his or her decision Capacity: ability of the patient to understand the relevant information and appreciate the consequences of his or her decision Voluntariness: right of patient to come to a decision freely, without force or manipulation, patients may choose a substitute decision maker (power-of- attorney) Voluntariness: right of patient to come to a decision freely, without force or manipulation, patients may choose a substitute decision maker (power-of- attorney) Explicit consent and implicit consent Explicit consent and implicit consent Consent forms only document the process Consent forms only document the process Exceptions Exceptions Consent is unnecessary where a delay in treatment would lead to serious harm or death and where reasonable persons would consent to the treatment Consent is unnecessary where a delay in treatment would lead to serious harm or death and where reasonable persons would consent to the treatment Non-compliant communicable disease patients Non-compliant communicable disease patients Mental health patients who may harm themselves or others, unable to take care of themselves, unless if there is evidence that they refuse when they were capable Mental health patients who may harm themselves or others, unable to take care of themselves, unless if there is evidence that they refuse when they were capable

10. Disclosure – Truth Telling Ethical reasons: to promote and maintain patient-physician relationship and patient’s right to be told important information Ethical reasons: to promote and maintain patient-physician relationship and patient’s right to be told important information Patient related reasons: shows respect to patient, allows them to make informed decisions, comfort and control in knowing Patient related reasons: shows respect to patient, allows them to make informed decisions, comfort and control in knowing Health related reasons: allows them to make informed decisions, allows them to seek medical attention when they should, and improves compliance and improves health outcomes Health related reasons: allows them to make informed decisions, allows them to seek medical attention when they should, and improves compliance and improves health outcomes

11. Reasons of not telling May lead to patient harm and increased anxiety May lead to patient harm and increased anxiety Critical illness can undermine autonomy and impair autonomous decision making Critical illness can undermine autonomy and impair autonomous decision making Some patient don’t want it; some may find it “cruel” Some patient don’t want it; some may find it “cruel” It may be against cultural norms and expectations It may be against cultural norms and expectations Medical uncertainty may result in the disclosure of uncertain or inaccurate information Medical uncertainty may result in the disclosure of uncertain or inaccurate information

12. Resource Allocation Ethics relate to justice and the physician’s duty towards his/her individual patients Ethics relate to justice and the physician’s duty towards his/her individual patients Resources should be available in a manner fair and equitable (need and benefit), without bias or discrimination Resources should be available in a manner fair and equitable (need and benefit), without bias or discrimination Dilemmas in resource allocation Dilemmas in resource allocation Fair chances for all versus best outcomes for some Fair chances for all versus best outcomes for some Priorities of Triage (priority for sickest) Priorities of Triage (priority for sickest) democracy – when to rely on democratic process as the only way to arrive at decision democracy – when to rely on democratic process as the only way to arrive at decision

13. Appropriately Allocating Resources Interventions with evidence of effectiveness Interventions with evidence of effectiveness Minimize marginally beneficial tests or interventions Minimize marginally beneficial tests or interventions Select the best test with minimal cost Select the best test with minimal cost Advocate for own patient but avoid manipulating the system Advocate for own patient but avoid manipulating the system Resolve conflicting claims justly Resolve conflicting claims justly Inform patients regarding cost constraints Inform patients regarding cost constraints Seek resolution of unacceptable shortages Seek resolution of unacceptable shortages

14. Physician Industry Relationship Participation in research, education, and clinical evaluation packages (product samples) must be in keeping with their duties to their patients and society Participation in research, education, and clinical evaluation packages (product samples) must be in keeping with their duties to their patients and society Primary goal is the advancement of health of Canadians Primary goal is the advancement of health of Canadians Relationship guided by the CMA code of ethics Relationship guided by the CMA code of ethics Primary obligation to patient Primary obligation to patient Avoidance of self-interest in prescribing and referral Avoidance of self-interest in prescribing and referral Maintain professional autonomy, independence and commitment to scientific method Maintain professional autonomy, independence and commitment to scientific method

15. Personal and Professional Conduct Personal conduct Personal conduct Professional manner (dignity, respect, integrity and honesty) Professional manner (dignity, respect, integrity and honesty) Poses and maintain medical expertise Poses and maintain medical expertise Practice competently (without impairment) Practice competently (without impairment) Professional Professional Recognition of the responsibility for self regulation Recognition of the responsibility for self regulation Maintain appropriate standards Maintain appropriate standards Participate in peer review Participate in peer review Participate in learning Participate in learning Assist peers and others in achieving effective methods of care, in the best interest of patients Assist peers and others in achieving effective methods of care, in the best interest of patients

16. Controversial Topics Euthanasia and Physician-assisted Suicide Euthanasia and Physician-assisted Suicide Maternal – Fetal Conflict of Rights Maternal – Fetal Conflict of Rights Advanced Reproductive Technologies Advanced Reproductive Technologies Fetal Tissue Fetal Tissue Abortion: active termination of pregnancy before fetal viability: greater 500gr weight or greater than 20 weeks since conception Abortion: active termination of pregnancy before fetal viability: greater 500gr weight or greater than 20 weeks since conception

17. Principles of Disclosure and Non-Disclosure Disclosure Disclosure Decision making Decision making Patient consent Patient consent Medical Error Medical Error Breaking bad news Breaking bad news Non-Disclosure Non-Disclosure Waived rights to know the truth Waived rights to know the truth Therapeutic privilige Therapeutic privilige