Presentation on theme: "Evidence-Based Ethics: Introduction and Applications to Medicine and Public Health John E. Snyder."— Presentation transcript:
1 Evidence-Based Ethics: Introduction and Applications to Medicine and Public Health John E. Snyder
2 Outline Introduction History of medical ethics Key ethical principles Advance DirectivesCasesApplications to public health
3 Introduction A need for practical medical ethics education Recognizes omnipresence of dilemmasSystematic approachCase-basedOffers guidanceDoesn’t define right/wrongIncorporates cultural competence
4 H/O Medical Ethics in Super FF Oath of Hippocrates ~5 B.C.Respect for confidentialityStrict prohibition for euthanasiaRelationship boundaries with patientsLimitations in applicability to modern world/medicineOath of Maimonides ~1100 A.D.
5 H/O Medical Ethics in Super FF First AMA Code of Ethics in 1847Doctor’s Trial in Nuremburg in Nuremburg Code“Voluntary Consent”Good for society and not “random”Based on animals firstRisk should be low, or include the scientistsTuskegee Syphilis Study, The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of ResearchIRBsInformed ConsentBeauchamp & Childress, 1979
6 Principles of Medical Bioethics The Principle of BeneficenceThe Principle of Non-MaleficenceThe Principle of Respect for AutonomyThe Principle of Respect for Dignity*The Principle of Respect for Veracity*The Principle of Distributive Justice* Snyder/Gauthier
7 The Principle of Beneficence Medical practitioners should act in the best interests of the patient.
8 The Principle of Non-Maleficence Medical practitioners must not harm the patient.
9 The Principle of Respect for Autonomy Capable persons must be allowed to accept or refuse recommended medical interventions.
10 The Principle of Respect for Dignity Patients, their families, and surrogate decision makers, as well as their health care providers, all have the right to dignity.
11 The Principle of Respect for Veracity The capable patient must be provided with the complete truth about her/his medical condition.
12 The Principle of Distributive Justice Health care resources should be distributed in a fair way among the members of society.
13 Evidence-Based Medical Ethics Proposed approach of evidence-based medical ethicsBased on the tenets of evidence-based medicine (EBM), which:Aims to apply the best available evidence (gained from rigorous application of the scientific method) to clinical decision makingSeeks to assess the strength of evidence of the risks and benefits of treatments (including lack of treatment) and diagnostic testsHelps clinicians to learn whether or not any treatment will do more good than harm
14 Evidence-Based Medical Ethics Aims to apply the best available “evidence” gained from EBM, widely accepted ethical principles, and legal precedentIncorporates aspects of cultural competency and an evolving medical knowledge set/technology (we can/but should we?), and an evolving set of lawsHelps clinicians guide patients to make “good decisions” for themselves, particularly when options have potential to do both good and harmEmphasizes that “right” and “wrong” decisions are personal choices of the patient and are acceptable if they are well- informed (it’s not about you)
15 Advance DirectivesSome of the most difficult medical decisions are made when the patient themselves is unable to make themIncludes how a patient’s life will endNatural Death Act, 1976 (California)First time a state allowed citizens to make their choices for end-of-life care known in advancePhysicians honoring this “directive” cannot be charged with criminal liability or unprofessional conductLed to development of the “Living Will”Later led to the “Power of Attorney for Health Care”These two documents collectively make up Advance Directives
16 Living Will Legally executed document by a capable patient Authorizes physicians to withhold or withdraw life-sustaining medical treatment when the patient, in the future, lacks the capacity to make health care decisionsIn some states requires a “terminal condition”, but in others includes states like PVSCan include decisions on “artificial nutrition and hydration”
17 (Durable) Power of Attorney for Health Care Legal document a capable patient uses to appoint a “health care agent” (HCA)Aka “representative”, “proxy”, “surrogate”Rules vary greatly from state to stateThat person will make decisions for the patient when they are no longer capableIncludes employing/discharging providersIncludes consent to admit/discharge from facilitiesIncludes ability to give, withdraw, or withhold consent for diagnostic and therapeutic procedures
18 (Durable) Power of Attorney for Health Care A patient’s wishes for end-of-life care, in particular, should be discussed in advance with the HCA… but often are notWhen not, often result in conflicts between family membersSometimes wishes are discussed but not legally documentedWhen a patient’s wishes are not documented, the HCA should act using one of two principles:“Substituted judgment”“Best interests standard”
19 Surrogate Decision Makers Come into play when there are no ADsLaws vary to some degree by state with respect to “priority” status of an individual to be a HCA on behalf of the patientLaws also vary state to state by what determines a “marriage” or “family”
21 Case 1: When a Patient is Unidentifiable John Doe, 50 year old AAM, found unresponsive in an alleyway by passersbyCovered with blood and dirt? HomelessNo identifying informationWeak pulse, shallow respirations
22 Case 1: When a Patient is Unidentifiable In the field:Placed on a backboard, intubated, and a hard cervical collar placedIn the ED:Fractures to the pelvis and bilateral femursSplenic and liver lacerationsCollapsed left lungLarge intracranial hemorrhage (subdural hematoma)Police involved, fingerprinting unrevealing
23 What do you do next? Place/keep on a ventilator ? Insert a PEG tube for nutrition?Place an IV? A “central line”?Transfuse blood?Take to the OR?
24 What do you do next? How much do you do to help this patient? How long do you wait before moving forward?When do you stop efforts/where do you draw the line?
25 The MedicineIn patients with CNS injuries, mechanical ventilation may be necessary to support lifeProlonged need for ventilation and placement of a tracheostomy may be observedThe goal of any patient on a ventilator is weaningStudy of 100 patients by Namen, et al.:GCS < 8: 33% success rate of extubationGCS > 8: 75% success rate
26 X The Law Canterbury V. Spence  464 F 2d 772, U.S. Court of Appeals, District of Columbia CircuitLegally-recognized exceptions to Informed Consent:“… when a patient is unconscious or otherwise incapable of consenting, and harm from a failure to treat is imminent and outweighs any harm threatened by the proposed treatment”X
27 The Ethics The Principle of Beneficence The Principle of Non-MaleficenceThe Principle of Respect for AutonomyThe Principle of Respect for DignityThe Principle of Respect for VeracityThe Principle of Distributive Justice
28 The Ethics The Principle of Beneficence Injuries have been initially treatedImmediate death has been preventedLife sustained until chances for recovery could be determinedPain was treatedThe Principle of Non-MaleficenceThe Principle of Respect for AutonomyThe Principle of Respect for DignityThe Principle of Respect for VeracityThe Principle of Distributive Justice
29 The Ethics The Principle of Beneficence The Principle of Non-MaleficenceRisks of interventions to date were weighed against benefitsFurther plan is being considered carefully with respect to this principleMust consider a “line” to draw re: possible futility of effortsThe Principle of Respect for AutonomyThe Principle of Respect for DignityThe Principle of Respect for VeracityThe Principle of Distributive Justice
30 The Ethics The Principle of Beneficence The Principle of Non-MaleficenceThe Principle of Respect for AutonomyDoes not apply herePatient cannot be identifiedFamily cannot be contactedNo “substituted judgment” can be madeA legal guardian must be soughtMust use “best interests standard” based on above two principlesTake likelihood for recovery/improvement and contrast with pain/suffering and QOL may attainWill reasonable goals be met or will the end of life be artificially postponed?Are there aspects of culture that should be considered here?The Principle of Respect for DignityThe Principle of Respect for VeracityThe Principle of Distributive Justice
31 The Ethics The Principle of Beneficence The Principle of Non-MaleficenceThe Principle of Respect for AutonomyThe Principle of Respect for DignityImportant as the patient is vulnerable and has no “voice”Must protect privacy and bodily integrity to greatest extent possibleInvasive life-sustaining measures should not be initiated simply because the patient’s own wishes cannot be knownThe Principle of Respect for VeracityThe Principle of Distributive Justice
32 The Ethics The Principle of Beneficence The Principle of Non-MaleficenceThe Principle of Respect for AutonomyThe Principle of Respect for DignityThe Principle of Respect for VeracityThe legal guardian must receive all possible and relevant informationInformation must be presented clearly and without bias/leadingThe Principle of Distributive Justice
33 The Ethics The Principle of Beneficence The Principle of Non-MaleficenceThe Principle of Respect for AutonomyThe Principle of Respect for DignityThe Principle of Respect for VeracityThe Principle of Distributive JusticeDoes not apply hereResources are not limited in this case***Decisions to withdraw or withhold medical treatment cannot be made because:Patient cannot be identifiedPatient’s “societal value”
34 } The Formulation Review Decide Act Medical evidenceLegal precedenceEthical principlesDecideActAttempt to foresee/preempt challengesDelve further to assist in sound decision-making}
36 Public Health EthicsRepresented on the PHLS Public Health Code of Ethics Committee are public health professionals from:Local and state public healthAcademiaThe Centers for Disease Control and Prevention (CDC)The American Public Health Association (APHA)Guide is published on the APHA websiteHas 12 guiding principlesHas a different perspective than medical bioethics
37 Public Health EthicsPublic health should address principally the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes.Public health should achieve community health in a way that respects the rights of individuals in the community.Public health policies, programs, and priorities should be developed and evaluated through processes that ensure an opportunity for input from community members.Public health should advocate and work for the empowerment of disenfranchised community members, aiming to ensure that the basic resources and conditions necessary for health are accessible to all.Public health should seek the information needed to implement effective policies and programs that protect and promote health.Public health institutions should provide communities with the information they have that is needed for decisions on policies or programs and should obtain the community’s consent for their implementation.
38 Public Health EthicsPublic health institutions should act in a timely manner on the information they have within the resources and the mandate given to them by the public.Public health programs and policies should incorporate a variety of approaches that anticipate and respect diverse values, beliefs, and cultures in the community.Public health programs and policies should be implemented in a manner that most enhances the physical and social environment.Public health institutions should protect the confidentiality of information that can bring harm to an individual or community if made public. Exceptions must be justified on the basis of the high likelihood of significant harm to the individual or others.Public health institutions should ensure the professional competence of their employees.Public health institutions and their employees should engage in collaborations and affiliations in ways that build the public’s trust and the institution’s effectiveness.
39 Public Health Ethics Principles offer guidance but not answers Principles should be considered when working on public health initiativesPrinciples often need to be thought of in light of medical bioethicsWho “polices” this?
41 Case 2: When a Partner is Excluded José M., 34 year old Latino male in NCKnown HIV infection x5 years, not on ARTHad not seen an MD x2 years as is uninsuredLast known CD4+ count was 201/μL2 months of cough, malaise, fevers, 15# weight lossProgressive shortness of breath, weaknessEncouraged to come in by partner of 4 years, Justin (HIV neg.)
42 Case 2: When a Partner is Excluded In the ED:FeverHigh heart and respiratory ratesLow oxygen saturationChest x-ray suggestive of diffuse pneumonia in both lungsSputum examination indicates presence of Pneumocystis jiroveciiCD4+ count reported now as 12/μL
43 Case 2: When a Partner is Excluded Hospital course:Symptoms worsenedTransferred to the ICUDeveloped acute respiratory distress syndrome (ARDS) and progressive multi-system organ failure (MSOF)Sedated and placed on mechanical ventilationHad not completed a Living Will or HCPOA paperwork previously
44 Case 2: When a Partner is Excluded Hospital course:José’s parents notifiedAlthough he had been in close contact with his parents, José had never disclosed his S.O. or HIV status to themHad never introduced them to Justin out of concern they would not be accepting
45 Case 2: When a Partner is Excluded Hospital course:José’s father asks “does my son have AIDS?”José’s mother says “that man” (Justin) should not be allowed into the ICU room any more
46 What do you do next?How much information do you disclose to José’s family?What decisions do they need to make now?What decisions might they need to make soon?What rights does Justin have?Should José’s parents be told that Justin is HIV negative?Can José’s parents make “good” medical decisions for him?What cultural aspects are important in this case?How does one best balance the principles of beneficence, autonomy, non-maleficence, veracity, and dignity in this case?