1. Introduction to Ethics Toby L. Schonfeld, Ph.D. Preventive and Societal Medicine

2. Today’s objectives To describe ways that values shape ethics and to give some examples of these in health care; To identify ways in which considerations of law and ethics often converge in health care; To explain how the contextual features of a case are central to its adequate resolution; To state three or four goals of medicine and give examples in which each goal dominates as a priority; To demonstrate how patient’s values influence patient decisions and how a provider’s values influence provider choices

3. Elliot J.

4. Ethics 101 Two fundamental questions Process of Rational Reflection Position + Reasons = Moral Argument Medical Ethics: developing, analyzing, and reforming moral arguments about health care in support of a particular position Goal of ethical analysis: a right answer, a choice, a recommendation

5. Rationing and Public Health Assume that an influenza epidemic was evolving in Omaha. The ICU in each hospital was full and nearly all ventilators were in use.

6. Two patients arrive in the emergency room simultaneously. One is 40 years old, has had influenza for 2 days, and is rapidly evolving into respiratory failure. The second is 50 years of age, was in a car accident 20 minutes before arriving in the Emergency room, and has respiratory failure from multiple fractures of his ribs causing ineffective respiratory function.

7. Finally, there is only one ventilator available in the hospital that was being reserved for an 80 year old man requiring coronary by-pass surgery the following morning. What are the ethical dilemmas in this case? What questions are asked and what should be considered in a deliberation about how the ventilators are used?

8. Values 101 Values = the fundamental building blocks of our moral system Sources: parents, culture and society, religion, law One goal of medical ethics: to identify, assess, and respect values in health care Principles: respect for autonomy, beneficence/nonmaleficence, justice, virtue, listening to silenced voices

9. How might these additional factors influence the decision? The 40 year old with influenza does not have insurance coverage. The 50 year old in the car accident was driving drunk. The 40 year old with flu is an undocumented immigrant living in an apartment with 8 other family members. The 80 year old is a major benefactor to the organization. The 50 year old in the car accident is the primary guardian for his 16 and 14 year old grandchildren.

10. Law Limits range of permissible action Enforcement of rights and liberties

11. Case Study Pregnancy and Privacy: where questions of law and questions of morality seem to conflict

12. Pregnancy and Privacy May 30, 2002: slain baby found in trash outside Storm Lake, Iowa Autopsy failed to reveal information about boy’s race, cause of death, or whether he was born alive Police had no leads

13. Legal maneuvering County officials want to find baby’s mother (presumably for prosecution) June 17, 2002: District Court judge ordered: Hospitals & clinics Planned Parenthood to turn over names of women with positive pregnancy tests between 8/15/01-5/30/02 Deadline: August 17, 2002

14. Planned Parenthood Planned Parenthood refused to comply Appealed case to Iowa Supreme Court Week of December 9, 2002: Court was scheduled to hear arguments

15. Legal conclusion County withdrew the case because of a “lack of time and resources to fight a case that could drag on for years” Was this the real reason, or was there another motive? May 2004: Storm Lake couple filed a lawsuit against a hospital that released their records 2 years earlier

16. Ethical Considerations Is the information about pregnancy being requested private or confidential? What justifies a breach of confidentiality? What is to be gained from this information? Will this information be adequate to reach the stated goals? Why assume the baby’s mother is responsible? Is there a way to get this information that is less invasive of individuals’ privacy?

17. Legal considerations Court order for records was obtained legally by county attorney Planned Parenthood went through legal channels to quash the subpoena and challenge its validity Was someone criminally liable for the death of the child, or merely for the disposal of a body?

18. Ethical Considerations Is the requested information about pregnancy private or confidential? What justifies a breach of confidentiality? What is to be gained from this information? Will this information serve the alleged purpose? Is there a way to get the desired information that is less invasive of individuals’ privacy? Why assume the baby’s mother is responsible?

19. Final thoughts We will return to this case in our confidentiality unit, but for now this will serve as an example of where the requirements of the law and the requirements of ethics may differ. It is important, therefore, to consider legal and ethical questions separately when evaluating a case.

20. Back to Elliot J. Case analysis consists of: (Medical) Facts Contextual Issues Goals: case, patient/family, medicine Values Resources

21. Supervisor, colleagues Professional Code of Ethics Institutional/organizational policies Consultation services (ethics, etc.)