An Introduction to Medical Ethics Christopher DeMella, Pharm.D. PGY2 Academic Pharmacy Resident VCU School of Pharmacy Spring Semester, 2016

Objectives Define “medical ethics” Summarize the 4 primary ethical principles Illustrate Kohlberg’s theory of ethical development

Medical Ethics Ethics o From the Greek ethos, meaning “character” o Defines what is good for the individual and for society and establishes the nature of obligations that people owe to themselves and one another Medical Ethics o The standard of behavior used to guide medical practitioners in relationships with patients, health professionals, and society o “Trying to do the right thing while achieving the best possible outcome for every patient.” – Medical Ethics for Dummies

Principles of Medical Ethics Beneficence Non-maleficence Autonomy Justice

Beneficence Promoting what is best for the patient Requires that health care providers: o Develop and maintain skills and knowledge o Continually update training (CEs) o Consider individual circumstances of each patient o Strive for net benefit o Acknowledge the patient’s wishes (autonomy)

Non-maleficence Do no harm Do the benefits outweigh the risks? Principle of double effect o A single action may have a good and a bad effect o In order to determine if the action is permissible, consider: The nature of the act must be good or neutral, it cannot be intrinsically wrong The agent intends the good effect and not the bad either as a means to the good or as an end itself The good effect must outweigh the evil that is permitted

Autonomy Recognizes the rights of individuals to make their own decisions o Free from both controlling interference by others and from limitations Basis for informed consent and advanced directives o Disclosure of medically relevant information Exceptions to autonomy o Certain disabilities o Mental status o Maturity o Incapacity

Justice Describes how people are treated when interests compete Persons who have similar circumstances and conditions should be treated alike Considerations when evaluating justice: o Fair distribution of scarce resources (distributive justice) o Respect for people’s rights (rights based justice) o Respect for morally acceptable laws (legal justice)

Kohlberg’s Theory of Ethical Development Three distinct levels of moral reasoning, each with two sub-stages People can only pass through the stages in order, with each new stage replacing the reasoning typical of the previous stage Not everyone achieves all the stages

Level 1: Pre-Conventional Morality Authority is outside the individual and reasoning is based on the physical consequences of actions Stage 1: Obedience and Punishment Orientation o The individual behaves in order to avoid being punished o If a person is punished, they must have done wrong Stage 2: Individualism and Exchange o The individual recognizes that there is not always just one right view o Different individuals have different viewpoints

Level 2: Conventional Morality Moral standards of role models become internalized Stage 3: Good Interpersonal Relationships o The individual is good in order to be seen as a good person o Answers and behaviors are related to the approval of others Stage 4: Maintaining the Social Order o The individual becomes aware of the rules of society so decisions are based on obeying rules in order to uphold the law and avoid guilt

Level 3: Post-Conventional Morality Individual judgment is based on self-chosen principles, and moral reasoning is based on individual rights and justice Stage 5: Social Contract and Individual Rights o The individual becomes aware that while rules/laws might exist for the good of the greatest number, there are times when they will work against the individual (Heinz’s dilemma) Stage 6: Universal Principles o The individual has developed their own set of moral guidelines which may or may not fit the law (human rights, justice, equality) o The individual is prepared to defend these principles, even if it goes against the rest of society

Comprehension Assessment Which of the following patients would be fully capable of making an autonomous decision? A.A patient with bipolar schizophrenia who is demonstrating aggravated behavior and is refusing his monthly haloperidol injection A.A patient with dementia and a DVT who is refusing to take warfarin in the nursing home A.A patient diagnosed with stage IV lung cancer who is refusing potentially life-saving chemotherapy A.A drug addict who requires inpatient IV antibiotics for treatment of an infection but is attempting to leave AMA due to their addiction