Medical Ethics 101 Balancing obligation, outcomes, and riskBalancing obligation, outcomes, and risk in clinical decision-makingin clinical decision-making Jill Ann Jarrell, MD, MPH Complex Care Program, Academic General Pediatrics Texas Children’s Hospital, Baylor College of Medicine

 Dr. Jarrell has no relevant conflicts of interest to disclose Disclosures

Patient-Provider Relationship

Patient-Healthcare Team Relationship

“Ethics is a branch of philosophy; the formal, rational, systemic examination of the rightness and wrongness of human actions.” 1 What is “Ethics”?

 Evaluating the rightness and wrongness of human actions in medicine  Bioethics What is “Medical Ethics”

Principles and Duties of Medical Ethics Principles Autonomy Justice Beneficence Nonmaleficence Duties Veracity Confidentiality Role Fidelity Respect for Societal Institutions

Autonomy Individual liberty, dignity, and capacity Justice What is fair or deserved Beneficence An obligation to do good Nonmaleficence An obligation to not harm Ethical Principles

Veracity Truth telling Privacy and Confidentiality Role Fidelity Professional responsibility and autonomy Respect for Societal Institutions Life, culture, family, religion Ethical Duties

Surrogate or substitute decision-making Advanced care planning Principle of double effect Informed consent Futility Hot Topics in Ethics

Able to understand medical treatment and make informed decisions. Decision-Making Capacity

Unable to understand the benefits, risks, alternatives to treatment. Incapacitated

Individual with authority to consent to medical treatment for an incapacitated patient. Surrogate Decision-Maker

Spouse Adult child with POA or majority of adult children Parents Clearly identified individual Nearest living relative Patient’s clergy Surrogate Decision-Makers

Parents available Natural parents Adoptive parents Sole managing conservator Possessory conservator (non-invasive procedures during possession) Surrogacy in Minors

Parents not available Grandparent Adult sibling Adult aunt/uncle Educational institution with written authorization Surrogacy in Minors

Parents not available (cont’d) Adult with custody and written authorization Court with jurisdiction Adult with care of child subject to juvenile court Peace officer Surrogacy in Minors

Schizophrenic Child With Absent Family

17 yo male with paranoid schizophrenia Attempted suicide Survived - multiple orthopedic and internal injuries History

Poorly compensated from a psychiatric perspective Mother quit visiting/answering calls Patient turned 18 during care Conflict

Who is the decision-maker? Patient Mom CPS/APS Legal Guardian Who is in charge?

Beneficence Autonomy Social Responsibility Ethical challenges

Pregnant patient with terminal cancer

30 yo woman 24 weeks gestation Stage IV breast cancer Pregnant Patient With Cancer

Intractable pain Progressive encephalopathy Previously told her OB/GYN she wanted to “have this baby” Pregnant Patient With Cancer

Patient’s condition declined Patient’s mother asked for hospice care for her daughter Pregnant Patient With Cancer

Two patients?

Pregnant Patient With Cancer Who is the decision-maker? Patient Mother Healthcare team

Pregnant Patient With Cancer Ethical Challenges? Beneficence Nonmaleficence Social responsibility Role Fidelity

To trach or not to trach…

5 yo with Trisomy 21, repaired CHD, CP admitted for pneumonia PICU, intubated, difficult wean, trach was discussed with family Palliative care consulted on HD 55 to discuss “options” History

Palliative care recommended not to trach and for medical team to collectively advise palliation ENT “just a technician” and uncomfortable PCP and CCM wish to proceed with trach Ethics committee consult requested Conflict

Benificence Non-maleficence Respect for family Autonomy (but how much?) Role fidelity Ethical challenges

Listening Conflict resolution Tolerance for ambiguity Ability to apply ethical principles and carry out duties Skills for Resolving Ethical Dilemmas 2

Medical indications Patient preferences Quality of life Contextual features Framework for Ethical Decisions 3

Continue to LEARN about your discipline and the ever-changing milieu in which it is practiced COMMUNICATION and COLLABORATION between care team members and decision-makers is key to success Take Home Messages

Questions?

1.1. Pellegrino, E. Toward a Reconstruction of Medical Morality. The American Journal of Bioethics 2006; “Legal and Ethical Issues” Physician Board Review Course in Hospice and Palliative Medicine, MD Anderson Cancer Center, 10/12/ Jonson A, Seigler M, Winslade W. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 6 th ed, page 11. References