Ethics 101

Case Study: Sam, the Patient An 85 year-old retired school teacher. C/O decreased vision in both eyes. Exam = 20/80 best corrected in right eye 20/60 best corrected in left eye Biomicroscopy = 3+ nuclear sclerotic cataracts Dr. E explains the risks and benefits to Sam of having surgery to improve his vision.

Case Study: Sam, the Patient Dr. also explains an alternative option to surgery that is part of a clinical trial. Dr. E is the PI in this trial. If this innovative technique proves effective, it may revolutionize cataract treatment. Dr. E could become famous and benefit financially. Sam asks Dr. E to do whatever he thinks is best - after all, he’s the expert.

1) What are the Ethical Issues in Sam’s Case ? 2) How should the ophthalmologist respond when Sam asks him to make the decision? 3) Should the ophthalmologist use therapeutic privilege and make the decision for Sam? 4) Is there a conflict of interest for Dr. E to offer Sam the option of participating in his study?

Overall Ethical Principle Sanctity of Life Respect for Life

4 Core Ethics Principles  Autonomy  Beneficence  Non-maleficence  Justice

Respect for Autonomy Derives from patient’s right to: Self-determination Privacy Imposes responsibility on physician: Veracity - Telling the truth Informed consent

Beneficence Derives from fiduciary relationship to: Do Good Act to Help Imposes responsibility on physician: Fidelity Advocacy

Non-maleficence Derives from general rule of human conduct that applies to everyone to: Do No Harm to Others Act to Prevent Harm to Others Imposes responsibility on physician to: Analyze the Burdens vs. Benefits of Tx Maintain Patient’s Confidentiality

Justice Derives from general rule of human conduct to treat others fairly: Like cases are treated alike - fairness. Imposes unclear responsibilities on physicians - society has not sorted this out! How well are resources allocated? What is futility?

“People have the right to justice in the distribution of health resources as opposed to a right to any and all specific care/treatments whether or not they need them and/or are likely to benefit from them.... Citizens must acknowledge their responsibility to themselves to maintain their health to the best to their abilities.” - Leah Curtin, RN

Principle Approach Analyzes problems, identifies values Does not always provide a good mechanism to resolve conflicts Helpful to combine with concepts in Ethics of Care

The Ethic of Care  Focuses on patient’s relationships  Recognizes the importance of feelings & emotions  Moral responsibility derived from clinician’s relationship to patient  Need to understand the context

The Meaning of Caring PDoing for PBeing responsive to PValuing PExtending compassion, mercy & kindness

The Meaning of Caring PEnhancing human dignity PConnecting with another PBeing touched PHelping another find meaning PEmpowering

Platinum Rule “Do Unto Others As They Would Like To Have Done Unto Them.” Cultural Diversity Quality of Life

Sir William Osler, MD “It’s much more important to know what sort of patient has the disease than what sort of disease the patient has.” - Porter (1997) The Greatest Gift To Mankind

Comparison Principle-based Ethics vs. Ethic of Care Rights & Duties Reason & Objectivity Detachment enhances fairness Focused on individual # Responsibility from the relationship # Emotions enhance reason # Engagement enhances understanding & fairness # Focused on family

 Ethics  How people relate to each other - Ancient Greeks  1960’s movements & beyond Trying to decide the “right” thing to do. Requires deliberation about facts and context reflective analysis of beliefs & values actions to solve moral problems

Ethical Dilemmas  s When legitimate ethical reasons support more than one alternative sWhen moral obligations exist on both sides sWhen disagreements about the right thing to do exist among patient, family, health care team, institution, and/or 3rd party payers

Why an Ethics Committee? Each institution has a responsibility to assure ethical treatment is provided to patients Professionals trained and experienced in ethics may provide insight and assistance to those faced with ethical dilemmas A multidisciplinary committee provides protection against idiosyncratic perspectives

The Role of the Ethics Committee â Provide consultation â Educate staff, patients/families, & public âRecommend organizational policy

Ethics Committee Goals To assure ethical health care To improve the quality of health care To improve health care outcomes

Ethics Consultation Approach * Advisory* Collecting pertinent facts. Making sure everyone’s voice is heard. Examining benefits & burdens of options. Attempting to build a consensus. Honoring the physician’s right to conscientious objection. * * NOT Authoritarian

Ethical Process Identifying ethical issues & conflicts Analyzing underlying values and sources of disagreement Resolving, if possible, ethical dilemmas in clinical cases

The Ethics Committee Does NOT Respond to: Clinical Inquires or Questions re: Clinical Care  Director of Clinical Quality Management Possible Physician Impairment  Chair, Physician Impairment Committee Billing Issues and Business Conflicts of Interest  Director of the Compliance Program

Have an Ethical Issue ? Call: