1. Overview –Readings –Introduction to Ethical Foundations –Clarification of basic terms –Clarification of the historical context of western medical ethics –Clarification of the current North American context

2. Readings Medical Ethics and the Place of Faith Medical Ethics and Secular Approaches

3. Introduction to Ethical Foundations Main take-away point of class

4. Clarify The Big Fish

5. Clarification of basic terms Bioethics Medical ethics Clinical ethics

6. Bioethics Broad term describing the study of ‘what’ constitutes ‘good/bad’ judgments and ‘right/wrong’ actions when faced with biological dilemmas

7. Medical Ethics Emphasis is the study of ethics applied to medicine and medical care

8. Clinical Ethics Subdivision of medical ethics Focus is on ethical issues surrounding a patient’s interface within medical community decision making complex i.e. patient-physician treatment decisions This is the primary area of our class

9. Clarification of historical of western medical ethics context Quiescent Period-the Hippocratic ethic Period of Principlism Period of Anti-principlism Period of Crisis Period of Social Utility

10. North American Context Varying expressions of Principlism Varying expressions social utility Lingering expressions of Christian ethic

11. Two contrasting worldviews –Judeo-Christianity (Abahamic Traditions in PC terms) –Darwinian Naturalism

12. Judeo-Christian Supernaturalism –Judeo-Christian Hippocratic Ethic –Christian Virtue Ethics

13. Darwinian Naturalism Principlism Social Contract

14. Principlism Beneficence Non-maleficence Autonomy Justice

15. Variation on Principlism Medical indication (medical norms) Patient Preference (autonomy) Quality of life (Beneficence/non maleficence) Contextual features (includes justice) Albert Jonson: Clinical Ethics

16. Social Contract Contracts made with voluntary consent to receive or give up benefits and burdens to its members, health care institutions and health care distributions must conform to the dictates of agree upon principles Equitable distribution of health care should be conceived in terms of justice Done under the ‘veil of ignorance’ Mini/max principle

17. The proper way to think abut health- care spending is to focus on the NET SOCIAL VALUE ADDED by health care, defined as: Net Social Gross Value The Opportunity Value Added = Added by - pp y Costs of that b th H lth y by the Health Health Care to Care for Society S t P ti t y System Patients Among these opportunity costs are: The education of our young Basic science and R&D The nation’s public infrastructure National security andthe safety of our warriors The proper way to think abut health-care spending is to focus on the NET SOCIAL VALUE ADDED by health care, defined as: Net social value Added by = Health System Gross Value Added by - Health Care to Patients The Opportunity Costs of that Care for Society Among these opportunity costs are: education of our young basic science R&D nation’s public infra-structure national security and defense David B. Reuben: Portland Providence Medical Center Grand Rounds Providence Nov. 16, 2011

18. A Matrix for Ethical Decision Making in a Pandemic Dr. John Tuohey An Example of Applied Synthesis of Principlism and Social Contract

19. Always Clarify

20. Robert Orr’s Method Framing the medico-ethics question Four elements for medical clarification Clarifying decision making agency Clarifying institutional level issues Operative norms and values Discussion Recommendations Follow-up Comments

21. Framing the Medico-ethics Question

22. Four elements for medical clarification Patient History Diagnosis Prognosis Treatment plan

23. Clarifying decision making agency Patient capacity Legal competency Surrogate agency

24. Clarifying institutional level issues Distinctives in policy and procedure Legal implications

25. Operative norms and values Primary agents Mitigating agents

26. Discussion

27. Recommendations

28. Follow-up and Comments

29. Ethics Exercise Interactive Exercise Orr’s Method