Practical Ethics Stuart Sprague, PhD

Practical Ethics Some see this as an oxymoron Some see this as an oxymoron Ethical realists think ethics stands above practice Ethical realists think ethics stands above practice Ethics is fixed and unchanging, regardless of practiceEthics is fixed and unchanging, regardless of practice Changing ethics in light of practice smacks of cultural relativismChanging ethics in light of practice smacks of cultural relativism Other post-modern views allow for ethics which rises out of practice Other post-modern views allow for ethics which rises out of practice

Solidarity Idea from Richard Rorty, and others, that moral progress is possible Idea from Richard Rorty, and others, that moral progress is possible Changes in moral standards over time reflect common human experiences of pain, humiliation, pity and benevolenceChanges in moral standards over time reflect common human experiences of pain, humiliation, pity and benevolence Reason can give “ideals,” but practice shows us an equilibrium between principles and practice. Reason can give “ideals,” but practice shows us an equilibrium between principles and practice.

Practice of Resuscitation Devised in modern medicine as a response to body systems arrest or failure Devised in modern medicine as a response to body systems arrest or failure Seen as something anyone can learn Seen as something anyone can learn Has a common sense appeal that it should be given to everyone who experiences cardiac or pulmonary arrest-”Why would you not do it?” Has a common sense appeal that it should be given to everyone who experiences cardiac or pulmonary arrest-”Why would you not do it?” Unlike other medical procedures, it becomes a default assumption. Must write order not to do it. Unlike other medical procedures, it becomes a default assumption. Must write order not to do it.

Autonomy Highly valued principle since the Enlightenment Highly valued principle since the Enlightenment One of four basic principles of medical ethics One of four basic principles of medical ethics Key element of physician-patient relationship Key element of physician-patient relationship Essential component of informed consent Essential component of informed consent

Autonomy Not an absolute Not an absolute Two persons in dyad, each of whom has autonomy Two persons in dyad, each of whom has autonomy Professionalism demands subjection to the interests of the patientProfessionalism demands subjection to the interests of the patient AMA Code of Ethics says no physician is required to give treatment simply because it is requestedAMA Code of Ethics says no physician is required to give treatment simply because it is requested

Resuscitation II Common assumption that CPR is always beneficial challenged in era of debilitating chronic illness Common assumption that CPR is always beneficial challenged in era of debilitating chronic illness Requests for CPR may not be based on fully autonomous choice Requests for CPR may not be based on fully autonomous choice Full autonomy requires full knowledgeFull autonomy requires full knowledge Substituted judgment of surrogate adds a layer of separation from full autonomySubstituted judgment of surrogate adds a layer of separation from full autonomy

Recent AMA action Opinion (AMA Code of Ethics) “Physicians are not ethically obligated to deliver care that, in their best professional judgment, will not have a reasonable chance of benefiting their patients. Patients should not be given treatments simply because they demand them.” Opinion (AMA Code of Ethics) “Physicians are not ethically obligated to deliver care that, in their best professional judgment, will not have a reasonable chance of benefiting their patients. Patients should not be given treatments simply because they demand them.” Annual Meeting 2011 saw request to CEJA “for practical ethical guidance to help them refuse inappropriate requests while maintaining positive relationships with patients.” Annual Meeting 2011 saw request to CEJA “for practical ethical guidance to help them refuse inappropriate requests while maintaining positive relationships with patients.”

Back to Practical Ethics Physicians commonly refuse patient requests for inappropriate treatments: narcotics,antibiotics, cesarean sections et al. Physicians commonly refuse patient requests for inappropriate treatments: narcotics,antibiotics, cesarean sections et al. What are reasons for acceding to requests for inappropriate CPR? What are reasons for acceding to requests for inappropriate CPR? Fear of legal repercussionsFear of legal repercussions “This is different; it’s life or death.”“This is different; it’s life or death.” Would solidarity of action create new guidelines from which to operate? Would solidarity of action create new guidelines from which to operate?

Potential Problems Could be seen as effort only to save money. Could be seen as effort only to save money. It would require a new perspective on CPR in the mind of the public. It would require a new perspective on CPR in the mind of the public. It is a major medical intervention requiring skill and judgment rather than something anybody can do and everybody ought to have.It is a major medical intervention requiring skill and judgment rather than something anybody can do and everybody ought to have. Guidelines needed will vary among patients.Guidelines needed will vary among patients. It would require true solidarity among a variety of institutions and perspectives. Buy in from the top is crucial. It would require true solidarity among a variety of institutions and perspectives. Buy in from the top is crucial.

Advantages Patients would be spared suffering from invasive therapy of little or no value. Patients would be spared suffering from invasive therapy of little or no value. Staff would experience less moral distress. Staff would experience less moral distress. Valuable resources could be devoted to other, more urgent needs. (e.g. shortages of epinephrine, etc.) Valuable resources could be devoted to other, more urgent needs. (e.g. shortages of epinephrine, etc.)

Strategies Work with ethics committees to raise discussion of a new approach. Work with ethics committees to raise discussion of a new approach. Work with policy making entities to develop new policies. Work with policy making entities to develop new policies. Do in-service with staff Do in-service with staff Develop role plays to practice the language of a new approach. Develop role plays to practice the language of a new approach. Join SC-CSI Join SC-CSI