PRINCIPLES OF BIOETHICS “What Principles Guide the Health Professional in Interacting with Patients/Clients?

Principles of Bioethics Are Based on the Moral Rule... “Do Your Duty” For purposes of this discussion we are going to consider all to be public health clinicians, as this will enable us to elucidate the principles more readily. However, the same principles would apply to public health professionals working either with individual clients, or organizational entities.

Moral Rules Become Moral Ideals The goals of a profession are always particular expressions of the moral ideals. Professions (specifically the health professions) exist to positively benefit those seeking their assistance. The moral rule, “do your duty,” is played out in the duties the professional has taken upon him/herself to do good for those seeking help. Thus violating a specified professional duty, is violating the moral rule, “do your duty.”

Professional Duties Moral Intellectual Just as in Aristotle’s Concept of the Virtues (Being Both Moral and Intellectual), Based on the Nature of Human-kind.

Moral Component of Bioethics (Professional Ethics) Primary to the notion of a health profession is benefiting society. The moral component of the profession of public health is doing good for the health of the public. The moral rule of not causing harm becomes the moral ideal of preventing harm to, and promoting good for, society’s health.

Troika of Principles of Bioethics We help promote the public’s health by observing three principles of bioethics: Beneficence Respect for Autonomy Justice

BENEFICIENCE (First Principle) The goal of the relationship in which one assumes the role of public health practitioner and the other the patient/client is the benefiting the “well-being” of the patient/client. This benefiting is accomplished by the public health professional providing the highest quality of information/care possible contingent on the profession’s current scientific understanding, the (clinical) circumstances, and the client/patient’s desires.

Hippocratic Oath “I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or wrong them.”

Continuum of Beneficence Promote Good Prevent Evil or Harm Remove Evil or Harm Do Not Cause Evil or Harm (Non-maleficence)

NON-MALEFICENCE “Do No Harm” Do not violate any of the moral rules

Who Decides About Goods and Harms-- Risks and Benefits? In providing goods or benefits, clinicians/public health professionals acknowledge there are inherent risks of harms. Professionals have the duty to weigh benefits against possible harms, and minimize the risk of harms. But the professional’s conception of benefits and risks may be different from the patient’s. An assessment of benefits and risks is not necessarily a factual issue, but judgment of value. Whose values should prevail?

RESPECT FOR AUTIONOMY (Second Principle) Autonomy derives from the Greek and literally means self-rule, self- governance, self- determination…being one’s own person; the author of one’s life. The moral rule, “do not deprive of freedom or opportunity,” means it is moral or right to grant self- governance/self-determination to others.

Kant’s Reformulation (Second Formulation) of the Categorical Imperative “Act so that you treat humanity, whether in your own person or in that of another, always as an end and never as a means.” Said another way, people are always to be treated as “subjects,” not as “objects.” Page 131, 132, 133 in text

Are Humans Curious? Are You Curious? Are Patients/Clients Curious? Why?

“Curiosity is the most insatiable of lusts.” Michel Foucault French Philosopher

Patients Want to Know In one study, 72% of patients said they prefer to make decisions regarding their care jointly with their physician. In contrast, the same study found that 88% of physicians believe that patients want physicians to choose for them the best alternative. We not only are curious, but we value self-determination.

Balancing The Two Bioethical Principles Provide the Ethical Foundation for Informed Consent: Principle of Beneficience: Do Good for the Patient by Promoting Their Well-Being. Principle of Respect for Autonomy: Each Person Should be Self- Determining, the Author of His/Her Own Life;deciding what is their “good.”

Instrumental Value of Self-Determination In most cases, the individual’s well-being is best served by his/her own subjective judgment. Page 44 of assigned reading from the President’s Commission

Intrinsic Value of Self- Determination “...Unless the patient has requested this course of conduct, the individual will not have been shown proper respect as a person nor provided with adequate protection against arbitrary, albeit well- meaning domination by others.” Even if it could be shown that another could do a better job of determining what is in the individual’s interest, there is still a reason for recognizing self-determination as an individual’s right. Page 45 of assigned reading from the President’s Commission

Quote from John Stuart Mill “The human faculties of perception, judgement, discriminative feeling, mental activity, and even moral preference, are exercised only in making a choice. He who does anything because it is the custom makes no choice. He gains no practice either in discerning or desiring what is best. The mental and moral, like the muscular powers, are improved by being used...

He who lets the world, or his own portion of it, choose his plan of life for him, has no need of any other faculty than the ape-like one of imitation. He who chooses his plan for himself employs all his faculties. He must use observation to see, activity to gather materials for decision, discrimination to decide, and when he has decided, firmness and self- control to hold his deliberative decision...

Where, not the person’s own character, but the traditions and customs of other people are the rules of conduct, there is wanting one of the principle ingredients of human happiness.” John Stuart Mill English Philosopher Formulator of Utilitarianism

Beneficence : Autonomy The definition of health is imprecise and indefinite. It depends to some extent upon the goals and values of the individual. Even when the definition is agreed upon, there is often no definitive criterion to determine how to achieve it. In recommending therapy, health professionals tend to reflect their own values and preferences, which may differ from their patients. Determining what constitutes health and how it is best promoted requires knowledge of the patient’s goals, values, and preferences.

For the reasons just given, determining whether a plan of therapy/action will, if successful, promote a patient/client’s well-being is a matter of individual judgement. In each case the goals and interests of particular patients incline them in different directions not only as to how, but even as to whether, treatment should be provided.

It is important to note that the ethical (and legal) imperative of informed consent does not give patient the right to insist upon anything they might want: –Health professionals are also bound by the concept of non- maleficence, not causing harm –The choices available to patients must be limited to medically accepted options, all of which scientific evidence indicates will have some possibility of promoting the patient’s welfare.

Opinion in John Canterbury versus William Spence (1972) “every human being of adult years and sound mind has a right to determine what shall be done with his body… True consent to what happens to one’s self is the informed exercise of a choice, and that entails an opportunity to evaluate knowledgeably the options available and the risks attendant upon each.”

Major Components of Informed Consent Disclosure of Adequate Information with Associated Adequate Understanding Lack of Coercion Competence (Decisional Capacity)

Adequate Information with Adequate Understanding

The concept of adequate information/understanding can deteriorate into a mechanical rehearsal of data to legally protect the professional unless tempered with the idea of client/patient comprehension. This is done by processing information reciprocally; asking for client/patient understanding and validation of the information. Adequate information/understanding does not require that the client/patient be told everything there is to know, but only the information adequate to make an ‘informed decision;’ information that a reasonable person would want to have.

Four Standards Considered For Adequate Information Full Disclosure Customary Disclosure Disclosure of all Risks Reasonable Person Standard

Full Disclosure Disclose every benefit and risk, no matter how small or remote. Rejected: Too prohibitive and unrealistic. If taken literally, full disclosure is impossible. If taken, as probably intended, to reveal adequate information, the standard provides no guidance.

Customary Disclosure Disclose all information that other practitioners would be likely to disclose under similar circumstances. (Also called “community or professional standard.”) Rejected: Customary practice does not necessarily ensure that the patient’s right to self-determination is respected; does not ensure that adequate information will be provided.

Disclose All Risks Disclose every risk that a patient would deem significant to his decision. Rejected: Places an undue burden on the practitioner in that it requires the practitioner to second guess the patient’s subjective view of what would count as significant information.

Reasonable Person Standard Disclose the benefits and risks that a reasonable person, in what the practitioner knows to be the patient’s position, would be likely to deem relevant in deciding whether to forego a proposed therapy. Accepted, on the grounds that “ the scope of the standard is not subjective as to the practitioner or the patient; it remains objective with due regard for the patient’s informational needs and with suitable leeway for the practitioner’s situation.”

Two Exceptions to the Rule of Disclosure Emergency situations where the patient is incapable of giving consent, and harm from failure to treat is imminent and outweighs any harm threatened by the proposed treatment. When disclosure of risks itself poses a threat of harm to the patient. However, this “privilege does not accept the paternalistic notion that the practitioner may remain silent simply because divulgence might prompt the patient to forego therapy the practitioner feels the patient really needs.”

Under the Reasonable Person Standard, Adequate Information Generally Includes: Nature of the treatment Benefits Harms Complications/Risks Alternatives Prognosis Non-Treatment Costs

From the Reading Alternative Rational Choices (page 153) Rational, yet unreasonable choices (page 154) Fair presentation of all alternatives (page 156) Treatment at different sites (page 160) Presenting harms and benefits (page 162) Alternative way of presenting information (page 165) Patient’s who do not want to know (page 171)

Lack of Coercion

Modifying Behavior Education Persuasion Manipulation Psychological Coercion Physical Coercion

Lack of Coercion Coercion is defined as a threat, either psychological or physical, of sufficient force that no rational person would be able to resist it. Education and persuasion are not coercive. Manipulation/deception and psychological or physical inducements of benefit or threats of harm are coercive. Key idea is that the consent is fully voluntary, thus voluntariness.

Decisional Capacity In much of the ethics literature, the term competency is used to designate decisional capacity. However, the term has taken on legal connotations with the decision regarding a person’s competency determined by the courts. Thus, increasingly the term decisional capacity is employed to designate the third ingredient necessary for a consent to be informed/valid. Implied is also the notion of moral agency. The individual is to be taken as an autonomous moral agent.

Decisional Making Capacity Requires: Possession of a set of values and goals. The ability to communicate and to understand information, and the ability to reason and deliberate about one’s choices. From: The President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research

Surrogate Decision Making Examples of individuals who cannot rationally deliberate in the process of informed consent are: minors persons with dementia psychotics persons with extreme anxiety or fear the mentally retarded persons under the influences of abused substances

Health Care Surrogacy in Kentucky Law (KRS ) Judicially appointed guardian Spouse An adult child of the patient; if more than one, the majority of the adult children who are reasonable available for consultation The parents of the patient The nearest living relative of the patient, or if more than one relative of the same relation is reasonable available for consultation, the majority of the nearest living relatives.

Misconceptions About Informed Consent Informed consent is merely a legal doctrine and has little to do with a good and ethical practice. Informed consent is a single event. Informed consent merely involves the listing of risks and benefits the health professional believes would best serve the patient/client’s interests.

Because of their special education and training, practitioners are the best judges of what would serve their patient/client’s best interests. The primary obligation of the health professional is to act in the best interest of the patient/client’s health, as the health professional understands it. It is permissible to forego informed consent so long as you are acting in the patient/client’s best interest.

Patients do not want to be informed of bad news and are always better served by practitioners remaining positive, even if it involves deception. Any individual who would make a decision that is obvious to the practitioner as contrary to their health and well is irrational. The practitioner’s obligations do not extend beyond the legal requirements concerning informed consent. Informed consent is a legal doctrine and a way to protect the health professional from legal action. A signature on a form, which describes the procedure, constitutes an informed consent.

Paternalism Assumptions: Acting Beneficently … Doing Good Violating a Moral Rule Client/Patient has not given an Informed Consent Client/Patient is Competent to give Consent

Intellectual Component of Profession

Life Long Learning Philosophical End Psychological End Practical End

Philosophical End Aristotle’s concept of “intellectual virtue.” We fulfill one of our vital functions as human being when we continue to learn. “we must cease conceiving of education (learning) as mere preparation for later life, and make it the full meaning of present life…an activity that does not have worth enough to be carried out for its own sake cannot be effective as preparation for something else.” John Dewey American philosopher

Psychological End Maslow’s concept of “being all you can be.” As we are by nature learning animals, we actualize our potential when we learn. Csikszentmihalyi’s concept of “flow.” Having our intellectuality exercised and stretched with new ideas, challenging concepts, and exciting understandings is to get in, and be in, flow.

Practical End A competent professional must apply the profession’s current knowledge base to patient or client care with integrity. Standards of care must be fulfilled, and those standards are continuously changing through research.

L’informatique 6, ,000 scientific articles published every day. Now … scientific and technological information increases 13% /year -- doubling every 5.5 years. Rates of information expansion will soon increase 40%/year due to more powerful information system and the increasing population of scientists. Then … the scientific information will double every twenty months.

“If we indoctrinate our students in an elaborate set of fixed beliefs, we are ensuring their early obsolescence. The alternative is to develop skills, attitudes, habits of mind, and kinds of knowledge and understanding that will be instruments of continuous change and growth. Then we will fabricate a system that provides for continuous renewal.” John Gardner in Self-Renewal