Introduction to Medical Ethics Paul Dassow, MD, MSPH MD 815 November 15, 2006

Objectives 1. Explain the difference between morality and ethics 2. Describe the Standard Medical Ethic in place in today’s medical environment 3. Apply this Ethic to a real world situation 4. Understand the inherent difficulties with the current medical ethic 5. Know alternatives to the standard ethic

The case of Terri Schiavo The facts: The facts: Born Theresa Marie Schindler December 3, 1963 Born Theresa Marie Schindler December 3, 1963 In 1983, Terri met Michael Schiavo at Bucks County Community College and the two began dating. He was the first romantic interest Terri had. In 1983, Terri met Michael Schiavo at Bucks County Community College and the two began dating. He was the first romantic interest Terri had. The couple was engaged within a few months and married a year later at Terri’s church in Southampton, Pa. She was 21. The couple was engaged within a few months and married a year later at Terri’s church in Southampton, Pa. She was 21.

The case of Terri Schiavo The facts: The facts: In 1990, at the age of 26, Terri suffered a mysterious cardio-respiratory arrest for which no cause has ever been determined. She was diagnosed with hypoxic encephalopathy – neurological injury caused by lack of oxygen to the brain. Terri was placed on a ventilator, but was soon able to breathe on her own and maintain vital function. She remained in a severely compromised neurological state and was provided a PEG tube to ensure the safe delivery of nourishment and hydration In 1990, at the age of 26, Terri suffered a mysterious cardio-respiratory arrest for which no cause has ever been determined. She was diagnosed with hypoxic encephalopathy – neurological injury caused by lack of oxygen to the brain. Terri was placed on a ventilator, but was soon able to breathe on her own and maintain vital function. She remained in a severely compromised neurological state and was provided a PEG tube to ensure the safe delivery of nourishment and hydration

Terri Schiavo Video clips from the last year of Terri’s life: Video clips from the last year of Terri’s life:

The case of Terri Schiavo The facts: The facts: On March 18, 2005, Terri Schiavo had her feeding tube removed under the order of Circuit Court Judge, George W. Greer of the Pinellas-Pasco’s Sixth Judicial Court. On March 31, 2005, Terri Schindler Schiavo died of marked dehydration following more than 13 days without nutrition or hydration. Terri was 41. On March 18, 2005, Terri Schiavo had her feeding tube removed under the order of Circuit Court Judge, George W. Greer of the Pinellas-Pasco’s Sixth Judicial Court. On March 31, 2005, Terri Schindler Schiavo died of marked dehydration following more than 13 days without nutrition or hydration. Terri was 41.

What was the right thing to do here?

Morals and Ethics Moral: Of or concerned with the judgment of the goodness or badness of human action and character Moral: Of or concerned with the judgment of the goodness or badness of human action and character Ethic: A principle of right or good conduct or a body of such principles Ethic: A principle of right or good conduct or a body of such principles

1. What was the morality of the decision to pull Terri’s feeding tube?

2. How do we decide what is the moral choice?

The Standard Medical Ethic Rooted in the 1979 Belmont Report from the Committee on the use of Human Subjects in research Rooted in the 1979 Belmont Report from the Committee on the use of Human Subjects in research Principles: Principles: Autonomy Autonomy Beneficence Beneficence Non-malfeasance Non-malfeasance Justice Justice

Autonomy The principle that persons should be able to decide for themselves what action, if any, should be taken in regards to their medical care The principle that persons should be able to decide for themselves what action, if any, should be taken in regards to their medical care Assumes appropriate informed consent Assumes appropriate informed consent Assumes capacity Assumes capacity Needs clarification when a patient cannot speak (or think) for themselves Needs clarification when a patient cannot speak (or think) for themselves

Beneficence The principle that physicians should always do what is in the best interest of the patient The principle that physicians should always do what is in the best interest of the patient May vary from physician to physician (Kevorkian) May vary from physician to physician (Kevorkian) Is this what the physician would want done to them (the golden rule), or what they think the patient would want for themselves? Is this what the physician would want done to them (the golden rule), or what they think the patient would want for themselves?

Non-malfeasance The principle that physicians should not harm patients nor treat with intent to harm The principle that physicians should not harm patients nor treat with intent to harm Often decisions must be made regarding which course of action will likely cause the least harm Often decisions must be made regarding which course of action will likely cause the least harm Again, physician dependent Again, physician dependent

Justice The principle that persons should be treated equally and fairly, without prejudice in regard to gender, race, or personal creed. The principle that persons should be treated equally and fairly, without prejudice in regard to gender, race, or personal creed. Very difficult in our present system Very difficult in our present system

So, back to Terri

Autonomy Did Terri want her feeding tube removed? Did Terri want her feeding tube removed? No living will No living will Conflicting reports from husband and parents regarding “what Terri would have wanted.” Conflicting reports from husband and parents regarding “what Terri would have wanted.” Since Terri deemed not to have the capacity to make decisions for herself, her next of kin (husband) is assigned the duty to make these decisions for her. Since Terri deemed not to have the capacity to make decisions for herself, her next of kin (husband) is assigned the duty to make these decisions for her. Terri’s next of kin said, “Yes.” Terri’s next of kin said, “Yes.”

Capacity Involves the demonstration of 3 characteristics: Involves the demonstration of 3 characteristics: Can understand the diagnosis and prognosis for a given condition Can understand the diagnosis and prognosis for a given condition Can understand the treatment options Can understand the treatment options Can understand the possible consequences involved in the various treatment options Can understand the possible consequences involved in the various treatment options

Beneficence What would be the right course of action to benefit Terri? What would be the right course of action to benefit Terri? Can death ever be considered a benefit for a patient? Can death ever be considered a benefit for a patient? Consider the Hippocratic Oath Consider the Hippocratic Oath Would pulling Terri’s feeding tube benefit her? Would pulling Terri’s feeding tube benefit her? If so, how? If so, how? Was artificially feeding Terri just prolonging her suffering? Was artificially feeding Terri just prolonging her suffering?

Non-malfeasance Would pulling Terri’s feeding tube cause her harm? Would pulling Terri’s feeding tube cause her harm? Suffering from dehydration? Suffering from dehydration? Is death the ultimate harm? Is death the ultimate harm? Were other motives at play in this decision Were other motives at play in this decision Money Money Husband’s desire to “get on with life.” Husband’s desire to “get on with life.”

Justice Is there precedent for this decision. That is, are other similar patients treated the same way? Is there precedent for this decision. That is, are other similar patients treated the same way? Neurologically impaired vs persistent vegetative state vs brain dead Neurologically impaired vs persistent vegetative state vs brain dead Is there a national policy regarding how to treat these patients (only brain death) Is there a national policy regarding how to treat these patients (only brain death)

What happens when principles conflict?

In life and death decisions, typically Autonomy trumps others In life and death decisions, typically Autonomy trumps others Exception: Assisted suicide in most states not legal Exception: Assisted suicide in most states not legal In Terri’s situation, the legal case surrounded whether she was in a persistent vegetative state or not. In Terri’s situation, the legal case surrounded whether she was in a persistent vegetative state or not. From this medical ethics framework, if autonomy trumps others, then pulling the tube was the right decision From this medical ethics framework, if autonomy trumps others, then pulling the tube was the right decision

A side note: Why did they pull the tube? Why not just not feed her?

So you’re the physician. Do you comply with the court decision?

The embattled physician If you disagree with the court’s decision, most states would allow you to “opt out” of performing the act. If you disagree with the court’s decision, most states would allow you to “opt out” of performing the act. Examples: As a physician, you do not have to provide contraception or abortion services Examples: As a physician, you do not have to provide contraception or abortion services However, some states do force behavior deemed essential to the job (eg, pharmacists must dispense emergency contraception) However, some states do force behavior deemed essential to the job (eg, pharmacists must dispense emergency contraception)