PRINCIPLES OF HEALTH CARE ETHICS Rels 300 / Nurs Sep 2015

Moral Principles Not tied to any one moral theory Emerged from critical analysis of medical research which was proven to violate the human dignity of the research subjects Developed as an attempt to provide a common language for healthcare professionals, researchers and members of the public Goal = to provide a means of determining & identifying morally right and morally wrong attitudes, actions and behaviours Within contexts of both clinical care and research 300/330 appleby 2

4 Principles of Bioethics Can be evaluated within a virtue, deontological, utilitarian, natural law, feminist or care framework ground rules But the 4 principles form the ground rules for the moral alternatives considered by the health care team People can use any form of moral reasoning and still discuss each of these principles 300/330 appleby 3

The 4 Principles are: 1. Autonomy 2. Beneficence 3. Non-maleficence (also called non-malfeasance, but this term is not generally used in Canada) 4. Justice 300/330 appleby 4

1.Autonomy auto / nomos = self / rule  respect the right of competent persons to make their own decisions  respect the personal dignity and worth of persons  respect the right of persons to be free to act without external restraints or manipulation 300/330 appleby 5

2.Beneficence  healthcare professionals have a duty to promote the health and well-being of the patient  Contribute to their benefit  healthcare professionals have a duty to further the important and legitimate interests of others  patients may not be treated in ways that only bring benefit to others 300/330 appleby 6

3.Non-maleficence  healthcare professionals have a duty to refrain from injuring or inflicting harm  minimize the pain and suffering caused by disease and medical treatment  “First, do no harm” 300/330 appleby 7

4.Justice  everyone has a duty to ensure fair treatment of patients  equals should be treated equally and unequals unequally  healthcare resources should be distributed in a fair manner  persons should not experience prejudice, discrimination or bias 300/330 appleby 8

What’s the value of adding another approach? Whether on deontological grounds, or according to utilitarian reasoning, or according to any other moral theory (i.e. virtue, natural law, care ethics), everyone is in agreement that patient autonomy must be respected reasons for respecting autonomy may differ according to moral perspectives, but all agree that it must be respected in providing health care for patients 300/330 appleby 9

Case Study #1 Ms. Jones, a 28-yr-old woman, comes to her primary care physician for advice. Her 25-yr-old brother, her only sibling, has developed renal failure. He & her parents, as well as the nephrologist, have urged her to be tested for suitability as a kidney donor. She is extremely anxious and says that while she feels guilty, she does not want to be a donor. How can the doctor help her make a decision? How can this decision be communicated to her parents and brother? 300/330 appleby 10

Case Study #2 Mr. Minto is a 67-yr-old man who has been institutionalized for mental retardation since the age of 1 year. His mental age is estimated at a 3-yr-old level, and his IQ is 20. He develops acute nonlymphoblastic leukemia. His guardian says, “His life is of such poor quality. Why should we try to extend it when medical treatment would be painful? He wouldn’t understand what was going on.” How should the nurse respond to this? How can she articulate her perspective and/or concerns? 300/330 appleby 11

Case Study #3 A frail patient recovering from recent surgery has been receiving intra-muscular antibiotic injections four times a day. The injection sites are very tender, and though the patient now is able to eat without problems, the intern refuses to change the order to an oral antibiotic because the absorption of the medication would be slightly less. What should the nurse do? How can he explain his ethical concerns to the intern? 300/330 appleby 12

Scenario 2: Conjoined Twins – BC p.38 One of the twins is much stronger than the other If separated from her sister, the weak one will certainly die If surgical separation is not performed, the stronger sister’s organs will be burdened by sustaining both twins Both would be likely to die within 2 years 300/330 appleby 13

HUSBAND – NO SURGERY – surgical separation will save the stronger twin only by killing the weaker twin – let nature take its course with no surgery Which moral theories could help the husband explain his view? Choose ONE moral theory and apply it in support of the husband WIFE – ATTEMPT THE SURGERY – why let both die when one twin could be saved Which moral theories could help the wife explain her view? Choose ONE moral theory and apply it in support of the wife 300/330 appleby 14

Imagine that you were the potential surgeon. Using a moral theory not yet applied, make your argument in favour of performing the surgery. Imagine that you were one of the nurses caring for the twins. Using a moral theory not yet applied, make your argument either in favour of or against performing the surgery. 300/330 appleby 15 Now, imagine that you are the clinical ethicist who has been consulted to assist with the decision-making. Use the four principles of health care ethics to help resolve the ethical dilemma. What will you recommend? (Not making a recommendation is NOT an option)

Sir Alan Ward, the former Lord Justice of Appeal, ruled that Jodi and Mary - as they were known in court proceedings - should undergo an operation to separate the twins despite knowing Mary would die Jodi, now 14, and Mary were conjoined at their abdomens and shared a bladder, but Mary's heart was not strong enough for her to survive on her own /Separated-twin-living-life-says-judge- ordered-operation-killed-conjoined-sister.html 300/330 appleby 16 Jodi (pictured) survived the operation that separated her from her twin sister, Mary, in 2000