Medical Ethics

Medical Ethics [vs. Professional ethics]  Principals to guide physicians in their relationships with others  Ethical dilemma is a predicament in which there is no clear course to resolve the problem of conflicting moral principles  Dynamic environment/evolving field

Principles  Autonomy  Beneficience  Nonmaleficence  Justice

Autonomy  Right to self-determination  Requires decision making capacity  Lack should be proven not assumed  Competence – legal determination  Liberty – freedom to influence course of life/treatment

Preservation of Autonomy  Advance Directives  A document in which an individual either states preferences or designates decision maker  Living Will  Takes effect when terminally ill and lacking decision making capacity

Preserving Autonomy  Surrogate Decision Makers  Represents patients interest  Best identified before critical illness  In absence of specific advanced directives should use substituted judgement

Preservation of Autonomy  The primary responsibility of the physician is to serve the patients interest

The patient self determination act of 1990  At the time of admission information re: the patients’ right to refuse care or create an advance directive must be dispensed

Informed Consent  Requirements  Decision making capacity  Volutariness  Reasonable person standard  Present all alternatives f/b recommendation  Respect refusal  All surgical and experimental procedures

Implied Consent  Invoked when true informed consent not possible  Emergency situations when harm would result without urgently needed intervention

Disclosure  Truth telling on part of physician is an integral part of patient autonomy

Paternalism  Justifiable if patient at risk of significant preventable harm, paternalistic action will prevent harm, benefits outweigh risks and the least autonomy-restrictive course of action is used

Confidentiality  Obligation of physician to maintain information in strict confidence  Exceptions if failure to release data to data to appropriate agencies may result in greater societal harm

Futility  Unilateral decision made on part of physician to withold or withdraw medical intervention based on predictable futile outcome  Physiologic futility  Medical futility – none of last 100 cases like this…

Beneficience  Obligation to preserve life, restore health, relieve suffering and maintain function  To do “good”  Nonabandonment – obligation to provide ongoing care  Conflict of interest – must not engage in activities that are not in patients best interest

Nonmaleficence  “Do no harm, prevent harm and remove harm”

Impaired Physician  Physicians have the obligation to report impaired behavior in colleagues

Principle of Double Effect  Act must be morally good  Actor intends good effect  Good effect outweighs bad effect  Bad effect not means to good effect

Justice  Allocation of medical resources must be fair and according to need  Physicians should not make decisions regarding individuals based upon societal needs

MD assisted suicide and euthanasia  Legally prohibited in the US except in Oregon which permits MD assisted suicide

DNR  DNR orders affect CPR only  Other therapies should not be influenced by DNR order  Should be reviewed frequently  Rationale should be in medical record

Withdrawing of Support  Brain death is not required  Same as not initiating  Does not conflict with basic principles

Persistent Vegetative State  Uncnsciousness/ loss of self awareness lasting more than weeks  Supreme court draws no distinction between artificial feeding, hydration vs. mechanical ventilation

Death  Irreversible cessation of circulatory and respiratory function  Irreversible cessation of all brain function (including brainstem)