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Patient Care & Ethical Dilemmas
Serving the Best Interests of the Patient
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Disclosure The speaker has no financial interest in the subject matter of this presentation and is not representing the Ethics Committee of the American Academy of Ophthalmology with this presentation. For questions about the material contained herein or about the Academy’s ethics program in general, please contact the ethics program manager, Mara Pearse Burke at
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Why is this Topic Important?
Integrity of the Profession Engenders Patient Trust Acting in the Best Interests of the Patient Putting the Patients’ Needs Before Your Own
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Pertinent Rules of the Code of Ethics
Rule 1. Competence Rule 2. Informed Consent Rule 3. Research & Innovation In Practice Rule 4. Other Opinions Rule 5. The Impaired Ophthalmologist Rule 6. Pretreatment Assessment Rule 7. Delegation of Services Rule 8. Postoperative Care Rule 9. Medical & Surgical Procedures Rule 10. Procedures & Materials Rule 11. Commercial Relationships Rule 13. Communications to the Public Rule 15. Conflicts of Interest Rule 17. Confidentiality
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Ethical Fundamentals Ethics address conduct and relate to what behavior is appropriate or inappropriate, as reasonably determined by the entity setting the ethical standards. An issue of ethics in ophthalmology is resolved by the determination that the best interests of patients are served. Ophthalmological services must be provided with compassion, respect for human dignity, honesty and integrity. It is the responsibility of an ophthalmologist to act in the best interest of the patient.
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Challenges to Ethical Patient Care
Impairment Improper informed consent Research vs. patient care Appropriate postoperative management Potentially unnecessary procedures/tests Advertising and competition Conflicts of interest Emerging technologies
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Rule 1. Competence Work within specific training and experience
Maintain competence: Regular experience Continuing education Learn / implement new skills appropriately
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Rule 2. Informed Consent The “process” of informed consent
A “reasonable” patient; “informed” decision. Rationale, benefits of proposed treatment Risks and complications Alternatives Securing a signature is not informed consent
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Rule 3: Research & Innovation in Practice
Institutional Review Board (IRB) oversight Special informed consent Clinical investigation vs. “routine care” Research without patient consent is unethical
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Rule 4. Other Opinions Respect patients’ request for other opinions
Obtain consultations as appropriate
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Rule 5. The Impaired Ophthalmologist
Impairment: physical, mental, emotional Voluntary withdrawal A duty to act Patient safety is the first priority. Rank does not have “privilege.”
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Rule 6. Pretreatment Assessment
Document accurately “Stretching it” is unethical Document without bias Falsification or fabrication Don’t do it! Unethical! Serious legal risk!
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Rule 7. Delegation of Services
Delegation of services, not responsibility Adequate qualification Adequate supervision Disclosure of auxiliaries’ roles
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Rule 8. Postoperative Care
The operating surgeon is responsible Alternative arrangements made before surgery Mutual consent of providers Arrangements disclosed before surgery May require written (preoperative) consent Commercial relationships, fees must be disclosed
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Rule 9. Misrepresentation of Services
Truthful description of services Misrepresentation by omission Misrepresentation by distortion Misrepresentation by using or avoiding specific language Appropriate charges for services
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Rule 10. Under-treatment & Over-Treatment
Extent of care must serve the patient’s interests Over-providing care is unethical (rendering unnecessary services) Under-providing care is unethical (withholding necessary services)
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Rules 11 & 15 Commercial Concerns & Conflicts of Interest
Commercial interests must not alter judgment Self referral Relationships with industry Unreasonable “co-management” fees Conflicts of interest are not necessarily economic Specific surgical experience Research Notoriety Conflicts of interests must be disclosed
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Rule 13. Advertising No false, deceptive or misleading information
No deceptive omissions No appeals to patients’ anxiety Must not create unjustified expectations of results Must disclose risks Must not misrepresent credentials No unsubstantiated claims of superiority
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Rule 17. Confidentiality Respect the confidential physician-patient relationship and safeguard confidential information consistent with the law.
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Back to the Basics Do what is in the Best Interests of the Patient
Beneficence Obligation to maximize benefit Obligation to minimize harm Non-maleficence Doctrine of “primum non nocere” No deliberate harm Justice: Equals should be treated equally Autonomy (self governance)
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