1. The Physician-Patient Relationship

2. Some Questions
What moral rules should physicians observe in dealing with patients?
Are physicians ever justified in lying to their patients?
How about withholding information from them?

3. How should physicians deal with multicultural issues?
What sorts of conflicts do physicians face with their patients as a result of managed care and pharmaceutical companies?

4. Physician’s Obligations and Virtues
The Hippocratic Oath reflects
the Traditional Paternalism of the medical profession

5. Physicians are to act to benefit the sick and “keep them from harm”
But it says nothing about patient’s rights

6. The American Medical Association reflected a similar approach
Until recently
The Codes of Ethics
developed by
The American Medical Association
reflected a similar approach

7. These codes expected physicians to promote their patients’ well-being
But never allowed their patients to define their own well-being

8. Over the past 30 years this has changed
Biomedical Ethics has stressed the patient’s right to self-determination
And Patient’s Rights

9. Self-Determination
Each individual has the right to determine for his / her self
What action should or should not be taken
What is the best care
What well-being means

10. Patient’s Rights
The right to access the complete information in all things regarding their health and procedures

11. Reflect Changing Attitudes
These patient rights reflect a changing attitude toward physicians
Physicians no longer viewed as above reproach

12. Reasons for current change in attitude toward physicians
1. Increasingly impersonal relationships between physician and patient
Increased specialization
Depersonalized medical institutions

13. 2. illness and injuries resulting from medical intervention
Raises doubts about physicians judgment and skills

14. 3. Physician practices that compromise patient interests
Financial Gain
Medical Institution
Insurance Companies
Pharmaceutical Companies

15. Paternalism and Respect for Patient Autonomy
Medical Professional acts like your father
Makes decisions for you
“The doctor knows best”

16. Paternalism Tends to focus on: 1. Care rather than respect
2. Patient’s needs rather than patient’s rights
3. Physician’s discretion rather than patient’s autonomy or self determination

17. Generally agreed that in an emergency Post Emergency Lawsuits?
Emergencies
Generally agreed that in an emergency
The physician can do what he/she feels in necessary to save patient’s life
Post Emergency Lawsuits?

18. Weak Paternalism Paternalism justified when: 1. Patient is incompetent
2. Substantially lacking in decision-making capacity
3. At risk of harm

19. Two Important Aspects of Medical Relationships
1. The autonomy of both parties
Mutual respect between parties
2. The ongoing nature of the relationship
Both parties determine what they consider acceptable terms for continuing the relationship

20. Situation #1
What should a physicians do when the patient is severely constrained by an illness (high fever, delirium) that make autonomous decisions questionable?
Should physicians do what he / she thinks best?
Paternalism v. Patient Autonomy

21. Situation #2 Disagreements about patient well-being
What should a physician do when he/she thinks continuing aggressive treatment for cancer is in the patient’s best interest even though past treatments have brought no positive results and the patients disagrees?
Whose definition of well-being should prevail?

22. Factors to Consider Whose to say what is best for the patient?
The physician or the patient?
Under what circumstances?

23. Truth Telling
Traditional codes of medical ethics have little to say about lying, deception, or truth telling
Until recently is was not unusual for physicians to lie to patients about their illness for paternalistic reasons

24. If so, under what conditions?
Are physicians ever morally justified in paternalistic lies or deceptive practices?
If so, under what conditions?

25. More general questions: Is it always morally wrong to lie?
Is it always right to tell the truth?

26. Suppose:
Physician argues that it is morally acceptable to lie to patient because:

27. 2. Most patients do not want to know the truth
1. It is very difficult to explain technical facts and uncertainties in some medical situations
2. Most patients do not want to know the truth
3. The truth can harm patients

28. Responses?
Utilitarian?
Deontologist?
Prima facie duties?
You?

29. Withholding information from a patient
Nondisclosure
Withholding information from a patient
Is this ever justified?

30. When an informed competent adult voluntary gives permission
Informed Consent
When an informed competent adult voluntary gives permission

31. How do you define “informed”?
Patients must have access to relevant information
Patient must understand relevant information

32. 1. Who is competent to give consent? How do we judge competency?
Application
1. Who is competent to give consent?
How do we judge competency?

33. Competency 1. Capable of consenting autonomously
2. Has sufficient understanding of circumstances
3. Has sufficient freedom from internal and external constraints

34. 1982 Commission
Individuals should be judged incapable of decision making only when they lack the ability to make decisions that promote their well-being in keeping with their own previously expressed values and preferences

35. When is consent informed?
How much information must a patient receive and understand before his or her consent is considered adequately informed?

36. Who is to determine what information is necessary?
Who is to determine how much information is necessary?

37. Studies have shown that patients who receive too much information may understand and retain little of the significant information

38. By contrast
Those who receive less information may be able to understand and retain more of the important information
But who should decide?

39. When is consent voluntary?
Sufficiently free of internal and external constraints?

40. 1. Patient Communication 2. Patient Information Processing
Important Aspects
1. Patient Communication
2. Patient Information Processing

41. Information must be clearly communicated
Patient must be assessed as to understanding of information given
There is no universally accepted standard to assess these

42. The Practice of Medicine in a Multicultural Society

43. Different Ethics / Morals
Different Languages
Different Cultures
Different Ethics / Morals
Different Worldview

44. Racial, Ethnic, National Prejudice
One race does not wanted to be treated by another race
One ethnicity does not want to be treated by another ethnicity
One national does not want to be treated by another nationality

45. Different views of who possess legitimate decision-making authority
Different perspective on truth telling
Different views of family influence
Different views of proper treatment of children

46. Other Beliefs What if patients believe:
Evil Spirit as the cause of disease?
Female Castration?
Against blood transfusions?

47. Contested Therapies with the Physician-Patient Relationship

48. the treatment or prevention of disease, impairment, or dysfunction?
Should physicians be permitted to employ their skills in a medical setting for purposes other than
the treatment or prevention of disease, impairment, or dysfunction?

49. Choosing the sex of our children Enhancing human traits
Examples
Gene Therapy
Choosing the sex of our children
Enhancing human traits

50. Use of Prozac to enhance personality
Cosmetic Surgery?
Use of Prozac to enhance personality
Sports performance enhancement drugs

51. Prescription of Ritalin for reasons other than ADHD
What about future life enhancing drugs?

52. Conflicts of Interest, Problems of Conscience, and Managed Care

53. The health-related interests of physicians
Conflicts
Patient well-being vs
The health-related interests of physicians
Do physicians have obligation to help others when physicians will be put at risk?
HIV / AIDS / H1N1

54. The financial interests of physicians
Patients well-being vs
The financial interests of physicians
Should physicians help those who cannot pay?

55. Society’s financial interests Who does physician represent?
Patient well-being Vs
Society’s financial interests
Should society allow very expensive medical care to those who cannot pay for it?
Who does physician represent?

56. The financial interests of an insurer
Patient well-being vs
The financial interests of an insurer
Should an insurer have a say in what medical treatment an insured patient should have?
Who does the physician represent?