1. Medical ethics Introduction to basic principles

2. Ethics are not … Ethics is not the same as feelings Ethics is not religion Ethics is not following the law Ethics is not following culturally accepted norms Ethics is not science

3. Ethics are … Moral Principles What is good and bad What is right and wrong Based on value system Ethical norms are not universal – depends on the sub culture of the society

4. Ethics refers to standards of behavior that tell us how human beings ought to act in the many situations in which they find themselves as friends, parents, children, citizens, businesspeople, teachers, professionals, and so on. “ Ethics is the study of morality – careful and systematic reflection and analysis of moral decisions and behaviour” Ethics is primarily a matter of knowing whereas morality is a matter of doing.

5. Medical ethics: Branch of ethics that deals with moral issues in medical practice. Medical ethics is closely related, but not identical to, bioethics (biomedical ethics). Whereas medical ethics focuses primarily on issues arising out of the practice of medicine. Ethical principles such as respect for persons, informed consent and confidentiality are basic to the physician-patient relationship.

6. However, application of these principles in specific situations is often problematic, since patients, their family members and other healthcare personnel may disagree about what is the right way to act in a situation. Hence, the study of ethics prepares the physicians to recognize difficult situations and to deal with them in a rational and principled manner. Ethics is also important in physicians’ interactions with society and their colleagues and for the conduct of medical research.

7. Historically medical ethics may be traced to guidelines on the duty of physicians such as the Hippocratic oath

8. a physician must recognize responsibility to patients first and foremost, as well as to society, to other health professionals, and to self. These are not laws, but standards of conduct which define the essentials of honorable behavior for the physician

9. Basic Principles of Medical Ethics  Autonomy Nonmaleficence Beneficence Justice Fidelity Confidentiality Veracity Accountability

10. Autonomy Patient has freedom of thought, intention and action when making decisions regarding health care procedures For a patient to make a fully informed decision, she/he must understand all risks and benefits of the procedure and the likelihood of success.

11. Always respect the autonomy of the patient - then the particular patient is free to choose Such respect is not simply a matter of attitude, but a way of acting so as to recognize and even promote the autonomous actions of the patient. The autonomous person may freely choose loyalties or systems of religious belief that may adversely affect him

12. The patient must be informed clearly the consequences of his action that may affect him adversely. Desiring to "benefit" the patient, the physician may strongly want to intervene believing it to be a clear "medical benefit." The physician has a duty to respect the autonomous choice of the patient, as well as a duty to avoid harm and to provide a medical benefit.

13. The physician should give greater priority to the respect for patient autonomy than to the other duties. However, at times this can be difficult because it can conflict with the paternalistic attitude of many health care professionals.

14. In the case of a child, the principle of avoiding the harm of death, and the principle of providing a medical benefit that can restore the child to health and life, would be given precedence over the autonomy of the child's parents as surrogate decision makers.

15. Beneficence The practitioner should act in “the best interest” of the patient - the procedure be provided with the intent of doing good to the patient This principle means “doing good” for others Physician needs to assist patients in all the three ways: –Biological –Psychological –Social

16. Patients believe that you are their for their benefit and will act charity and kind towards them. Physician should communicate with the patient compassionately what is going to happen for them and why this treatment is given and benefits and outcome of the treatment modality. Practising beneficence is often challenging in the way that you should deliver a bad news but you don’t have to be brutal

17. This needs health care provider to,develop and maintain skills and knowledge by continually updating training. Consider individual circumstances of all patients. Create benefit to the society and to contribute optimum health for indivduals and community at large To help those in trouble, protect patients rights and provide treatment those who need it. Suffering and dying are part of your professional life.you must concentrate on how much effort you are giving to your patients to make them to be healthy.

18. Non maleficence “ Above all, do no harm,“ – Make sure that the procedure does not harm the patient or others in society, either unintentionally or deliberately This principle requires physicians to protect individuals who are unable to protect themselves

19. When interventions undertaken by physicians to the patients create a positive outcome while also potentially doing harm it is known as the "double effect." Eg,. the use of morphine in the dying patient. eases pain and suffering whileit affects the functions of the respiratory system sometimes.  Infection control and other environmental practice is also a part of providing care and avoiding harm

20. Physicians are obligated not prescribe medications they know to be harmful. Exclude the practice of euthanasia (painless killing of patient) Violation of non-maleficence is the subject of medical malpractice litigation Prolonging treatment is a violation of the principle of non maleficence. It is also important to respect and support the wishes of the family who requests continuation of interventions.

21. When giving treatment to the childrens, special care should be given by the physicians talking all the possible harms to the child as a result of treatment. Further, providers must consider the potential for harm from iatrogenic effects (adverse effects of medical treatment) of treatment, particularly with long-term treatment, and must commit to reducing medical errors and harmful events. Iatrogenic conditions do not necessarily result from medical errors, such as mistakes made in surgery, or the prescription or dispensing of the wrong therapy, such as a drug.

22. In fact, intrinsic and sometimes adverse effects of a medical treatment are iatrogenic. The focus of reports from the Institute of Medicine regarding health care quality aim to reduce preventable harm to patients and improve favorable outcomes Summary: Ethical and legal duty to avoid harming others, treatment procedure and rights of patients and also how you treat your employees in your practice as a health care provider

23. Medical malpractice An act or omission by a health care provider that deviates from accepted standards of practice in the medical community which causes injury to the patient.

24. Justice The distribution of scarce health resources, and the decision of who gets what treatment “fairness and equality” The burdens and benefits of new or experimental treatments must be distributed equally among all groups in society

25. The four main areas that Health care provider must consider when evaluating justice 1.Fair distribution of scarce resources 2.Competing needs 3.Rights and obligations 4.Potential conflicts with established legislations

26. Fidelity Loyalty The promise to fulfill all commitments The basis of accountability Includes the professionals faithfulness or loyalty to agreements, responsibilities accepted as part of the practice of the profession

27. Confidentiality Anything stated to health-care providers by patients must remain confidential The only times this principle may be violated are: –If patients may indicate harm to themselves or others –If the patient gives permission for the information to be shared

28. Veracity This principle implies “truthfulness” physician need to be truthful to their clients Veracity is an important component of building trusting relationships

29. Accountability Individuals need to be responsible for their own actions Physicians are accountable to themselves and to their colleagues

30. Ethical Dilemmas Occur when a problem exists between ethical principles Deciding in favor of one principle usually violates another Both sides have “goodness” and “badness” associated with them

31. Why call an Ethics Consult? Ethics Consult can help: –Discover and understand the issues –Serves as a forum for sharing of concerns and questions –Identifies possible treatment alternatives –Provides guidance to the staff, patient, and family members –Resolves conflicts

32. Assessment Planning Implementation Evaluation

33. Approach to Ethical Dilemma

34. Ethical Decision Making Process Describe the problem Gather the facts Clarify values Note reactions Identify ethical Principles Clarify legal rules Explore options and alternatives Decide on a recommendation Develop an action plan Evaluate the plan

35. Autonomy? Nonmaleficence? Beneficence? Justice? Fidelity? Confidentiality? Veracity? Accountability? Is there an Ethical dilemma?

36. What would you do? Tell “new” physician to get on board with the rest of the healthcare providers in following the wife and daughter’s request… Tell the patient that his wife and daughter are keeping information from him… Do nothing… Call for an ethics consult?

37. Ethical Decision Making Process Describe the problem Gather the facts Clarify values Note reactions Identify ethical Principles Clarify legal rules Explore options and alternatives Decide on a recommendation Develop an action plan Evaluate the plan

38. Resolution Ethics spoke with Attending physician and plan was to speak first with daughter and wife regarding their role as health care surrogates. Attending physician, healthcare team, and ethics would then meet with patient and inquire if he wanted information regarding his prognosis and/or medical care. After speaking with daughter, wife, and patient individually and obtaining a clearer understanding of the patient’s wishes, and the clarification of the healthcare surrogates role, a family conference would be scheduled with health care team and family to summarize the findings…

39. Resolution Things never go as you plan them… Daughter refused to have wife speak with the team Daughter wanted to be part of the conversation when attending spoke to her father to inquire if he wanted information or not… Attending agreed to let daughter be present during the conversation (mistake)

40. Case 88 year old male with extensive medical history including end stage Parkinson's disease. He was admitted due to pneumonia and was intubated and now is in Intensive care unit. Patient’s wife was identified as proxy since patient had never completed an Advance Directive or had a Living Will. 2 weeks have passed and patient has been unable to be weaned from ventilator. Wife continues to indicate she wants to take patient home on the ventilator… Attending physician did not feel that wife’s request to take patient home were realistic nor did he feel patient would have “a good quality of life.” His recommendations were Comfort Measure/Withdraw of life support.

41. Case # 2 Continued Palliative Care is involved and many family conferences have been held. Wife refuses to make patient a Do Not Resuscitate, or sign any type of withdrawal papers. She wants “full care” She continues to verbalize she wants to take patient home. Wife had full time 24 hour care team at home taking care of patient and she wants to take him home. Ethics consult is called by attending physician….

42. What would you do? Try to convince wife that a DNR would be the best for the patient in his condition… Speak to physician to find out what he plans to do next… Call for an ethics consult

43. Ethical Decision Making Process Describe the problem Gather the facts Clarify values Note reactions Identify ethical Principles Clarify legal rules Explore options and alternatives Decide on a recommendation Develop an action plan Evaluate the plan

44. Resolution Palliative Care and ethics consultant met with wife and she understood that if he went home, he would have to have a tracheotomy. Recommendations from team was to arrange Respiratory department to show caregivers and wife how to take care of patient once he was at home with tracheotomy. Wife agrees to tracheotomy and a consult is requested. Wife was also informed of him having to go to a skilled nursing facility first and then after he was stronger would be able to go home. Patient was trached and discharge to skilled nursing facility for rehab.

45. Case #3 54 year old male - history of previous subdural hematoma, HTN, and atrial fibrillation. Patient aspirated and coded. He is in intensive care unit on ventilator and Dopamine for hemodynamic stability. Attempts at weaning have been unsuccessful…wife (healthcare surrogate) signed consent for tracheotomy in order for patient to be weaned off ventilator as recommended by pulmonologist… On the same day wife signed consent for tracheotomy, Primary Care Physicians during rounds feels that his prognosis is poor, and his recommendation for plan of care is to have patient made CMO and eventually withdrawal of life support should be initiated, he did not agree with pulmonologist recommendations… Pulmonologist does not agree with current plan to make patient CMO and withdrawal and wants to continue therapy…”he can improve, give him time”.

46. Case #3 Cont. Pulmonologist contacts wife regarding the scheduling of the tracheotomy, and is surprised to find out that she has signed papers for Comfort Measures Only & withdrawal of ventilator… Family is now confused with conflicting goals of care…wife has agreed to CMO and withdrawal of vent after speaking with attending but is still not sure she is doing the right thing…she would like to give time but “how long?” Staff is torn between wife’s decision and her verbalization of “confusion” and physician’s recommendations and conflicting opinions by pulmonologist and attending physician… Pulmonologists calls for ethics consult…patient is not withdrawn awaiting ethics recommendations…

47. What would you do? Tell wife attending is right and she should sign the CMO papers… Tell wife she should get a pulmonologists second opinion… Call Risk Management because of the conflict between the attending and pulmonary doctor… Call attending and tell him wife is confused… Do NOTHING! ** Ethics Consult was requested by pulmonologist…

48. Resolution Social Work and ethics chair spoke individually to attending and pulmonologist to clarify goals of care and prognosis. Social Work and ethics consultant spoke with patient's wife and she verbalized her confusion but had agreed to sign CMO and Withdrawal of life support at the time because she didn’t really understand what that meant… Wife wanted to give her husband a chance to be weaned off ventilator and she rescinded the CMO and Withdrawal of Life Support forms Patient had the scheduled trache done the following day Patient was transferred to vent floor and was transferred to long term care facility for rehab…