1. Ethics for Transfusion Medicine Residents Dr. Jerry Growe Prof. Michael McDonald

2.  Stop and look around:  there are Ethical matters of concern in Transfusion practice.

3. Part I. What is ethics?  Ethics as the systematic study of human conduct and moral judgement, including good/bad, good/bad, right/wrong right/wrong virtue/vice virtue/vice  Critical reflection on moral beliefs and practices What are people’s moral beliefs? What are people’s moral beliefs? What choices should we make? What choices should we make?

4. Moral psychology (Rest) 4 Components of Moral Behaviour 1. Ability to recognize a situation as having a moral component 2. Ability to make a judgement as to which action is right, fair, just, appropriate 3. Commitment to morally appropriate action 4. Possession of appropriate personal qualities (perseverance, courage) to carry out morally appropriate actions James Rest James Rest

5. Acquisition of moral values  Many values are “caught” rather than “taught” Importance of peers and workplace Importance of peers and workplace Socialisation and acculturation Socialisation and acculturation Life experiences Life experiences  Reflective engagement

6. Ethical judgements  Centre on important values  Based on reason, not authority  Override self-interest to assure mutual benefit  Based on impartial considerations  Special words and emotions  “All things considered judgements” Not optional add-on judgements Not optional add-on judgements Integrative or holistic Integrative or holistic

7. Learning objectives  Identify and discuss Some ethical issues in transfusion medicine Some ethical issues in transfusion medicine Methods for resolving ethical issues Methods for resolving ethical issues  Offer resources  Ethical Issues in Transfusion Medicine; aabb Ethical framework Ethical framework http://www.ethics.ubc.ca/people/mcdonald/decisions.htmhttp://www.ethics.ubc.ca/people/mcdonald/decisions.htmhttp://www.ethics.ubc.ca/people/mcdonald/decisions.htm Ethics lit search Ethics lit search http://bioethics.georgetown.edu/http://bioethics.georgetown.edu/http://bioethics.georgetown.edu/

8. Ethical judgements & principles  Ethical judgements involve a dual test: “Are the means acceptable?” AND “Are the means acceptable?” AND “Are the ends worthwhile?” “Are the ends worthwhile?”  Consensus principles in bioethics  Treat people with respect  Do no harm  Do good  Act fairly  Be caring

9. Part 2. Ethics & Transfusion  Clinical practice ethics centres on patient care  Requires Patient (or guardian) consent Patient (or guardian) consent Fairness to other patients Fairness to other patients  Within institutional parameters Licensing, medical appointment, general health care system authorisation Licensing, medical appointment, general health care system authorisation

10. Clinical Case #1 You received a phone call from a donor asking why a "Coombs" test, (DAT), or an HTLV test was done and reported positive to her. Should the donor be surprised? Did the donor truly give informed consent to the test?

11. Clinical case 2 The Special Services Nurse has brought cases to you on several occasions as he has wondered about your colleague's interpretation of the medical data, and the acceptance of the donors involved. You also have been informed through the grapevine that he frequently is unavailable by pager when on call and, as a result, three plateletpheresis donors have been disqualified. What should you do?

12. How does CBS manage the Altruistic Gift of Blood?  Obligations of the CBS: Not to harm the donor Not to harm the donor To use the donation appropriately To use the donation appropriately To ensure privacy and confidentiality To ensure privacy and confidentiality  Obligations of the Donor: To answer all questions truthfully To answer all questions truthfully Not donate if engaged in any risky activities Not donate if engaged in any risky activities

13. Research ethics basics  Research involving humans is a privilege, not a right!  Those who conduct research involving humans must meet norms for ethical research  The onus is on those who conduct, house or sponsor research to show these norms are met.

14. Three central questions 1. Does the research meet relevant scholarly/scientific standards? Bad science is bad ethics Bad science is bad ethics Is the science honestly done and accurately reported? Is the science honestly done and accurately reported? 2. Will the likely net benefits of the research will outweigh overall harms? 3. Does the research respect the rights of the research subject, including Protection from undue harm & Protection from undue harm & Informed consent? Informed consent?

15. Norms for clinical research 1. Socially valuable research 2. Scientifically sound research 3. Fair subject selection 4. Favourable risk-benefit ratio 5. Independent review by an REB 6. Informed consent 7. Respect for actual and potential research subjects in the conduct of research Emmanuel et al. JAMA 2000

16. CBS REB  RESEARCH REGISTRATION  RESEARCH ETHICS BOARD APPLICATION  GUIDANCE DOCUMENT

17. Research case  A physician-researcher you know at the provincial cancer agency asks that you provide her with left-over blood from routine medical tests of patients with a certain type of tumour in order to test a research hypothesis she has about tumour growth. She also asks that you do a chart review of these patients. She offers you co-authorship on the resulting publication. What should you do? Are there are any special rules and procedures to follow with the use of blood for research purposes?

18. Blood Contingency Planning in BC  To ensure a consistent and coordinated approach to blood shortages.  Guidelines activated at Red Alert phase.  PBCO and CBS will coordinate.

19. Principles from BC Plan  All patients in BC should have equal access to the available blood on the basis of need. No hospital should stockpile blood for “its” patients.  When available resources are exceeded, the focus should shift from doing the best for the individual patient to the public health goal of doing the greatest good for the greatest number. May include suspension of prophylactic transfusions and elective procedures and cessation of transfusion support in terminal or moribund patients May include suspension of prophylactic transfusions and elective procedures and cessation of transfusion support in terminal or moribund patients  Blood inventory transparency is essential in a shortage. Decision- makers need to know what inventory is available in the province, regardless of whether it is at CBS or hospitals.

20. Assumptions from BC Plan  The supply of blood is insufficient to meet current or anticipated demand, despite ongoing efforts to increase the available supply.  Hospitals and CBS will share inventory information.  During a blood shortage, blood use will be triaged to ensure the most urgent cases receive the available supply.  Measures to ensure appropriate blood use and reduce waste during non-shortages contribute significantly to blood contingency preparedness.

21. Further Points to Consider  Guidelines for “stopping principles”  How to operationalize guidelines Under what circumstances will guidelines come into effect? Under what circumstances will guidelines come into effect? What is the decision-making process? What is the decision-making process? Who will make decisions? Who will make decisions? How will process and decisions be communicated? How will process and decisions be communicated? To attending physicians, staff, familiesTo attending physicians, staff, families How will process and decisions be documented? How will process and decisions be documented?