1. Medical Ethics Unit 19 HIV Care and ART: A Course for Healthcare Providers

2. 2 Learning Objectives  Explain the importance and utility of medical ethics  Describe the methodology of ethical deliberation  Analyze practical issues in the clinical setting from an ethics perspective

3. Skepticism and Medical Ethics Trainer Role Play

4. 4 Basic Rights and Ethical Duties  Human Rights  Access to health care  Right to non-discrimination  Right to privacy and confidentiality  Right to environment that is not harmful to health or well being Human Dignity

5. 5 Medical Ethics: Definition  The practice of medicine is rooted in a covenant of trust among patients, healthcare professionals, and society.  The ethics of medicine must seek to balance the healthcare professional’s responsibility to each patient and the professional, collective obligation to all who need medical care. The Council of Medical Specialty Societies, 2000 http://www.nyu.edu/gsas/dept/philo/faculty/ruddick/papers/medethics.html

6. 6 Utility of Medical Ethics  Medical ethics principles provide a framework for discussing ethical issues and for medical decision making  The principles provide consistent guidance where there are substantive considerations on both sides of an issue

7. 7 Ethical vs. Legal Obligations  Medical ethics and the law are not the same, but often help define each other  Breach of ethical obligation may not necessarily mean breach of law  Breach of ethical obligation may be used to prove medical malpractice or medical negligence

8. 8 Healthcare Professional Role  Paternalistic model Emphasizes health and well-being (beneficence) over respect for autonomy and patient choice Patient is selectively given information  Evolution of newer decision-making models Independent choice vs. enhanced autonomy Paternalistic vs. informative vs. interpretive vs. deliberative

9. 9 Patient Rights Health Care Worker Obligations Public Trust Interconnectedness of Rights, Trust, and Obligation

10. 10 Benetar’s Levels of Ethics in HIV/AIDS  Micro Level Individual doctor-patient relationship  Meso Level Civic and public health ethics, including equitable access to health care  Macro level Ethics of interdependance and international relationships

11. 11 Micro Level Ethical Principles  I. Respect for Autonomy (or Person)  Respect the decisions of autonomous persons and protect persons who lack decision-making capacity (e.g., confused pts, mentally ill).  Recognize the capacity of mentally and legally competent patients : To think and make decisions independently To act on the basis of their decisions To communicate their wishes to health workers  Uphold patient confidentiality

12. 12 Ethical Principles (2)  II. Non-Maleficence (Not inflicting harm)  Health professionals should not inflict harm on patients (Premum non nocere)  III. Beneficence  Act in the best interests of patients or research participants.  Contribute to patient welfare – help patients further health interests

13. 13 Ethical Principles (3)  Sometimes there is ethical tension between beneficence (attaining a beneficial outcome) vs. non-maleficence (not inflicting harm)  It is important to weigh the chance of success against risks of treatment

14. 14 Ethical Principles (4)  IV. Justice Requires that people be treated fairly. (It is often understood to require that benefits and burdens be distributed fairly within society.) Treat all patients equally – no unfair discrimination Distributive justice

15. 15 Informed Consent  Definition: A patient’s willing acceptance of a medical intervention after adequate disclosure from their MD of the nature of the intervention, risks, benefits and alternative treatment options  What constitutes informed consent? Disclosure: information to allow reasonable person to make a decision Understanding: comprehension of the information given Voluntary: no coercion or incentive to accept or deny a treatment Agreement: verbal or written (preferred) to discussed intervention

16. 16 Confidentiality  Patient confidentiality must be upheld  Breaching patient confidentiality may be merited only: When ordered by court of law – a court case Where statutory requirement – public health laws Where required in health professional’s defense – malpractice suit Where necessary for appropriate patient care- speaking to another provider in the medical care system

17. 17 Honesty  The percentage of patients who would like to be told their diagnosis if it is a: Metastatic cancer Terminal Prognosis European Americans87%69% African Americans88%63% Mexican Americans65%48% Korean Americans47%35% Ethiopians (can you guess?)??%??% Source: Blackhall LJ, et al. (1995) JAMA 274: 820-5.  The more traditional the culture … the less truth telling regarding patient condition

18. 18 Standards Declara- tions Capacity Ethics Committees Legislation/ Guidelines Ethics Teaching Awareness Academics/ Teaching/ Research Seminar/ Workshops/ Trainings OUTCOMES platforms for ethical action intensive public debate informed public opinion (inter)national normative frameworks morally sensitized professionals and health professionals assisted policy- making Framework for Medical Ethics Development in Ethiopia Publications

19. Case Studies

20. 20 Case Study: Lake  Lake, your 36-year-old patient, has just tested positive for HIV. He asks that you not inform his wife of the results and claims he is not ready to tell her yet.

21. 21 Case Study: Lielit  Lielit, a 22 year-old woman, is admitted to the hospital with a headache, stiff neck and photophobia but an intact mental status. Lab tests reveal cryptococcal meningitis, an infection commonly associated with HIV infection. When given the diagnosis, she adamantly refuses to be tested for HIV.

22. 22 Case Study: Berhan  Berhan, a 35 year-old man with AIDS, admits that he is often unable to take his medicines regularly because of his alcohol and chat addictions. His lab profile is consistent with immunological treatment failure.

23. 23 Case Study: Mihret  Mihret, a 27 year-old healthy looking mother, brings her 3 year-old son to a clinic with chronic diarrhea, weight loss, and failure to thrive. She reports that an older child died several years ago, at age 2. She is advised to have her son tested for HIV, but she adamantly refuses because of her fear of knowing her own HIV status and that of her husband.

24. 24 Case Study: Mikael  You are have been caring for a 12 year-old HIV- infected boy who has been clinically stable until recently. He now meets criteria for ARV treatment but you are very concerned because his mother has refused to allow disclosure of his HIV-status to him. He has been asking questions about why he keeps getting sick.

25. Medical Ethics27

26. 26 Key Points  The most commonly accepted principles of medical ethics include: Respect for Patient Autonomy Beneficence and Nonmaleficence Justice  Other principles include informed consent, confidentiality and honesty  Medical ethical discussions need to take into account the cultural situation in which they occur.