1. The Culture of Healthcare Ethics and Professionalism Lecture c This material (Comp2_Unit8c) was developed by Oregon Health and Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015.

2. Ethics and Professionalism Learning Objectives Provide an orientation to ideas about medical ethics and professionalism (Lecture a) Explore the relationships among ethical ideals, professionalism, and legal duties (Lecture a, b) Apply the general principles of ethics and professionalism to specific topics (Lecture c, d) Examine ethical issues in health informatics (Lecture d) 2 Health IT Workforce Curriculum Version 3.0/Spring 2012 Ethics and Professionalism Contemporary Topics in Medical Ethics Lecture c

3. Contemporary Topics in Medical Ethics Informed consent End-of-life issues Conflicts of interest Healthcare disparities Conscientious objection 3 Health IT Workforce Curriculum Version 3.0/Spring 2012 Ethics and Professionalism Contemporary Topics in Medical Ethics Lecture c

4. Informed Consent Patients must: Be capable of making medical decisions Be provided with all relevant information Understand the information given Communicate a decision Make voluntary decisions 4 Health IT Workforce Curriculum Version 3.0/Spring 2012 Ethics and Professionalism Contemporary Topics in Medical Ethics Lecture c

5. Relevant Information Nature of the treatment –What is the purpose? –What will be done? Availability of reasonable alternatives Risks and benefits of proposed treatment 5 Health IT Workforce Curriculum Version 3.0/Spring 2012 Ethics and Professionalism Contemporary Topics in Medical Ethics Lecture c

6. Examples of Exceptions to Informed Consent Requirement Patient lacks mental capacity –Adult with severe developmental disability –Adult has severe dementia Children usually lack legal capacity Implied or presumed consent in an emergency –Patient is unconscious OR lacks capacity AND –No surrogate decision-maker is available 6 Health IT Workforce Curriculum Version 3.0/Spring 2012 Ethics and Professionalism Contemporary Topics in Medical Ethics Lecture c

7. End-of-Life Issues Definition of death can be unclear –Can a person be “alive” if their heart has stopped beating? –Can a person be “dead” if they are still breathing? Other prominent end-of-life issues –Medical futility –Advance directives 7 Health IT Workforce Curriculum Version 3.0/Spring 2012 Ethics and Professionalism Contemporary Topics in Medical Ethics Lecture c

8. Medical Futility Treatment would not improve the patient’s condition –Decision considers the unique situation of an individual patient –Should be consistent with general professional standards Relationship to healthcare “rationing” –Advocates say there is no cost/benefit analysis –Question is benefit of treatment for individual 8 Health IT Workforce Curriculum Version 3.0/Spring 2012 Ethics and Professionalism Contemporary Topics in Medical Ethics Lecture c

9. Arguments about Futility ProsCons Spares patient pain, expense, and inconvenience of unnecessary treatment Increases chances that patient will receive more appropriate care Saves healthcare resources Care could be labeled as futile to divert resources from disadvantaged populations Definitions of what is futile are unclear Treatments that patients consider beneficial could be limited or eliminated if providers consider them futile 8.7 Table: Pros and Cons of medical futility (CC BY-NC-SA 3.0, 2012). 9 Health IT Workforce Curriculum Version 3.0/Spring 2012 Ethics and Professionalism Contemporary Topics in Medical Ethics Lecture c

10. Advance Directives Living will –“Do not resuscitate” –Wishes regarding artificial food or drink Durable power of attorney for healthcare –Designates someone to make decisions –Can be combined with instructions in living will 10 Health IT Workforce Curriculum Version 3.0/Spring 2012 Ethics and Professionalism Contemporary Topics in Medical Ethics Lecture c

11. Arguments about Advance Directives ProsCons Preserves patient autonomy Prevents waste of resources Helps family know patient’s wishes May lead to undertreatment May be motivated by fear Can waste providers’ time 8.8 Table: Pros and Cons of advance directives (CC BY-NC-SA 3.0, 2012). 11 Health IT Workforce Curriculum Version 3.0/Spring 2012 Ethics and Professionalism Contemporary Topics in Medical Ethics Lecture c

12. Conflict of Interest “A conflict of interest is a set of circumstances that creates a risk that professional judgment or actions regarding a primary interest will be unduly influenced by a secondary interest.” 12 Health IT Workforce Curriculum Version 3.0/Spring 2012 Ethics and Professionalism Contemporary Topics in Medical Ethics Lecture c Institute of Medicine. 2009. Conflict of Interest in Medical Research, Education, and Practice. Washington, DC: The National Academies Press.

13. Primary and Secondary Interests in Medical Practice PrimarySecondary The welfare of patients The integrity of medical research The quality of medical education Financial gain Desire for professional advancement Recognition for personal achievement Favors to friends and family or to students and colleagues 8.9 Table: Primary and secondary interests in medical practice (CC BY-NC-SA 3.0, 2012). 13 Health IT Workforce Curriculum Version 3.0/Spring 2012 Ethics and Professionalism Contemporary Topics in Medical Ethics Lecture c

14. Physician Compensation Payment for each service –Can motivate physicians to inappropriately increase the number of services they provide –Can motivate selection of services that have a high profit margin Flat fee per patient –Can motivate undertreatment 14 Health IT Workforce Curriculum Version 3.0/Spring 2012 Ethics and Professionalism Contemporary Topics in Medical Ethics Lecture c

15. Healthcare Disparities Differences in access to healthcare Differences in quality of healthcare Differences in overall health Most frequent comparisons are by: –Socioeconomic status –Race –Presence or absence of disability 15 Health IT Workforce Curriculum Version 3.0/Spring 2012 Ethics and Professionalism Contemporary Topics in Medical Ethics Lecture c

16. Causes of Health Differences Natural biological variation Voluntary participation in potentially health- damaging activities, such as certain sports Exposure to unhealthy, stressful living and working conditions Inadequate access to essential health services and other basic services 16 Health IT Workforce Curriculum Version 3.0/Spring 2012 Ethics and Professionalism Contemporary Topics in Medical Ethics Lecture c

17. Systematic Discrimination 3 features, when combined, turn a mere differences in health into a social inequity in health: The difference is systematic The difference is socially produced, and therefore modifiable The difference is unfair 17 Health IT Workforce Curriculum Version 3.0/Spring 2012 Ethics and Professionalism Contemporary Topics in Medical Ethics Lecture c

18. Conscientious Objection A healthcare professional’s moral or religious objection to a certain medical intervention Healthcare professionals have refused to provide medical interventions, for example: –Abortions –Sterilization procedures, such as vasectomy –Pain medications for terminally ill patients –Emergency contraception 18 Health IT Workforce Curriculum Version 3.0/Spring 2012 Ethics and Professionalism Contemporary Topics in Medical Ethics Lecture c

19. Conscience, Ethics, and Law Laws protect patients’ rights to access to medical interventions Laws protect medical professionals’ rights to refuse to provide certain medical interventions Laws vary from state to state 19 Health IT Workforce Curriculum Version 3.0/Spring 2012 Ethics and Professionalism Contemporary Topics in Medical Ethics Lecture c

20. Ethics and Professionalism Summary – Lecture c Informed consent is based in the duty to respect patient autonomy Caring for terminally ill patients involves thorny ethical questions about the definition of death, medical futility, and the use of advance directives Conflicts of interest can pose temptations Health inequities require system-wide solutions Conscientious objection represents a clash between professionals’ rights and patients’ rights 20 Health IT Workforce Curriculum Version 3.0/Spring 2012 Ethics and Professionalism Contemporary Topics in Medical Ethics Lecture c

21. Ethics and Professionalism References – Lecture c References Committee on Bioethics, American Academy of Pediatrics. Policy statement: physician refusal to provide information or treatment on the basis of claims of conscience. Pediatrics. 2009;124(6):1689-1693. del Carmen MG, Joffe S. Informed consent for medical treatment and research: a review. Oncologist. 2005;10(8):636-641. Institute of Medicine [Internet]. 2009 [cited 2011 Dec 27]. Conflict of Interest in Medical Research, Education, and Practice [436 pages]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK22942. http://www.ncbi.nlm.nih.gov/books/NBK22942 Pope TM. Legal briefing: conscience clauses and conscientious refusal. J Clin Ethics. 2010;21(2):163-176. Schneiderman LJ, Jecker NS, Jonsen AR. Medical futility: its meaning and ethical implications. Ann Intern Med. 1990;112:949-954. Tillyard AR. Ethics review: “living wills” and intensive care—an overview of the American experience. Critical Care. 2007;11(4):219. University of Minnesota Center for Bioethics [Internet]. 2005 [cited 2011 Dec 26]. End of Life Care: An Ethical Overview [75 pages]. Available from: http://www.ahc.umn.edu/img/assets/26104/End_of_Life.pdf.http://www.ahc.umn.edu/img/assets/26104/End_of_Life.pdf University of Washington School of Medicine [Internet]. Updated April 11, 2008 [cited 2011 Dec 26]. Edwards KA. Ethics in medicine: informed consent [1 page]. Available from: http://depts.washington.edu/bioethx/topics/consent.html. http://depts.washington.edu/bioethx/topics/consent.html 21 Health IT Workforce Curriculum Version 3.0/Spring 2012 Ethics and Professionalism Contemporary Topics in Medical Ethics Lecture c

22. Ethics and Professionalism References – Lecture c (continued) World Health Organization Regional Office for Europe [Internet]. 1990 [cited 2011 Dec 27]. Whitehead M. The concepts and principles of equity and health [31 pages]. Available from: http://whqlibdoc.who.int/euro/- 1993/EUR_ICP_RPD_414.pdf.http://whqlibdoc.who.int/euro/- 1993/EUR_ICP_RPD_414.pdf World Health Organization Regional Office for Europe [Internet]. 2006 [cited 2011 Dec 27]. Whitehead M, Dahlgren G. Concepts and principles for tackling social inequities in health: levelling up, part 1 [45 pages]. Available from: http://www.euro.who.int/__data/assets/pdf_file/0010/74737/E89383.pdf. http://www.euro.who.int/__data/assets/pdf_file/0010/74737/E89383.pdf Charts, Tables, Figures 8.7 Table: Pros and Cons of medical futility (CC BY-NC-SA 3.0, 2012). 8.8 Table: Pros and Cons of advance directives (CC BY-NC-SA 3.0, 2012). 8.9 Table: Protection of whilstleblowers (CC BY-NC-SA 3.0, 2012). 8.9 Table: Primary and secondary interests in medical practice (CC BY-NC-SA 3.0, 2012). 22 Health IT Workforce Curriculum Version 3.0/Spring 2012 Ethics and Professionalism Contemporary Topics in Medical Ethics Lecture c