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ETHICS & DECISION-MAKING
I. Definition of Ethics
Ethics – The study of a system of decision-making
based on moral
Principals
Morality-traditions of belief about right/wrong human
conduct.
Values – differences
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ETHICS & DECISION-MAKING
“Ethics brings structure & order to the decision-making process about our responsibilities for patient care and institutional management”
Larry McCullough, PhD.
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ETHICS & DECISION-MAKING
Ethics should lead the Law Main discipline of Ethics is to follow
the arguments where they lead us
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ETHICS & DECISION-MAKING
“Medicine is the science of
uncertainty and the art of
probability”
-W.Osler, M.D.
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ETHICS & DECISION-MAKING
Families, Doctors, Nurses,Health care team members
No simple algorithms to follow
We have fiduciary obligations to our patients
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ETHICS & DECISION-MAKING Tools for Ethical Analysis
Clarity Consistency Coherence Clinical Applicability Clinical Adequacy
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ETHICS & DECISION-MAKING
II. Principles
Do good and Do no harm--Beneficence
(Obligation as foundations of social morality)
1. One should not inflict harm
2. One should prevent harm
3. One should remove harm
4. One should promote good
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ETHICS & DECISION-MAKING Principles
Justice – Persons should be treated equally
Many theories of justice
Respect for Autonomy – to allow person to act for
themselves
Responsibility for self and family
This means that the person understands
Consent
Disclosure of risk/benefits/complications
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ETHICS & DECISION-MAKING
III. Approaches to Care
Wait until certainty
1. Treatment started on every infant
thought to
have a chance
2. Collect all information before making
decision –
Decision to err on side of maintaining
life
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ETHICS & DECISION-MAKING
3. Aggressive approach in accordance
with
society that values individual(ism)
4. Price to pay may have some patients
with
severe handicaps to salvage that one
patient.
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ETHICS & DECISION-MAKING
Statistical Approach
1. Categorizes patients into groups which
would
benefit from care
2. Goal is to avoid creating severely
impaired
infants even at cost of those who might
have been normal
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ETHICS & DECISION-MAKING
Individualized Approach
1. Initiate care on infants who have a chance
2. Deciding as soon as possible if continuing
is in best interest of infant.
3. Decisions made before all information in
4. Problem – What degree of certainty is
necessary?
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ETHICS & DECISION-MAKING
Responsibility – Accountability
Process should be consistent
One needs to ethically justify one’s
decisions
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ETHICS & DECISION-MAKING
The technology is imperative -
1. Availability of technology
2. Does it mean we have to use it?
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ETHICS & DECISION MAKING
“Tyranny of the Normal”
1. Only acceptable outcome is normal
(subjective & varies from person to
person)
2. Worry about unrealistic expectations
3. Need to understand family value
systems
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ETHICS & DECISION-MAKING
IV. Principal of Best Interests
1. Patient can not speak for self.
2. Parents have responsibility for decision-
making.
Who are we treating – the patient or the family?
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ETHICS & DECISION MAKING
Certainly want:
1. Relief of suffering
2. Preservation or restoration of function
3. Quality of life – (subjective)
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ETHICS & DECISION-MAKING
Outcome
Anecdotal experiences both positive and
negative
How many times have we been wrong?
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ETHICS & DECISION-MAKING
IV. Principal of Proportionality
Treatment should lead to greater benefit
than burden.
One needs to agree on expectations
1. Curing the patients
2. Restoring patient to reasonable
quality of life
3. Minimizing pain & suffering
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ETHICS & DECISION-MAKING
V. Who Decides?
Decision-making Team
1. Physicians
2. Parents & Family
3. Other members of healthcare
team
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ETHICS & DECISION-MAKING
Today there is increased respect for patient autonomy
1. Role of parents in decision-making is increased
2. We should not be afraid to think out-loud
a. This closes the gap between
physician/parent.
b. Demonstrate the trial & error nature
of treatment.
c. Parents need time to process
information
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ETHICS & DECISION-MAKING Rationing-using limited resources
wisely Needs Ethical Impact Statement
Needs to meet rigorous standards Scientific Moral Economic
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ETHICS & DECISION-MAKING
Summary – Very Important
1. Honest decisions with patients and
family early
2. Awareness of power of decisions made
each hour
3. Responsibility of thinking
4. Justification of thought
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ETHICS & DECISION-MAKING
Summary – Very Important
5. Respect for life
6. An acceptable decision may mean no
intervention
7. Physician needs skill to help families explore
their values
8. Cannot leave family alone in decision-making
process
9. Decisions should be difficult
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Tools for Ethical Analysis
Clarity Consistency Coherence Clinical Applicability Clinical Adequacy