EUTHANASIA 101212

Greek-Roman period - A noble death - No role for doctors

17th

century - Medical assistance in good dying - No active intervention

19th

century - Active medical intervention

Euthanasia

The intentional termination of life of a person by someone else upon the formers request.

Respect for patients autonomy and freedom of choice Why are there requests for euthanasia?

When the following needs of terminally ill patients are not properly addressed: - Physical - Mental - Social - Spiritual

Countries where it is legally accepted:

Netherlands

Belgium

USA (Oregon, Washington) Netherlands

Voluntary and well-considered request by the patient

Hopeless and unbearable suffering on the part of the patient

The doctor informed the patient about the situation and his prospects, and come to conclusion with the latter that there is absence of other reasonable solutions

Physician must consult at least one other independent physician

Good medical practice

Things to consider

Hopelessness - Not determined by patient alone - Medical irreversibility

Unbearability

Euthanasia can never be an option for a psychiatric patient Euthanasia (Netherlands) 2001

768 doctors

87% - euthanasia is justifiable

57% have carried out euthanasia

10% will not carry out but will refer

1% reject euthanasia, will not carry out nor refer Euthanasia and Palliative Care

There is a direct connection between the quality of palliative care and the demand for euthanasia. The demand decreases if the quality of care increases.

Good palliative care cannot prevent or take away all requests for euthanasia.

Important things to remember:

Life is a gift from God

Transgresses Thou shall not kill.

Deplorable shift in the vocation of medicine

Undermine trusting relationship between caregivers and patient and their families

Request for euthanasia is just a protest against situation of suffering and anxiety.

Med Ethics Genetics

Diseases with established genetic predisposition Cancer CVD Dementia Cystic fibrosis Huntingtons disease Diabetes

Genetic Testing/Screening

More knowledge re Human Genome

Future of pharmacogenetics

3rd

party interest (Health Insurance, etc)

Genetic Testing for individual situation, individual (a family member) takes the initiative, genetic condition present.

For population/ groups, little or no information/ direct experience, health authorities take the initiative/chose target groups.

Forms of Genetic Testing

1. Diagnostic 2. Predictive (pre-symptomatic, predisposition) 3. Reproductive 4. Pharmacogenetic

Benefits of Genetic Testing/Screening

1. Certainty-better planning f life decisions 2. Prophylactic/preventive measures 3. Avoidance of future pain/suffering 4. Alleviate burden in the society 5. Avoidance of serious side effects 6. More effective drug use 7. Savings in health costs 8. Personalized drugs

Potential harm of genetic testing/screening 1. difficult decisions 2. psychological stress (loss of hop, anxiety, etc.) 3. Family tension 4. Stress-diet and lifestyle modifiaion 5. Exclusion 6. Marginalization

Gene Therapy

1. personalized treatment 2. avoidance of pain/suffering 3. lesser burden to family and society 4. loner life 5. better quality of life

Embryo experimentation - a tempting pre-requisite/consequence of gene therapy - opens legalizations of abortion to societies

Ethical Considerations

- values and rights - bioethical principles; respect for persons, beneficence, non-malifecence,

justice, solidarity.

Abortion

Debate Should abortion be legalized in our country?

3 views on moral assessment of abortion

I. Pro life

Abortion is seldom if ever morally acceptable

Fetus = person from the moment of conception

Abortion= killing

Declaration of procured abortion (SCDF, Feb 1987) o Life is at the same time a gift and responsibility o Man can never be treated simply as a means to be disposed of

in order to obtain a higher end. o The first right of human is right to life

II. Pro-choice

Fetus is not equal to human person.

Abortion is almost always justifiable

Asymmetry in the moral status of the fetus and the pregnant woman III. Intermediate

Abortion is sometimes morally permissible

Depends on the fetus prospect for future health and welfare

Womans reason for seeking abortion

Stage of fetal development.

MEDICAL ETHICS NOTES

ETHICAL CASE DELIBERATION

Morals/ Morality entirety of intuitions, beliefs, convictions and considered judgments

Ethics the systematic reflection and deliberation about morals and morality

The Nijmegen Method

1. What is the moral problem? o Moral we solve the problem ourselves o Clinical can be solved through case presentations, grand

rounds

2. Inventory of facts and interpretation o Medical diagnosis, therapy, prognosis o Nursing o Patients values and social situation

Patients view on life Religious community; pastoral care Patients view of his illness Social background Effect of illness to patients family, his life

o Organizational

3. Moral evaluation

4. Decision-making SPECIAL CIRCUMSTANCES IN DEALING WITH ETHICAL CASES

1. Children 2. Incapable patients 3. Patients undergoing long-term treatments

ASSISTED REPRODUCTIVE TECHNOLOGY

1. Ovulatory 2. Artificial Intrauterine Insemination (IUI)

o Homologous o Heterologous

3. In-Vitro Fertilization separates the unitive and procreative aspects of marriage; involves intracytoplasmic sperm injection (ICSI)

RESPONSIBILITY TOWARDS LIFE

1. Vulnerable, fragile A. Not to harm but to safeguard

Thou shall not kill. B. Do not put life at a disproportionate risk

Embryonic cell research In-vitro Fertilization

Do good.

Uphold the intrinsic dignity of the human person

Born within and from marriage in an act of conjugal love o Technology over humanity, i.e. IVF, surrogate pregnancy,

gamete donation, etc. Promote life.

Within the nature of man. (Technology should not replace this) Used as a means

To save a name, legacy, marriage, therapeutic cloning

MEDICAL ETHICS LECTURE (081712) XU-JPRSM Batch 2014

MEDICAL UTOPIAN IDEAS

Life without disease or pain

Overcoming of the aging process

Improvement and perfection of man GENETICS

Diseases with established genetic predisposition: o Cancer o Cardiovascular diseases o Dementia o Cystic Fibrosis o Huntingtons Disease o Diabetes

GENETIC TESTING/ SCREENING

More knowledge regarding the human genome

Future of pharmacogenetics (advantage)

Third party interest (Health insurance, etc.)

Genetic testing for individual situation, individual (a family member) takes the initiative, genetic condition present.

TESTING SCREENING

Initiative come from individuals themselves

Initiative comes from health authorities/ government to

allocate budget for the susceptible individuals

Parents with DM who want to check if their 5 children have the disease so that they can modify the risk factors already present.

For populations/ groups, little/ no information/ direct experience,

health authorities take the initiative and choose the target

groups

FORMS OF GENETIC TESTS:

1. Diagnostic for those already having the s/sx 2. Predictive (pre-symptomatic, predisposition) checking individual

status before getting married whether 1 of them carries the gene of a special disease that can be passed on to their future children

3. Reproductive

4. Pharmacogenetic eg. Some medications are tailor-made to avoid specific reactions

BENEFITS

Certainty better planning of life-decisions

Prophylactic/ preventive measures

Avoidance of future pain/ suffering

Alleviate burden in the society

Avoidance of serious side effects

More effective drug use

Savings in health costs

Personalized drugs POTENTIAL HARM OF GENETIC TESTING/ SCREENING

Difficult decision

Psychological stress (loss of hope; anxiety, etc.)

Family tensions children might blame their parents

Stress diet and lifestyle modification

Exclusion

Marginalization (insurance problems) GENE THERAPY

Personalized treatment

Avoidance of pain and suffering

Lesser burden to the family and society

Better quality of life EMBRYO EXPERIMENTATION

A tempting prerequisite/ consequence of gene therapy

Opens legalization of abortion to societies

Devaluation of human life

Respect to human life is violated ETHICAL CONSIDERATIONS

Values and rights

Bioethical principles: o Respect for persons o Beneficence o Non-maleficence o Justice

o Solidarity ABORTION

3 views: o Pro-life o Pro-choice o Intermediate

PRO-LIFE

Abortion is seldom, if ever morally evil

Fetus = person killing

Declaration on Procured Abortion (SCDF, Feb 1987) o In the image of God man was made o Life is at the same time a gift and a responsibility o The first right of the human person is his life

PRO CHOICE

Abortion is almost always justifiable

Asymmetry in the moral value of the fetus and the pregnant woman

Woman fetus INTERMEDIATE

Abortion is sometimes morally permissible

Depends on: o Fetus with respect to future health and welfare o Womans reasons for selecting abortion o Stage of fetal development

MEDICAL ETHICS 2ND

YEAR NOTES XU-JPRSM Batch 2014

PRINCIPLES OF STEWARDSHIP, ACCOUNTABILITY, and TOTALITY

Stewardship

Man is only a steward

Everything in this planet is a gift from God

Man has the responsibility to improve, to care, to cultivate, and to respect each others capabilities and limitations

Man is accountable for what he is, what he is capable of doing, and what he makes of himself.

Ownership Stewardship

To have dominion over something

Freely given

Involves control Involves taking care of the gits

Issues involving stewardship: a) Assisted reproduction b) Face-lift, liposuction, breast augmentation c) Use of prosthetic legs and tooth braces d) Use of memory-enhancing drugs e) Human experimentation

Whatever you do, see to it that your motivation is good, and that the effect will be good for you, the society, and the environment.

Informed consent is important the person involved should be aware of the risks and the available alternative that he/ she can have.

Weigh the benefits from the potential risks (involves the Principle of Double Effect).

Totality

Wholeness; it involves not only the physical but also the spiritual, emotional, intellectual, and social aspects of the person as well.

Individual parts versus the whole

Removal of a diseased organ versus removal of a healthy organ

Totality is compromised when vital structures are damaged.

CONFIDENTIALITY, COOPERATION, PROMISE KEEPING, and TRUTH-TELLING

Confidentiality

An essential element of a good physician-patient relationship

Based on respect for person, trust

What a health worker knows about the patient he keeps to himself, he CANNOT tell others.

Why is confidentiality important?

To develop trust from the patient

To promote peace What information should be held confidential?

Those which can hurt the dignity of the patient

Names/ identities of patients with specific diseases To what extent should confidentiality be kept?

When keeping the secret already harms others

Violation is permitted if the greater good is at stake.

Secrets should be revealed if it can already endanger the lives of others. This is done to avoid further harm to those who are immediately at risk. e.g. The family of a patient with communicable disease.

Before revealing the secret to a third party, the doctor should ask permission from the patient.

Cooperation

The participation of more than 1 person with another (primary agent) to produce a particular/ joint effect.

Considered problematic when the action of the primary agent is morally wrong.

Kinds: 1. Formal 2. Material

a) Immediate b) Mediate

Formal

The secondary agent willingly participates, agrees, advises, counsels, promotes, or condones

The co-operator is equally guilty as the principal agent

Material

The co-operator does not willingly participate Immediate Material

The action of the co-operator is inherently borne to the performance of the evil action

Equally guilty with the primary agent.

Mediate Material

Not one with another in action and intention

Doing good/ indifferent action that provides occasion of sin to another; or give assistance, means, or preparation for the sinful action of another.

Promise Keeping

Dependence, trust, and open communication

Health care workers have duties to the patients which may conflict with other entities (government, company, teaching, research society)

Doctors are the patients advocates Truth-telling/ Veracity

An essential part of a good patient-doctor relationship

An essential component of informed consent

An art, especially when communicating disturbing news

Comprehensive, accurate, and objective transmission of information, and at the same time fostering the patients understanding

Elements of the art of clinical communication: a) To whom? b) When? c) Where? d) By whom? e) Mitigating factors f) Voluntary refusal g) Understanding by the patient

THE HEALTH CARE PROVIDER

The Health care provider:

Is committed to health care.

Is invested with authority moral or expert authority

Is responsible to the patients, his profession, and to the society

Should be competent; has scientific and interpersonal skill

Has a right to cooperation, just compensation, respect, and good reputation

Has the right to refuse a patient Virtues

Acquired habits or the disposition to do what is morally right Virtues of Health care professionals:

1. FIDELITY

Faithfulness

Keeping promises to patients, colleagues and superiors

Keeping the patients best interest first

2. HONESTY

Truthfulness to the patient, his family, to fellow colleagues and to the society

Telling the truth with regards to the patients illness, its nature, prognosis, effectiveness of care and research findings

3. INTEGRITY

Wholeness

Coherence

Doing what you are saying.

4. HUMILITY

Recognizing ones capabilities and limitations

Recognizing that the patient knows what is best for him.

5. RESPECT

Paying attention to others (patient, colleagues, etc.)

6. COMPASSION

Loving kindness

Feeling for those who suffer

Self-sacrifice voluntarily given for the benefit of another without counting the cost.

E.g. Working even beyond duty hours

7. PRUDENCE

Foresight

Habitual deliberateness, caution, and circumspection in action

Looking before you leap.

Consider different options before making a decision

Know your patient first before you reveal the truth

8. COURAGE

Doing what one sees as right without undue fear

Standing up against what one sees as wrong even if it means standing up alone.

Goes hand-in-hand with honesty Vices

1. PRIDE

Inordinate self-esteem; conceit

A behaviour of superiority over others

2. GREED

Inordinate acquisitiveness (wealth, position, power)

Asking for a fee that is too much Developing virtues

A physician cannot buy or rent a virtue. He must develop it.

Each one has the potential to have it

It requires effort to cultivate and nurture

Without virtues, health care delivery becomes nothing more than a business contract.

With virtues, your service becomes priceless.

A reminder: Providing health care is not a career but a vocation.

RELIGIONS INFLUENCE IN BIOETHICS

Different religions have different views

Some scholars in Islam believe that life begins 40 days after birth

It is important to consider the views of your patients and colleagues

Religion has a great influence in Bioethics.

Extraordinary measures: a) Use of mechanical ventilator b) Use of medicines like Epinephrine to revive the patient c) Use of dialysis

In the end, the intention is whats most important.

MEDICAL ETHICS FIRST BIMONTHLY EXAM

XU-JPRSM Batch 2014 I. Choose the best answer.

1. A 78-year old woman has stage IV breast CA. She had a heart attack a week ago and is now conscious and coherent. As the attending physician, her daughter asked you not to tell her mother that she has cancer. What bioethical principle was violated?

ANS: Principle of Autonomy

2. Elsa had ectopic tubal pregnancy. Her doctor did a salpingectomy. What bioethical principle was involved?

ANS: Beneficence

3. A 16-year old girl underwent a bilateral mastectomy because her mother was diagnosed to have breast carcinoma. What bioethical principle was violated?

ANS: Non-maleficence

4. MC, 56 years old, a chain smoker, had an acute myocardial infarction. AN, 54 years old, a non-smoker, was admitted due to severe pain. Both were advised to undergo coronary artery bypass. Only one cardiac catheter was available in the locality. What bioethical principle is involved?

ANS: Justice

5. In ethical case deliberation, the following are included in the medical facts, except:

A. Diagnosis B. Arrangements in patients care C. Prognosis

D. Treatment interventions

6. Which of the following is not a function of the Healthcare Ethics committee?

A. Consultation B. Request for acquisition of new high-tech gadgets C. Policy/ guideline development D. Multidisciplinary discussion

7. Giving up ones claim on a health care resource so that those who can

benefit more from it can have it. ANS: Solidarity

8. Milo, an office employee, had a sprained ankle. He asked his doctor to

admit him in a hospital so that he can charge his expenses to his company and so that he can be excused from his work. What virtue of a physician is at stake?

ANS: Veracity

9. We are always morally required to perform all possible acts of generosity that would benefit others.

ANS: False

10. The Principle of Double Effect includes the following, except: A. The good effect is the intended effect B. The act is indifferent if not good C. The effect always justifies the means D. There is a proportionate reason why the bad effect was

allowed

11. This is a positive aspect of the Healthcare Ethics Committee: A. Diffusion of responsibilities B. Wide scope of the agenda C. Enhance the education of all involved D. Takes longer time to arrive at a decision

12. Biomedical ethics came about due to:

A. Socio-cultural changes B. Emergence of modern medical technologies C. None of the above D. All of the above

13. Patients autonomy includes the following:

A. Being spared from knowing his illness B. Be informed only of modern interventions C. His involvement in the decision-making process D. Family values, opinions, and judgment prevail

14. Informed consent is an expression of what bioethical principle?

ANS: Autonomy

15. The bioethical principle that is concerned of distributing health resources to the greatest number of population:

ANS: Justice

16. Elsa is 34 years old, single, who works in a bank. She does not want to get married but she badly wants to have a child. She came to your fertility clinic for an IVF. She does not want to know any data about the sperm donor.

ANS: Autonomy

17. Mario and Glenda would like to have another baby. Sue, their first child is 4 years old and is suffering of Leukemia. No one among their relatives is histocompatible with Sue. They went to a clinic for IVF so that they can choose only the histocompatible embryo to be transferred for implantation.

ANS: Autonomy

18. A researcher at an infertility clinic is making use of the 3 years old excess human embryos. The clinic tells their clients that they will keep their excess embryos for 5 years.

ANS: Autonomy