Medical EthicsMedical Ethics

Medical Ethics [vs. Professional ethics]

Ethical dilemma is a predicament in which there is no clear course to resolve the problem of conflicting moral principles

Principles

Autonomy Beneficience Nonmaleficence Justice

Autonomy

Freedom to influence course of life/treatment– Requires the person to be competent in

decision making capacity

Preservation of Autonomy

Living Will• Takes effect when terminally ill and lacking

decision making capacity

Surrogate Decision Makers– Represents patients interest

Preservation of Autonomy

The primary responsibility of the physician is to serve the patients interest

The patient self determination act of 1990

At the time of admission information re: the patients’ right to refuse care or create an advance directive must be dispensed

Informed Consent

Patient is presented all alternatives so they can make a decision. Must be competent

Requirements– Decision making capacity– Volutariness– Reasonable person standard

Present all alternatives f/b recommendation Respect refusal All surgical and experimental procedures

Implied Consent

Invoked when in emergency situations when harm would result without urgently needed intervention

Disclosure

Truth telling on part of physician is an integral part of patient autonomy

Paternalism

Justifiable if patient at risk of significant preventable harm, paternalistic action will prevent harm, benefits outweigh risks and the least autonomy-restrictive course of action is used

Confidentiality

Obligation of physician to maintain information in strict confidence

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

The percentage of patients who would like to be told their diagnosis if it is a:

Metastatic cancer Terminal Prognosis

European Americans 87% 69%African Americans 88% 63%Mexican Americans 65% 48%Korean Americans 47% 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

Beneficience

Obligation to preserve life, restore health, relieve suffering and maintain function

To do “good” Nonabandonment – obligation to provide

ongoing care Conflict of interest – must not engage in

activities that are not in patients best interest

Nonmaleficence

“Do no harm”

Justice

Allocation of medical resources must be fair and according to need

Physicians should not make decisions regarding individuals based upon societal needs

DNR

DNR orders affect CPR only Other therapies should not be influenced

by DNR order Should be reviewed frequently Rationale should be in medical record

Persistent Vegetative State

Uncnsciousness/ loss of self awareness lasting more than weeks

Supreme court draws no distinction between artificial feeding, hydration vs. mechanical ventilation

Death

Irreversible cessation of circulatory and respiratory function

Irreversible cessation of all brain function (including brainstem)

Ethical Dilemas

Euthanasia– Legally prohibited in the US except in Oregon

which permits MD assisted suicide

Destroying Frozen Embryos

Case Studies

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.

Case Studies

22 year-old woman, is admitted to the hospital with a headache, stiff neck and photophobia but an intact mental status. Lab tests reveal contagious meningitis. She refuses treatment for it.

A 25 year old woman victim of a single car MVA enters a persistent vegetative state. After four years, her parents petition to have her feeding tube removed. The hospital insists on a court order, and the victim’s closest friend and parents testify that she would not have wanted to have a feeding tube.