Medical Ethics and Professionalism

1. Richard L. Elliott, MD, PhD, FAPA Professor, Internal Medicine Director, Medical Ethics Mercer University School of Medicine Adjunct Professor Mercer University School of Law Medical Ethics and Professionalism

2. What would you do? Your patient tells you of the parents of a 16 year-old boy who lives next door. The boy appears ill, but has never seen a doctor because of his parents religious beliefs. The parents had a 15 month-old-granddaughter who died several months ago from pneumonia for which she also received no medical care.

3. Neil Beagley, died 2008 at age 16 Oregon parents guilty of negligent homicide in son's death By WILLIAM McCALL The Associated Press OREGON CITY, Ore. — Oregon parents were found guilty Tuesday of criminally negligent homicide for praying over their ill son instead of seeking medical help. The jury returned the verdict on the second day of deliberations in the trial of Jeff and Marci Beagley, both members of the Followers of Christ Church in Oregon City. Church members gasped as Judge Steven Maurer read the verdicts. The couple, who remain free on bail, are scheduled for sentencing Feb. 18. Because neither has a prior conviction, state sentencing guidelines call for 16 to 18 months in prison. Prosecutors said the Beagleys had a duty as parents to provide medical care for their 16-year-old son, Neil, who died in 2008 of complications from a urinary-tract blockage. The defense argued the teen had symptoms more like a cold or the flu. The couple and other church members at the hearing declined to comment Tuesday. Wayne Mackeson, Jeff Beagley's attorney, said they would consider an appeal. "It's never been a referendum on the church. This case involves parents who didn't understand how sick their child was," he said. The Followers of Christ Church shuns conventional medicine in favor of faith healing. The church has been in Oregon City since early in the 20th century. Its members, by their own description and that of others, keep to themselves. State authorities have found that an unusual number of children whose families belonged to the Followers of Christ had died at an early age, leading to a 1999 state law that eliminated faith healing as a defense in some manslaughter cases. The trial of the Beagleys was the second major faith-healing trial since the law was changed, although previous laws on criminally negligent homicide applied in their case. Greg Horner, the chief deputy district attorney, also prosecuted the faith-healing trial last year of the Beagleys' daughter, Raylene Worthington, and her husband, Carl Brent Worthington. The Worthingtons were acquitted of manslaughter in the March 2008 death of their 15-month-old daughter, Ava, from pneumonia and a blood infection, but Brent Worthington was convicted of misdemeanor criminal mistreatment. The Beagleys were present at the death of their granddaughter, laying on hands after anointing her with oil and praying for her to be healed instead of seeking medical care that church members avoid. Horner argued that the Beagleys should have been alert to the potential for relatively mild symptoms to mask serious and even fatal disease after the death of their granddaughter. Defense lawyers argued the Beagleys were acting reasonably and did not believe Neil was in danger of dying. Attorney Wayne Mackeson told the jury that all of Neil Beagley's symptoms were "nonspecific," meaning they could have been a sign of any number of diseases, including a common cold or the flu. District Attorney John Foote said his office would have no comment until after sentencing. "The jury's verdicts of guilty are extremely important for this community," he said. "However, the cases are still not complete." Copyright © The Seattle Times Company Neil Beagley, died 2008 at age 16 Oregon parents guilty of negligent homicide in son's death By WILLIAM McCALL The Associated Press OREGON CITY, Ore. — Oregon parents were found guilty Tuesday of criminally negligent homicide for praying over their ill son instead of seeking medical help. The jury returned the verdict on the second day of deliberations in the trial of Jeff and Marci Beagley, both members of the Followers of Christ Church in Oregon City. Church members gasped as Judge Steven Maurer read the verdicts. The couple, who remain free on bail, are scheduled for sentencing Feb. 18. Because neither has a prior conviction, state sentencing guidelines call for 16 to 18 months in prison. Prosecutors said the Beagleys had a duty as parents to provide medical care for their 16-year-old son, Neil, who died in 2008 of complications from a urinary-tract blockage. The defense argued the teen had symptoms more like a cold or the flu. The couple and other church members at the hearing declined to comment Tuesday. Wayne Mackeson, Jeff Beagley's attorney, said they would consider an appeal. "It's never been a referendum on the church. This case involves parents who didn't understand how sick their child was," he said. The Followers of Christ Church shuns conventional medicine in favor of faith healing. The church has been in Oregon City since early in the 20th century. Its members, by their own description and that of others, keep to themselves. State authorities have found that an unusual number of children whose families belonged to the Followers of Christ had died at an early age, leading to a 1999 state law that eliminated faith healing as a defense in some manslaughter cases. The trial of the Beagleys was the second major faith-healing trial since the law was changed, although previous laws on criminally negligent homicide applied in their case. Greg Horner, the chief deputy district attorney, also prosecuted the faith-healing trial last year of the Beagleys' daughter, Raylene Worthington, and her husband, Carl Brent Worthington. The Worthingtons were acquitted of manslaughter in the March 2008 death of their 15-month-old daughter, Ava, from pneumonia and a blood infection, but Brent Worthington was convicted of misdemeanor criminal mistreatment. The Beagleys were present at the death of their granddaughter, laying on hands after anointing her with oil and praying for her to be healed instead of seeking medical care that church members avoid. Horner argued that the Beagleys should have been alert to the potential for relatively mild symptoms to mask serious and even fatal disease after the death of their granddaughter. Defense lawyers argued the Beagleys were acting reasonably and did not believe Neil was in danger of dying. Attorney Wayne Mackeson told the jury that all of Neil Beagley's symptoms were "nonspecific," meaning they could have been a sign of any number of diseases, including a common cold or the flu. District Attorney John Foote said his office would have no comment until after sentencing. "The jury's verdicts of guilty are extremely important for this community," he said. "However, the cases are still not complete." Copyright © The Seattle Times Company

4. What is Medical Ethics? The application of moral principles and analysis to medical situations Not bioethics This is what we’ll be teaching over the next four years. We will discuss the moral principles relevant to medical ethics and professionalism shortly. Not bioethics – not talking about rain forests, toxic waste dumps, or bioterrorism.This is what we’ll be teaching over the next four years. We will discuss the moral principles relevant to medical ethics and professionalism shortly. Not bioethics – not talking about rain forests, toxic waste dumps, or bioterrorism.

5. Overview of MUSM Medical Ethics and Professionalism First Year Orientation, White Coat ceremony Medical history, Delivering bad news, . . . Introduction to Medical Ethics and Professionalism Research opportunity as Summer Scholar PPL?

6. Medical Ethics and Professionalism Overview Second Year Clinical research Pharmaceutical companies Physician impairment Student abuse

7. Medical Ethics and Professionalism Overview Third Year Professionalism as a third year student Internal medicine – end-of-life, futility of care, physician assisted suicide Pediatrics - child abuse, neonatal care Obstetrics and gynecology – reproductive technologies, genetic screening Surgery – case analyses Psychiatry – competence, involuntary treatment, boundary violations, duties to third parties Family medicine – elder abuse, domestic violence, medical errors

8. Medical Ethics and Professionalism Overview Fourth Year Senior Case analysis Ethics in the Emergency Room Capstone? Risk management Health care and resource allocation Special topics

9. Community Medicine I What are the principles of medical ethics? What is an ethical dilemma? How do you analyze an ethical dilemma? What is “The Law?” Informed consent Confidentiality Challenges in Medical Ethics and Professionalism Let’s look at what we’ll do the next two weeksLet’s look at what we’ll do the next two weeks

10. Medical Ethics and Professionalism – Year One First week - two lectures Introduction to Medical Ethics and Professionalism Principles of medical ethics Informed consent and surrogate decisionmaking Confidentiality Procedure for ethical case analysis Principles and Codes of Medical Ethics and Professionalism Oath of Geneva Second week Group discussion of two cases on medical ethics site Advance directives Confidentiality

11. At the end of these two weeks, you should be able to: Describe principles of medical ethics Identify an ethical dilemma Describe process of ethical case analysis State basis and principles of informed consent State basis for and exceptions to patient confidentiality Describe current challenges to the medical profession

12. Examination 10-15 questions Matching, multiple choice, short answer

13. What Would You Do? Case 1: 36 year old man presents in respiratory distress, in the course of which he is found to be infected with HIV. He is firm that he does not want his wife to know. Case 2: 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 friends and parents testify that she would not have wanted to have a feeding tube. These are examples of what we would call ethical dilemmas.These are examples of what we would call ethical dilemmas.

14. What is an Ethical Dilemma? A conflict between moral imperatives, i.e., “what is the right thing to do?” What is “medically” right vs. patient preference Jehovah’s Witnesses and transfusions What is preferred by patient vs. proxy decision maker Rights of minor vs. legal guardians What is best for patient vs. what is best for society Commitment laws, notification of sexual partners of patients with HIV In our cases: conflicts between autonomy/confidentiality and protecting others, and between preserving life and respecting autonomyIn our cases: conflicts between autonomy/confidentiality and protecting others, and between preserving life and respecting autonomy

15. What do Mercer Students Consider Ethical Dilemmas? 2008 2009 Confidentiality 17 6 Decisionmakers 17 15 Right to refuse 4 8 Right to treatment 4 3 Futility of care 4 15 Medical error 2 3 AIDS/HIV 7 4 Pregnancy 6 8 Jehovah’s Witness 3 4 DNR/ventilator 4 Professionalism 12 Professionalism truth telling, lying, not responding to patients, taking care of prisoners, procedures for studentsProfessionalism truth telling, lying, not responding to patients, taking care of prisoners, procedures for students

16. What Would You Do? Case 1: 36 year old man presents in respiratory distress, in the course of which he is found to be infected with HIV. He is firm that he does not want his wife to know. Case 2: 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 friends and parents testify that she would not have wanted to have a feeding tube. These are examples of what we would call ethical dilemmas.These are examples of what we would call ethical dilemmas.

17. Principles of Medical Ethics Autonomy “Every human being of adult years and sound mind has a right to determine what shall be done with his own body” Schloendorff, 1914 Right to Privacy Beneficence Act for the good of the patient Promote good Remove or prevent harm Non-maleficence Primum non nocere First, do no harm Social justice Access to heath care resources We’ve been referring to these principles – let’s talk about them Mary E. Schloendorff, Appellant, v. The Society of the New York Hospital, Respondent Court of Appeals of New York211 N.Y. 125; 105 N.E. 92Decided April 14, 1914. Facts: Prepared by Tony Szczygiel Mary Schloendorff entered New York Hospital in January 1908, "suffering from some disorder of the stomach." She agreed to an "ether examination" to aid in identifying a lump that had been detected. While the patient was under the effects of the anesthesia, the surgeon removed a fibroid tumor discovered during the examination. An infection, gangrene and the amputation of several fingers allegedly resulted from the operation.Mary sued the non-profit hospital, seeking to hold the institution liable for the acts of the doctors and nurses it employed. This is the legal doctrine of respondeat superior. There was no claim of liability against the individual physicians or nurses in this case. This oft-quoted and misunderstood decision gives a fascinating view of hospital care in the U.S. as it existed in the early 20th century. The well-to-do paid $7 a week for care, the needy paid nothing. The decision describes the nurse's role in advising the patient about a surgery planned by the physicians: There may be cases where a patient ought not to be advised of a contemplated operation until shortly before the appointed hour. To discuss such a subject at midnight might cause needless and even harmful agitation. About such matters a nurse is not qualified to judge. She is drilled to habits of strict obedience. She is accustomed to rely unquestioningly upon the judgment of her superiors. Case History: Mary Schloendorff sued New York Hospital alleging that the doctors it employed performed the surgery contrary to her express direction. The judge was asked by the defendant hospital to rule that as a legal matter, even if her allegations were true, Mary would lose. The judge agreed, and directed that a verdict be entered in favor of the defendant hospital. The intermediate level court, the Appellate Division, First Department, upheld the trial judge's directed verdict. Schloendorff v. New York Hospital, 149 App. Div. 915 (March 1, 1912). The case was then appealed to New York's highest state court, the Court of Appeals. To decide the case, the court had to define a non-profit hospital's liability for acts performed by the doctors and nurses it employed. Two theories were offered supporting the conclusion that the hospital was immune from liability for the patient's damages. One theory was that a patient waived the right to sue for negligent treatment when the patient turned to a charity for help (charitable immunity). In rejecting this, Justice Cardozo summarized the state of the common law regarding consent to surgery: In the case at hand, the wrong complained of is not merely negligence. It is trespass. Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient's consent commits an assault, for which he is liable in damages. This ringing phrase is technically incorrect. Rather than an assault, Mary Schloendorff's injuries resulted from a battery. A civil assault is "an intentional attempt to do injury or commit a battery upon the person of another." 6 N.Y. JUR. 2d Assault-Civil Aspects s 1 (1980). The assault requires an intent to inflict injury or put the victim in apprehension of such injury. 6 N.Y. JUR. 2d Assault-Civil Aspects s 1. A battery consists of the slightest touching, with the only intent required being the intent to make contact, not intent to do injury. Id. at s 4. Primary Holding: The Court of Appeals held that a hospital could not be held liable for acts of its employed physicians. The New York Court of Appeals has since rejected the "Schloendorff rule" and held that the principles of respondeat superior should be applied to render a hospital liable for the negligence of the physicians and nurses that it employs. Bing v. Thunig, 143 N.E.2d 3, 9 (1957).Judges: Justice Cardozo wrote the opinion We’ve been referring to these principles – let’s talk about them Mary E. Schloendorff, Appellant, v. The Society of the New York Hospital, Respondent Court of Appeals of New York211 N.Y. 125; 105 N.E. 92Decided April 14, 1914. Facts: Prepared by Tony Szczygiel Mary Schloendorff entered New York Hospital in January 1908, "suffering from some disorder of the stomach." She agreed to an "ether examination" to aid in identifying a lump that had been detected. While the patient was under the effects of the anesthesia, the surgeon removed a fibroid tumor discovered during the examination. An infection, gangrene and the amputation of several fingers allegedly resulted from the operation.Mary sued the non-profit hospital, seeking to hold the institution liable for the acts of the doctors and nurses it employed. This is the legal doctrine of respondeat superior. There was no claim of liability against the individual physicians or nurses in this case. This oft-quoted and misunderstood decision gives a fascinating view of hospital care in the U.S. as it existed in the early 20th century. The well-to-do paid $7 a week for care, the needy paid nothing. The decision describes the nurse's role in advising the patient about a surgery planned by the physicians: There may be cases where a patient ought not to be advised of a contemplated operation until shortly before the appointed hour. To discuss such a subject at midnight might cause needless and even harmful agitation. About such matters a nurse is not qualified to judge. She is drilled to habits of strict obedience. She is accustomed to rely unquestioningly upon the judgment of her superiors. Case History: Mary Schloendorff sued New York Hospital alleging that the doctors it employed performed the surgery contrary to her express direction. The judge was asked by the defendant hospital to rule that as a legal matter, even if her allegations were true, Mary would lose. The judge agreed, and directed that a verdict be entered in favor of the defendant hospital. The intermediate level court, the Appellate Division, First Department, upheld the trial judge's directed verdict. Schloendorff v. New York Hospital, 149 App. Div. 915 (March 1, 1912). The case was then appealed to New York's highest state court, the Court of Appeals. To decide the case, the court had to define a non-profit hospital's liability for acts performed by the doctors and nurses it employed. Two theories were offered supporting the conclusion that the hospital was immune from liability for the patient's damages. One theory was that a patient waived the right to sue for negligent treatment when the patient turned to a charity for help (charitable immunity). In rejecting this, Justice Cardozo summarized the state of the common law regarding consent to surgery: In the case at hand, the wrong complained of is not merely negligence. It is trespass. Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient's consent commits an assault, for which he is liable in damages. This ringing phrase is technically incorrect. Rather than an assault, Mary Schloendorff's injuries resulted from a battery. A civil assault is "an intentional attempt to do injury or commit a battery upon the person of another." 6 N.Y. JUR. 2d Assault-Civil Aspects s 1 (1980). The assault requires an intent to inflict injury or put the victim in apprehension of such injury. 6 N.Y. JUR. 2d Assault-Civil Aspects s 1. A battery consists of the slightest touching, with the only intent required being the intent to make contact, not intent to do injury. Id. at s 4. Primary Holding: The Court of Appeals held that a hospital could not be held liable for acts of its employed physicians. The New York Court of Appeals has since rejected the "Schloendorff rule" and held that the principles of respondeat superior should be applied to render a hospital liable for the negligence of the physicians and nurses that it employs. Bing v. Thunig, 143 N.E.2d 3, 9 (1957).Judges: Justice Cardozo wrote the opinion

18. Two Medical Dilemmas Case 1 – HIV and confidentiality The patient has a right to keep his records confidential Autonomy, Non-maleficence HIPAA The wife has a right to be protected Right to privacy (?) Case 2 - PVS and feeding tube removal Patient has right to have wishes respected Right to privacy, Autonomy State has right to have its laws respected Hospital has a right to determine what interventions it supports Physicians have a right to decide what treatments they provide How do we decide what is to be done?How do we decide what is to be done?

19. How do you decide the right course of action in an ethical dilemma? Principles of ethical case analysis

20. How to Analyze an Ethics Case What are the medical issues? Risks, benefits, alternatives, prognoses Who are the stakeholders? Patient, family, medical staff, hospital, state Cultural and religious concerns What are the relevant laws, regulations, ethical codes? Why is an ethical dilemma being created? Conflicts between decision makers, law and ethical principles Who are possible consultants? Medical, family, ethicists, ethics committee, lawyers Possible courses of action Proposed resolution Hospital – not do abortions in Christian hospitalHospital – not do abortions in Christian hospital

21. Get the medical facts – what is being proposed, prognosis with and without, risks, alternatives?Get the medical facts – what is being proposed, prognosis with and without, risks, alternatives?

22. What are the Medical Issues? Rule #1 We are doctors, not moral philosophers or lawyers Know your medicine! Most ethical problems have a clinical solution Diagnosis, nature of treatment proposed, risks, benefits, prognosis with and without treatment, alternatives Evidence-based decisions

23. Medical Issues Case 1 – HIV and confidentiality What is course, prognosis, and treatment for HIV? What is likelihood wife is or will be infected? What is wife’s prognosis without treatment? What is likelihood wife will infect fetus, children? Case 2 - PVS and feeding tube removal What is PVS? What are possible interventions? What is prognosis with and without feeding tube?

24. Stakeholder – who has a stake in the outcome? Patient, family, doctor, hospital, insurers, state, others?Stakeholder – who has a stake in the outcome? Patient, family, doctor, hospital, insurers, state, others?

25. Who are the stakeholders? Patient Quality of life, autonomy, spiritual needs Family Proxy decision makers, quality of life Physician Risk management concerns Medical profession Standards Hospital Policies, accreditation, affiliations State Resource allocation, legal regulation

26. Stakeholders Case 1 – HIV and confidentiality Patient Wife Children Physician Medical profession State Case 2 - PVS and feeding tube removal Patient Parents Medical profession State State as stakeholder – uphold laws, protect citizens (parens patriae), prevent harm (police power)State as stakeholder – uphold laws, protect citizens (parens patriae), prevent harm (police power)

27. What are the relevant laws, codes, regulations?What are the relevant laws, codes, regulations?

28. What are the Relevant Laws? Statutory vs. case law Official Code of Georgia, Code of Federal Regulations (Federal registry) Case law Binding at appellate level in jurisdiction Two famous (board material) ethics cases Karen Ann Quinlan Nancy Cruzan

29. Legal Issues – HIV and Confidentiality Case 1 – HIV and confidentiality HIPAA O.C.G.A and confidential nature of HIV information § 24-9-47.  Disclosure of AIDS confidential information (b) Except as otherwise provided in this Code section:   (1) No person or legal entity which receives AIDS confidential information pursuant to this Code section or which is responsible for recording, reporting, or maintaining AIDS confidential information shall:      (A) Intentionally or knowingly disclose that information to another person or legal entity; or

30. Legal Issues – HIV and Confidentiality But: (g) When the patient of a physician has been determined to be infected with HIV and that patient's physician reasonably believes that the spouse or sexual partner or any child of the patient, spouse, or sexual partner is a person at risk of being infected with HIV by that patient, the physician may disclose to that spouse, sexual partner, or child that the patient has been determined to be infected with HIV, after first attempting to notify the patient that such disclosure is going to be made; And: A physician having a patient who has been determined to be infected with HIV may disclose to the Division of Public Health      (A) The name and address of that patient;      (B) That such patient has been determined to be infected with HIV; and      (C) The name and address of any other person whom the disclosing physician or administrator reasonably believes to be a person at risk of being infected with HIV by that patient.

31. Legal Issues – Removal of Feeding Tube Case 2 - PVS and feeding tube removal The patient did not have an advance directive Power of attorney for health care Living Will In the absence of an advance directive, the state may require by clear and convincing evidence a showing of what the patient would have chosen under the same or similar circumstances

32. Why Does an Ethical Dilemma Exist? Conflict Law and morality (e.g., religion-based) Refusal of transfusion Different decision makers Patient and proxy Patient and physician Between ethical principles

33. Why Does an Ethical Dilemma Exist? Case 1 – HIV and confidentiality The patient has a right to keep his records confidential Autonomy, Non-maleficence HIPAA The wife has a right to be protected Right to privacy (?) Case 2 - PVS and feeding tube removal Patient has right to have wishes respected Right to privacy, Autonomy State has right to have its laws respected Hospital has a right to determine what interventions it supports Physicians have a right to decide what treatments they provide

34. Consultants – who might be consulted? Clinical, legal, ethicalConsultants – who might be consulted? Clinical, legal, ethical

35. Possible Consultants Case 1 – HIV and confidentiality Infectious disease Clinical Policy on HIV and confidentiality Division of Public Health Ethicist Health or malpractice insurance lawyer Case 2 - PVS and feeding tube removal Medical Establish prognosis, possible alternative interventions Others who knew patient’s wishes Ethics Committee Medical Director Futility Policy? Mediator

36. Possible Courses of Action Case 1 – HIV and confidentiality Do nothing Contact wife Contact Division of Public Health Refer to another physician Case 2 - PVS and feeding tube removal Do nothing Remove tube Contact hospital attorney to block family’s wishes Refer to another hospital/physician

37. Proposed Resolution Case 1 – HIV and confidentiality Attempt to meet with patient and wife to discuss test results and implications, offer to test wife If patient refuses, contact DPH for partner notification Case 2 - PVS and feeding tube removal Remove tube or refer to another physician/hospital

38. Two Ethically Problematic Situations Informed consent Surrogate decisionmakers Right to die/wrongful life Advance directives Confidentiality When to breach confidentiality

39. Ethical and Legal Bases of Informed Consent Autonomy Beneficence Assault and (intentional tort of) battery

40. Informed Consent Three Elements of informed consent Voluntariness Information Competence (capacity)

41. Voluntariness Freedom from undue influence Incentives for research? Would decision of patient with HIV to disclose information to wife be voluntary if alternative is partner notification through public health? Would decision of family to request withdrawal of feeding tube be voluntary if hospital threatened them with threat of massive health care costs? Areas not well exploredAreas not well explored

42. Information Diagnosis, nature of treatment, risks, benefits, alternatives, prognosis with and without treatment “disclosure of the material risks generally recognized and accepted by reasonably prudent physicians which, if disclosed to a reasonably prudent person in the patient's position, could reasonably be expected to cause that person to decline the proposed treatment or procedure because of the risk of injury that could result” (Ketchup v Howard) But, Ketchup overturned!! No general informed consent in Georgia. Alternative standard of disclosure is physician standard

43. What should be disclosed? Case 1 – HIV and confidentiality Meaning of test Risk of infecting wife Possible criminal consequences for failing to inform her HIV and fetus, children Treatment possibilities, alternatives, prognoses Case 2 – PVS and removal of feeding tube Prognosis with and without feeding tube Costs What is percutaneous endoscopic gastrostomy (PEG)? Percutaneous endoscopic gastrostomy (PEG) is a surgical procedure for placing a tube for feeding without having to perform an open operation on the abdomen (laparotomy). It is used in patients who will be unable to take in food by mouth for a prolonged period of time. A gastrostomy, or surgical opening into the stomach, is made through the skin using an a flexible, lighted instrument (endoscope) passed orally into the stomach to assist with the placement of the tube and secure it in place. What is the purpose of percutaneous endoscopic gastronomy? The purpose of a percutaneous endoscopic gastronomy is to feed those patients who cannot swallow food. Irrespective of the age of the patient or their medical condition, the purpose of percutaneous endoscopic gastronomy is to provide fluids and nutrition directly into the stomach. Who does percutaneous endoscopic gastronomy? Percutaneous endoscopic gastronomy is done by a physician. The physician may be a general surgeon, an otolaryngologist (ENT specialist), radiologist, or a gastroenterologist (gastrointestinal specialist). Where is percutaneous endoscopic gastronomy done? PEG is performed in a hospital or outpatient surgical facility. It is not necessary to perform a percutaneous endoscopic gastronomy in an operating room. What is percutaneous endoscopic gastrostomy (PEG)? Percutaneous endoscopic gastrostomy (PEG) is a surgical procedure for placing a tube for feeding without having to perform an open operation on the abdomen (laparotomy). It is used in patients who will be unable to take in food by mouth for a prolonged period of time. A gastrostomy, or surgical opening into the stomach, is made through the skin using an a flexible, lighted instrument (endoscope) passed orally into the stomach to assist with the placement of the tube and secure it in place. What is the purpose of percutaneous endoscopic gastronomy? The purpose of a percutaneous endoscopic gastronomy is to feed those patients who cannot swallow food. Irrespective of the age of the patient or their medical condition, the purpose of percutaneous endoscopic gastronomy is to provide fluids and nutrition directly into the stomach. Who does percutaneous endoscopic gastronomy? Percutaneous endoscopic gastronomy is done by a physician. The physician may be a general surgeon, an otolaryngologist (ENT specialist), radiologist, or a gastroenterologist (gastrointestinal specialist). Where is percutaneous endoscopic gastronomy done? PEG is performed in a hospital or outpatient surgical facility. It is not necessary to perform a percutaneous endoscopic gastronomy in an operating room.

44. Competence § 31-9-2. (c) For purposes of this Code section, "inability of any adult to consent for himself" [shall mean the adult] "lacks sufficient understanding or capacity to make significant responsible decisions" regarding his medical treatment or the ability to communicate by any means such decisions.

45. Competence Competence or capacity is specific to a particular decision Competence is a legal decision, but used synonymously with capacity Range of competence: Ability to communicate decision Not refusing Simple assent Simple Understanding E.g., able to paraphrase Appreciate complexities of decision Medical Interpersonal Spiritual Level of competence needed related to risk/benefit

46. Competence Case 1 – HIV and confidentiality Was patient competent to release or to deny release of information? What if retarded? Depressed? Demented (HIV dementia)? Delirious? Case 2 – PVS and PEG removal Were parents competent to request tube removal?

47. When the Patient is Incompetent Karen Ann Quinlan 1954-85 21 yo, Valium and ETOH PVS, ventilator Parents sued to remove ventilator 1976 New Jersey Supreme Court decided on right to privacy “Right to die”

48. When the Patient is Incompetent Nancy Cruzan 1957-90 1983 MVA PVS, feeding tube 1987 parents sued to remove tube Patient Self-Determination Act 1990

49. When the Patient is Incompetent Guardian Probate court Guardian of person or estate or both Advance directive Specifies what is to be done in the event patient is unable to make a decision Durable Power of Attorney for Health Care Who will make decision Based on what patient would have decided – substituted judgment Living Will Specifies particular decisions, e.g., ventilators Default list of surrogate decisionmakers under Georgia Law

50. Georgia Advance Directive for Health Care (1) HEALTH CARE AGENT I select the following person as my health care agent to make health care decisions for me: Name, Address, Telephone Numbers , email If my health care agent cannot be contacted in a reasonable time period and cannot be located with reasonable efforts or for any reason my health care agent is unavailable or unable or unwilling to act as my health care agent, then I select the following, each to act successively in the order named, as my back-up health care agent(s): First Back–up Agent Second Back-up Agent

51. Georgia Advance Directive for Health Care My health care agent will have the same authority to make any health care decision that I could make. My health care agent’s authority includes the following powers: • To authorize my admission to or discharge (including transfers) from any hospital, skilled nursing facility, hospice, or other health care facility or service • To request, consent to, withhold, or withdraw any type of health care • Contract for any health care facility or service for me, and to obligate me to pay for these services

52. Georgia Advance Directive for Health Care GUIDANCE FOR HEALTH CARE AGENT When making health care decisions for me, my health care agent should think about what action would be consistent with past conversations we have had, my treatment preferences as expressed in PART TWO, my religious and other beliefs and values, and how I have handled medical and other important issues in the past. If what I would decide is still unclear, then my health care agent should make decisions for me that my health care agent believes are in my best interest, considering the benefits, burdens, and risks of my current circumstances and treatment options.

53. Georgia Advance Directive for Health Care PART TWO will be effective if I am in any of the following conditions: A terminal condition, which means I have an incurable or irreversible condition that will result in my death in a relatively short period of time, and/or; A state of permanent unconsciousness, which means I am in an incurable or irreversible condition in which I am not aware of myself or my environment and I show no behavioral response to my environment. To be determined by personal and second physician

54. Georgia Advance Directive for Health Care Try to extend my life for as long as possible, using all medications, machines, or other medical procedures that in reasonable medical judgment could keep me alive. If I am unable to take nutrition or fluids by mouth, then I want to receive nutrition or fluids by tube or other medical means, OR; Allow my natural death to occur. I do not want any medications, machines, or other medical procedures that in reasonable medical judgment could keep me alive but cannot cure me. I do not want to receive nutrition or fluids by tube or other medical means except as needed to provide pain medication, OR;

55. Georgia Advance Directive for Health Care I do not want any medications, machines, or other medical procedures that in reasonable medical judgment could keep me alive but cannot cure me, except as follows: [Initial each statement that you want to apply] If I am unable to take nutrition by mouth, I want to receive nutrition by tube or other medical means. If I am unable to take fluids by mouth, I want to receive fluids by tube or other medical means. If I need assistance to breathe, I want to have a ventilator used. If my heart or pulse has stopped, I want to have cardiopulmonary resuscitation (CPR) used.

56. Default Surrogate Decisionmakers I § 31-9-2. Persons authorized to consent to surgical or medical treatment (a) any one of the following persons is empowered to consent: (1) Any [competent] adult, for himself or herself, whether by living will, advance directive for health care, or otherwise; (1.1) Any person authorized to give such consent for the adult under an advance directive for health care or durable power of attorney for health care under Chapter 32 of Title 31; (2) In the absence or unavailability of a living spouse, any parent, whether an adult or a minor, for his or her minor child; (3) Any married person, whether an adult or a minor, for himself or herself and for his or her spouse;

57. Default Surrogate Decisionmakers II (4) Any person temporarily standing in loco parentis, whether formally serving or not, for the minor under his or her care; and any guardian, for his or her ward; (5) Any female, regardless of age or marital status, for herself when given in connection with pregnancy, or the prevention thereof, or childbirth; or (6) Upon the inability of any adult to consent for himself or herself and in the absence of any person to consent under paragraphs (2) through (5) of this subsection, the following persons in the following order of priority: (A) Any adult child for his or her parents; (B) Any parent for his or her adult child; (C) Any adult for his or her brother or sister; or (D) Any grandparent for his or her grandchild. [P]rocedures which the patient would have wanted had the patient understood the circumstances under which such treatment or procedures are provided.

58. Medical Consent in Minors Under the age of 18 or emancipated (age 16 or 17, married, living independently, court order) May consent to: Treatment for drug abuse HIV testing Prevention of pregnancy Treatment during pregnancy and childbirth Treatment for STD Abortion with parental notification

59. Informed Consent Not just a piece of paper Informed consent is a means of engaging a patient in important health care decisions There is therapeutic value to true informed consent

60. Exceptions to Informed Consent Emergency exceptions to informed consent Consent is implied in emergency when patient is lacks capacity and surrogate unavailable Therapeutic privilege We are doctors, not lawyers Docere Questions on informed consent? Trauma and teenagers – Steve’s exampleTrauma and teenagers – Steve’s example

61. Confidentiality What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself Hippocrates

62. Confidentiality Confidentiality is the obligation on the physician not to reveal what has been learned during the course of treatment Privilege is the right of a patient, established only by statute, whereby a patient may prevent his physician from testifying. Privilege is a legal right belonging only to the patient and not to the physician.

63. Breaking Confidentiality Reporting child abuse or neglect Abuse of seniors Abuse of disabled Residents of long term care facilities Reporting HIV to state Notifying sexual partners of HIV “Tarasoff” warnings “protective privilege ends where the public peril begins” Many people are required by Georgia law to report when they suspect abuse, neglect or exploitation. Mandated reporters must make a report when they have a reasonable cause to believe that a disabled or elder adult has had an injury or injuries inflicted upon them, other than by accidental means, by a caretaker or has been neglected or exploited by a caretaker. Mandated reporters who do not fulfill their obligation to report elder or disabled adult abuse may be charged with a misdemeanor. Georgia law lists mandated reporters at Code Section 30-5-8 for alleged victims who are disabled adults or elder persons who live in the community; and at Code Section 31-8-80 for alleged victims who are long-term care facility residents. All other parties are encouraged to make reports if they believe that a disabled adult or elder person is in need of protective services or has been the victim of abuse, neglect, or exploitation. By law the following are mandated reporters of abuse, neglect, and exploitation: Anyone who makes a report of fraud, testifies in any judicial proceeding, assists protective services, or participates in a required investigation is immune from any civil or criminal liability as a result of such report, testimony, or participation, unless such person acted in bad faith or with a malicious purpose, or was a party to such crime or fraud. • Physicians (including interns and residents) • Osteopaths • Dentists • Chiropractors • Podiatrist • Psychologists • Licensed professionals counselors • Social workers • Employees of a public or private agency engaged in professional health-related services to elder persons or disabled adults • Adult Day care personnel • Other hospital or medical personnel • Pharmacists • Physical therapists • Occupational therapists • Nursing personnel • Coroners and medical examiners • Nursing personnel • Any employee of a financial institution • Law enforcement personnel • Administrators, managers or other employees of a personal care home or nursing home Many people are required by Georgia law to report when they suspect abuse, neglect or exploitation. Mandated reporters must make a report when they have a reasonable cause to believe that a disabled or elder adult has had an injury or injuries inflicted upon them, other than by accidental means, by a caretaker or has been neglected or exploited by a caretaker. Mandated reporters who do not fulfill their obligation to report elder or disabled adult abuse may be charged with a misdemeanor. Georgia law lists mandated reporters at Code Section 30-5-8 for alleged victims who are disabled adults or elder persons who live in the community; and at Code Section 31-8-80 for alleged victims who are long-term care facility residents. All other parties are encouraged to make reports if they believe that a disabled adult or elder person is in need of protective services or has been the victim of abuse, neglect, or exploitation. By law the following are mandated reporters of abuse, neglect, and exploitation: Anyone who makes a report of fraud, testifies in any judicial proceeding, assists protective services, or participates in a required investigation is immune from any civil or criminal liability as a result of such report, testimony, or participation, unless such person acted in bad faith or with a malicious purpose, or was a party to such crime or fraud. • Physicians (including interns and residents) • Osteopaths • Dentists • Chiropractors • Podiatrist • Psychologists • Licensed professionals counselors • Social workers • Employees of a public or private agency engaged in professional health-related services to elder persons or disabled adults • Adult Day care personnel • Other hospital or medical personnel • Pharmacists • Physical therapists • Occupational therapists • Nursing personnel • Coroners and medical examiners • Nursing personnel • Any employee of a financial institution • Law enforcement personnel • Administrators, managers or other employees of a personal care home or nursing home

64. Resources MUSM Ethics faculty Elliott_rl@mercer.edu Williams_RS@mercer.edu Greenma2@memorialhealth.com On-line resources http://medicine.mercer.edu/Resources/Student%20Resources/medicalethicsprogram Library Official Code of Georgia http://www.lexis-nexis.com/hottopics/gacode/default.asp MCCG Ethics Committee members YOU!! Suggestions, comments, criticisms

65. What is Rule #1? We are doctors!

66. Groups Read cases on site medicine.mercer.edu Academics-Degree Programs-Doctor of Medicine Analyze using case analysis form

67. Summer Research on Faith and Ethics

68. Medical Ethics and Professionalism Program Goals Adhere to highest ethical and professionalism standards Recognize and respond to ethically problematic situations using relevant principles, codes, and laws But before we jump into the various ethical issues and frays, let us step back a bit and look at our origins.But before we jump into the various ethical issues and frays, let us step back a bit and look at our origins.

69. Ethics and Law Statutory vs. case law Official Code of Georgia, Code of Federal Regulations (Federal registry) Case law Binding at appellate level in jurisdiction Two famous (board material) ethics cases Karen Ann Quinlan Nancy Cruzan

70. When patients are not competent - Sometimes other decisionmakers enter the picture - Surrogate decisionmakersWhen patients are not competent - Sometimes other decisionmakers enter the picture - Surrogate decisionmakers