Medical Ethics Where Does It Come From?

1. The Keys to Doing the Right Thing Medical Ethics Where Does It Come From? Robert M. Sade, M.D. Professor of Surgery Director, Institute of Human Values in Health Care Medical University of South Carolina

2. A History of Ethics Principles

3. Ethics • Ethics is the discipline that considers how human beings ought to behave to achieve certain goals. • what is the goal? • what behavior will reach it? • Ethical problem occurs when: • several plausible actions available • unclear which is most likely to achieve the goal.

4. Solution to a Problem The good of the patient What’s right is the greatest good for the greatest number Science single standard of truth single goal What’s right is intuitively self-evident The good of the hospital What’s right is what serves social justice goal a standard a Ethics The good of science goal b standard b What’s right is what Jesus, or Mohammed, or Buddha, or … says goal c standard c The good of society goal d standard d

5. Solutions to Ethical Problems • Not simple • Ethics not like science • Is ethics arbitrary? Or • Can we discover an ethic for medicine?

6. Where Does Ethics Come From? • Tradition “That’s the way it’s always been.” • Authority • “That’s the way I • was taught to do it.” • Reason • “That’s the way • reality determines • we ought to behave.”

7. Human nature: what analysis tells us about medical ethics

8. A View of Morality and Medical Ethics • Human beings live, must maintain life • Main tool is intelligence • Rationality permits percepts concepts • Understand real world and choose actions • Potentialities can be actualized • generic (think, choose, walk, talk) • unique (coordination, abstract thought)

9. A View of Morality and Medical Ethics • Goal: human flourishing • achieved only through choices and actions of individuals • specific goals, needs (values) • health, wealth, friendship • no instincts, but habits of mind (virtues) • honesty, integrity, courage, rationality, compassion basic virtues needed by every human being, BUT • values and virtues require unique ranking • unique talents, capacities, interests, tastes, etc. • unique ranking also for professions

10. Ethics Virtues Values Flourishing life Basic template for professions: • identify distinguishing characteristic • rank virtues for particular profession • define professional excellence

11. Medical Ethics Virtues Good of the patient Excellent physician biological-medical good self-understood good

12. Distinguishing Characteristic • The overarching need for TRUST • Successful treatment of patients requires physicians have access to: • intimate details of personal history • intimate access to the body itself • Intimacy greater than anyone else, including minister, lawyer, spouse. • The fundamental need for those intimacies requires that physicians be trusted to serve patients’ interests before their own Trust

13. VirtuesServing the Good of Patients • Biological-medical good • scientific objectivity • competence (medical/technical) • integrity in using knowledge/skills • Patient’s perception of own good • respecting patients’ self-determination (autonomy) • honesty in disclosure • compassion for patients’ humanity • beneficence in supporting patients’ goals

14. The Ethical Core of Medicine The patient’s good is paramount TRUST is sine qua non • Effacement of self-interest by MD • financial (fees, incentives, indigent care) • own health (epidemics, AIDS) • inconveniences for patients’needs • Secondary goods: • corporations • colleagues, partnership • society

15. Business Ethics Virtues Good of the owners Excellent businessman trading goods & services long term profit

16. Distinguishing Characteristic • Maximize owner value over long term • unlike charity, government, family, hobby

17. VirtuesServing the Good of Owners • Making money • no intimacy-vulnerability • no effacement of financial self-interest • Assure confidence in future transactions • Honesty (no deception--bluffing, puffing, spinning) • Promise-keeping (reliability)

18. The Philosopher of Business “Men who drive sharp bargains with their customers, acting as if they never expect to see them again, will not be mistaken.” “No man can be dishonest without soon being found out, and when his lack of principle is discovered, nearly every avenue to success is closed against him forever.”

19. Ethics of Science Virtues Good of science Excellent scientist Seeking reliable new knowledge

20. Distinguishing Characteristic • Discovering truth: how the world (human biology) works • dedication to scientific method (hypothesis, systematic observation, validation, theory) • unlike medicine, business, government, etc.

21. VirtuesServing the Good of Science • Integrity/honesty • Avoid negligence (e.g., sloppiness, premature reporting) • No dishonesty (e.g., fabrication, falsification, plagiarism) • Objectivity • diligent application of ‘scientific method’ • Conscientiousness in applying knowledge/skills • technical competence • Respect for subjects • rights of humans, humaneness toward animals

22. Potential Conflicts of Obligation • The physician as healer • Goal: the good of the patient • The physician as healer • Goal: the good of the patient • The physician as scientist • Goal: the good of science • The physician as businessman • Goal: make money • The physician as private person • Goal: the good of self, family, community, etc.

23. Principles of Medical Ethics The good of the patient is paramount • TRUST must be nurtured before all else • Avoid conflicts of interest (COI) • Avoid perception of COI • Respect rights of pt • safeguard confidentiality • respect self-determination • communicate honestly with all • maintain competence

24. Caveat:Self-deception: Human Trait • Concealing truth to benefit pt • Deception of insurance companies (e.g., miscoding) benefits only pt • Gifts from industry do not influence prescribing practices or device use • Industry-controlled CME activities do not have biasing influence on clinical practice

25. Conflicts In Professional Ethics • Medicine versus business versus science • Example from real life

26. Jesse Gelsinger Story Inst Hum Gene Tx—U Penn • gene tranfer expt • ornithine transcarbamylase defic. • ammonia, 50% 1 mo, 75% 5 yr • 1st direct inj by cath into liver • no problems, 1st 17 pts

27. Jesse Gelsinger J.G., 18yo wm: • OTC def. mild, atypical (low protein diet, drugs) “What’s the worse that can happen to me? I die, and it’s for the babies.” • 18th subject, 9/13/99 • jaundice, 9/14/99 • mult organ systems failure • dead 9/17/99 (1st hum gene tx)

28. Allegations in lawsuit • Earlier subjects’ serious reactions not reported, study not D/C • Death of 2/11 exptl monkeys removed from consent form w/o notif. • Upper limit of bld ammonia raised w/o notif.; JG’s exceeded it • WHY was protocol violated in these and other ways? News media revelations, May, 2000: • Dr. James Wilson (PI) had 30% interest in Genovo (gene manufacturer) • U Penn owned 5% of Genovo • Dr. Wm Kelly, former dean of UPMS, owned several patents of experiment • Genovo gave $4 M a year to IHGT/UPenn

29. Paul Gelsinger • At RAC hearing (Dec 9, 1999) said: “These guys didn’t do anything wrong” • After lawsuit settled (2000), P.G. concluded that “he had been duped by scientists who cared more about profit than safety” • Allegations unproved; major damage from public perceptions

30. Contemporary Ethical Issues • Informing patients of errors • Profiting from company ownership • Lying to insurance companies • Crossing interpersonal boundaries • Accepting gifts from industry • Telling the truth to terminally ill patients • Gaming transplant list to gain priority • Responsibilities to medically indigent • Advertising of favorable outcome statistics • Making decisions at the end of life Ferrol Sams

31. Types of Ethics • Medical Ethics: Clinical obligations • fidelity first to patients’ interests • telling the truth (cancer, errors) • Professional Ethics: Obligations of the profession • self-regulation • education of self and others • Bioethics: Guides for public policy • gene technology, stem cell research • health system reform

32. Medical Ethics as Aspirational • AAPS Principles of Medical Ethics • Principle 3: The physician shall not condone the taking of human life in the practice of his profession, but shall at all times respect the sanctity of human life and seek to preserve or improve the quality of life. • Principle 6: …the value of professional services should be determined only by mutual agreement between the physician and patient, and in no other way. • Mother Theresa

33. Principles of Medical Ethics • AAPS (best) • AMA (good) • Code of Medical Ethics: Current Opinions • ACP-ASIM (dangerous)

34. Comparison of Principles:Common Grounds

35. Comparison of Principles:Differences

36. Hippocrates Primacy of the patient’s good Plato andAristotle Teleological tools to discover ethics Osler and Halsted Transmitting knowledge & ethics to future physicians With Gratitude:

37. Thank You!