Medical ethics and professionalism
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Medical Ethics and Professionalism. Richard L. Elliott, MD, PhD, FAPA Director, Medical Ethics Professor, Internal Medicine and Community Medicine Mercer University School of Medicine Adjunct Professor Mercer University School of Law. Ethical dilemma?.

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Medical ethics and professionalism

Medical Ethics and Professionalism

Richard L. Elliott, MD, PhD, FAPA

Director, Medical Ethics

Professor, Internal Medicine and Community Medicine

Mercer University School of Medicine

Adjunct Professor

Mercer University School of Law


Ethical dilemma

Ethical dilemma?

  • You, as the on call member for the hospital ethics committee, are asked to consult about a mother who is 11 weeks pregnant, has BP 240/160, impending heart failure, and the physician tells you that if surgery is not performed to terminate the pregnancy there is almost a 100% certainty the mother and baby will die. All other measures have been unsuccessful. What do you do?

  • The hospital is Catholic, which forbids abortion even to save the life of the mother. What do you do?


Medical ethics and professionalism

  • November 2009 Mother, 11 weeks pregnant with severe pulmonary hypertension, doctors believed only way to save life was to terminate pregnancy

  • Sister McBride on call as member of hospital ethics committee, decided along with patient, doctors, to terminate pregnancy

  • May 19, 2010 Sister McBride excommunicated and reassigned

  • December 22, 2010 Bishop Olmsted ruled St Joseph’s Hospital cannot call itself Catholic


Goals

Goals

  • What is medical ethics?

  • Medical ethics and professionalism at MUSM

  • Expectations for Community Medicine I

  • What is an ethical dilemma?

  • What are the principles of medical ethics?

  • How to analyze an ethical problem

  • Introduction to informed consent and confidentiality

  • Introduction to surrogate decisionmaking

  • Introduction to professionalism


What is medical ethics

What is Medical Ethics?

  • The application of moral principles and analysis to medical situations

  • Not bioethics


Overview of musm medical ethics and professionalism

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

    • Basics of Health Care Reform

    • Ethics Interest Group - Savannah

    • PPL?


Medical ethics and professionalism overview

Medical Ethics and Professionalism Overview

  • Second Year

    • Clinical research

    • Pharmaceutical companies

    • Physician impairment

    • Student abuse


Medical ethics and professionalism overview1

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


Medical ethics and professionalism overview2

Medical Ethics and Professionalism Overview

  • Fourth Year

    • Senior Case analysis

    • Ethics in the Emergency Room

    • Electives

    • Capstone?

      • Risk management

      • Health care and resource allocation

      • Special topics


Medical ethics and professionalism year one

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


At the end of these two weeks you should be able to

At the end of these two weeks, you should be able to:

  • Describe principles of ethics and professionalism

  • Identify an ethical dilemma

  • Describe process of ethical case analysis

  • State basis and principles of informed consent

  • State basis and exceptions to patient confidentiality

  • Describe current challenges to the medical profession


Resources and examination

Resources and Examination

  • [email protected]

  • Dr. Greenberg [email protected]

  • Medicine.mercer.edu Ethics site

    • Academics

      • Degree Programs

        • Doctor of Medicine -> Medical Ethics -> First Year

  • Powerpoints posted on Ethics site Thursday Feb 16

  • Exam on Powerpoint material

    • 10-15 questions

    • MDE format

    • Not a fluff exam – look at details!


What would you do

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 friend and parents testify that she would not have wanted to have a feeding tube.


What is an ethical dilemma

What is an Ethical Dilemma?

  • A conflict between ethical principles, 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


What do mercer students consider ethical dilemmas

What do Mercer Students Consider Ethical Dilemmas?

2008 2009

  • Confidentiality17 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


Two medical dilemmas

Two Medical Dilemmas

  • Case 1 – HIV and Confidentiality

  • Case 2 – PVS and feeding tube removal


Two medical dilemmas1

Two Medical Dilemmas

  • Case 1 – HIV and confidentiality

    • The patient has a right to keep his records confidential

    • The wife has a right to be protected

  • Case 2 - PVS and feeding tube removal

    • Patient has right to have wishes respected

    • 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 to analyze an ethics case or how do i figure out what s the right thing to do

How to Analyze an Ethics Case,(or how do I figure out what’s the right thing to do?)

  • 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 ethics

  • Who are possible consultants?

    • Medical, family, ethicists, ethics committee, lawyers

  • Possible courses of action

  • Proposed resolution


  • What are the medical issues

    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

    • Remember this when you analyze cases next week!


    Medical issues

    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 alternatives?

      • What is prognosis with and without feeding tube?


    Who are the stakeholders potential decisionmakers

    Who are the stakeholders (potential decisionmakers)?

    • 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


    Stakeholders

    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


    What are the relevant laws

    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


    Legal issues hiv and confidentiality

    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


    Legal issues hiv and confidentiality1

    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 must disclose to the Division of Public Health (O.C.G.A. 31-12-2(b))      (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.


    Legal issues removal of feeding tube

    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

    • Georgia Advance Directive for Health Care

      • Combines Living Will and Durable Power of Attorney for Health Care


    Medical ethics and professionalism

    • Ethical dilemmas are conflicts between or among ethical principles

    • What are commonly accepted ethical principles in medicine?


    Principles of medical ethics

    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


    Four principles of medical ethics

    Four Principles of Medical Ethics

    • Autonomy

    • Beneficence

    • Nonmaleficence

    • Social Justice


    Why does an ethical dilemma exist

    Why Does an Ethical Dilemma Exist?

    • Case 1 – HIV and confidentiality

      • The patient has a right to keep his records confidential

        • Autonomy, Nonmaleficence

        • 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


    Possible consultants

    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


    Possible courses of action

    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


    Proposed resolution

    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


    Two ethically problematic situations

    Two Ethically Problematic Situations

    • Informed consent

      • Surrogate decisionmakers

      • Right to die/wrongful life

        • Karen Ann Quinlan, Nancy Cruzan, Terry Schiavo

      • Advance directives

      • Rights of minors

      • Treatment refusal

        • Jehovah’s Witnesses, dialysis, Dax

    • Confidentiality

      • When to breach confidentiality

      • Tarasoff


    Ethical and legal bases of informed consent

    Ethical and Legal Bases of Informed Consent

    • What is the ethical basis for informed consent?

    • Autonomy underlies informed consent

    • Assault and (intentional tort of) battery


    Informed consent

    Informed Consent

    • Three Elements of informed consent

      • Voluntariness

      • Information

      • Competence (capacity)


    Three elements of informed consent

    Three Elements of Informed Consent

    • What three elements comprise informed consent?

    • Information

      • How much?

    • Competence (capacity)

      • How do we determine this?

    • Voluntariness

      • What constitutes coercion?


    Voluntariness

    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?

      • Voluntary within constraints

    • Would decision of family to request withdrawal of feeding tube be voluntary if hospital threatened them with threat of massive health care costs?


    Information what must be disclosed

    Information – What must be disclosed??

    • No doctrine of informed consent in Georgia. Georgia requires disclosure “in general terms the treatment or course of treatment” but for surgical or diagnostic treatments standard is higher (O.C.G.A.31-9-6.1)

    • For surgical procedures, amniocentesis, contrast material “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”

    • Good practice to disclose diagnosis, nature of treatment, risks, benefits, alternatives, prognosis with and without treatment, and to invite questions


    What should be disclosed

    What should be disclosed?

    • Case 1 – HIV and confidentiality

      • Meaning of test

      • Risk of infecting wife

      • Possible criminal consequences for failing to inform her

        • Woodrow Grady, Macon, sentenced to two years in 2009

      • HIV and fetus, children

      • Treatment possibilities, alternatives, side effects, prognosis

    • Case 2 – PVS and removal of feeding tube

      • Prognosis with and without feeding tube

      • Alternatives

      • Costs – make it clear care does not depend on ability to pay


    Competence

    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.


    Competence1

    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


    Competence2

    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?


    When the patient is incompetent

    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”


    When the patient is incompetent1

    When the Patient is Incompetent

    • Nancy Cruzan

    • 1983 MVA

    • PVS, feeding tube

    • 1987 parents sued to remove tube

    • Court liberty interest in being free from unwanted intrusions

    • Loosely “right to die”

    • Patient Self-Determination Act 1990


    When the patient is incompetent2

    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

        • Living Will

          • Specifies particular decisions, e.g., ventilators

    • Georgia Advance Directive for Health Care includes both Power of Attorney and Living Will provisions (posted on ethics site, First Year)


    Georgia advance directive for health care

    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 (if I have filled out 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.


    Substituted judgment v best interests

    Substituted Judgment v Best Interests

    • Substituted judgment – for persons who have been competent to express a choice but who presently lack capacity

      • Dementia

      • Delirium

      • Severe mental illness

    • Best interests standard – for persons never competent to have decided

      • Children

      • Mentally retarded/developmentally disabled


    Georgia advance directive for health care1

    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


    Georgia advance directive for health care2

    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;


    Georgia advance directive for health care3

    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 to option (C).]

      • 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.


    Default surrogate decisionmakers i

    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

    • (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;


    Default surrogate decisionmakers ii

    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) Others

    • (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.

    • (E) Grandchild

    • (F) Niece, nephew, aunt, or uncle

    • Treatment which the patient would have wanted had the patient understood the circumstances under which such treatment or procedures are provided.


    Medical consent in minors

    Medical Consent in Minors

    • Under the age of 18 may consent to:

      • Treatment for drug abuse

      • HIV testing

      • Prevention of pregnancy

      • Treatment during pregnancy and childbirth

      • Treatment for STD

      • Abortion with parental notification


    Informed consent1

    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


    Exceptions to informed consent

    Exceptions to Informed Consent

    • Emergency exceptions to informed consent

      • Consent is implied in emergency when patient is lacks capacity and surrogate unavailable

    • Therapeutic privilege

    • What is Rule #1?

    • Rule #1 - We are doctors, not lawyers


    Confidentiality

    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


    Confidentiality1

    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.


    Health insurance portability and accountability act hipaa 1996

    Health Insurance Portability and Accountability Act (HIPAA) 1996

    • Title II: Preventing Health Care Fraud and Abuse; Administrative Simplification; Medical Liability Reform

      • Intent to restrict release of information to only that necessary to achieve the purpose

      • Patients are guaranteed access to their medical records and may amend

        • Not “psychotherapy” notes

      • What about disclosing information to a family member in an emergency?

        • Consent not required if disclosure necessary for treatment

        • Notification of family may be necessary for treatment


    Subpoena duces tecum

    Subpoena Duces Tecum

    • Immediate response: Reply, don’t comply

    • Check with patient

    • Get legal advice if needed

    • Release minimum information necessary


    Breaking confidentiality

    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”


    Optional review of first meeting

    Optional Review of First Meeting

    • What is an ethical dilemma?

      • Conflict between or among moral imperatives

    • Principles of medical ethics

      • Autonomy, beneficence, non-maleficence, justice

    • Procedure for ethical case analysis

      • Rule #1, stakeholders, relevant laws, potential consultants, possible decisions, proposed resolution


    Review

    Review

    • What are four commonly accepted ethical principles?

    • What is an ethical dilemma?

    • Where can you find resources for medical ethics at Mercer?

    • What ethical principle is the basis for informed consent?

    • What does the Karen Ann Quinlan case emphasize?

    • What legislation resulted from the Nancy Cruzan case?


    Medical ethics and professionalism

    • The principle of autonomy in medical ethics concerns the patient’s

      • Right to determine what shall be done to her own body

    • A capacity determination is

      • A judgment about the patient’s ability to make a particular decision about her medical care

    • When obtaining informed consent from a patient for a surgical procedure, the standard in Georgia for disclosure of risks includes material risks which are


    Medical ethics and professionalism

    • Accepted by reasonably prudent physicians that would cause a reasonably prudent patient in similar circumstances to refuse the procedure

    • When a decision must be made about the medical care of an adult patient who has had, but who no longer has, decision-making capacity, the surrogate decision-maker should

      • Use the “substituted judgment” standard to reach a decision, i.e., what the patient would have decided if competent


    Medical ethics and professionalism

    • Which three elements comprise valid, informed consent?

      • Competence, relevant information, voluntary

    •  Which of the following is recognized as the primary ethical foundation for informed consent?

    • a. Principle of autonomy


    Medical ethics and professionalism

    • The case of Tatiana Tarasoff in California led to the enunciation of which legal principle?

    • That there is a duty to protect identifiable third parties when a clinician knows, or, pursuant to the standards of the profession ought to know, that the patient presents an imminent threat of danger to that third party.

    • The Karen Ann Quinlan and Nancy Cruzan cases were both related to:

    • c. Right to die


    Medical ethics and professionalism

    • Which law led to the requirement that hospitals ask about the presence of Advance Directives?

      • Patient Self-Determination Act

    •  The Oath of Hippocrates includes which of the following?

    • b. A warning to keep secret knowledge learned from professional contacts as well as knowledge learned “in the daily commerce with men”


    Next time wednesday feb 15

    Next Time – Wednesday Feb 15

    • Professionalism

    • Optional review


    Review1

    Review

    • Four principles of medical ethics

    • Ethical principle - basis for informed consent

    • Karen Ann Quinlan

    • Nancy Cruzan

    • Tatiana Tarasoff

    • Three elements of informed consent


    What does it mean to be professional

    What does it mean to be professional?

    • As a preclinical student?

      • Prepared

      • On time

      • Respectful

    • As a clinical student?

      • Appearance

      • Prepared

      • On time

      • Respectful

        • Nurses

      • Extra duty


    Some characteristics of a professional

    Some Characteristics of a “Professional”

    • Self-regulating

    • Specialized education, training, knowledge

      • Competence

    • Behaviors

      • Dress

      • Timeliness

      • Preparedness

      • Courtesy

      • Hard working


    On entering a profession

    On Entering a Profession

    • An oath is taken pledging to uphold the standards of that profession


    Medical ethics and professionalism

    The Oath of Geneva

    AT THE TIME OF BEING ADMITTED AS A MEMBER OF THE MEDICAL PROFESSION:

    I SOLEMNLY PLEDGE myself to consecrate my life to the service of humanity;

    I WILL GIVE to my teachers the respect and gratitude which is their due;

    I WILL PRACTICE my profession with conscience and dignity;

    THE HEALTH OF MY PATIENT will be my first consideration;

    I WILL RESPECT the secrets which are confided in me, even after a patient has died;

    I WILL REMAIN by all means in my power, the honor and the noble traditions of the medical profession;

    MY COLLEAGUES will be my brothers and sisters;

    I WILL NOT PERMIT considerations of religion, nationality, race, party politics or social understanding to intervene between my duty and my patient;

    I WILL MAINTAIN the utmost respect for human life from its beginning, even under threat, and I will not use my medical knowledge contrary to the laws of humanity;

    I MAKE THESE PROMISES solemnly, freely and upon my honor.


    Consecrate my life

    “Consecrate My Life”

    • I SOLEMNLY PLEDGE myself to consecrate my life to the service of humanity


    Respect and gratitude

    “Respect and Gratitude”

    • I WILL GIVE to my teachers the respect and gratitude which is their due


    Conscience and dignity

    “Conscience and Dignity”

    • I WILL PRACTICE my profession with conscience and dignity


    My first consideration

    “My First Consideration”

    • THE HEALTH OF MY PATIENT will be my first consideration


    Confided in me

    “Confided in Me”

    • I WILL RESPECT the secrets which are confided in me, even after a patient has died


    Traditions

    “Traditions”

    • I WILL REMAIN by all means in my power, the honor and the noble traditions of the medical profession


    Brothers and sisters

    “Brothers and Sisters”

    • MY COLLEAGUES will be my brothers and sisters


    No other considerations

    No Other Considerations

    • I WILL NOT PERMIT considerations of religion, nationality, race, party politics or social understanding to intervene between my duty and my patient


    Respect for human life

    “Respect for Human Life”

    • I WILL MAINTAIN the utmost respect for human life from its beginning, even under threat, and I will not use my medical knowledge contrary to the laws of humanity


    Promises

    “Promises”

    • I MAKE THESE PROMISES solemnly, freely and upon my honor.


    The oath of geneva

    The Oath of Geneva

    • Challenges to professionalism – But what about . . .?


    Consecrate my life1

    Consecrate My Life

    • I SOLEMNLY PLEDGE myself to consecrate my life to the service of humanity

      • What does it mean to “consecrate?”

      • Are you ready when you come to class/rounds?

      • Do you do just the minimum work required (e.g., number of patients)?

      • Resident work hours – what to do when you’ve reached the limit and patient continuity of care or a learning might be compromised?

      • Will you take responsibility for your continuing education, attending meetings, reading journals, obtaining consultations?


    Respect teachers

    Respect Teachers

    • I WILL GIVE to my teachers the respect and gratitude which is their due

      • An attending asks you to suture a deep facial wound. You have little experience with this and express your concern. The attending tells you “Well, this is how you learn” and leaves.

      • An attending asks you to obtain informed consent regarding a complex procedure with which you are unfamiliar and brushes aside your reservations about your ability to describe the procedure, its risks and benefits, prognosis, and alternatives.

      • An attending deliberately exposes parents of a newborn to a surgical procedure on their baby to demonstrate the futility of further intervention. They are devastated.


    Conscience

    Conscience

    • I WILL PRACTICE my profession with conscience and dignity

      • A recent graduate opens a primary care clinic advertising itself as catering to gay and lesbian patients. It is one of very few clinics in this rural area. Residents who are not gay or lesbian are reluctant to visit the clinic.

      • A fertility specialist is approached by a woman who seeks to have six stored fertilized embryos implanted. She has six children at home.

      • A woman approaches you for advice about an elective abortion, to which you are opposed for religious reasons. Should you refer her to a colleague who performs abortions?


    Health of my patient

    Health of My Patient

    • THE HEALTH OF MY PATIENT will be my first consideration

      • Your patient comes to you for an exam prior to traveling to Greece for his wedding. You discover him to have TB and express your concern over his trip.

      • A woman is brought by her husband to the EC with a history of severe depression, auditory hallucinations, and has been suicidal in the past. She gave birth six weeks ago to a health baby. She tells you “Whatever you do, don’t take my baby or make me come in the hospital. I couldn’t take it.” You are considering involuntary hospitalization (“commitment”).


    Brothers and sisters1

    Brothers and Sisters

    • MY COLLEAGUES will be my brothers and sisters

      • Another student has been coming to groups late, lives by himself, and there is concern among other students over his drinking and use of antianxiety (Xanax), pain, and stimulant medications.

      • During your EC and Internal medicine rotations you become aware of a community physician who seems to have a large number of patients coming to the hospital toxic on pain medications for which the indications are unclear, e.g., “fibromyalgia.”


    Secrets

    Secrets

    • I WILL RESPECT the secrets which are confided in me, even after a patient has died

      • Your patient is going through a painful divorce and, during his annual physical examination, tells you “Sometimes I think the only way to protect the kids from her is just to get her out of picture entirely, if you know what I mean.”


    Respect for life

    Respect for Life

    • I WILL MAINTAIN the utmost respect for human life from its beginning, even under threat, and I will not use my medical knowledge contrary to the laws of humanity

      • Patient Rights groups strongly support the “Death with Dignity Act” in Oregon and seek to pass a similar law in Georgia. Your local legislator asks for your opinion.

      • Your hospital is considering a futility of care policy applicable to newborns and adults with severe medical conditions for which medical care is unlikely to provide anything but maintenance of vegetative functions. The policy would permit, after due process, termination of life supports over the objections of family.


    Medical ethics and professionalism

    Threat to professionalism

    Mangled care


    Medical ethics and professionalism

    Threat to professionalism

    Medical Industry


    Medical ethics and professionalism

    Threats to professionalism

    “Alternative health care”

    Social justice and lack of access


    Unprofessional conduct and board action

    Unprofessional Conduct and Board Action

    235 MDs disciplined by board 1990-2003

    469 MDs controlled for school and year of graduation

    Disciplined for:

    Unprofessional conduct (74%)

    Incompetence

    Other

    Papadakis et al. Disciplinary Action by Medical Boards and Prior Behavior in Medical School. NEJM 2005;353:2673-82


    740 board violations by 235 physicians

    740 Board Violations by 235 Physicians

    Use of drugs or alcohol108

    Unprofessional conduct 82

    Conviction for a crime 46

    Negligence 42

    Prescribing/acquisition substances 39

    Violation of Board order/condition 32

    Sexual misconduct 29

    Other – Failure to meet CME, fraud, billing, failure to maintain adequate records


    Disciplined vs control physicians

    Disciplined vs. Control Physicians

    No gender differences

    Highly significant differences (p< 0.05– 0.001)

    Medical school academic performance

    USMLE

    Unprofessional conduct in school predicted subsequent disciplinary problems

    39% of disciplined physicians displayed unprofessional behaviors in school vs 19% of undisciplined physicians (disciplined physicians twice as likely to have records of unprofessional conduct during school)

    P<0.001


    Unprofessional conduct in school

    Unprofessional Conduct in School

    OR

    Irresponsibility (>2) 8

    Attendance, follow-up

    Lack of self-improvement (>2) 3

    Response to criticism

    Immaturity

    Poor initiative

    Motivation, enthusiasm

    Relationships (students, nurses, faculty, patients)


    Lessons

    Lessons

    Professionalism starts now

    Good news – the two most significant predictors are modifiable

    If you have problems with attendance, preparedness – change!

    If you have a problem accepting criticism – learn!

    Smiling inward is deadly


    Groups

    Groups

    Prepare as a professional

    Read the cases

    Analyze using case analysis format

    Discuss with colleagues as you like

    Rule #! - Wear white coats to our groups


    Review2

    Review

    • Case analysis


    Principles of medical ethics1

    Principles of Medical Ethics

    • Which of the following is NOT widely considered a principle of medical ethics?

      • Autonomy

      • Beneficence

      • Respect

      • Social justice

      • Non-Malfeasance


    Hipaa

    HIPAA

    • HIPAA is an important piece of federal legislation covering:

      • Privacy of health care information

      • Treatment in emergency rooms

      • The right to privacy in medical decisionmaking


    Mandatory disclosure

    Mandatory Disclosure

    • In which of the following cases is disclosure of information NOT required:

      • Suspected child abuse

      • New HIV patient

      • Receipt of a subpoena for medical records to be used at a divorce proceeding

      • Previously undisclosed criminal history


    Match case with the concept most closely identified with it

    Match case with the concept most closely identified with it

    • National attention on “right to die” and removal of life sustaining devices

    • Duty to protect third parties

    • Removal of feeding tube, Patient Self Determination Act

    • Tarasoff

    • Nancy Cruzan

    • Karen Ann Quinlan


    Autonomy

    Autonomy

    • The principle of autonomy concerns the patient’s 

      • Right to be treated with compassion

      • Right to determine what shall be done with one’s body

      • Right to basic medical care

      • Right to drive an automobile


    Capacity competence

    Capacity (competence)

    • A capacity determination is

      • A judgment about the patient’s ability to be a good patient

      • A judgment about the patient’s ability to make good decisions in general

      • A judgment about the patient’s ability to make good medical decisions

      • A judgment about the patient’s ability to make a particular decision about her medical care


    Which is the more acceptable view

    Which is the more acceptable view?

    • Providing the degree of information necessary for genuine informed consent is understood to require

      • Disclosing what a reasonable physician would disclose in the circumstances

      • Disclosing information that a reasonable person in those circumstances would judge relevant

      • Both


    Best interests or substituted judgment

    Best Interests or Substituted Judgment?

    • When a decision must be made about the medical care of an adult patient who has had, but who no longer has, decisionmaking capacity, the surrogate decisionmaker should 

      • Use the “best interest” standard to reach a decision, i.e., what, in the opinion of the surrogate decisionmaker is in the best interests of the patient

      • Use the “substituted judgment” standard to reach a decision, i.e., what the patient would have decided if competent


    Best interests or substituted judgment1

    Best Interests or Substituted Judgment?

    • When a decision must be made about the medical care of a patient who never had decisionmaking capacity, the surrogate decisionmaker should

      • Use the “best interest” standard to reach a decision, i.e., what, in the opinion of the surrogate decisionmaker is in the best interests of the patient

      • Use the “substituted judgment” standard to reach a decision, i.e., what the patient would have decided if competent

      • Neither a nor b


    Informed consent2

    Informed Consent

    • Which of the following is NOT one of the three elements of a valid informed consent?

      • Information

      • Confidentiality

      • Voluntariness

      • Competence

      • Witnessed


    Minors and medical decisions

    Minors and Medical Decisions

    • To which medical decisions may a minor in Georgia give consent?

      • Drug abuse treatment

      • STD

      • Treatment of the minor’s child

      • Pregnancy

      • Prevention of pregnancy

      • Abortion with parental notification (except emergency or with court approval)


    Questions

    Questions?


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