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Medical Ethics [vs. Professional ethics] • Ethical dilemma is a predicament in which there is no clear course to resolve the problem of conflicting moral principles
Principles • Autonomy • Beneficience • Nonmaleficence • Justice
Autonomy • Freedom to influence course of life/treatment • Requires the person to be competent in decision making capacity
Preservation of Autonomy • Living Will • Takes effect when terminally ill and lacking decision making capacity • Surrogate Decision Makers • Represents patients interest
Preservation of Autonomy • The primary responsibility of the physician is to serve the patients interest
The patient self determination act of 1990 • At the time of admission information re: the patients’ right to refuse care or create an advance directive must be dispensed
Informed Consent • Patient is presented all alternatives so they can make a decision. Must be competent • Requirements • Decision making capacity • Volutariness • Reasonable person standard • Present all alternatives f/b recommendation • Respect refusal • All surgical and experimental procedures
Implied Consent • Invoked when in emergency situations when harm would result without urgently needed intervention
Disclosure • Truth telling on part of physician is an integral part of patient autonomy
Paternalism • Justifiable if patient at risk of significant preventable harm, paternalistic action will prevent harm, benefits outweigh risks and the least autonomy-restrictive course of action is used
Confidentiality • Obligation of physician to maintain information in strict confidence • Breaching patient confidentiality may be merited only: • When ordered by court of law – a court case • Where statutory requirement – public health laws • Where required in health professional’s defense –malpractice suit • Where necessary for appropriate patient care-speaking to another provider in the medical care system
The percentage of patients who would like to be told their diagnosis if it is a: Metastatic cancerTerminal Prognosis European Americans 87% 69% African Americans 88% 63% Mexican Americans 65% 48% Korean Americans 47% 35% Ethiopians (can you guess?)??% ??% Source: Blackhall LJ, et al. (1995) JAMA 274: 820-5. • The more traditional the culture … the less truth telling regarding patient condition
Beneficience • Obligation to preserve life, restore health, relieve suffering and maintain function • To do “good” • Nonabandonment – obligation to provide ongoing care • Conflict of interest – must not engage in activities that are not in patients best interest
Nonmaleficence • “Do no harm”
Justice • Allocation of medical resources must be fair and according to need • Physicians should not make decisions regarding individuals based upon societal needs
DNR • DNR orders affect CPR only • Other therapies should not be influenced by DNR order • Should be reviewed frequently • Rationale should be in medical record
Persistent Vegetative State • Uncnsciousness/ loss of self awareness lasting more than weeks • Supreme court draws no distinction between artificial feeding, hydration vs. mechanical ventilation
Death • Irreversible cessation of circulatory and respiratory function • Irreversible cessation of all brain function (including brainstem)
Ethical Dilemas • Euthanasia • Legally prohibited in the US except in Oregon which permits MD assisted suicide • Destroying Frozen Embryos
Case Studies • Lake, your 36-year-old patient, has just tested positive for HIV. He asks that you not inform his wife of the results and claims he is not ready to tell her yet.
Case Studies • 22 year-old woman, is admitted to the hospital with a headache, stiff neck and photophobia but an intact mental status. Lab tests reveal contagious meningitis. She refuses treatment for it.
A 25 year old woman victim of a single car MVA enters a persistent vegetative state. After four years, her parents petition to have her feeding tube removed. The hospital insists on a court order, and the victim’s closest friend and parents testify that she would not have wanted to have a feeding tube.