Medical Ethics and Professionalism Review of Part 1 February 11 2013

1. Medical Ethics and ProfessionalismReview of Part 1 February 11 2013 • Four principles of medical ethics • Autonomy • Beneficence • Non-maleficence • Social Justice • Three elements of informed consent • Voluntariness • Information • Competence

2. 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)

3. 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.

4. 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 • Or when there is no information as to what the person would have decided

5. 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

6. 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;

7. 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.

8. Default Surrogate Decisionmakers I • If a decisionmaker is not specified or is not available: • § 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;

9. 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.

10. 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

11. 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

12. 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

14. 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

15. 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.

16. 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 • Rule #1

17. Subpoena Duces Tecum • Immediate response: Reply, don’t comply • Check with patient • Get legal advice if needed • Release minimum information necessary

18. 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 (permissive) • “Tarasoff” warnings • “protective privilege ends where the public peril begins” • Duty to protect identfiable third parties at imminent risk • No law in Georgia

20. 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

21. Some Characteristics of a “Professional” • Self-regulating • Specialized education, training, knowledge • Competence • Behaviors • Dress • Timeliness • Preparedness • Courtesy • Hard working

22. On Entering a Profession • An oath is taken pledging to uphold the standards of that profession

23. 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.

24. “Consecrate My Life” • I SOLEMNLY PLEDGE myself to consecrate my life to the service of humanity

25. “Respect and Gratitude” • I WILL GIVE to my teachers the respect and gratitude which is their due

26. “Conscience and Dignity” • I WILL PRACTICE my profession with conscience and dignity

27. “My First Consideration” • THE HEALTH OF MY PATIENT will be my first consideration

28. “Confided in Me” • I WILL RESPECT the secrets which are confided in me, even after a patient has died

29. “Traditions” • I WILL REMAIN by all means in my power, the honor and the noble traditions of the medical profession

30. “Brothers and Sisters” • MY COLLEAGUES will be my brothers and sisters

31. 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

32. “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

33. “Promises” • I MAKE THESE PROMISES solemnly, freely and upon my honor.

34. The Oath of Geneva • Challenges to professionalism – But what about . . .?

35. 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?

36. 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.

37. 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?

38. 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”).

39. 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.”

40. 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.”

41. 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.

42. Threat to professionalism Mangled care

43. Threat to professionalism Medical Industry

44. 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

45. 740 Board Violations by 235 Physicians Use of drugs or alcohol 108 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

46. 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

47. 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)

48. 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

49. Groups Prepare as a professional Read the cases Analyze using case analysis format Discuss with colleagues as you like

50. 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