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  1. Objectives • Review briefly the history of medical ethics • Define autonomy, beneficence, non maleficence, truth telling and justice • Balance competing medical ethics in making decisions about patient care

  2. The Origin of Ethics

  3. Socrates’ question “How shall we live?”

  4. Applied Ethics in the palliative care setting Phil Lawson MD NHHPCO Annual Meeting November, 2011

  5. The Origins of Ethics Aristotle: • “It is thought that every activity, artistic or scientific, in fact every deliberate action of pursuit, has for its object the attainment of some good.“ Aristotle “Ethics”

  6. Ethics, Morality and the Law • Ethics: collective guiding principles • Morals: personal sets of beliefs • Law: rules to run society

  7. Ethical principles • Jainist philosophy (Ghandi): “nonviolence to all life” • Christian (Jesus): “love one’s neighbor as oneself” • Hippocrates: “strive to help, but above all do no harm”

  8. Ethical principles • Kant: “act as if that act would become a universal law” • Bentham: “act to provide the greatest good to the greatest number” (utilitarianism) • Rawls: “maximize the benefit to those minimally advantaged” (maximim theory)

  9. The Goal of Medical Ethics

  10. Medical Ethics Medical ethics and principles Autonomy Beneficence Nonmaleficence Justice Truthtelling

  11. The Basic Ethical Principles Autonomy: respects autonomous decision making (‘self-rule’ ) - promotes patients to act as their own agent - free will with informed consent The down side: Consumerism: commitment to non-involvement in client decision making Non Caring

  12. The Basic Ethical Principles Beneficence: Do good (or ‘provide benefit’ ) - the basic principle of “caring” - act in accordance with a patient’s welfare The down side Paternalism: health provider makes decision for the patient based on provider’s values more than patient’s values

  13. The Basic Ethical Principles Non maleficence: Do no harm - the calculation of risk in medical decision making and determining risk/benefit ratio - the balance of benefit and harm = utility The down side Non action or unwillingness to offer treatments with questionable benefit

  14. The Basic Ethical Principles Justice: Be fair (distributive justice > entitlement) - the appropriate distribution of limited resources; non discrimination - transparency, accountability and consistency The down side Restriction of higher end resources from those who could “afford” it Transparency can drive inappropriate practice (data mongering)

  15. Other Ethical Principles Truth-telling or Veracity: - full, honest disclosure The down side Assaulting patients with “the truth”

  16. Other Ethical Principles Fidelity: -do as you say you will do + respect confidentiality The down side Confidentialty can impede quality and efficiency of care

  17. A Process of Ethical Decision Making • Define the situation clearly and as completely as possible including the context • Decide on which ethical principles are involved • Weigh the competing principles • Make a decision

  18. Ethics “The practice of ethics is NOT the application of rules; but the careful consideration of principles in the complex world of decision making about human action.”

  19. AMA Code of Ethics • Display competence, with compassion and respect for human dignity and rights • Uphold standards, be honest, and report those deficient in character or competence or engaging in fraud • Respect the law and try to change those laws contrary to the best interests of the patient

  20. AMA Code of Ethics 4. Respect rights of patients and colleagues and maintain confidentiality within constraints of the law 5. Continue education, consult appropriately and present information to patients 6. Be free about whom to care for, whom to associate with, and where to provide care (except in emergencies)

  21. AMA Code of Ethics 7. Recognize a responsibility to participate in activities that better community and public health 8. Regard responsibility to the patient as paramount 9. Support access to medical care for all people Adopted by the AMA's House of Delegates June 17, 2001.

  22. Palliative Care Issues “Double Effect” “Decision Making Capacity” and “Informed Consent” “Futility”

  23. The Ethic of Dignity

  24. Situations?/ Cases?

  25. Terry • 51 year old cachetic (95 lb) male in hospital due to pneumonia not recovering • 5 year hx metastatic prostate ca multiple mounting complications (c diff, recurrent SVT, hypotension, hypoalbuminemia and edema) • not eating and resistant to attempts to assist in recovery from pneumonia • full code and states he wants to treat all conditions and get back to work

  26. Terry • Also states he does not want to linger, only wants comfort care when he is dying, and “if I knew what this past year was going to be like, I would have preferred to die.” • Refuses to eat and angrily reacts to anyone suggesting his recovery would benefit from better nutrition • Has a different symptom (often different pain source) that comes and goes each day when PT/OT comes by to help him

  27. Terry • Palliative care consultation requested

  28. Question Continue to aggressively try to treat complications vs focus on aggressive symptom control?

  29. Gerard • 65 yo male malnourished alcoholic • Admitted for acute sepsis • No prior medical care until saw surgeon 3 wks previous for non-healing stage IV LE ulcers • 10 cm hepatocellular carcinoma dx during treatment for ulcers • Initially alert

  30. Gerard • Suddenly develops acute renal failure and loses decision making capacity • Requires dialysis or will die • Attending surgeon thinks comfort care; GI consultant pushing hard for dialysis

  31. Gerard • Only ‘family’ is son of a former girlfriend who he raised (who is on probation) • Owns own home where they lived • Has no AD’s, no financial will • Ethics consultation requested

  32. QUESTION Refer for dialysis or comfort care?

  33. Other examples • Access to harmful treatment • Radiation and chemotherapy at end of life (ECOG IV) • Access to treatments that cannot be afforded • Targeted vemurafenib for melanoma with BRAF mutation • $120,000 for a course of therapy

  34. Other examples • Physician assisted suicide