Medical Ethics PRE-MID.docx

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Mary Anne Banks

Introduction Week 0 Weeks 1-3 Autonomy and Consent Weeks 4-10 Should there be limits in Medicine? Weeks 11-12 Allocation Moral and Ethical Theories Week 1: Jan 7-11 Introduction Week 1: (Jan 7-11) Introduction 1.2 Morality and Ethics 1.3 Moral Theories 1.2 Morality and Ethics: Philosophical Method:  identify the problem (engage doubt and sense of wonder)  formulate questions and problems/break down the problem into pieces and examine  generate solutions  assess and justify solution  monitor success What is Ethics?  is being ethical the same as acting within the law? o not all congruent o with medicine, law is always catching up because it moves too fast  what is the definition of it? Medical Ethics:  theoretical foundation of rights and obligations in health care relationships  practical moral issues arising within these relationships Hippocratic Oath  father of western medicine, doctors used to have to swear this oath  keep people from harm  rules out euthanasia and abortion  don’t sleep with patients  confidentiality  MODERNIZED: o collaborative with new knowledge o “all required measures” o confidentiality o may save, but may take a life -> idea of doctors can’t be killers gone o treat them as individuals and whole person CASE STUDY:  Anael being treated for cancerous tumours in brain and spinal cord o recommended chemo but parents chose healthy diet o officials asked province’s child protection agency to intervene  Considerations: o capacity to make decision o expertise o chance of survival with chosen treatment course o protect children o short-term vs. long-term 1.3 Moral Theories Deontology/Kantianism (Ned Stark)  Immanuel Kant (German Philosopher)  humans are valuable because we can reason and discover the objective moral laws that govern our behaviour o side with the idea that you should be able to make a rational decision for yourself  moral duties are categorical (unqualified and unconditional) universal and absolutely binding on all people at all times o person is morally good if her intention (will) is good o intention is good if it is based on the motive of doing our duty o being motivated by duty means respecting the moral law  Your Duty: o categorical imperative 1: act only according to that maxim by which you can at the same time will that it should become a universal law o Immanuel Kant's Categorical Imperative is generally summarized as the principle that if a moral rule applies to someone, then it applies to everyone.  Example: o If I believe that homosexuality is immoral, then I must accept the fact that if I engage in a homosexual act, I am immoral as well--or I must abandon my belief.  e.g. lying: I should be able to lie when its beneficial, but if everyone lies then you will know that they are lying to you in those circumstances o in everyday life could be a situation where you are at a red light early in the morning. No one is coming in any direction and this red light is notorious for being long, and you are running late for work. Now you could go ahead and run this light if and only if you would will this action into a universal law. That means would you want everyone to run red lights anytime they want, or anytime they are running late to work etc o o what is my motive for doing this? o what is my maxim for this behaviour? o what is the universal form of this maxim? o can this universalized maxim be made a moral law? o Anael:  what’s the doctor’s motive?: save Anael  what’s his maxim?: override patient when they’re wrong  universal form?: all doctor’s should override patients when they’re wrong  can it be moral law?: eliminates patient autonomy> paternalism  In other words o Categorical Imperative focuses on all mankind. How ALL mankind should wish for all people to act towards everyone, and not just to himself (golden rule-treat others as you treated involves only self) o categorical imperative 2: act so that you treat humanity, whether in your own person or in the person of any other, always as an end and never as a means only  treat how you want to be treated (devaluing them)  people are intrinsically valuable and should not be treated as merely objects we use to achieve our goals  cannot: coerce, deceive, manipulate  Aneal:  failed the second Utilitarianism  Jeremy Bentham o associated with Hedonism: good and bad=what is pleasurable and painful  morally good action=produces more pleasure and/or avoids more pain  strict equality: my pleasure/pain does not matter more than that of others  John Stuart Mill o not all pleasure are equal  higher= intellect, lower=sensory  competent judges determine which are which o produce the greatest amount of happiness for all members of the moral community  Foundation: o all things that feel pleasure and pain want the former  morally good maximizes pleasure/happy, minimize pain  no person’s is more important than anyone else’s. must be based on strict equality o an action is right only if it produces at least as much good (utility) for all people affected by the action as any alternative action the person could do instead  Choice: o identify the relevant parties and choices available  parties: anael, parents, hospital, wider public  choices: (1) override (2) respect o identify their pleasure/pain  (1) pleasure/happiness: greater probability that Anael will get better pain/unhappiness: feel autonomy ignored, watching anael go through chemo  (2) pleasure: parents get to take him home pain: unlikely it will heal him o minus their pain from their pleasure o rank available actions starting with that which will produce the greatest happiness for most people  in this case the highest utility is for (1) because of Anael recovering Care Ethics  Carol Gilligan (social psychology from Harvard)  instead of “thinking morality” to determine what ethical principles we should use, Gilligan looks at how we act morally. What principles do we already use?  care is a virtue – disposition to act in a certain way. it is a meta- virtue – it provides an organizing principle for all other virtues  act in a caring way, and whatever the outcome will be will be correct  when we truly care about something or someone we have certain emotions and motivations. if I see someone in dire need I will feel compassion and feel motivated to do something to respond to the need  caring is a response to a variety of features of moral situations: o need: our obligation to respond in an appropriately caring way arises when we able to to the need o harm: being the cause of harming someone else creates an obligation to respond o past promising: when we promise we commit ourselves to a certain course of action o role responsibility: being in a certain position (teacher, parent, doctor) comes with a set of general obligations  method: o moral attention: look at all the details of the situaition, and indentify need, harm, and past promising o sympathetic understanding: what would those involved want you to do? o relationship awareness: what relationship do you have to those affected? o accommodation and harmony: how can you do what is best and involve those affected?  take your daughter to the beach and your daughter and two other girls appear to be drowning o utilitarian: save the two, as many as you can o kant: treat each drowning child impartially, obey the duty of beneficence and save whoever you can  if you made a promise, you would have to save daughter o care ethics: your daughter is dependent on you, you brought her, your greatest obligation is to save your daughter  Anael: o moral attention:  attention to the situation in all its complexity. in order to understand what our obligations are we have to know all the details that might make a difference in our understanding and respond to the particular situation at hand  what does Anael and his parents need? has the HCP promised to help them? what harm will result from either choice? o sympathetic understanding:  open to sympathizing and even identifying with the persons in the situation. be aware of what the other in the situation would want you to do, what would be in their best interests, how they would like you to carry out their wishes and interests and meet their needs  anael’s parents have made it clear that they their child to get better and that they that the chemo will not work (will cause Anael pain) o relationship awareness:  recognizing the type of relationship at play  fellow creatures  immediate relationship of need and ability to fill the need  role relationship  doctor-patient (professional) o accommodation and harmony:  often many are involved and cannot (or should not) do what they all think they need. instead do what you think is best while giving everyone a sense of being involved and considered  even if the HCP overrides the parents’ decision, it is important that they are consulted Compare All Three: kantianism utilitarianism care ethics rationality is intrinsicallall feeling things want humans are social good and is why pleasure and want to creatures and are humans are valuable avoid pain. all feelings miserable without things are equal in this relationships. we cannot way accomplish many of the tasks we undertake without fostering good relationships thus: morally good thus: morally good thus: morally good action is relationship action is concerned with action is concerned with and logical and maximizing pleasure out relationships with praiseworthy action is and minimizing pain one another done because it adheres to the moral law We come up with: 4 Principles of Bioethics (Medical Ethics)  respect for autonomy (self-rule) (Kant) o everyone should be left free to formulate their own interests will minimal interference from others  beneficence (utilitarianism) o must promote beneficence – doing good and helping the patient  non-maleficence (utilitarianism) o must promote non-maleficence – not inflict unnecessary pain, suffering and/or harm to the patient  justice (moral community/social co-operation) o treat similar cases the same and different cases differently Autonomy and Consent Week 2: Jan 14-18 Autonomy and Consent Week 2: Autonomy and Informed Consent Faden and Beauchamp, “The Concept of Informed Consent” (111) Harrison, “Involving Children in Medical Decisions” (30) Buchanan and Brock, “Standards of Competence.” (26) missing Sherwin, “A Relational Approach to Autonomy in Health Care.” (35) “The Concept of Informed Consent” Informed Consent:  informed consent is the primary legal and ethical tool for protecting patient autonomy o can’t touch patient without explaining the procedure and getting consent o medical intervention without consent is battery under the law  must be fully informed, voluntary and given by either a competent patient or valid surrogate o 1. Fully informed  must tell all the options and both risks/benefits  when not fully informed there is a restriction on patient autonomy  problem?  can’t tell the patient everything  tell enough for a “responsible” decision o 2. Voluntariness  cannot threaten the patient  natural event may limit the options but does not make it involuntary because the limit is not imposed by a person  reward for participation in research? be careful, reward must be something above the level of resources everyone is entitled to. Offering basic medical care is coercive, giant tv is not. o 3. Competence  patient must be capable of making a decision  excludes infants, unconscious, mental illness  wishes vs. interests:  interests are what is best (good health)  consent based on expressed wishes  when wishes and interest are radically different we may question a patient’s competency Four Models of Physician-Patient Relationship  what should ideal relationship be?  4 considerations: o goals of physician-patient interaction o physician’s obligations o role of patient values o conception of patient autonomy  Paternalistic Model: o goal- for patient to receivce the intervention that best promotes their health/wellbeing  physician determines medical condition and best treatment  physician encourages patient to proceed with treatment (or at extreme does not require patient consent) o assumed patient and physician values are the same o autonomy: patient assents to physician’s treatment (before or after)  The Informative Model (Doctor as Expert) o goal- for the physician to provide all relevant information and have the patient choose their desired treatment  patient’s values are well defined, but lacks facts, so the physician needs to provide them o autonomy: patient control over medical decision making  The Interpretive Model (Doctor as Interpreter) o goal- identify patient’s values and what they really want and help the patient select the option that will allow them to realize these values  physician provides the patient with information and helps her understand her own values o autonomy: self-understanding regarding treatment  The Deliberative Model (Doctor as Teacher) o goal- to help patient determine and choose best health- related values that can be realized in clinical situation. Includes physician explaining why some values are more worthy than others  aims at moral persuasion not coercion, engaging the patient in a dialogue on best course of action o autonomy: moral self-development  Compare: o 43 premenopausal woman who has recently discovered a breast mass  paternalistic: two treatment options, A and B. B offers best chance of recovery. Also need to perform C. This is the best option for you.  informative: there are two treatment options, A and B. A offers 70% chance, B offers 50% but less invasive. let me know what you want to do.  interpretive: same as informative then add “ sounds like you have conflicting wishes, let me try to express a perspective that fits your position”  deliberative: same as informative and interpretive add “seems clear that you should undergo B. looking at your options it seems to be your best choice for the following three reasons. First… I have sought to explain our current knowledge and offer my recommendation so you can make the best possible decision”  Faden and Beauchamp “ The Concept of Informed Consent” o informed consent has two different meanings o Sense 1 – informed consent as autonomous authorization  more than saying “yes” to treatment but also authorizing it  an autonomous action by patient that authorizes a professional either to involve the subject in research or intiate medical plan  given by patient with  substantial understanding  substantial absence of control by others  intentionally  authorizes a professional to do intervention  “spirit of the law” o Sense 2 – informed consent as effective consent  emerges from the policy of ensuring informed consent – just need to satisfy the rules  means patient can provide consent in sense 1 and not is sense 2  example- minor may provide informed consent in sense 1 but too young to provide it according to hospital policy (sense 2) Harrison, “Involving Children in Medical Decisions” Why include children in medical decision making?  Christine Harrison, Nuala Kenny, Mona Sidarous, Mary Rowell, "Involving Children in Medical Decisions" o Case: Samantha is 11 years old. She had cancer which has now returned. There is an aggressive treatment available, but even with this treatment Samantha's chances for recovery are only 20% o Samantha refuses further treatment, her parents want her to go through with it  Our concept of competence for adults (voluntariness, disclosure of information, etc.) are insufficient in the context of caring for children  Adult models assume that the patient is autonomous, has a stable sense of self, established values, and mature cognitive skills  A family-centred ethic is the best model for understanding the interdependent relationships that bear upon a child's situation. Includes considering the effects of a decision on all family members, their responsibilities toward one another, and the burdens and benefits of a decision for each member o "Triadic" relationship with child, parents, and physician  When parents and child disagree o Assumption: parents best understand what is in the best interest of their child (and will chose that option)  However - distress can prevent the parents from doing so  In this case, the physician cannot simply comply with parent's wishes  Physician needs to affirm parents' responsibility for the child while allowing the child to exercise choice in an appropriate manner. This recognises that the child is the patient to whom the physician has a primary duty of care  This approach will seek to harmonize the values of everyone The law  Legal right to refuse treatment because you have the right to exercise control over your own body  To refuse treatment must be competent  In common law "mature minor" recognizes that some children are capable of making their own health care choices despite their age. When a child's capacity is in doubt and assessment is required  When children are not considered competent, parents/guardians are surrogates and can make a decision that is in the best interest of the child The child as decision maker  As children grow they develop decision making skills, the ability to reason, and an understanding of death  However - while we can make general statements about children at a certain age, no two children of the same age will necessarily have the same ability to make choices Competency at different ages  Infants and young children: preschool children have no significant decision-making capacity and cannot provide their own consent  Primary-school children: these children should participate in the decision, but do not have full decision making capacity  Adolescents: determine capacity in light of his or her o Ability to understand and communicate relevant info o Ability to think and choose with come degree of independence o Ability to assess the potential for benefits, risks, or harms as well as to consider consequences and multiple options o Achievement of a fairly stable set of values Physician's job  Ensure good decisions are made on behalf of the child  Need to consider o The potential benefits to the child o The potential harmful consequences to the child, including the physical suffering, psychological or spiritual distress, and death o The moral, spiritual, and cultural values of the child's family Samantha's case  Discussions between parents, Samantha, physician, and health care team  Discussions focus on reaching a common understanding about the goals of treatment for Samantha  Her decision is respected, and goal moves from cure to care Care ethics and children  While children may themselves not qualify as equal moral agents, our relationships with them, and their relationships with us, means their needs must be taken into consideration  Relationship with children o Parents: obligation to protect, care for, etc o Physician: obligation to child as patient, but also recognise relation to others o Society/state: protection of children Goals  Harmony, consider the needs/wants of everyone Participation Activity #1  Group discussion of Samantha's case through Kantianism or Utilitarianism. Would the outcome be the same or different than Care Ethics? Defend the position Buchanan and Brock, “Standards of Competence.” Sherwin, “A Relational Approach to Autonomy in Health Care.” 1. Difficulties with “autonomy”  ideal conditions (unrealistic to real life situations) Patient Autonomy:  patient decisions are considered to be autonomous if the patient is o deemed to be sufficiently competent to make the decision at issue  competency criterion threatens to exclude the oppressed because competency is usually tied to objective and emotion-free reasoning. stereotypical assumptions about certain groups can exclude them o makes a reasonable choice from set of available options  depending on how the options are determined, the list of available options might already seriously limit the patient’s autonomy  problematic for oppressed groups because they are underrepresented on the bodies that make these decisions o has adequate information and understanding about the available choices  information made available is what has been deemed relevant by HCP  large class differences between physician and seriously disadvantaged patient making it hard to anticipate the needs of patients o free from explicit coercion toward or away from one of those options  hard to evaluate when individual in question is oppressed, particularly if the choice is in a sphere tied to her oppression Autonomy and Agency  agency: one needs only to exercise a reasonable choice o you can choose to have risky plastic surgery to find love, if being more attractive will help you find love. it is rational o however this accepts oppression, and seems can not be fully autonomous  “ in order to ensure that we recognize and address the restrictions that oppression places on people’s health choices, then , we need a wider notion of autonomy that will allow us to distinguish genuinely autonomous behaviour from acts of merely rational agency” 2. Sherwin’s Relational Alternative  concept of self  the relational self  “under a relational view, autonomy is best understood to be a capacity or skill that is developed and constrained by social circumstances It is exercised within relationships and social structures that jointly help to shape the individual while also affecting others’ responses to her efforts at autonomy o What does this mean?  in short term, it may be necessary to spend more time than usual in supporting patients in the deliberative process of decision-making and providing them with access to relevant political as well as medical information when they contemplate controversial procedures  however we must maintain a focus on the individual  rather, it can be seen as democratizing access to autonomy by helping to identify and remove the effects of barriers to autonomy that are created by oppression To sum up..  Buchanan and Brock argue that the type of competence a patient needs to display depends on the circumstances  feminist analysis of autonomy challenges the control oppressed agents have when it comes to medical decisions  Sherwin argues that the conventional model for autonomy in bioethics fails to account for situations where agents are less free but would appear rational  we must identify and be sensitive to the social nature of autonomy Cultural Diversity and Care Week 3: Jan 21-25 Week 3: (Jan 21-25) Kipnis, “Quality Care and the Wounds of Diversity” (44) Macklin, “Ethical Relativism in a Multicultural Society.” (47) Macklin, “Consent, Coercion, and Conflicts of Rights.” (115) Quality Care and the Wounds of Diversity Patient Self Interest  Kenneth Kipnis – try to explain to the patient, but if this fails, choose on behalf of the patient and his or her well being o focus on beneficence/non-maleficence o example of Korean patient  Korean patient doesn’t want treatment because doctors are Japanese and thinks that doctors are trying to kill him o when is it appropriate to accommodate patient prejudice, and when is it not? o conflict between the clear duty to minister as best one can to the patient’s pressing health care needs, and equally clear prohibition on becoming an instrument of injustice o tentative suggestions:  confront patient directly (“you’re being racist”)  but if it fails, choose on behalf of the patient and his or her physical well-being (switch doctors) Ethical Relativism in a Multicultural Society  Ruth Macklin – more emphasis on explanation and tolerance for patient, however, when it comes to children emphasis on equality of treatment o cultural diversity (ethical relativism) creates problems for doctors o ethical relativism = claim that there are no universal moral obligations binding on all people in all places at all times, that morality is created by individuals or by cultures/societies so each is morally right and none is morally wrong o example of informing patient or family  traditions differ in different parts of the world  conclusion: doctors should ask how their patient would like them to proceed (which maintains patient autonomy, while also supporting patient’s cultural needs) o example of nurse who takes patient off pain medication  intolerance vs. overtolerance  patient is delusional on pain medication and family believes patient is delusional  conclusion: must respect wishes of people based on traditional beliefs. however when beliefs issue in actions that cause harm to others, attempts to prevent those harmful consequences are justifiable o example of Navajo  belief systems of a subculture, sometimes beliefs are more than a difference in value  words have a power in themselves, but you have to tell them all the risks, informed consent  conclusion: carry out the informed consent discussion in manner appropriate to the patient’s beliefs and understanding o obligations of physicians  what about when the values differ greatly?  female genital mutilation  fear=cultural imperialism  conclusion: to refrain from seeking to educate such parents and to not exhort them to alter their traditional practices is unjust, as it exposes the immigrant children to health risks that are not borne by children from the majority culture o argument against relativism  multiculturalism cannot be a form of relativism, for it states that all cultural groups be treated with respect and as equals  but not all their beliefs are equally valid  Autonomy o focus on autonomy o buchanon and brock  multiple standards of competence. no single answer will be adequate in all situations. require a greater degree of competence when the stakes are higher o Sherwin  traditional account of autonomy contains implicit aspects that support oppression. while patient may have agency, they may not be autonomous  thus-need to spend more time with patient, provide them with relevant political as well as medical inform when contemplating controversial procedures o kipnis  when the patient’s well being is at stake, you do what you have to do (work with their intolerance) o Macklin  cultural diversity means the doctor needs to work with what the patient needs in order to ensure they are autonomous Consent, Coercion, and Conflicts of Rights When Religion and Medicine Collide…  Motl Bordy’s body grew tired after he had been at hospital for five months being treated for brain cancer. already in a coma his brain stopped functioning, and his team of doctors declared him legally dead, but family said orthodox Judaism didn’t define death as such and sought court order to keep on life support, Motl’s heart stopped beating and it ended the debate.  teenage jehovah’s witness refuses blood transfusion and dies When rights conflict  I have a right to an education so the government should provide education through taxes  I have a right to keep the money I earn. the government should not require any of my money to help other citizens Macklin  this paper will focus on a particular conflict of rights; the case of the Jehovah’s Witnesses who refuse blood transfusions for religious reasons and the question of whether there is a right to compel medical treatment Jehovah’s Witnesses:  Christian denomination  witnesses base their beliefs on the bible and prefer their own translation  central belief is in the imminent destruction of the present world order (Armageddon) and establishment of god’s kingdom on earth  blood transfusion are in violation of god’s law, since 1961 willing acceptance of a blood transfusion has been grounds for expulsion from religion  has implications for life after death Conflicts of Rights and Values  doctor o heal patient  jehovah’s witness o freedom of religious belief o life on earth not as important as life after death Problems with Compelling Treatment for Adults  doctor o do physicians have a right to do what medical treatment dictates o what if the patient’s choices will result in malpractice  jehovah’s witness o autonomoy: do patients have a right to determine details of their medical treatment o religious freedom: do patients have a right to refuse treatment in accordance with their religious beliefs Courts Say..  US v. George court held that a physician cannot be required to ignore the mandates of her own conscience, even in the name of religious freedom. patient can knowingly refuse treatment, but he cannot demand mistreatment  problems with this: o conflicts with:  religious freedom of patient  autonomy of the patient  ignores informed consent  competency?  what about children? o jehovah’s witness parents object to blood transfusion o court rules.. transfuse child What does this mean?  religious right of parent is secondary to the right to life of child  implications? o in case of adult patients that cannot speak for themselves, doctors will also privilege life over religious freedom Macklin’s solution  Macklin argues that Jehovah witnesses should be given an option. either o being treated in accordance with the dictates of accepted medical practice, including blood transfusion if necessary o refusing in advance of any treatment in which transfusion is normally a necessary component or is likely to be required o advantages: preserves patient’s autonomy and does not require physician to perform partial treatment that may fail Conflicts of Rights  doctors’ right to treat patient to the best of their ability o religious freedom o autonomy o (paternalism) Is this good enough?  doctor described the treatment but grandmother said “ I’ve heard everything I need to hear, but are you Christian” doctor was jewish, said “I’m as Christian as you need me to be” Iranians – the conflict  17 Iranian girl admitted unconscious, get her heart beating and put on ventilator, however brain dead  family comes to ICU, demands medical treatments, won’t listen to the fact that she is dead  Culture o life and death controlled by God o persons are entrusted with their body and moral duty to seek medical help when needed, no right to die.  life support obligation o initiating convo about life support may anger patient or family, considered inappropriate and insensitive o in iran and many other middle eastern countries, the family is expected to be demanding – shows concern for family member Korean Americans – the conflict  54 Korean man admitted deteriorating rapidly and clear that death would occur in a week. physician wanted to get a DNR order.  family disagreed. wanted to get him home to korea  Culture o most Koreans religious (mostly Buddhist and protestant) o stopping life support interfering with God’s will o great loyalty to one’s parents, elders cared and respected for o children responsible for parents and must preserve their life o traditional values dictate that a patient die at home. while he might die on the way important to try Mexican Americans – the conflict  43 mexican woman admitted with known breast cancer, said she wanted no heroic measures done. condition deteriorated and entered coma.  DNR discussed with children, were aware but wanted to be intubated until father could come from Mexico  Culture o influenced by indigenous native traditions, customs imported from spain and Africa, influences from America o health is gift from god, illness may be punishment o some studies suggest they may have more fear of dying than other ethnic groups,. more than 85% catholic and against anything that hastens death o family is involved in all aspects of decision making in treatment o won’t directly contradict doctor, because seen as rude Defintion of Death:  cardiorespiratory death o death is “permanent loss of circulation and respiration” o simple advantage that it is very clear o however this would rule out organ harvesting  whole brain death o death is the loss of all brain function o death is defined as the “permanent cessation of functioning of the organism as a whole”; since human organisms cannot function without the brain, a sufficient criterion is the “permanent cessation of functioning of the entire brain”; whether this has happened can be determined by specific tests o problems  clinicians have observed that patients who fulfill the tests for brain death frequently respond to surgical incision at the time of organ procurements with a significant rise in both hearth rate and blood pressure  higher-brain death o death is “permanent unconsciousness”
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