IVMS Shaping Professionalism: Bioethics I

8/14/2019 IVMS Shaping Professionalism: Bioethics I

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Marc Imhotep Cray, M.D.

Shaping Professionalism:

Bioethics IPrepared and presented by

Marc Imhotep Cray, M.D.Basic Medical Sciences and Clinical Knowledge (CK) Teacher
http://www.imhotepvirtualmedsch.com/http://www.imhotepvirtualmedsch.com/


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What is Bioethics?

Study of ethical issues arising frombiological and medical sciences
http://www.imhotepvirtualmedsch.com/


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Varieties of Bioethics Medical ethics

Physician-centered

Health care ethicsIncludes nurses & other healthcare professionals

Clinical ethicsHospital care decisions with aid of committees andconsultants

Bioethics in generalIncludes issues in genetics, reproductive technologies,experimentation, and distribution of life-saving resources

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Origins of Bioethics

Emerged in early 1960s in the U.S.

Arose out of public concerns

E.g., issue of selecting patients for chronic haemodialysis in Seattlein 1962

Represented the view that ethical problems inmedicine and biological sciences can be solved

by applying moral principles(Source: Albert R. Jonsen, Journal of Medicine and Philosophy(1991),

pp. 113-30)

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Why is Bioethics Important? Changing doctor-patient relationship

Recognition of patient autonomy in decision-making

New technologies

E.g., assisted reproduction, gene therapy, supportand prolonging of life

Changing economics of medicineManaged care, health insurance, commercialization ofmedicine (profit motive)

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Who Should Do Bioethics?

Lawyers and Doctors

Historically, issue is for doctors to avoid or to deal with charges of

negligence.

Philosophers

Ethical dilemmas go beyond issues of legality. Philosophers can

help doctors to make sound ethical decisions and to justify themto their patients and the public.

If you need an analysis, send the urine to the biochemist, and theethics to the philosopher.

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Philosophy and Bioethics

METAETHICS NORMATIVE ETHICS

ETHICAL THEORY

MEDICAL ETHICS

BIOETHICS

APPLIED ETHICS

MORAL PHILOSOPHY

PHILOSOPHY

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What Moral Philosophers Do

Use reason and arguments

Apply general moral principles

Provide conceptual and analytical tools

Justify or question moral practices

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Normative EthicsDeveloping principles that tell us whichactions are right, and what we are morallyrequired to do.



Normative Theories

Deontological theories

Associated with German philosopher Immanuel Kant.

Consequentialist theoriesMost well-known theory is utilitarianism.

Utilitarians seek to maximize general humanhappiness or well-being.

Famous utilitarian philosophers include John StuartMill and Jeremy Bentham.

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Deontological Theories A type of action is right or wrong no matter

what its consequences are.

Moral agents have duties which oblige themto do certain types of action.

Duties can be specified in the form of rulesthat must be universally applicable.

Persons and their autonomy should berespected at all times.

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Consequentialist Theories

What makes an action right or wrong are itsconsequences.

The consequences of an action can always be

measured by a common standard: what itcontributes to the good of all who areaffected by the action

The right action is one that has the maximum

beneficial results. The same unit of benefit to any person

should be given equal weight.

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What is Applied Ethics?Use of general moral principles to testthe morality of particular actions.



Problem for Applied Ethics

Presence of competing moral principlesDoes this make applied ethics subjective?

Room for reasoning, argument and

justificationEthics is not a matter of taste.

Ethical dilemmas are real dilemmas

There are no easy answers.

Important to learn why people disagree

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Ethical Theory and Bioethics

Straightforward application of principlesFour-principles approach (Childress & Beauchamp)

Case-study approachMethodology of casuistry (Jonsen & Toulmin)

Interplay between theory and case-

studyBioethics contributes to ethical theory as well asbenefiting from it

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Problems for application of principles

Choice of ethical theory cannot bejustified

Real life is too messy and detailed

Priority of principles cannot be resolvedE.g., principles of autonomy and beneficence can be

in conflict.

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Problems for case-study approach

Problem of bias

Intuitions need to be critically examined.

Too many mid-level principles inevaluating cases

Theoretical issues cannot be avoided

E.g., euthanasia raises questions about the value ofhuman life; allocation of resources raises questions ofdistributive justice.

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Bioethics and the Doctor

Philosophers can help doctors toidentify goals in medicine and to

develop practical principles. Moral philosophy will impact on clinical

practice by improving understanding

and affecting the way in which ethicalproblems in medicine are described.

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Medical ethics

Medical ethics is grounded inphilosophical ethics, it concerns itself

with the ethical questions and dilemmasin medicine.

Medical ethics is not any special ethics

but an ethics which deals with specialcases from medical practice.

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Doctor-patient relationship

Medical ethics has three centres:doctor, patient and society.

Its centre is the doctor-patientrelationship.

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The moral duties of the doctor

The duty to help, cure

The duty to promote and protect the patients

health The duty to inform

The duty to confidentiality

The duty to protect the patients life

The duty to respect the patients autonomy

The duty to protect privacy

The duty to respect the patients dignity

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Principles of biomedical ethics

Nonmaleficence

Beneficence

Respect for autonomy

Justice

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Hippocratic oath5-4 centuries B.C.

An obligation of nonmaleficence and anobligation of beneficence are both

expressed in the Hippocratic oath:I will use treatment to help the sick

according to my ability and judgement,

but I will never use it to injure or wrongthem.

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Nonmaleficence andbeneficence

The principle of nonmaleficence assertsan obligation not to inflict harm

intentionally. Principles of beneficencepotentially demand more than theprinciple of nonmaleficence, because

agents must take positive steps to helpothers, not merely refrain from harmfulacts.

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The differerence of twoprinciples

Nonmaleficence

One ought not to

inflict evil or harm

Beneficence

One ought to

prevent evil or harmOne ought toremove evil or harm

One ought to do orpromote good

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The concept of autonomy

The word autonomy is derived from the Greekautos (self) and nomos (rule, governance orlaw).

It was first used to refer to the self-rule or self-governance of independent Hellenic city-states

Autonomy has since been extended toindividuals and has acquired meanings as

diverse as self-governance, liberty rights, privacy,individual choice, freedom of the will, causingones behaviour, and being ones own person.

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Autonomous person

We analyze autonomous persons intems of

liberty (independence from controllinginfluences)

agency(capacity for intentional action)

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Autonomous action

We analyze autonomous action in termsof persons who act

Intentionally

Withunderstanding

Without controlling influencesthatdetermine their action

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To respect an autonomousagent

Is to acknowledge that persons right to holdviews, to make choices, and to take actionsbased on personal values and beliefs.

Such respect involves respectful action, notmerely a respectful attitude.Respect involves treating persons to enablethem to act autonomously, whereas

disrespect for autonomy involves attitudesand actions that ignore, insult, or demeanothers autonomy and thus deny a minimalequity to persons.

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Informed consent isanalyzable

Through the account of autonomous choice.

A person must do more than express agreement

or comply with a proposal. He/she must authorize through an act of

informed and voluntary consent.

in terms of the social rules of consent in

institutions that must obtain legally valid consentfrom patients or subjects before proceeding withtherapeutic procedures or research.

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The standards used todetermine the incompetence

Inability to express or communicate apreference or choice.

Inability to understand ones situation and

its consequences. Inability to understand relevant

information. Inability to give a (rational) reason.

Inability to give risk/benefit relatedreasons. Inability to reach a reasonable decision.

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Paternalism

is the intentional overriding of onepersons known preferences or actions

by another person, where the personwho overrides justifies the action by thegoal of benefiting or avoiding harm to

the person whose will is overriden.

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Weak paternalism

In weak paternalism an agentintervenes on ground of beneficence or

nonmaleficence only to preventsubstantially nonvoluntary conduct, i.e.to protect persons against their own

substantially nonautonomous actions.

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Strong paternalism

Strong paternalism involvesinterventions intended to benefit a

person despite the fact that thepersons risky choices and actions areinformed, voluntary and autonomous.

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A central problem inbiomedical ethics

Whether respect for autonomy ofpatients should have priority over

professional beneficence.

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The concept of justice

The terms fairness, desert (what isdeserved), and entitlement (that to

which one is entitled) have been usedby various philosophers in attempts toexplicate justice. These accounts all

interpret justice as fair, equitable, andappropriate treatment in light of what isdue or owed to person.

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Principles of distributive justice

To each person an equal share (formalequity)

To each person according to need To each person according to effort To each person according to

contribution To each person according to merit To each person according to free-

market exchanges

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Useful References

Tom Beauchamp & James Childress, Principles ofBiomedical Ethics(Oxford University Press, 1994)

Nancy Jecker, Albert Jonsen & Robert Pearlman(editors), Bioethics: An Introduction to the History,Methods, and Practice(Jones & Bartlett, 1997)

Robert Veatch (editor), Medical Ethics(Jones &Bartlett, 1997)

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QUESTIONS AND ANSWERS

Q#: 1 Question: Under which circumstance is the mentalhealth professional required to disregard doctor-patientconfidentiality in most jurisdictions by reporting to the properpeace-keeping authorities?

A. The patient who states that he's going to kill his girlfriend thecoming weekend by shooting her at homeB. The patient who says that at least once a week he feels likekilling his boss, but that on other days he interacts adequately withhis boss and coworkersC. The patient who states that he secretly put arsenic in his

brother's food over a three month period five years earlier, but thatnow he loves his brother dearlyD. The patient who says that he would like to see France bombedout of existenceE. The patient who threatens to kill himself

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Q#: 2 Question:A medical resident will be enteringprivate practice next year and is concerned about theethics of patient confidentiality and when it can bebreached. There are certain circumstances under whichphysicians in most jurisdictions are obligated to violatepatient confidentiality. Which of the following is acommon one?

A. Gunshot woundsB. Intravenous drug abuseC. Venereal diseases, including acquiredimmunodeficiency syndrome (AIDS)D. PsychosisE. Spousal abuse

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Q#: 3 Question:A 70-year-old female with a lifelong mentalage of 18 to 24 months lives in a special care area where herspecial needs are met is referred to your hospital when she isobserved to be somewhat pale. An examination of herperipheral blood reveals a pattern consistent with an acuteleukemia. Her only living relatives are her two younger brothers,a 68-year-old retired automotive mechanic, and a 62-year-oldretired police officer, who, on being informed of their sister'scondition state, "Doctor you do what you think is best. We trustyou to do the right thing for our sister!" How will you proceed?

A. Obtain a guardian ad litem

B. Obtain an ethics committee consultation for the patientC. Obtain a written consultation from a colleagueD. Obtain a pastoral counseling consultation for the patientE. Obtain an informed consent from the patient

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Q#: 4 Question:A 5-year-old child is brought to youremergency department with full thickness, third degree burnsover seventy percent of her body. It is the strong opinion of thedirector of your burn unit that she must have blood transfusionsor she will die. Her parents inform you that blood transfusionsviolate their faith. How do you resolve this issue?

A. Contact your hospital chaplainB. Allow the parents to take their child home to dieC. Ask a colleague what you should doD. Contact your hospital attorney

E. Ask a friend in law school what you should doF. Order blood over the objections of the parents and their spiritualbeliefs

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Q#: 5 Question:A 15-year-old female presents to your office, requesting a

prescription for isotretinoin (Accutane). She has previously tried topical benzoylperoxide, topical and oral antibiotics, and topical tretinoin (Retin-A) products,with only minimal improvement in her acne. Family history is positive for cysticacne in her father and brother. Examination reveals nodulocystic acne localizedto her face and chest, with diffuse comedones and pustules across the face,chest and back, and some scarring. You ask her mother to leave the examroom, and ask the patient if she is sexually active. She reports that she has hadintercourse "a couple of times," but becomes tearful when you tell her that shewill need to use two forms of contraception if you prescribe isotretinoin for heracne. She refuses to take oral contraceptives, saying that she promises not tohave intercourse while on isotretinoin. What should you do next?

A. Tell her mother that she is sexually active and thus isotretinoin is contraindicatedB. Prescribe isotretinoin at only 10 mg, since the teratogenicity of isotretinoin isdose-dependent

C. Counsel the patient regarding the teratogenicity-pregnancy prevention programand do not prescribeisotretinoinD. Tell the patient to avoid intercourse during the fertile period of her cycleE. Prescribe isotretinoin, since the risk for pregnancy is low in a 15-year-old femaleand her acne is so severe

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Q#: 6 Question:A 35-year-old associate professor of chemicalengineering returns to your office following surgery for terminal,metastatic ovarian cancer. She states that she has persistentdull pain so you obtain an x-ray. The x-ray reveals aten-centimeter metal clamp. What do you do now?

A. Say nothing to the patient about the clamp since she is terminaland may never find out about itB. Inform her about the clamp and tell her you hope it will dissolvein time on its ownC. Inform her about the clamp and refer her back to her surgeon

D. Telephone your attorney and ask for adviceE. Telephone the surgeon and ask for advice

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QUESTIONS AND ANSWERS Q#: 7 Question:A 42-year-old certified occupational therapy assistant

(COTA) is diagnosed with ovarian carcinoma. After a long battle, includingsurgery and chemotherapy, she succumbs. As you are leaving hergraveside funeral, having expressed your sense of grief and loss to herfamily and friends, the funeral director takes you aside and informs you, "Ifound a metal clamp inside of her when I was embalming her." The

funeral director states further, "Doctor I have a whole box of clamps that Ifound while preparing bodies for burial". What do you do with thisinformation?

A. Thank the funeral director and inform the operating surgeon immediatelyB. Thank the funeral director and say nothing further since she is dead andburiedC. Thank the funeral director and inform your attorney immediatelyD. Thank the funeral director and inform the bereaved family immediatelyE. Thank the funeral director and inform any plaintiffs attorney in yourcommunityF. Thank the funeral director and inform your hospital quality control officeimmediately

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Q#: 8 Question: During a first year medical school ethics class, a25-year-old medical student interrupts stating, "Gosh I just don'tunderstand why so much of our time is spent on ethics. I thoughtthat ethics was if a patient wants to use your office telephone, doyou or do you not charge him or her a quarter?" You areunderstandably aghast at his gauche interruption and you informhim that

A. He must leave the classroom as he has just failed the ethics courseB. He must leave the classroom and write one hundred times I will not

interrupt our ethics class with silly questions

C. He must leave the classroom to prepare a special paper on thevalue of ethics in medical schoolD. He must leave the classroom, as he is clearly a ninny

E. He must leave the classroom and report directly to the office of thedean for dismissal from medical school

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ANSWERS TO QUESTIONS

1=A

2=A

3=A4=D

5=C

6=C7=F

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Reference Resources and


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Reference Resources andFurther Study

Bioethics Online Study RecoursesNIH - Bioethics Resources

University of Toronto - Joint Center for BioethicsWorld Medical Association - Medical Ethics Manual

Virtual Mentor

Video Education (drimhoteptv)

IVMS-MEDICAL ETHICS & PROFESSIONALISM12 videos, 3 hrs. and 16 min.http://www.youtube.com/playlist?list=PL08E700EA3F8313EB

E-TextbookMedical Ethics Today: The BMAs handbook of ethics

and law Books; 3 edition (January 30, 2012)Updateshttp://bma.org.uk/practical-support-at-work/ethics/medical-ethics-today

Best Price $148.33or Buy New $181.49
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IVMS Shaping Professionalism: Bioethics I