Medical Ethics

Rev. Donna Field, M. Div. BSN PCCNMedical Ethics Fellow 2013-2014

North Shore LIJ Division of Medical Ethics, Department of Medicine

BIOETHICS

• Arises from dilemmas or conflicts encountered in moral choices about clinical issues in the care of patients

Reason for a Clinical Consult• Medical Indications - all clinical encounters include a review of diagnosis and

treatment options

• Patient Preferences - all clinical encounters occur because a patient presents before the physician with a compliant. The patient's values are integral to the encounter.

• Quality of Life - the objective of all clinical encounters is to improve, or at least address, quality of life for the patient

(i.e. proportionality: survival /\ prognosis, morbidity & mortality) • Contextual Features - all clinical encounters occur in a wider context beyond

physician and patient, to include family, the law, hospital policy, insurance companies, and so forth.

ParadigmMedical Indications: Consider each medical condition and its proposed treatment. Ask the following questions: •Does it fulfill any of the goals of medicine? •With what likelihood? •If not, is the proposed treatment futile?

•Quality of Life: Describe the Patient's quality of life in the patient's terms. •What is the patient's subjective acceptance of likely quality of life? •What are the views of the care providers about the quality of life? •Is quality of life "less than minimal?" (i.e., qualitative futility) • Careful balance of proportionality (i.e. prognosis, survivability)

Patient Preferences: Address the following: •What does the patient want? •Does the patient have the capacity to decide? If not, who will decide for the patient? •Do the patient's wishes reflect a process that is

• informed? • understood? • voluntary?

Contextual Features: Social, legal, economic, and institutional circumstances in the case that can: •influence the decision •be influenced by the decision e.g., inability to pay for treatment; inadequate

BENEFICENCE

NONMALEFICENCE

AUTONOMY

PATI

ENT’

S MORA

L STA

TUS

Provider’s Virtue

BIO-PSYCHO-SOCIAL CONTEXT

RELIGION, ETHNIC/FA

MILY CUSTOM

PROFESSION, CLASS

CULTURE, LAW, WORKPLACE

MEDICAL ETHICS

Health Stake-Holders in US

LAW,REGULATORS

SOCIETY

HEALTHCARESYSTEM

DOCTOR

‘FAMILY’

PATIENT

WORK PLACE CARE

NURSE

Medical Ethics--Principles of proper professional conduct concerning the rights and duties of the physician, patients, and fellow practitioners, as well as the physician's actions in the care of patients and in relations with their families. A common framework used in the analysis of medical ethics is the "four principles" approach postulated by Tom Beauchamp and James Childress by in their textbook Principles of Biomedical Ethics, 2008. It recognizes four basic moral principles, which are to be judged and weighed against each other, with attention given to the scope of their application.

4 PRINCIPLES of Bioethics (analytic, operational)

(FOCUS = INDIVIDUALS) APPLICATION

AUTONOMY (of individual)

Dignity Controlling body’s integrityInformed, voluntary choice

NON-MALEFICENCE (by provider)

Avoid/reduce harm in treating (primum non nocere)

BENEFICENCE (by provider)

Prevent harmRemediate harmPromote best possible health or quality of living/dying

JUSTICE (by society’s standards, applied by its agents – including health care providers)

Fairness (include marginal ‘other’)Equal opportunity‘Good’ of whole society and maximum number of members

Three DOMAINS of Bioethics

APPLICATION1. MORAL STATUS (of patient – and, to lesser degree, surrogate[s] and ‘significant others’)

1. Part of the moral human community2. Inherent dignity, right to be respected as

person; not to be demeaned, excluded3. Capable of being related to, appreciated4. Capable of suffering

2. VIRTUE (of provider) Altruistic moral character needs to be

internalized (patient’s interest first) - Duty, yes – hopefully more Aspire to ‘best care’ for every person Empathy, compassion ‘Practical wisdom’ ( ‘s with experience)

3. CONTEXT (specific) 1. Biological condition, prognosis2. Psycho-spiritual values3. Social context (family, tradition)4. Surrounding laws & rules

AUTONOMY

• Daily Consideration in Practice Informed Consent Family Health Care Decision Act End of Life Decisions

Non-Maleficence

• Daily Consideration in Practice• Refraining from providing tests or procedures

not medically indicated• Escalation of treatment in cases of medical

futility (i.e. dialysis, etc.)

NYS Family Healthcare Decision Act

• On March 16, 2010, Governor Paterson signed into law the Family Health Care Decisions Act (FHCDA).1 The FHCDA establishes the authority of a patient’s family member or close friend to make medical treatment decisions for the patient in the event the patient lacks capacity to make such decisions personally, and did not previously make such decisions or appoint a health care agent.

The 2010 NYS Health Care Decisions Act addresses the situation of a sick individual who lacks capacity, but has an available surrogate: the surrogate has the exclusive right to make decisions about whether to use or forgo of life-sustaining-treatments (LSTs) when it appears that the patient will die without them. The FHCDA sets forth in order of hierarchy persons who may act as a surrogate decision maker for the incapable patient:

an MHL Article 81 court appointed guardian -the spouse or domestic partner (as defined by the FHDCA)-an adult child-a parent-a brother or sister- a close friend

NYS Family Healthcare Decision Act

• Under the FHCDA, a decision to withhold LSTs must meet two criteria:

• Criterion 1: Treatment would be an extraordinary burden to the patient; AND

• Criterion 2: (Pick EITHER ‘a’ OR ‘b’) a. The patient is permanently unconscious; OR b. The patient has an irreversible or incurable condition causing “inhumane or excessively burdensome suffering under the circumstances” (see Criterion 1).

• Do patients want physicians to address their spirituality?

• USA Weekend Faith and Health Poll, 65% felt that it was good for doctors to speak with them about their spiritual beliefs, yet only 10% said a doctor had had such a conversation with them.1

Regardless of what we believe…

• Why is life so fragile? What is the meaning of my life?

• How do I deal with pain and suffering? Why am I suffering?

• How will people remember me?• And for those with faith— “why is God,

Mother Earth, The Universe……doing this to me?”

Heidelberg Catechism

• The purpose of the Heidelberg Catechism was twofold: to provide a guide for the religious instruction of the city’s youth and to provide a confession of faith for the Church. The Heidelberg Catechism aimed at squelching conflict as opposed to drawing lines in the sand, and is the most “ecumenical” of all the Reformed confessions.

Schaff calls the Catechism “by far the richest and deepest in Church history next to the age of Christ and his inspired apostles,” and this is hardly an exaggeration. “It is the product of the heart as well as the head, full of faith and unction from above. It is fresh, lively, glowing, yet clear, sober, self-sustained. The ideas are Biblical and orthodox, and well fortified by apt Scripture proofs.”

The first question of the Heidelberg Catechism provides a powerful summary of the gospel:

Question 1. What is thy only comfort in life and death?

Answer: That I with body and soul, both in life and death, am not my own, but belong unto my faithful Savior Jesus Christ; who, with his precious blood, has fully satisfied for all my sins, and delivered me from all the power of the devil; and so preserves me that without the will of my heavenly Father, not a hair can fall from my head; yea, that all things must be subservient to my salvation, and therefore, by his Holy Spirit, He also assures me of eternal life, and makes me sincerely willing and ready, henceforth, to live unto him.

While many Christians today view God’s guiding hand of providence as a threat, the Heidelberg Catechism sees the doctrine an essential element of the Christian’s confident trust in God:Question 28: What advantage is it to us to know that God has created, and by his providence does still uphold all things? Answer: That we may be patient in adversity; thankful in prosperity; and that in all things, which may hereafter befall us, we place our firm trust in our faithful God and Father, that nothing shall separate us from his love; since all creatures are so in his hand, that without his will they cannot so much as move.”

Discussion In our covenant with God and each other. Ethics of relationship The fine line between “Total Depravity” and a person’s autonomy– moral status—is it God’s will for the sinful to also needlessly suffer in pain, not just the patient, but their loved ones too.

What would you do?

Resources

• Principles of Biomedical Ethics- 6th edition Tom L. Beauchamp, James Childress

• Is God Still at the Bedside? : The Medical, Ethical, and Pastoral Issues of Death and Dying by Abigail Rian Evans, Dec 2010.

• Living the Heidelberg: The Heidelberg Catechism and the Moral Life- CRC Publications (March 1986)

• Christian Ethics: A Historical Introduction. J. Philip Wogaman.

• Drawn to Freedom: Christian Faith Today: In Conversation with the Heidelberg Catechism. Eberhard Busch.

• THE CREEDS OF CHRISTENDOM: History of the Creeds - Volume I, Part I. Philip Schaff,

• On Moral Medicine: Theological Perspectives in Medical Ethics by Stephen E. Lammers and Allen Verhey (May 11, 1998)