Ethics 101

Case Study: Sam, the Patient

• An 85 year-old retired school teacher.

• C/O decreased vision in both eyes.

• Exam = 20/80 best corrected in right eye

20/60 best corrected in left eye

• Biomicroscopy = 3+ nuclear sclerotic cataracts

• Dr. E explains the risks and benefits to Sam of having surgery to improve his vision.

Case Study: Sam, the Patient

• Dr. also explains an alternative option to surgery that is part of a clinical trial.

• Dr. E is the PI in this trial. If this innovative technique proves effective, it may revolutionize cataract treatment. Dr. E could become famous and benefit financially.

• Sam asks Dr. E to do whatever he thinks is best - after all, he’s the expert.

1) What are the Ethical Issues

in Sam’s Case ?

2) How should the ophthalmologist respond when Sam asks him to make the decision?

3) Should the ophthalmologist use therapeutic privilege and make the decision for Sam?

4) Is there a conflict of interest for Dr. E to offer Sam the option of participating in his study?

Overall Ethical Principle

Sanctity of Life

Respect for Life

4 Core Ethics Principles

Autonomy Beneficence Non-maleficence Justice

Respect for Autonomy

Derives from patient’s right to:Self-determinationPrivacy

Imposes responsibility on physician:Veracity - Telling the truthInformed consent

BeneficenceDerives from fiduciary relationship to:Do GoodAct to Help

Imposes responsibility on physician:FidelityAdvocacy

Non-maleficenceDerives from general rule of human

conduct that applies to everyone to:Do No Harm to OthersAct to Prevent Harm to Others

Imposes responsibility on physician to:Analyze the Burdens vs. Benefits of TxMaintain Patient’s Confidentiality

JusticeDerives from general rule of human

conduct to treat others fairly:Like cases are treated alike - fairness.

Imposes unclear responsibilities on

physicians - society has not sorted this out!How well are resources allocated?What is futility?

“People have the right to justice in the distribution of health resources

as opposed to a right to any and allspecific care/treatments

whether or not they need them and/or are likely to benefit from them.

. . . Citizens must acknowledge their responsibility to themselves

to maintain their healthto the best to their abilities.”

- Leah Curtin, RN

Principle Approach• Analyzes problems, identifies

values

• Does not always provide a good mechanism to resolve conflicts

• Helpful to combine with concepts in Ethics of Care

The Ethic of Care

Focuses on patient’s relationships

Recognizes the importance of feelings & emotions

Moral responsibility derived from clinician’s relationship to patient

Need to understand the context

The Meaning of Caring

Doing for Being responsive to Valuing Extending compassion, mercy

& kindness

The Meaning of Caring

Enhancing human dignity Connecting with another Being touched Helping another find meaning Empowering

Platinum Rule

“Do Unto Others As They Would Like To Have Done Unto

Them.”

• Cultural Diversity

• Quality of Life

Sir William Osler, MD

“It’s much more important to know

what sort of patient

has the disease

than what sort of disease

the patient has.”

- Porter (1997) The Greatest Gift To Mankind

Comparison Principle-based Ethics vs.

Ethic of Care

Rights & Duties

Reason & Objectivity

Detachment enhances fairness

Focused on individual

Responsibility from the relationship

Emotions enhance reason

Engagement enhances understanding & fairness

Focused on family

Ethics

How people relate to each other - Ancient Greeks 1960’s movements &

beyond

Trying to decide the “right” thing to do.Requires

deliberation about facts and context reflective analysis of beliefs & values actions to solve moral problems

Ethical Dilemmas When legitimate ethical reasons support

more than one alternative

When moral obligations exist on both sides

When disagreements about the right thing to do exist among patient, family, health care team, institution, and/or 3rd party payers

Why an Ethics Committee?

• Each institution has a responsibility to assure ethical treatment is provided to patients

• Professionals trained and experienced in ethics may provide insight and assistance to those faced with ethical dilemmas

• A multidisciplinary committee provides protection against idiosyncratic perspectives

The Role of the

Ethics Committee

Provide consultation

Educate staff, patients/families, & public

Recommend organizational policy

Ethics Committee Goals

• To assure ethical health care • To improve the quality of

health care• To improve health care

outcomes

Ethics Consultation Approach

Advisory** Collecting pertinent facts.

Making sure everyone’s voice is heard.

Examining benefits & burdens of options.

Attempting to build a consensus.

Honoring the physician’s right to conscientious objection.

* * NOT Authoritarian

Ethical Process

• Identifying ethical issues & conflicts

• Analyzing underlying values and sources of disagreement

• Resolving, if possible, ethical dilemmas in clinical cases

The Ethics CommitteeDoes NOT Respond to:

Clinical Inquires or Questions re: Clinical Care

Director of Clinical Quality Management

Possible Physician Impairment

Chair, Physician Impairment Committee

Billing Issues and Business Conflicts of Interest

Director of the Compliance Program

Have an Ethical Issue ?

Call: