A Sprint through Bioethics

A Sprint through BioethicsKyle Galbraith, PhDFebruary 16, 2015OverviewWhat is ethics and why does it matter?

What are common approaches to doing ethics?

What ethical principles guide patient care and clinical research?

Topic-focused, as time allows.What do we mean by ethics?Ethics is NOT:

You have your opinion, I have mine.

Well, the law says...

Most people agree

What do we mean by ethics?Ethics as critical reflection on:

Our goals as individuals, families, communities, professionals;

Our standards for making judgments;

Above all, ethics is about being able to give thoughtful reasons for our actions.How do people do ethics?Four primary approaches to ethical reasoning:

Ends-based (Teleological)

Rule-based (Deontological)

Virtue-based

Appeals to Principles

Ends-based ApproachesTeleological: Gk. telos, meaning end/goal.

Action judged based on outcome, not the act itself.

Cost/benefit analysis

Rule-based ApproachesDeontological: Gk. deon, meaning duty.

Action judged based on how it adheres to proper rules.

Emphasis on rationality, universality, lack of self-interest.

Virtue-based ApproachesEmphasis on personal characternot rules or isolated acts.

Virtue as a matter of habit/practice.

What is good is that which makes me who I want to be.

Appeals to PrinciplesSimilar to virtues.

Actions/Decisions flow from commitment to shared ideals.

Primary mode of ethics in healthcare and research.

Principles of Medical EthicsAutonomy

Beneficence

Nonmaleficence

Justice

Ethical Principle 1: AutonomyAuto (self) / Nomos (law)in the clinic, it means:

Patients have the right to make medical decisions for themselveswithin certain limits.

Informed consent is crucial for both clinical care and research.

Participation in research is voluntary.

Additional protections in place for those who may have diminished autonomy.

Ethical Principle 2: BeneficenceActions should benefit the patientactively promote good, avoid bad.

Limited duty

In research: standard of care provided to control subjects, when possible.

Study risks should be commensurate with anticipated benefits.

Ethical Principle 3: NonmaleficenceFirst, do no harm.

Refrain from ineffective treatments.

Also a limited duty.

Promotion of professional competence.

Ethical Principle 4: JusticeUsu. structural concern, but plays out in one-on-one situations.

How are healthcare goods distributed? Whats the standard?

In research: equitable subject selection.

Risks/Benefits of research are distributed fairly.

Ethics Mechanisms in Clinical SettingsSince 1992, Joint Commission requires every hospital to have a mechanism for addressing ethical concerns of patients and employees.

Ethics committeeEthics consultation serviceFormal ethics forumClinical Ethics Consultation (CEC)Ethics consultants in 81% of American hospitals and 100% of hospitals with >400 beds.1

0.16% (~1 in 600) of all hospital admissions result in an ethics consult.2

Begun in late 1950s/early 60s.Topics for DiscussionMedical decision-making (including right-to-refuse), Do-Not-Resuscitate

Organ transplant facts

Anything else that interests you!

What are the ethical principles at play in these areas?Medical Decision-MakingYOU are in charge of your body. In general, YOU decide happens to you, provided you have the capacity to make decisions.

This DOES NOT mean that a physician is obligated to do whatever you ask.Elements of Capacity4 basic elements of the capacity to make medical decisions:

Understanding of the factsDo you know what is going on?AppreciationDo you recognize the significance of your situation?ReasoningCan you give reasons for your decision/preferences, esp. in consideration of alternatives?ChoiceCan you express your wishes?

Grisso, Tom and Paul A. Appelbaum, 1998. The Assessment of Decision-Making Capacity: A Guide for Physicians and Other Health Professionals, Oxford: Oxford University Press.

IL Health Care Surrogate Act (755 ILCS 40)Allows someone else to make medical decisions on behalf of someone who lacks decisional capacity.

Usu. only needed when one does not have a designated healthcare decision-maker or advance directive.

Decisions made in consult w/treating physician.IL Health Care Surrogate Act (755 ILCS 40)In order of standing:Patients guardian;Spouse;Adult son or daughter;Either parent;Adult sibling; Adult grandchildClose friend of the patient; Guardian of the estate.Medical Decision-MakingFor previously competent adult, surrogate is to make decisions consistent w/values and preferences of the patient, if known.

If unknown (and for minors), decisions are to be in the best interest of the patient.Do Not Resuscitate OrdersDo Not Attempt Resuscitation (DNR) orders are medical orders.

Historically, DNR orders limited to cardiopulmonary resuscitation (CPR) when heart stops or breathing stops.Written by a doctor.A doctor is not required to attempt CPR in every circumstance.

IL POLST FormIllinois one of 42 states to develop a Practitioner Orders for Life-Sustaining Treatment (POLST) document.

Allows pts. to clearly document their wishes in the event of a medical emergency.

Intended to work with a Healthcare Power of Attorney designation, not as a replacement.

Can be revised at any time.

www.polstil.org Organ TransplantsOrgans: Heart, lungs, liver, pancreas, kidneys, intestine, thymus.

2014: 27,036 organ transplants in the United States.From 21,780 deceased donations, 5,256 living donations13,125 total donors990 organ transplants in Illinois for 2014

Patients assigned to the United Network for Organ Sharing (UNOS) waiting list.

12 IL facilities listed as providing organ transplants.

Currently, 123,234 patients on the UNOS waiting list. 77,919 active waiting list candidates.

Organ TransplantSelection based on multiple criteria, including:Time on the waiting listSeverity of illnessProximity to available organFacilitys organ donation/acceptance ratioPatients history of non-complianceSupport system availability to patient post-transplant

$ not an exclusion criteria, but transplants can result in up to $250K/yr. additional expenses.Organ Procurement and Transplantation Network. Online: http://optn.transplant.hrsa.gov/. United Network for Organ Sharing. Online: http://www.unos.org

Thank You!