Overview

– Readings

– Introduction to Ethical Foundations

– Clarification of basic terms

– Clarification of the historical context of western medical ethics

– Clarification of the current North American context

Readings

• Medical Ethics and the Place of Faith

• Medical Ethics and Secular Approaches

Introduction to Ethical Foundations

Main take-away point of class

Clarify

The Big Fish

Clarification of basic terms

• Bioethics

• Medical ethics

• Clinical ethics

Bioethics

Broad term describing the study of ‘what’ constitutes ‘good/bad’ judgments and ‘right/wrong’ actions when faced with biological dilemmas

Medical Ethics

Emphasis is the study of ethics applied to medicine and medical care

Clinical Ethics

• Subdivision of medical ethics

• Focus is on ethical issues surrounding a patient’s interface within medical community decision making complex i.e. patient-physician treatment decisions

• This is the primary area of our class

Clarification of historical of western medical ethics context

• Quiescent Period-the Hippocratic ethic

• Period of Principlism

• Period of Anti-principlism

• Period of Crisis

• Period of Social Utility

North American Context

• Varying expressions of Principlism

• Varying expressions social utility

• Lingering expressions of Christian ethic

Two contrasting worldviews

– Judeo-Christianity (Abahamic Traditions in PC terms)

– Darwinian Naturalism

Judeo-Christian Supernaturalism

– Judeo-Christian Hippocratic Ethic

– Christian Virtue Ethics

Darwinian Naturalism

• Principlism

• Social Contract

Principlism

• Beneficence

• Non-maleficence

• Autonomy

• Justice

Variation on Principlism

• Medical indication (medical norms)

• Patient Preference (autonomy)

• Quality of life (Beneficence/non maleficence)

• Contextual features (includes justice)

Albert Jonson: Clinical Ethics

Social Contract

• Contracts made with voluntary consent to receive or give up benefits and burdens to its members, health care institutions and health care distributions must conform to the dictates of agree upon principles

• Equitable distribution of health care should be conceived in terms of justice

• Done under the ‘veil of ignorance’

• Mini/max principle

The proper way to think abut health-care spending is tofocus on the NET SOCIAL VALUE ADDED by health care,defined as:

Net social value Added by = Health System

Gross Value Added by - Health Care to Patients

The Opportunity Costs of that Care for Society

Among these opportunity costs are:• education of our young• basic science R&D• nation’s public infra-structure• national security and defense

David B. Reuben: Portland Providence Medical Center Grand Rounds Providence Nov. 16, 2011

A Matrix for Ethical DecisionMaking in a Pandemic

Dr. John Tuohey

An Example of Applied Synthesis of Principlism and Social Contract

Always Clarify

Robert Orr’s Method• Framing the medico-ethics question

• Four elements for medical clarification

• Clarifying decision making agency

• Clarifying institutional level issues

• Operative norms and values

• Discussion

• Recommendations

• Follow-up

• Comments

Framing the Medico-ethics Question

Four elements for medical clarification

• Patient History

• Diagnosis

• Prognosis

• Treatment plan

Clarifying decision making agency

• Patient capacity

• Legal competency

• Surrogate agency

Clarifying institutional level issues

• Distinctives in policy and procedure

• Legal implications

Operative norms and values

• Primary agents

• Mitigating agents

Discussion

Recommendations

Follow-up and Comments

Ethics Exercise

• Interactive Exercise

• Orr’s Method