Ethics Consultations

St. Joseph Mercy OaklandMarch 2014

Ethics Consultation Education

!▪ What is an ethics consultation?!▪ Principles of bioethics!▪ 4 Box Method!

▪ Case Study!▪ Tips / Suggestions!▪ Documentation

What is an ethics consultation?

!!Healthcare ethics consultation is a set of services provided by an individual or group in response to questions form patients, families, surrogates, healthcare professionals, or other involved parties who seek to resolve uncertainty or conflict regarding value-laden concerns that emerge in health care.

Core Competencies for Healthcare Ethics Consultation. 2nd Edition ed. Glenview, IL: American Society for Bioethics & Humanities; 2011.

Goals of an ethics consultation

!Improve the quality of health care through the identification, analysis and resolution of ethical questions or concerns!• identify & analyze the nature of the value

uncertainty or conflict that underlies the consultation!

• facilitate resolution of conflicts in a respectful atmosphere with attention to the interests, rights and responsibilities of all those involved.

Core Competencies for Healthcare Ethics Consultation. 2nd Edition ed. Glenview, IL: American Society for Bioethics & Humanities; 2011.

Typical concerns of an ethics consultation

Shared decision making with patients!Who should be authorized to make decisions on behalf of a patient who lacks medical decision-making authority?!

Ethical practices in end of life care!Should CPR attempts be withheld without patient/surrogate consent?!

Ethical practices at the beginning of life!Should a woman in full-term labor be allowed to refuse a recommended cesarean section?!

Patient privacy and confidentiality!Should a woman be allowed to keep her son’s HIV+ status secret from the child’s father?

Core Competencies for Healthcare Ethics Consultation. 2nd Edition ed. Glenview, IL: American Society for Bioethics & Humanities; 2011.

Typical concerns of an ethics consultation

Professionalism in patient care!When are overlapping professional/personal relationships inappropriate?!

Ethical practices in resource allocation!Should disposable medical devices be sterilized and reused to save resources?!

Ethical practices in the everyday workplace!When is it ethically justifiable for a nurse to refuse to implement an order s/he finds morally objectionable? !

Ethical practices in research!Should a child who no longer wants to continue in a research study be kept in the study because her parent wishes that she continue?

Core Competencies for Healthcare Ethics Consultation. 2nd Edition ed. Glenview, IL: American Society for Bioethics & Humanities; 2011.

Principles of Bioethics

!▪ Respect for Autonomy!▪ Nonmaleficence!▪ Beneficence!▪ Justice

Beauchamp TL, Childress JF. Principles of biomedical ethics. 7th ed. New York: Oxford University Press; 2013.

Respect for Autonomy

!▪ Greek autos (self) and nomos (rule, governance, law)!▪ Self determination!!

self rule that is free from both controlling interference by others and from limitations, such as inadequate understanding, that prevent meaningful choice (B&C, p.101)

Beauchamp TL, Childress JF. Principles of biomedical ethics. 7th ed. New York: Oxford University Press; 2013.

Nonmaleficence

!▪ Primum non nocere — First do no harm!▪ Fundamental principle in the Hippocratic tradition!▪ Asserts an obligation not to inflict harm on others.!▪ Only requires intentionally refraining from actions that cause

harm.!!

One ought not to inflict evil or harm (B&C, p. 152)

Beauchamp TL, Childress JF. Principles of biomedical ethics. 7th ed. New York: Oxford University Press; 2013.

Beneficence

!▪ Acts of mercy, kindness, friendship, charity and the like!▪ A statement of moral obligation to act for the benefit of

others.!One ought to prevent evil or harm!One ought to remove evil or harm!One ought to do or promote good!(B&C, p. 152, 202-203)

Beauchamp TL, Childress JF. Principles of biomedical ethics. 7th ed. New York: Oxford University Press; 2013.

Justice

!▪ Fair, equitable and appropriate treatment in light of what is due

or owed to persons!▪ Right relationships!!

Equals must be treated equally,Unequals must be treated unequally.! ! ! — Aristotle

Beauchamp TL, Childress JF. Principles of biomedical ethics. 7th ed. New York: Oxford University Press; 2013.

4 Box Method of Ethical Analysis

!▪ Medical Indications!▪ Patient Preferences!▪ Quality of Life!▪ Contextual Features

Jonsen AR, Siegler M, Winslade WJ. Clinical ethics : a practical approach to ethical decisions in clinical medicine. 7th ed. New York: McGraw-Hill Medical; 2010.

Case study

John, a 32 year-old lawyer, had worried for several years about developing Huntington's chorea, a neurological disorder that appears in a person's 30s or 40s, bringing rapid uncontrollable twitching and contractions and progressive, irreversible dementia. It leads to death in about 10 years.!!John's mother died from this disease. Huntington's is autosomal dominant and afflicts 50% of an affected parent's offspring. John had indicated to many people that he would prefer to die rather than to live and die as his mother had. He was anxious, drank heavily, and had intermittent depression, for which he saw a psychiatrist. Nevertheless, he was a productive lawyer.!!John first noticed facial twitching 3 months ago, and 2 neurologists independently confirmed a diagnosis of Huntington's. He explained his situation to his psychiatrist and requested help committing suicide. When the psychiatrist refused, John reassured him that he did not plan to attempt suicide any time soon. But when he went home, he ingested all his antidepressant medicine after pinning a note to his shirt to explain his actions and to refuse any medical assistance that might be offered. His wife, who did not yet know about his diagnosis, found him unconscious and rushed him to the emergency room without removing the note.!!What should the care team at the emergency room do?

https://depts.washington.edu/bioethx/tools/cecase.html

Ethics Consultation Education

!▪ What is an ethics consultation?!▪ Principles of bioethics!▪ 4 Box Method!

▪ Case Study!▪ Tips / Suggestions!▪ Documentation