HCR 210 Ethics for the Healthcare Professional Learning Objectives: At the completion of this lecture, students will be able to: • Understand and evaluate ethical principles utilized to make decisions in healthcare and compare the interaction with the major ethical theories • Understand and utilize a system for ethical decision making • Understand and discuss the impact of culture on ethical decision making ? Principles of Bioethics By Beauchamp and Childress…and why should we care? Beauchamp and Childress • Tom L Beauchamp and James F Childress • Principles of Bioethics published in 1985 • Established the 4 main principles on how to decide if an act in medicine was ethical or non-ethical • Autonomy, Nonmaleficience, Beneficence, Justice Nonmaleficience: Case Study Hypothetical scenario: You are a nurse practitioner in a clinical trial responsible for testing out a new drug against colon cancer. As an unintended side effect, some of your patients developed loss of vision. Did you “do a harm”? Nonmaleficience • “Do no harm” – Hippocratic Oath • Harm in the clinical setting: pain, discomfort, inconvenience, expense, disfigurement, and disability, morbidity, mortality • Harm that may not be physical or obvious: negligence, violations of autonomy Nonmaleficience: Case Study Hypothetical scenario: You are a nurse practitioner in a clinical trial responsible for testing out a new drug against colon cancer. As an unintended side effect, some of your patients developed loss of vision. Did you “do a harm”? • Natural Law Principle of Double Effect: If the side effect was not the intended outcome and is not the causality but rather a coincidence of the drug then it is still moral. • Consequentialist: What are the effects of not treating the cancer? Choose the lesser evil. • Deontologist: As a healthcare provider, you had a duty to help. As long as you had good intent and respected the categorical imperatives, you did not do any harm. Beneficence: Case Study Hypothetical scenario: You are a resident physician on an airplane flying back from your honeymoon. Mid-flight, there is an overhead announcement requesting assistance from a healthcare personnel. Someone is in labor. You are nervous because you have limited experience in OB-gyn. What should do you do? Beneficence • “Benefit only” – Hippocratic Oath • Morally obligated to do altruistic and beneficent acts • Expectation that all people involved in healthcare (physicians, nurses, administrators) will act with beneficence and are held to higher standards than the general public Beneficence: Case Study Hypothetical scenario: you are a physician-in-training on an airplane flying back from your honeymoon. Midflight, there is an overhead announcement requesting assistance from a healthcare personnel. Someone is giving birth and needs your help but you have limited experience in OB-gyn. What do you do? We have to examine this case from an ethical and a legal standpoint. Beneficence: Case Study • Most healthcare providers would say they are ethical obligated to help • This is reflected in the Professional Code of Ethics of many healthcare professionals • Supported by virtue ethics, deontology (and many other ethical theories) • Directly against ethical egoism • “Duty to rescue” laws vary by state Beneficence: Case Study • There is no law that states healthcare professionals are legally obligated to help during in-flight emergencies • There are laws to help individuals who choose to help o Good Samaritan Laws o Aviation Medical Assistance Act of 1998 o Remember that laws will vary by country Autonomy: Case Study Hypothetical situation: You are a certified nursing assistant taking care of a diabetic patient who is requesting a slice of chocolate cake. You know that the doctors have had multiple conversations with this patient stating that his glucose levels are out of control and he needs to stop eating sweets. You explain this to the patient, but he gets angry and demands that you give him his chocolate cake. What should you do? Autonomy • “auto” (self) + “nomos” (rule) • Right to make your own decisions • Are patients competent to make the decisions for themselves? o Can be tricky as some patients may have waxing/waning mental status such as neuro patients • Are patients free of coercion? o What the patient wants may be different from what the patient’s family and the healthcare team want Autonomy: Case Study Hypothetical situation: You are a certified nurses assistant taking care of a diabetic patient who is requesting a slice of chocolate cake. You know that the doctors have had multiple conversations with this patient stating that his glucose levels are out of control and he needs to stop eating sweets. You explain this to the patient, but he gets angry and demands that you give him his chocolate cake. What should you do? Highlighted text demonstrates informed consent. If the patient is mentally competent to make decisions, then you are ethically obligated to give them the chocolate cake. This is also reflected in many hospital/nursing home bylaws. Autonomy Other potential hypothetical situations: • Patient wants to be DNR/DNI but is incapacitated and family wants to continue everything • Patient is incapacitated and there are no known family/friends • Patient desires something that is harmful to themselves that is NOT approved by hospital bylaws Procedural Justice: Case Study Carrie is 25 year old female who has been suffering from general fatigue and malaise for the past month. She finally decides to see her primary care physician, however she is disappointed with the experience. While Carrie’s PCP seems to spend a lot of time working with the other patients, Carrie’s appointment took only 5 minutes and the physician did not seem to want to spend any time with her. When Carrie mentions this to the physician, the physician states “I’m sorry, I was just trying to get everything done before 5pm so that I can pick up my son from school.” Did Carrie’s physician act unethically by not giving Carrie as much attention as the other patients? Procedural Justice • Right to “due process” – fair treatment • Healthcare examples o did you receive the same attention from your physician as the patient before? o Are there procedures to decide who gets furloughed first in times of economic stress? Procedural Justice: Case Study Carrie is 25 year old female who has been suffering from general fatigue and malaise for the past month. She finally decides to see her primary care physician, however she is disappointed with the experience. While Carrie’s PCP seems to spend a lot of time working with the other patients, Carrie’s appointment took only 5 minutes and the physician did not seem to want to spend any time with her. When Carrie mentions this to the physician, the physician states “I’m sorry, I was just trying to get everything done before 5pm so that I can pick up my son from school.” Did Carrie’s physician act unethically by not giving Carrie as much attention as the other patients? • Deontology (categorical imperatives) could make an argument that Carrie’s physician was acting immorally • Natural Law can argue for either (basic goods include “life” but also “reproduction”) Distributive Justice: Case Study (Not so) Hypothetical situation: During the COVID-19 pandemic, many hospitals in New York were in short supply of ventilators. Healthcare administrators were forced to create ventilator allocation guidelines. The New York Guidelines emphasized saving the most lives by triaging based on the patient’s likelihood of acute survival with exclusion criteria such as irreversible shock, organ failure, etc. Is this fair? Read more at: https://www.nejm.org/doi/full/10.1056/nejmp2005689 Distributive Justice • Determining what is fair when deciding how to divide benefits and burdens Distributive Justice Everyone should get an equal share of burdens and benefits unless there is a material reason to discriminate • Ex: deserving or worthy of merit, disabilities, special talents, opportunities a person might have or lose, past discrimination against a group that is perceived as having negative effects in the present, structural social problems perceived as restricting opportunity Distributive Justice Healthcare often operates on discrimination based on need • Triage in emergency department • Trauma levels in emergency department • Healthcare workers prioritize which patients to see first Distributive Justice: Case Study (Not so) Hypothetical situation: During the COVID-19 pandemic, many hospitals in New York were in short supply of ventilators. Healthcare administrators were forced to create ventilator allocation guidelines. The New York Guidelines emphasized saving the most lives by triaging based on the patient’s likelihood of acute survival with exclusion criteria such as irreversible shock, organ failure, etc. Is this fair? No right or wrong answer. Consequentialist: Yes, saving the greatest amount of people possible. Deontologist: Maybe. You have a duty to save people but you are also harming other patients which is a violation of categorical imperatives. Violation of maleficence and autonomy? Distributive Justice https://www.nejm.org/doi/full/10.1056/nejmp2005689 Reflective Equilibrium Hypothetical situations were examples of reflective equilibrium. The back and forth process of analyzing the application of theory, principle, and judgement in assessing a healthcare issue. Issues of Culture …and why should we care? Culture in Ethical Decision Making Everyone has a culture • Ex: religion, your ethnicity, national origin, where you immigrated to, mobility status, disability status, sexual orientation etc Culture in Ethical Decision Making Cultural competence: understanding of the diverse cultures and the ability to deliver culturally appropriate and specifically tailored care to patients Cultural sensitivity: being open to learning about other cultures How to Acquire Cultural Competence • • • • • • • • Be sensitive to personal health beliefs and practices of your patients Be sensitive to language barriers Consider body language Consider your patients’: gender, wealth or social status, presence of disability, sexual orientation Consider religious/spiritual factors Recognizes differences and build your self-awareness Avoid assumptions or judgements Acknowledge any discomfort, hesitations, or concern Effects on Ethical Decision Making • Understand what values and beliefs your patients and patients’ family members have that may differ from your own • Understand your own values and beliefs and identify if you have any implicit biases Implicit Bias Take implicit bias tests at: Question: • What culture(s) do you identify with? • Have you, or someone close to you, ever experienced cultural insensitivity or discrimination in healthcare? • Have you, or someone close to you, ever experienced cultural insensitivity or discrimination outside of healthcare? Decision Making in Healthcare …and why should we care? Identify and State the Dilemma or Issue Evaluate the Outcome Collect and Analyze the Data/Facts Subjective/Objective, External Forces, Moral Agents Ethical Decision Making What are the ethical theory and principles that apply? Make A Decision and Implement What the possible alternative decisions? Ethical Decision Making • What ethical conflicts are involved? • What is the desired outcome of ethical deliberations? Identify and State the Dilemma or Issue Ethical Decision Making • Objective: Describe the situation. Has a similar dilemma occurred before? What are the quality of life considerations? • Subjective: Who holds what positions about the issue? What are the values of the people involved? • Moral agents: Who are we looking to for an answer to this dilemma? Do we need to get more people involved? • External forces: economic, legal, socio-cultural, political, religious/spiritual Collect and Analyze the Data/Facts Subjective/Objective, External Forces, Moral Agents Ethical Decision Making • What ethical theory best addresses the situation? • What are the flaws of this ethical theory, and do these flaws apply to this situation? • What ethical principles apply to the situation? Collect and Analyze the What are the Data/Facts ethical theory Subjective/Objective, and principles External Forces, that Agents apply? Moral Ethical Decision Making • Explore possible solutions to your ethical dilemma • What are the consequences of each solution? • Who would be affected by these consequences? Do the people who would be affected by the consequences have a role in the decision making process? Collect and Analyze the What the Data/Facts possible Subjective/Objective, alternative External Forces, decisions? Moral Agents Ethical Decision Making • Choose a potential solution • Implement an action plan for your solution • • • • Evaluate how your action plan worked Were there any unforeseen consequences? Would a different decision have been better? Who benefitted and who suffered? Make A Decision and Implement Evaluate the Outcome Questions? Assignments See assignments in Canvas • Read chapter 2 • Quiz #1 due Sunday (timed quiz, one attempt only) • Take an implicit bias test at (0 points but will discuss next week) Small Groups Use the reflective equilibrium and the ethical decision making model to come up with a solution for the following ethical dilemma: You are working in a hospital as an intensive care nurse. Your patient is intubated and sedated – this means that they are unable to make their own decisions. They had previously indicated that they did not want to be on lifesupport if there was a minimal chance of meaningful recovery. The doctors have explained to the family members that this is unfortunately the case, and they recommend palliative care. However the family members have strong cultural beliefs that removing the patient from life-support is the same as murder. They want to continue full care and keep the patient alive. What should you do? Identify and State the Dilemma or Issue Evaluate the Outcome Collect and Analyze the Data/Facts Subjective/Objective, External Forces, Moral Agents Ethical Decision Making What are the ethical theory and principles that apply? Make A Decision and Implement What the possible alternative decisions?