Medical Ethics Board Review

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Medical Ethics Board Review

• Robert S. Crausman, MD, MMS

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Medical Ethics vs. Professional ethics

• Principals to guide physicians in their
  relationships with others
• Ethical dilemma is a predicament in which there
  is no clear course to resolve the problem of
  conflicting moral principles
• Dynamic environment/evolving field

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Principles

• Autonomy
• Beneficience
• Nonmaleficence
• Justice

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Autonomy

• Right to self-determination
• Requires decision making capacity
• Lack should be proven not assumed
• Competence legal determination
• Liberty freedom to influence course of
  life/treatment

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Preservation of Autonomy

• Advance Directives
• A document in which an individual either states
  preferences or designates decision maker
• Living Will
• Takes effect when terminally ill and lacking
  decision making capacity

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Preserving Autonomy

• Surrogate Decision Makers
• Represents patients interest
• Best identified before critical illness
• In absence of specific advanced directives should
  use substituted judgement

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Preservation of Autonomy

• The primary responsibility of the physician is to
  serve the patients interest

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The patient self determination act of 1990

• At the time of admission information re the
  patients right to refuse care or create an
  advance directive must be dispensed

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Informed Consent

• Requirements
• Decision making capacity
• Volutariness
• Reasonable person standard
• Present all alternatives f/b recommendation
• Respect refusal
• All surgical and experimental procedures

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Implied Consent

• Invoked when true informed consent not possible
• Emergency situations when harm would result
  without urgently needed intervention

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Disclosure

• Truth telling on part of physician is an integral
  part of patient autonomy

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Paternalism

• Justifiable if patient at risk of significant
  preventable harm, paternalistic action will
  prevent harm, benefits outweigh risks and the
  least autonomy-restrictive course of action is
  used

13
Confidentiality

• Obligation of physician to maintain information
  in strict confidence
• Exceptions if failure to release data to data to
  appropriate agencies may result in greater
  societal harm

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Futility

• Unilateral decision made on part of physician to
  withold or withdraw medical intervention based on
  predictable futile outcome
• Physiologic futility
• Medical futility none of last 100 cases like
  this

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Beneficience

• Obligation to preserve life, restore health,
  relieve suffering and maintain function
• To do good
• Nonabandonment obligation to provide ongoing
  care
• Conflict of interest must not engage in
  activities that are not in patients best interest

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Nonmaleficence

• Do no harm, prevent harm and remove harm

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Impaired Physician

• Physicians have the obligation to report impaired
  behavior in colleagues

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Principle of Double Effect

• Act must be morally good
• Actor intends good effect
• Good effect outweighs bad effect
• Bad effect not means to good effect

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Justice

• Allocation of medical resources must be fair and
  according to need
• Physicians should not make decisions regarding
  individuals based upon societal needs

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MD assisted suicide and euthanasia

• Legally prohibited in the US except in Oregon
  which permits MD assisted suicide

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DNR

• DNR orders affect CPR only
• Other therapies should not be influenced by DNR
  order
• Should be reviewed frequently
• Rationale should be in medical record

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Withdrawing of Support

• Brain death is not required
• Same as not initiating
• Does not conflict with basic principles

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Persistent Vegetative State

• Uncnsciousness/ loss of self awareness lasting
  more than weeks
• Supreme court draws no distinction between
  artificial feeding, hydration vs. mechanical
  ventilation

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Death

• Irreversible cessation of circulatory and
  respiratory function
• Irreversible cessation of all brain function
  (including brainstem)