Objectives

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Objectives

1. Review briefly the history of medical ethics
2. Define autonomy, beneficence, non maleficence,
   truth telling and justice
3. Balance competing medical ethics in making
   decisions about patient care

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The Origin of Ethics
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Socrates question

• How shall we live?

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Applied Ethics in the palliative care setting

• Phil Lawson MD
• NHHPCO Annual Meeting
• November, 2011

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The Origins of Ethics

• Aristotle
• It is thought that every activity, artistic or
  scientific, in fact every deliberate action of
  pursuit, has for its object the attainment of
  some good.
• Aristotle Ethics

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Ethics, Morality and the Law

1. Ethics collective guiding principles
2. Morals personal sets of beliefs
3. Law rules to run society

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Ethical principles

• Jainist philosophy (Ghandi) nonviolence to all
  life
• Christian (Jesus) love ones neighbor as
  oneself
• Hippocrates strive to help, but above all do
  no harm

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Ethical principles

• Kant act as if that act would become a
  universal law
• Bentham act to provide the greatest good to the
  greatest number (utilitarianism)
• Rawls maximize the benefit to those minimally
  advantaged (maximim theory)

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The Goal of Medical Ethics
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Medical Ethics

• Medical ethics and principles
• Autonomy
• Beneficence
• Nonmaleficence
• Justice
• Truthtelling

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The Basic Ethical Principles

• Autonomy
• respects autonomous decision making
• (self-rule )
• - promotes patients to act as their own agent
• - free will with informed consent
• The down side
• Consumerism commitment to non-involvement in
  client decision making
• Non Caring

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The Basic Ethical Principles

• Beneficence
• Do good (or provide benefit )
• - the basic principle of caring
• - act in accordance with a patients welfare
• The down side
• Paternalism health provider makes decision for
  the patient based on providers values more
  than patients values

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The Basic Ethical Principles

• Non maleficence
• Do no harm
• - the calculation of risk in medical decision
  making and determining risk/benefit ratio
• - the balance of benefit and harm utility
• The down side
• Non action or unwillingness to offer treatments
  with questionable benefit

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The Basic Ethical Principles

• Justice
• Be fair (distributive justice gt entitlement)
• - the appropriate distribution of limited
  resources
• non discrimination
• - transparency, accountability and consistency
• The down side
• Restriction of higher end resources from those
  who could afford it
• Transparency can drive inappropriate practice
  (data mongering)

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Other Ethical Principles

• Truth-telling or Veracity
• - full, honest disclosure
• The down side
• Assaulting patients with the truth

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Other Ethical Principles

• Fidelity
• -do as you say you will do respect
  confidentiality
• The down side
• Confidentialty can impede quality and
  efficiency of care

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Ethical Principle Moral basis Over Emphasis
Autonomy Respect for individual Consumerism Lack of caring
Beneficence Do good Paternalism
Non- maleficence Do no harm Lack of action
Justice Be fair Lack of individualization
Veracity Be truthful Truth causing harm
Fidelity Maintain confidentiality Treating patient as an island
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A Process of Ethical Decision Making

• Define the situation clearly and as completely as
  possible including the context
• Decide on which ethical principles are involved
• Weigh the competing principles
• Make a decision

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Ethics

• The practice of ethics is NOT the application
  of rules but the careful consideration of
  principles in the complex world of decision
  making about human action.

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AMA Code of Ethics

1. Display competence, with compassion and respect
   for human dignity and rights
2. Uphold standards, be honest, and report those
   deficient in character or competence or engaging
   in fraud
3. Respect the law and try to change those laws
   contrary to the best interests of the patient

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AMA Code of Ethics

• 4. Respect rights of patients and colleagues and
  maintain confidentiality within constraints of
  the law
• 5. Continue education, consult appropriately and
  present information to patients
• 6. Be free about whom to care for, whom to
  associate with, and where to provide care (except
  in emergencies)

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AMA Code of Ethics

• 7. Recognize a responsibility to participate in
  activities that better community and public
  health
• 8. Regard responsibility to the patient as
  paramount
• 9. Support access to medical care for all people
• Adopted by the AMA's House of Delegates June 17,
  2001.

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Palliative Care Issues

• Double Effect
• Decision Making Capacity and Informed Consent
• Futility

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The Ethic of Dignity
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Situations?/ Cases?
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Terry

• 51 year old cachetic (95 lb) male in hospital due
  to pneumonia not recovering
• 5 year hx metastatic prostate ca multiple
  mounting complications (c diff, recurrent SVT,
  hypotension, hypoalbuminemia and edema)
• not eating and resistant to attempts to assist in
  recovery from pneumonia
• full code and states he wants to treat all
  conditions and get back to work

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Terry

• Also states he does not want to linger, only
  wants comfort care when he is dying, and if I
  knew what this past year was going to be like, I
  would have preferred to die.
• Refuses to eat and angrily reacts to anyone
  suggesting his recovery would benefit from better
  nutrition
• Has a different symptom (often different pain
  source) that comes and goes each day when PT/OT
  comes by to help him

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Terry

• Palliative care consultation requested

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Question

• Continue to aggressively try to treat
  complications vs focus on aggressive symptom
  control?

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Gerard

• 65 yo male malnourished alcoholic
• Admitted for acute sepsis
• No prior medical care until saw surgeon 3 wks
  previous for non-healing stage IV LE ulcers
• 10 cm hepatocellular carcinoma dx during
  treatment for ulcers
• Initially alert

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Gerard

• Suddenly develops acute renal failure and loses
  decision making capacity
• Requires dialysis or will die
• Attending surgeon thinks comfort care
• GI consultant pushing hard for dialysis

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Gerard

• Only family is son of a former girlfriend who
  he raised (who is on probation)
• Owns own home where they lived
• Has no ADs, no financial will
• Ethics consultation requested

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QUESTION

• Refer for dialysis or comfort care?

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Other examples

• Access to harmful treatment
• Radiation and chemotherapy at end of life (ECOG
  IV)
• Access to treatments that cannot be afforded
• Targeted vemurafenib for melanoma with BRAF
  mutation
• 120,000 for a course of therapy

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Other examples

• Physician assisted suicide