Bioethics

A science of morals in human conduct. (how we aught to behave)

-Application of ethics to medicine and all life sciences -Discipline grounded in Principles -encompasses professionalism -a body of theories that can be taught -a public discourse

'professing to be skilled' -value performance vs. payment -central: attitudes, behaviour, character -involves codes and standards -competencies that evolve during medical training

A moral enterprise grounded in Standards

distinguish between right and wrong. May differ in cultural context vs. Ethics that do not vary

General Rule or truth regarding conduct; described as common morality what the general public holds as common sense

Enacted rule in a community enjoining or prohibiting certain actions. Integrated with morality and ethics (Enforces the morals of a given society)

is the use of reason and argument in seeking truth and knowledge of reality esp. in the principles governing existence

is the customs and achievements of a particular civilization

Results from gloabilzation and international immigration

Patient specific care across any culture. NOT knowledge of all cultures, but ability to reflect and recog. own cultural preferences and biases and communicate effectively with pts.

The science of processing data for storage and retrieval; need to be able to obtain reliable information (medical informatics)

Basic Facts

Data that has additional meaning in different contexts

information that is understood and defines relationships between different data

Provision of healthcare from a distance

-reduce pts. to data -websites with unreliable info -pts. may not understand or info could be misleading

-act in a patient's interest -prevent injury, illness -provide comfort -cure when poss

-Do no harm -balance risk, side effects -patient utility vs. social utility

-Alturism -Honor and integrity -Caring and compassion -Respectfulness -Accountability

-Present Presentable Punctual Prepared Positive Proficient Proactive

-Active listening -Adaptive questioning (following open ended Q's with directed Q's) -Nonverbal Communication -Facilitation (mmhmm, go on, I'm listening) -Echoing -Empathetic Response -Validation -Reassurance -Summarization -HIghlighting transitions: making clear the change from one section of the interview to another or from the interview to the examination

-exercise independent judgement -high standards of conduct -deal honestly -report to authorities those that don't -certify only those verified -give loyalty to patients

BritMJ, JAMA, CMAJ, WHO, Centers for Disease Control, WMA

Cognitive, Integrative, Relational, Moral

Start with factual info and recall: -knowledge -info management -application of information to real life situations -ability to recog. gaps in own knowledge -ability to learn from experience -use of tacit knowledge and personal experience -self directed acquisition of new knowledge -ability to generate useful questions -awareness of biases

Seeing the whole as well as the parts: -incorporation of scientific, clinical, and ethics -appropriate use of reasoning strategies -linking of interdisciplinary and clinical knowledge -managing uncertainty -examining and refining one's own reasoning strategies

Communication and the image one projects of oneself: -communication skills -handling conflict -teamwork -teaching -professional image

Ability to see what is morally relevant -attentiveness -critical curiosity -awareness of thought and emotion -recognition of cognitive and emotional biases -willingness to acknowledge and correct errors -ability to respond with others

Technical error is cognitive Moral is Moral competency; denying responsibility for a technical error

1.Respect for persons 2. Beneficence 3. Nonmaleficence 4. Utility 5. Justice

-Autonomy -believing the patient -Veracity (habitual truthfulness) -Dignity (privacy and confidentiality) -Fidelity (loyal to their interests) -Avoiding killing -Communication --> Does not mean simply giving the person what they want Democratic societies = (right to self unless harming others)

respect for individual dignity and rights -relies on respect for persons -any form of discrimination violates sense of personal dignity

autos= self nomos= rule -the capacity humans have to make decisions with regard to their best interests -informed consent, privacy -democratic right to self

under 12 or Alzheimers

Extensions of autonomy -one is 'living will' another is '5 wishes' tells who you want to make decisions for you etc.

Harm Principle: -the only purpose for which power can rightfully be exercised over any member of a civilized community is prevent of harm ie. with diminished autonomy

The view that the doctor knows best -used in attempts to justify violating autonomy

-Act in the patient's best interest -Prevent illness, injury -Provide comfort, cure when poss -treating pain is always in the patient's best interest

is metabolic and does not constitute abuse or addiction -when precisely titrated and monitored, there is no max safe dose for opioids

-Do no harm -balance risk, side effects -patient utility vs. social utility

-Balance to attain the net good --probability of risks --severity of harms --value of benefit -patient utility -social utility

-Provide Best standard for all -Fair distribution of goods

1) Respect for Autonomy > beneficence and nonmaleficence 2) the interests of others may > respect for autonomy (harm principle) 3) if the harm = benefits, then nonmaleficence > beneficence

-the doc will inform patient of all consequences of decisions -the patient has the right to the information necessary for decisions -the patient should clearly understand what the purpose of any test or treatment is, what the results imply, and what would be the implications of withholding consent (if a test is mandatory there is no consent)

-each patient should be informed of all info that a reasonable person would want to know beforehand -must understand -be able to discuss with doc all options that might realistically benefit them and to express their preferences (OR ELSE: choice is not autonomous or informed)

'True consent to what happens to one's self...entails an opportunity to evaluate knowledgeably the options available and the risks attendant upon each. " aka. reasonable person standard

1-Decision-making capacity 2-Disclosure (info from doc to patient) 3-Understanding (asking a patient to describe what they've been told) 4-Voluntariness (compromised by the 'white coat syndrome' where patients give consent because the doctor is seen as an authority to obey) 5-Authorization (signing a consent form alone does not itself constitute as informed consent)

-uncertain mental or legal status -coercive influences -incomplete understanding of the patient -anxiety, pain, language, time, inadequate disclosure, value judgements that impact upon disclosure (ie. poor, stupid, foreign) -ex. patient who consents to prostate surgery without the understanding that it is likely to leave him sterile has authorized the procedure, but has not provided informed consent

-unconsciousness -mandatory vaccinations for public health protection

1. Deontological 2. Consequential 3. Virtue Ethics

some things are always wrong (like killing a person) and under no condition would doing it ever be right. Guided by what is morally 'right'. Intrinsic value for human life. -human life's value derives from dignity and agency= ability to chose -Moral worth stems from reason -immoral to intentionally lie or harm -MUST: be truthful about prognoses -maintain confidentiality -obtain informed consent -Keep promises, obey rules, no matter what (because doing so is always right). aka. Kantianism

-moral duties that apply to everyone -override self interest

outcomes. Be guided by consequences (ends justify the means). Seek the most good for the most people. (protect confidentiality unless harm to others). aka. the Utilitarian theory. Jeremy Bentham and John Mill. Criticism: supererogatory demands on everyone...are physicians morally req'd to expose themselves to patients with SARS etc. -benefit some, harm some -threaten doctor/pt. relationship ie. pt. confidentiality -offering false hope?

character: gives rise to actions. -Morality req's good character. (praiseworthy, act from right motivation) -Oldest theory dating back to ancient Greece. -ie. it is good if you intend to do good Problems: Relying on virtue alone for guidance req's the agreement about the definition of 'Good'. -Pellegrino, Plato, and Aristotle, virtue is a character trait that deals with striving for excellence and goodness in oneself even if no one knows about it, and with habitually striving for excellence.

Action is moral if it max's happiness -capacity of happiness is intrinsic

-knowledge of good and choose the good -consciously working to develop virtuous character (req's practice) -Aristotle doesn't define how to behave but values virtue -actions by virtuous people from virtuous motives are morally right even if consequences are bad -ex. if politeness is acheived without virtuous motive it is not virtue -right actions not the same for everyone at all times

-Deontological: no b/c the duty to obey the law trumps other concerns -Conseq.: Yes is it max's the good for the most people (ie. pt and family) -Virtue: Depends on the doctor's character and whether she means well

-who has legitimate interest in the outcome? -what actions might one take at this point and what are the conseq's -what are the probabilities and severities of each conseq? -what obligations does one have to each interested party? -what are some other ethical questions --> These questions will enable you to defend your actions and improve outcomes

Ask Questions, Speak up, Strengthen Communication

speaking up in a constructive, non-threatening way generates discussion and promotes resolution. Constitutes Aristotle's process of developing virtue through experience.

12.5% of world wide deaths = substance abuse -

-craving -loss of control (not being able to stop once you start) -physical dependence -tolerance- the need for greater amounts to get the same feeling

Maladaptive pattern of substance use leading to impairment of : 1. Role Failure 2. Risky situations 3. Run-ins with law 4. Relationship problems Work quality is often the last to go

Diversion programs to prevent board action

Tay Sach's Disease. -recognize certain 'carepoints' as an unmet need being recognized -Differences between effective treatment and treatment goals -creates deeper connection between doctor/patient relationship

-physicians should be monitored for: -criminal record, drug abuse, aggressive behaviour, etc. all unprofessional behaviours

-council on ethical and judicial affairs

-Reporting adverse drug/Device Events -an obligation to communicate to the broader medical community -spontaneous reports of adverse events are irreplaceable source of valuable info -certainty or even reasonable likelihood of a causal relationship will rarely exist and is NOT req'd before reporting

-An individual's opinion is a personal moral decision -a physician as a member of a profession dedicated to preserving life when there is hope of doing so should not be a participant in legally authorized execution -organ donation only permissible if decision to donate was made before the prisoner's conviction

1. Duties of physicians -independent judgement -maintain highest standards of conduct -report unethical or incompetent colleagues 2. Duties of physicians to patients -not enter into sexual relationship with a current patient or into any abusive or exploitative relationship 3. Duties of physicians to colleagues -communicate effectively

-Honour bound to help -the moral authority and independence of physicians in service to others -profession's responsibility to care for the sick, and emphasized individual honour

-Who has legitimate interest in the outcome? -What actions might you take? -What are the consequences? (probabilities, severities) -What are you obligations? -What other ethical concerns are involved?

-OR. resident -At least 18 yrs old -2 oral requests separated by 15 days -Signed written request -2 confirm diagnosis, prognosis, capacity -prescribing doc inform pt. of alternatives -report all RXNs to DHS

societal trust

Impedes the ability to access and assess credibility and relevance of information

when the doctor prescribes medications that a patient can end their own life when a pt. chooses. -A response to a pt. request autonomy and agency -It does not accord specifically with any one theory -If The patient has become depressed to the extent that this may be affecting decision making, psychiatric evaluation is needed, clinical practice standards require you to seek psychiatric evaluation and ensure that the patient has mental capacity before proceeding further

is when a doctor kills a pt. through lethal injection or other means for whatever reason

is both ethical and legal but uncertainty and conflicts persist because people disagree about what constitutes improvement or benefit. Does NOT constitute PAS, euthanasia or terminal sedation

fundamentally incompatible with a physician's role as a healer -physicians must aggressively respond to the needs of patients at the end of life

advocates to legalize PAS -lost his license and was imprisoned after a videotape broadcast on CBS 60 minutes documented him providing PAS -released in 2007

to gain information that will inform the medical profession about how to improve RXNs -improve care of future pts. -conflicts with the goals of clinical practice -Done to remove uncertainty about current RXNs not always to improve existing treatments

-to help the pt.

-accept risks in the hopes that doing so will benefit themselves and/or others -People choose to participate in research for varied reasons. Prisoners have the right to serve as research participants

BELIEF that a drug or treatment is efficacious when it has not been conclusively proven to be so

IMPLYING that a drug or treatment is efficacious knowing that it has not conclusively been proven to be so

tests a new drug or treatment for the first time on a sm. group (20-80) ppl to evaluate overall safety and determine safe dosage range, toxicity, and side effects

testing the safe dosage range among a larger group (100-300) to examine efficacy and further evaluate safety

tests on large group of ppl (1000-3000) to confirm effectiveness, monitor side effects, compare to other treatments, and determine what constitutes safe and appropriate use -in the US approval from the FDA is usually sought after phase 3 success

-post marketing studies wherein data is sought from clinicians -delineates doctor satisfaction with outcomes of using the new treatment -in the US there is evidence that phase 4 studies are not conducted with scientific rigour and that possible side effects and adverse events do not lead to reviews, warnings or recalls as soon as they should.

refers to a treatment or procedure that is routinely administered for a given condition because it is known to be effective -Contrasts with Experimental or innovative Therapy

there is uncertainty that the patients enrolled as research subjects will obtain any therapeutic effect

-genuine uncertainty about which arm of a clinical trial will provide the most benefits or harms to pts. research subjects or future pts. -particularly difficult to attain for physicians whose pts. are their research subjects

states that 'the well-being of the human subject should take precedence over the interests of science and society' -produced by the WMA which was formed in 1947

this was adopted in 1949 b/c of deadly experiments of the Nazis on unwilling human subjects -"the voluntary consent of the human subject is absolutely essential...must make an understanding and enlightened decision." (informed consent)

-commissioned and adopted in the IS in the 70's after the Tuskegee study new broke -basis of laws that protect subjects of research -req's informed consent, AND mandates the review of potential risks and benefits to participants by impartial committees called Institutional Review Boards (IRB's)

aka. Local research ethics Committees, Research Ethics Boards -weight the utility of each protocol and approve them when the benefits outweigh associated risks

1. Scientifically valid 2. Uses fair subject selection 3. Favourable benefit/harm ratio 4. Dignity for persons 5. Informed Consent 6. Voluntariness of participants 7. Undergoes Ethical Review

-philanthropic project to diagnose and treat black men in Alabama who had syphillis -AB's were unknown at the time -US Public Health Service -set up the study to document the natural history of syphilis

-offered 'special treatment' which was really a spinal tap for 'bad blood' -was to determine if syphilis had spread into their nervous system -AUTHORIZED the spinal taps but informed consent not met -intentionally deceived the patients into thinking it was treatment not research -40's penicillin became standard treatment but treatment withheld even into the 70's -medical students rotated in through the unit during that timeframe

Peter Buxton. approached authorities -news media report leading to the Belmont Report and subsequent policies

-come to symbolize racism in medicine, ethical misconduct in human research, paternalism by physicians and government abuse of vulnerable people -'hurt our progress and divided our nation'

-obligates te doctors to provide treatment to women who present with complications of pregnancy or abortion -obligates the provision of access to contraceptives and contraceptive advice with which women can protect themselves against unwanted pregnancy -respect for persons follows that people of either gender should have the right to control their own bodies to the extent that doing so does not interfere with others

to resist ethically mandated change because of long held beliefs or practices is an error -that the state of affairs has existed in the past, does not justify it continuing into the present or future

-stemming from ancient greece -saving life -curing disease -relieving suffering -promoting health

-prevent disease and injury -promote and maintain health -releve pain and suffering -care for and about patients, including those that can't be cured -avoid premature death -pursue a peaceful death for patients

-not all death is premature -death is not a medical failure

-aimed to distinguish facts from opinions and attain consensus about what is in the patients best interests -if ongoing consultations fail to attain agreement a legal challenge could be brought by either party

do not resuscitate

-pt. is no longer autonomous so substituted judgement is justifiable -supports respect for persons

-high tech therapies are not always in the patient's best interests -cannot cure chronically ill pts. but must continue to provide care that relieves pain and suffering -make the most of their remaining time

-article about washington proposing an Oregon-style law that would allow legal access to potentially lethal medication for terminally ill patients -benefits of legalization to patients by relieving otherwise intractable suffering (ie. voluntarily, stopping eating/drinking, forgoing life-sustaining therapies, sedation to unconsciousness) outweigh the risks -coming of age of palliative care movement

-patients who are terminally ill and are willing to forgo further treatment of their underlying disease -coordinates quality-of-life treatment

1. Right to intensive pain and symptom management 2. Right to forgo life-sustaining therapy 3. Voluntary stopping eating and drinking (VSED) -different from the natural loss of interest in food and drink that normally occurs when a person is actively dying -needs to be 'physician supported' 4. Sedation to unconsciousness

-failure of clinicians to elucidate 'the big picture' -realization of the price to be paid for going the longer way towards death and not the shorter -rethink objections to legalizing PAS

-docs have knowledge and political leverage -BMA encourages docs to set example for others to reduce impact on environment -AMA urges physicians to advocate for reform -must recog physicians responsibility for punic and global health -identify and deal with ethical issues associated with resource allocation and scarcity

-material (food, healthcare, employment) -social (respect, security, participation) -cultural (identity, religion, education)

-emotional reactions -faulty perceptions -avoidance of conflict

BMJ video about the impact of climate change on babies born today, and how the NHS can reduce its carbon footprint. -NHS is responsible for 1/4 of the carbon production

Modern medicine is good at staving off death with aggressive interventions—and bad at knowing when to focus, instead, on improving the days that terminal patients have left. Twenty-five per cent of all Medicare spending is for the five per cent of patients who are in their final year of life, and most of that money goes for care in their last couple of months which is of little apparent benefit. Surveys of patients with terminal illness find that their top priorities include, in addition to avoiding suffering, being with family, having the touch of others, being mentally aware, and not becoming a burden to others. Our system of technological medical care has utterly failed to meet these needs

The pain of sickle cell anemia is very frustrating. You never know when it will strike and it is often difficult to get it under control A fear of addiction, by patients, families, and health care workers can sometimes interfere with appropriate treatment of pain. However, there are detailed treatment guidelines that outline the right way to treat sickle cell pain.

-struggle to extend health-care coverage while curbing health-care costs McAllen has another distinction, too: it is one of the most expensive health-care markets in the country -The primary cause of McAllen's extreme costs was, very simply, the across-the-board overuse of medicine without improving the quality of overall care Americans like to believe that, with most things, more is better. But research suggests that where medicine is concerned it may actually be worse because nothing in medicine is without risks. Health-care costs ultimately arise from the accumulation of individual decisions doctors make about which services and treatments to write an order for. The most expensive piece of medical equipment, as the saying goes, is a doctor's pen.

LIBERTARIAN - resources should be distributed according to market principles (individual choice conditioned by ability and willingness to pay, with limited charity care for the destitute); • UTILITARIAN - resources should be distributed according to the principle of maximum benefit for all; • EGALITARIAN - resources should be distributed strictly according to need; • RESTORATIvE - resources should be distributed so as to favour the historically disadvantaged

-obedience -imitation -feeling/desire -intuition -habit

-Deontology -Consequentialism -Principlism (considers law and conseq's) -Virtue Ethics

Declaration of Geneva requires of the physician that "The health of my patient will be my first consideration," and the International Code of Medical Ethics states, "A physician shall owe his/her patients complete loyalty and all the scientific resources available to him/her."

an approach to the care of patients, especially those who are likely to die in the relatively near future from serious, incurable disease, that focuses on the patient's quality of life, especially pain control. It can be provided in hospitals, special institutions for dying patients (commonly called hospices), or in the patient's home.

Yes, failure to do so violates societal trust and the AMA Code of Ethics.

-geographic origin: dress, diet -May change with Age

-Holds that beliefs and practices in a given culture are ethical if they represent traditional norms and values in that culture -Does not support cultural competence (since some practices may be harmful)