Ch 12: Healthcare Ethics

Lateral Violence

- 'Nurse to nurse' aggression (verbal & nonverbal behavior)

Organ Transplants from family members

- About 4 out of every 10 donations are living donations, which often comes from family members or close friends Family members are often transplant donors because their compatibility can be very high, which reduces the risk of the organ being rejected. Related living donors include siblings, parents, children, and other relatives (aunts, uncles, cousins, half-siblings, etc.). - The ethical issue that occurs with organ transplant from family members, is that the family member may feel emotional pressure or coerced into agreeing to donate an organ Family relationships, roles, and emotional bonds are huge factors that affect the decision to donate. A study by the Mayo clinic found that 84% of people would consider donating to a family member or friend, whereas only 49% would consider donating to a stranger - Physical, psychological, and emotional evaluations are done on donors to ensure they are a match and that they provide autonomous consent to proceed with the organ donation process. Any negative judgement made by either the donor or recipient will cease the organ donation. - It is the healthcare professional's job to inform the donor the risks and benefits of the procedure and to advocate for them. Many family members feel rewarded by helping another family member through their organ donation.

Designer or Donor Babies

- Alternative reproductive methods of contraception that parents use to have children - Methods: > In Vitro Fertilization: embryo is fertilized in a clinic using the sperm from the father > Preimplementation genetic diagnosis: used to test embryos for tissue compatibility with their siblings prior ti being transplanted into the mother; Designer baby can provide bone marrow transplant to a sibling that is ill, if tissue is compatible, embryo can be destroyed if not compatible to sibling > CRISPR-Cas9: edit a defective gene in DNA sequence by deleting and/or inserting bases at the zygote stage thus ridding the embryo of a particular disease > Mitochondrial transfer: a childbearing woman with potential to have a child with a severe birth defect will have DNA removed from her egg and implanted into an egg from another woman with healthy mitochondria; developing embryo will have gens from mom and dad as well as mitochondrial DNA from donor egg - Ethical concerns: embryo considered to be early human life, science playing God, creating a child for the sole purpose to save their sibling, eugenics, eradicating disease (cystic fibrosis and sickle-cell), unintended health consequences later in life

Ethical Values

- Autonomy > Respect pts decisions even if they differ - Beneficence > pts best interest when making a decision is primary - Non-malfiesance > HCP will cause no harm when taking action - Justice > HCP will make fair decisions - Dignity > pt should be treated with respect & dignity decisions

Ethics & Doctor-Pt Relationship

- Engineering Model > provider empowers the pt with knowledge to make a decision - Priestly Model > Doctor will make the best decisions for pts health - Contractual Model (legal) > agreement btw two parties, assumes mutual goals - Collegial Model > trust btw pt & doctor and that decision is an equal effort

Euthanasia

- Euthanasia generally refers to a doctor ending a patient's life by a compassionate means. This includes lethal injection or administering a lethal overdose of a euphoric drug. This differs from assisted suicide. - Assisted suicide is when a patient is given the means to take their own life. - Euthanasia is illegal in the United states, however, physician assisted suicide is legal in 5 states (Oregon, Washington, Montana, Vermont, California). In Texas doctors are allowed to remove life support of patients and let them die naturally. - How does this effect Nursing? > Often nurses are the healthcare provider that stays with the patient through the dying process. Since nurses have such a unique relationship with patients it is up to us to advocate on their behalf. Since we view the patient as a person, we can also have more insight into why they are making medical decisions. - Is it ethically permissible to aid a patient in dying? > One of the ethical principles of nursing is to treat patients with beneficence, or to do good unto other through a moral obligation. It is up to the nurse to determine if the act of euthanasia does harm to the patient or not. If a nurse takes part in taking a patient's life, even if the patient has consented, they can be seen as a killer and lose the trust of the public. On the other hand, if the patient views euthanasia as a relief of pain, maybe euthanasia can be viewed as a way to relieve the patient' pain and suffering. Nurses should respect a patient's autonomy to make their own decisions. It is important to note that a nurse's autonomy should also be respected. No healthcare provider should be forced to participate in euthanasia if they do not wish to. Ethical principles of nonmaleficence and beneficence can be used as arguments that outweigh the patients right to autonomy

Ethics and Public Health

- Healthcare inaccessibility for certain populations - responding to bio-terrorism - research in developing countries - Health promotion & its infringement on individuals lifestyle choices - public heath's response to emergencies

Duty to Treat

- Hurricane Katrina > Many healthcare professionals volunteered to stay behind in the local hospital > Several pts in the hospital died > providers were accused of negligence > many professionals are now wary of volunteering during a crisis > The decision to remain was ethical, but now they are rewarded with a criminal liability (Good Samaritan Law, Physicians practicing in free clinics: federal law protects)

Other ethical issues

- Medial Tourism > Medical value travel; evolved bc US healthcare services is expensive - IndUShealth and Global Health Administrators INC: > collaborated with insurance companies to arrange fir US residents to obtain medical treatment in other countries - United Group Programs: offers living and deceased organ donor transplants from foreign countries > US organ transplants cost about 100,00: considerably less expensive overseas

2 Federal Laws that can be applied in workplace bullying:

- Occupational Safety & Health Act of 1970 > Employers must provide a safe and healthful working environment for their employees - Title VII of the Civil Rights Acts of 1964 > If a protected class employees (gender, religion, ethnicity) is bullied by another employee, the action can be illegal based on the concept of a hostile work environment

Workplace Bullying

- Ongoing harassing workplace behavior btw employees > Neg health outcomes for the targets employees > Eg: Btw physicians & nurses, nurse to nurse & family to nurse - Center for American Nurses; American Association of Critical-Care Nurses; International Council of Nurses; National Student Nurses Association: > Statements regarding he need for healthcare organizations to eliminate bullying in the healthcare workplace - The Joint Commission > Standard for workplace bullying called "intimidating & disruptive behaviors in the workplace" - American College of Physicians & Harvard Pilgrim Health care ethics program: > Statement of ethics for managed care - No federal legislation in the US that forbids workplace bullying > New York (only state): enacted legislation that forbids this type of behavior in the workplace

Dr. Jack Kevorkian & Dr. Philip Nitzschke

- Physician-assisted suicide, legalized in the Netherlands in February 1993, was largely opposed by the American medical establishment. Many practitioners believed that such actions violate the most basic principle of medicine: to do no harm. Two physicians who have strongly supported euthanasia throughout the years include U.S. physician Dr. Jack Kevorkian and Australian physician Dr. Phillip Nitschke. - Dr. Jack Kevorkian, aka Dr. Death, provided assisted-suicide services to at least 45 ill patients. In 1989, he developed a suicide machine that allowed patients to administer a lethal injection of medication to themselves. The U.S. Supreme Court later ruled that individuals who want to kill themselves, but are physically unable to do so, have no constitutional right to end their lives. Dr. Kevorkian was charged to first-degree murder and sentenced to 10-25 years in prison after a video was released of him administering a lethal injection to a patient suffering from Lou Gehrig disease. He was paroled in 2007 because he was in failing health and died in 2011. - Australian physician Dr. Phillip Nitschke travels internationally presenting "how to commit suicide" clinics. He is the founder of Exit International, a non-profit organization advocating legalization of voluntary euthanasia and assisted suicide, and co-author of the best-selling Peaceful Pill eHandbook. He believes that if there is a right to life, there is also a right to die and that individuals should have the right to choose to end life. He does not restrict this right to just the terminally ill. He also believes that the depressed, elderly, and grieving should have the right to end their lives. - In a study done in 2018 by Gallup, 72% of Americans say that doctors should be able to help terminally ill patients die, 65%of Americans express support when the question includes the words "commit suicide," and 54% think doctor-assisted suicide is morally acceptable.

Ethics in Research

- Research involving human subjects requires the assessment of the risks and benefits to human subjects; must be clearly explained to them before the consent to participate is given - Principles of ethical research are outlined in Institutional Review Boards (IRBs) > IRB has the authority to approve, require modifications, or disapprove research > protects the rights and welfare of human research subjects (children, women, disabilities, mentally disabled, prisoner)

Consent for Organ Donation

- The United States uses an expressed consent model when dealing with organ donation. This means that organ donation consent must to be explicitly stated. This is normally in an advanced directive, driver's license, by a medical power of attorney, or someone with decision-making responsibility in the case that the patient cannot make the decision themselves. - In some states, people can enroll in a program that grants permission for organ harvesting when death occurs. - Another type of consent is presumed consent, which is used by other countries around the world such as Spain, Belgium, Austria, France, Columbia, Norway, Italy, and Singapore - With presumed consent, individuals are expected to want to donate their organs if brain death were to occur, unless this is explicitly objected. - Every country has slightly different policies, but there is an underlying protocol that the individuals must be properly informed of the policy and given the opportunity to opt out of donating

Financial Payoff for organ donation

- The demand for organs needed for transplants continues to grow in the United States, and there is a failure to meet this need. Therefore, financial incentives have been considered to help increase the number of available organs. In the recent years, scholars and members have proposed providing donors with financial incentives through a federally regulated system, which has gained much attention to help decrease the shortage. - Financial incentives are considered any material gain or valuable consideration obtained by those who directly consent to the process of organ donation, including the donor himself, the donor's estate, or the donor's family. Because financial incentives change the process of organ acquisition, the term "donor", will no longer apply. Instead, it would be replaced by the term "vendor", or other suggestions such as "reward gifting," although this term has received much criticism. - Overall, there have been many suggests to help increase the number of available organs for transplant, financial incentives being one of them. However, there are many ethical considerations to be discussed, and terms to be defined. The National Organ Transplant Act (NOTA) of 1984 does not legally permit donors to sell organs. Because of this, it is unlikely that financial incentives will move forward into practice.

Transplantation & Who Should Receive organs

- Transplantation: the procedure of implanting a functional organ from one person to another. Can include blood transfusions or heart, lung, and bone marrow transplants. Organ transplantation is becoming more common, and many recipients have a significant chance for survival - Waiting times vary due to shortage of organs, how sick recipients are, how quickly recipients are deteriorating, or medical conditions that may make them compatible or incompatible with a donor — Patients should be notified of placement on the list, removal from the list, or decision to not be added to the list (for any reason other than completed transplant or death) within ten days of those events occurring — In Texas, more than 10,000 people are awaiting transplants. > To be a donor, one must pass in a hospital on a ventilator usually of TBI or stroke. > Corneal and tissue transplants can come from people who pass outside of the hospital in specific circumstances - Two major ethical and legal issues with transplantation: > The decision-making process for who receives the organ > Financial remuneration from selling organs (it is illegal in the US to buy and sell organs, which has led to a black market for organs) - Who should receive organs? > The organ waiting list is managed by United Network of Organ Sharing > Patients awaiting a transplant are assigned a priority based on medical need > Those in ICU or life support have highest priority for heart transplants. > Those awaiting liver transplants must have 6 months of sobriety from alcohol to be eligible for a transplant, and some transplant centers refuse to give alcoholics liver transplants at all — Justifications for organ priority are based on four areas: > Lifespan account (assesses lifespan and quality of life) > Fair innings account (assumes that everyone deserves to live a full life and that society's resources should be used to maximize everyone's opportunity at a full life) > Maximum principle (states that when allocating a scarce resource, like an organ, inequalities will exist and those who are most disadvantaged should benefit the most) > Concept of utility (focuses on the greatest percentage of survival when receiving the organ). —NOTA (National Organ Transplant Act) identifies three principles of primary importance when allocating human organs: > Utility. Justice, Respect for persons (respect for autonomy) > Some factors in organ allocation include waiting time, compatibility, medical need, distance from donor hospital, survival benefit, and medical urgency

Xenotransplantation

- What is it? > Xenotransplantation refers to the practice of transplanting, implanting, or infusing living cells, tissues, or organs from a nonhuman animal sources into a human recipient. > is intended to benefit the health of individuals by replacing nonfunctioning or malfunctioning human cells, tissues, or organs with functioning nonhuman animals cells, tissue, or organs. Pigs and primates are the most common organ donor in xenotransplantation. > offers a solution to the shortage of organ donors and may offer resistance to human-specific pathogens. - PROS: 1. Transplanted animal cells to be used for hemophilia, diabetes, Alzheimer's, and Parkinson's disease 2. Organ Transplants 3. A way of delivering genes of therapeutic importance - Ethical Issues: 1. Animal Rights - We are killing animals for these experimental procedures so the big question is, "Why should animals suffer for humans?" The animals have a right to life. 2. Religion - Jewish: forbidden to eat any part of a pig. Hindu: forbidden the killing of cows, since cows are a sacred animal 3. HIGH rejection rate 4. Public health risks - Risk for transmission of animal disease into humans - endogenous retroviruses are present in the genomes of all mammalian cells, have an inadequately defined ability to infect human cells, and have generated public health concern. 25 known diseases can be contacted from pig to human. If it is to be successful, it is important that the animals be screened for any diseases that humans may contract, such as rabies and viruses. The FDA is responsible for regulating Xenotransplantation activities.

How to develop a Code of Ethics

- Written clearly: employees at all organizational levels will utilize it > Memorable title, leadership letter, table of contents, introduction, core values of the organization, code provisions, information and resources - User-friendly resource for the organization - Should be updates to include current laws and regulations

Ethical Standards

- actions that are hoped for & expected by individuals - Actions > legal but not ethical - Many definitions > right & wrong choices as perceived by society & its individual

Basic stakeholder relationship

- btw the physician/clinician and the patient - impacts ethical decision-making process

Bioethics

- concerned with ethical implications of certain biologic & medical procedures & technologies - EX: organ transplants & genetic engineering - concept evolved as a result of Nazi's human experimentation: WWII prisoner camps

Physicians actions

- duty to treat

Medical Ethics

- focuses on decisions healthcare providers make on pts medical txmt > Ex: euthanasia or physician-assisted suicide

Paternalism and Public Health

- individual freedom will be restricted for the sake of public health activities bc the government infringes on individual choices for the sake of protecting the community

Pharmaceutical Research & Manufacturers of America (2002, 2009)

- new code of conduct governing physician- industry relationships

Physician Payment Sunshine Act (2010)

- part of affordable care act - Requires manufacturers of drugs, medical devices & other healthcare products with relationships with Medicare & Medicaid providers & CHIP programs > submit annual reports- payments & items of value - reports ownership interests held by physicians & their families

Stewardship Model

- public health officials should achieve that stated health outcomes for the population while minimizing restrictions on people's freedom of choice > While promoting a healthy lifestyle: imp that public health programs do not force people into programs without their consent or introduce interventions that may invade people privacy

Healthcare Ethical Dilemma

- situations that test a providers belief & what the provider should do professionally - often conflict between personal & professional ethics - Problem, situation, or opportunity that requires an individual (HCP), or an organization (manage care practice), to choose an action that could be unethical

Genetic Testing

- testing performed on individuals with predisposing risk factors to determine if they are at risk for or carriers of a specific genetic disease - genetic testing looks for changes in genes, chromosomes, and proteins - most often done on blood or cheek swabs; may also use samples of hair, saliva, skin or amniotic fluid - Purpose: > Screening purposes (newborn screening) > Diagnostic purposes when an individual is symptomatic > Predictive purposes when an individual is at risk for a certain disease > Pharmacogentic purpose to individualize medications and dosage - Human Genome Project > Complete mapping and understanding of all genes that make up in human DNA > Identified several genes as markers of predictors or disease; For example the BRCA gene for breast cancer > Covers 99% of human genome with 99.99% accuracy - Ethical Considerations: > No standards or safeguards currently exist to govern the appropriate use of DNA analysis and storage from newborn screening tests > Genetic discrimination in employment or insurance > Genetic counseling is strongly encouraged to help individuals understand the test, weigh the risk and benefit, and explain the results > Genetics raises important questions of where individual rights end and where responsibilities to a group, such as one's family or society, begins

Hippocrates

- the father of medicine - Hippocratic Oath > foundation for ethical guidelines for pt treatment by physicians

Ethical Dilemmas

- when the ethical reasoning of the decision maker conflicts with the ethical reasoning of the pts and the institution - Resolution > guidelines provided by codes of medical ethics of medical associations or healthcare institutions, ongoing training & implementing ethical decision making models > AMA, Code of Ethics for Doctors: revised and adopted in 2001 > ANA, Code for nurses: Revised 1995 & 2001 > Healthcare Executives, Code of ethics: 1941 relationship with their stakeholders

5 justifications for public health interventions (PHI) that infringe in individual choices

1. Effectiveness: Demonstrate that PHI are successful, therefore, necessary to limit individual freedom of choice 2. Need: Demonstrate that PHI are successful, therefore, necessary to limit individual freedom of choice 3. Proportionality: if it outweighs freedom of choice, then PHI must be warranted 4. Minimal Infringement: if PHI satisfies effectiveness, need & proportionality, least restrictive intervention or minimal infringement on individual freedoms should be considered first 5. Public Education: must explain PHI & why the infringement on individual choices is warranted

Recommendations to Eliminate Workplace Bullying

1. Policy of zero tolerance for workplace bullying & develop measures to discipline bullies 2. Organizational culture that focuses on positive work environment enabling all individuals to pursue their careers 3. Reward behaviors that encourage teamwork & collaboration among employees & their supervisors 4. Develop an educational program for all employees