ETHICS FINAL

Paternalism

"...the interference of a state or an individual with another person, against their will, and defended or motivated by a claim that the person interfered with will be better off or protected from harm. " Doing something to someone: that is against their wishes or without consent; for their own good.

Implicit Bias

"A term of art referring to relatively unconscious and relatively automatic features of prejudiced judgment and social behavior."

HIPAA on Duty to Warn/Protect:

"The Privacy Rule permits a health care provider to disclose necessary information about a patient to law enforcement, family members of the patient, or other persons, when the provider believes the patient presents a serious and imminent threat to self or others. The Privacy Rule allows the provider, consistent with applicable law and standards of ethical conduct, to alert those persons whom the provider believes are reasonably able to prevent or lessen the threat.

Clinical Ethical Dilemmas usually take the form of either:

*A conflict between more than one principle, each supporting incompatible courses of action.* Example: Should I prioritize confidentiality and keep the information about the patient's drinking habits private? Or should I prioritize duty to warn and report the patient to the DMV? OR... *Uncertainty about what one concept or principle requires in a particular case.* E.g. What does confidentiality require in this case, in which the patient is asking me to help conceal their tubal ligation surgery from their spouse?

Other minors who understand risks and benefits of treatment may consent to:

-Reproductive healthcare; -Contraception -Emergency contraception -Abortion services -Pre-natal, L/D, and Post-natal care -STI treatment; -Certain mental health services (must be 16 to consent for inpatient care); -Certain substance abuse services

Ethical Obligations to the Hateful Patient:

1) "If my behavior toward you is reactive, the solution to altering it is to change my perceptions." 2) Mediation and conflict resolutions skills help. 3) It is unreasonable to expect a stakeholder (e.g. the treating physician) to also serve as mediator. 4) Ethics consultation service can help.

Conflict of Interest

1) A conflict of interest occurs when a judgment concerning a primary interest (such as patient welfare or the validity of research) may be unduly influenced by secondary interest (such as financial gain).

Informed Consent:

1) A physician is required to communicate with a patient in a way that enables the patient to make an informed choice about any proposed intervention and whether to accept or refuse treatment. 2) This moral requirement is supported by the requirement of respect for autonomy and the presumption that people typically prefer to make decisions for themselves. 3) Eliciting informed consent for tests and treatment also promotes trust in the doctor-patient relationship.

What does Nonjudgmental Regard Require?

1) Accept distinctive role-based duty. 2) Acknowledge emotions and judgments. 3) Reflect on decision-making processes. 4) Seek help from colleagues when appropriate. 5) Commit to compassionate care of patients according to principles of justice.

Assessing surrogate appropriateness requires a physician to:

1) Assess the decisional capacity of the potential surrogate 2) Determine whether the surrogate demonstrates appropriate concern for the patient's well being 3) Assess the surrogate's decisions to assure that they are not unreasonable *refers to the physician's obligation to ensure that surrogate decision makers:* a) have capacity and b) demonstrate concern for the patient. This principle is relevant because if the patient loses capacity, his wife, as designated health care proxy, will have the authority to make decisions on his behalf.

Abandonment occurs when a physician terminates a relationship:

1) At an unreasonable time; or 2) Without ensuring that the patient can find a replacement.

Decisional Capacity (Respect for autonomy):

1) Autonomy is the ability or capacity to make decisions that reflect a person's values, commitments, and goals. 2) In medical ethics, respect for autonomy is the principle that requires medical professionals to allow patients to make decisions for themselves. 3) A patient with decisional capacity must be able to: understand and appreciate the diagnosis, prognosis, and the likelihood of the risks and benefits of the treatment and its alternatives make and communicate a choice articulate a reason for the choice that is consistent with the patient's values be free from a related mood disorder or other distortion of judgment (e.g., depression, fear, anxiety) *Entails the right to refuse any medical treatment if the patient has decisional capacity, but it does not entail an equal right to demand specific treatment.*

Justified Paternalism:

1) Because paternalistic actions often involve depriving others of liberty or pleasure, paternalistic interventions always require a moral justification. 2) A paternalistic action may be justified when: (i) there are significant reasons that make it worthwhile; (ii) public discussion would show the intervention was legitimate or generally accepted; and (iii) the beneficiary lacks decisional capacity to some degree. *In a clinical setting, a physician acts paternalistically when s/he intervenes or provides recommended treatment despite a patient's refusal or desire to the contrary.* *"doing something against a patient's will or without their knowledge to promote what is best for them."*

Why have Advance Directives/Surrogate Decision-makers?

1) Beneficence/Non-maleficence: Documents created by the patient, and people who know the patient and are acting on their behalf, can be reliable sources of information about what is in the patient's best interest. 2) Respect for Patient Autonomy: Documents created by the patient, and people who know the patient and are acting on their behalf, can be reliable sources of information about the patient's values, goals, and preferences.

Providers must report, to DOH:

1) Cases of infectious disease (including HIV) 2) Certain violent crimes (gunshot, knife)

Duties to peers and institutions:

1) Defined as "a duty to participate as members of the medical community and to cooperate in sustaining medical institutions." 2)This is relevant because medical professionals cannot effectively recommend against dangerous behaviors or practices if other medical professionals are willing to normalize those practices.

Justice:

1) Defined as the obligation to distribute scarce resources fairly. 2) It is relevant here because responding effectively to this patient's complex situation will likely require me to take extra time counseling him, which will shorten the amount of time I have to devote to other patients.

Challenges in Informed Consent:

1) Enduring challenges: -Patients have difficulty understanding information. -Scarce resources. Uncertainty about what information is relevant. 2) New challenges: -New technologies/studies raise new questions about ownership of samples/tissues and data. -Increasingly pluralistic society may mean variations in consent procedures to address cultural differences.

What three aspects of the Clinical Moral Reasoning Process do we need to know?

1) Identify the concepts and principles involved and explain how they relate to the case. 2) Articulate the dilemma: -Do two or more concepts/principles conflict? Or is there uncertainty about what one principle directs you to do? -Express the dilemma as a question for the physician. 3) Decide on a resolution to the dilemma. -What concept/principle should be prioritized? -Why? -If uncertainty persists, note any missing information. How would it help resolve the dilemma?

Who determines capacity?

1) In NYS, decisional capacity must be determined by a physician. Generally, any physician can determine capacity. In cases involving mental or neurological illness, a psychiatrist or neurologist must determine capacity. 2) Other states have different requirements. 3) Findings of incapacity are noted in the patient's chart. Must explain what decision the patient lacks capacity to make. Must explain why the patient lacks decisional capacity

Fiduciary Responsibility:

1) In their practice physicians must seek trust and be deserving of it. 2)To be trustworthy, physicians must maintain their knowledge and skills and demonstrate professional competence. 3) Fiduciary responsibility also requires that members of the profession act in their patients' interest, putting the well-being of patients before their own.

Futility:

1) Medical futility refers to the l prospect that an intervention is unlikely to achieve its intended goal. 2) In New York State the concept of medical futility is employed only in the context of determining whether or not resuscitation after a cardiac or pulmonary arrest may not be initiated (i.e., DNR) and only when the patient has not indicated a preference about resuscitation and when no guardian, proxy, or surrogate is available to make a decision.

What 2 things are necessary for Public Trust?

1) Nonjudgemental Regard 2) Justice

Nonjudgmental regard:

1) Nonjudgmental regard is a set of attitudes, actions and behaviors required by the ethics of medicine. 2) Physicians are required to assess the health of each individual patient and select a course of treatment based on medically relevant factors. 3) Regardless of a physician's personal feelings about a patient's unworthiness, a physician is required to treat every patient with respect and caring. 4) Factors beyond the patient's medical condition and health should not play a part in medical decisions or the treatment of a patient. 5) Neither social facts about the patient (e.g., gender, religion, race), nor factors about the patient's social life (e.g., wife beating, tax evasion, drunk driving), nor factors contributing to the patient's current medical need (e.g., alcoholism, non-adherence with diet, previous refusal of medical care), nor aesthetic concerns (e.g., bad breath, obesity, obnoxious behavior) 6) In everyday morality we can freely decide who to embraced as friends, and how to allocate our time and resources. In contrast, physicians are committed to providing care and treatment to anyone who needs it. For example: physicians are required to treat enemy soldiers in battle, terrorists, and prisoners, even those convicted of heinous crimes.

Kipnis' Assumptions

1) People will lie or withhold information from physicians to protect their information. 2) People will make decisions about seeking care to protect their information. 3) How can we evaluate these assumptions?

Duty to Provide Care:

1) Physicians have an obligation to provide competent medical care to those who need it, with minimal exceptions. 2) Physicians must not let their personal judgments about a patient's worthiness or feelings about a patient's personal decisions interfere with the treatment of patients, and they must assure that they themselves are competent to provide care according to the standards of the profession. 3) Once a physician has agreed to treat a patient, s/he must continue to provide care or ensure that access to care is continued elsewhere.

Other Factors that Conflict with Duty to Provide Care:

1) Self-interest—a provider fears contacting an infectious disease from a patient. 2) Moral objections to specific care sought—a provider objects to abortion, euthanasia, contraception, etc. 3) Conscious negative reaction to a patient—the patient is aggressive, hostile, or their behavior is otherwise challenging. 4) Conscious negative reaction to a patient—the patient arouses strong negative feelings in a provider due to the provider's personal circumstances or conscious biases. 5) Subconscious negative reaction to a patient—the provider's implicit biases influence their medical judgment.

How to assess decisional capacity:

1) Talk to the patient. 2) Ask questions. What have the doctors told you about your illness? Do you have any questions for me? What are your reasons for wanting/not wanting this treatment? What will happen if you don't get this treatment? What are your goals for your medical care? What are you hoping we can achieve? What does your family think? How is all of this affecting them? 3) Talk to family members. 4) Talk to other providers. 5) Cognitive tests (mini-mental, etc.) 6) Consult psychiatry in difficult cases.

Duty to Warn:

1) The "duty to warn" is formulated in the court ruling on the 1974 case of Tarasoff v. The Regents of the University of California. 2) In this case, Prosenjit Poddar confessed to his psychotherapist that he was planning to kill Tatiana Tarasoff, and subsequently did so in 1969. 3) Justice Matthew Tobriner concluded that the "special relationship" between doctor and patient obligates the doctor to warn third parties in case a patient threatens physical harm to a specific person. 4) Although, this ruling is originally meant to apply to psychologists, psychotherapists, and psychiatrists, it has been extended to provide justification for other physicians breaching confidentiality 5) In accordance with the duty to warn, physicians are obligated to warn the person who might be threatened by the patient or to notify authorities about the imminent threat the patient poses to a third party. 6) In order to warrant a breach of confidentiality, the patient must pose a credible, direct, serious, and imminent threat to an identifiable particular person. *Has been interpreted by the courts as applying to identifiable, immediate threats.*

Justice (Clinical justice):

1) The concept of justice is central to medical practice because physicians and other health care professionals often must decide how to allocate the limited supply of medical resources such as ICU beds, staff, time, energy, vaccines, medications, and transplant organs. 2) They must also decide how prioritize patients in emergency situations. Justice requires that we allocate these resources and set priorities fairly. 3) In a clinical setting, a just distribution of resources is one that takes medical factors into account such as the severity of need, the urgency of need, and the efficacy of the allocation. 4) Justice requires that physicians adopt a nonjudgmental regard toward their patients so that they make allocation decisions on medical grounds alone.

Required Elements of Informed Consent:

1) The patient's diagnosis, if known 2) The nature and purpose of a proposed treatment or procedure; 3) The risks and benefits [and their likelihood - added element]of a proposed treatment or procedure; 4) Treatment alternatives (regardless of their cost or the extent to which the treatment options are covered by health insurance); 5) The risks and benefits of the alternative treatment or procedure [and their likelihood - added element]; and 6) The risks and benefits [and their likelihood - added element]of not receiving or undergoing a treatment or procedure.

Professional Obligations are Not:

1) The same thing as legal obligations. -Legal duties can conflict with professional duties. -Upholding legal duties might be morally wrong for other reasons. 2) The same thing as personal morality. What a good Christian would do may not = what a good doctor would do. 3) The same thing as personal values.

Criteria for Decisional Capacity:

1)Understand the relevant information: diagnosis, prognosis, and risks and benefits of all indicated treatments, as well as no treatment. 2) Appreciate the situation and how its consequences apply to the patient's own case. 3) Communicate a consistent choice. 4) Justify the decision rationally/in accordance with patient's values. (Appelbaum, 2007)

AMA Ethical Guidance:

A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care. Physicians' fiduciary responsibility to patients entails an obligation to support continuity of care for their patients. At the beginning of patient-physician relationship, the physician should alert the patient to any foreseeable impediments to continuity of care. When considering withdrawing from a case, physicians must : -Notify the patient (or authorized decision maker) long enough in advance to permit the patient to secure another physician. -Facilitate transfer of care when appropriate.

Fiduciary Responsibility

Act for the patient's good requires the physician to assess both whether a potential surrogate is an appropriate decision maker on the patient's behalf and whether the decision the surrogate makes about the patient's care is appropriate

Surrogates v. Proxies/Agents:

All US states and most countries recognize health care proxies. Laws about other surrogates vary. Proxies are entitled to make health care decisions for patients: In virtue of having been selected by the patient. Subject to fairly consistent laws. Non-proxy surrogates are entitled to make health care decisions for patients: In virtue of their relationship to the patient. Subject to varying laws.

Arguments in Favor of Allowing CO:

Allowing CO need not pose tremendous consequences/burdens. (e.g. a GP who refuses to perform abortions.) Forcing physicians to violate their personal moral convictions causes harm to them and the profession. Moral objections to abortion/euthanasia/etc. ≠ Racist/sexist refusals. Moral status of these procedures not settled in society. View of medicine as a calling compatible with view of all life as sacred. Pro-life people might make very good doctors. Addressing disparate access to care in remote areas is the responsibility of the healthcare system, not individual physicians.

Justify

Appelbaum: "Reason about treatment options." Requires explaining why the patient has made the particular choice. Emphasis on process of reasoning, not "reasonableness" of decision. Patients can make unreasonable decisions for themselves. Ideally involves consideration of the patient's values.

Competence

Applies globally to decisions in all major areas of life. Determined by a legal process. Incompetence usually caused by something serious. Incompetence -> Guardian appointed, person loses right to make certain legal decisions.

Beneficence

Beneficence entails *promoting the patient's good* by curing or preventing disease, and, more generally, by promoting the patient's medical well-being 1) Beneficence is sometimes used to designate both the negative duty to do no harm (primum non nocere) and... 2) The positive duty to act in a way that advances the patient's medical interests. *In some cases it might be necessary to impose temporary harm (e.g., discomfort) to benefit the patient, for example, where surgery could be lifesaving.*

What is the difference between beneficence and non-maleficence?

Beneficence: *the obligation to provide care that will benefit the patient and promote their interests.* Non-maleficence: *the obligation to not harm the patient.* EX: If I report the patient to the DMV, it will likely have catastrophic effects on his life.

Patient has an AD but no surrogate?

Consent may not be necessary.

What criteria should surrogates meet?

Decisional capacity 1) Understand risks & benefits of all treatment options/no treatment. 2) Appreciate how those risks/benefits apply to the patient's case. 3)Articulate a consistent decision. 4) Justify decision in accordance with patient's values. Concern for the patient's welfare 1) Surrogates cannot make unreasonable decisions (e.g. refusing treatments with low risks and significant likelihood of benefits)

Professionalism

Defined as *"an obligation to behave in ways that would be acceptable to a group of ethically exemplary physicians."* It is relevant because decisions about prescribing a drug to one patient must reflect a view that it is reasonable for all physicians to prescribe the drug to all patients in identical medical circumstances.

Goldman's focus:

Do not lie, do not hold, do not impose treatment, etc.

Communicate

Does not need to be verbal. Does need to be consistent.

Medicine Today

Embrace of respect for autonomy. More, shorter relationships. Team-based health care. Significant resource constraints. Health information readily available.

When patients lack decisional capacity:

Emergencies: Physicians can act without consent. Non-emergencies, significant decisions: Advance directives Health care proxy/surrogate decision making Court orders Non-emergencies, less significant decisions: Surrogate decision-making Do not provide refused care

The Beneficence Argument:

Evidence shows that withholding information generally does not benefit patients or prevent harm. It is difficult for physicians to determine potential benefits/harms of withholding; therefore, default should be disclosing. Withholding as a practice undermines public trust.

Within the scope of their routine practice, physicians have discretion over whom they choose to treat:

Exception: Emergency care Exception: Discrimination

KNOW THIS:

Exceptional cases: Incapacity doesn't necessarily lead to treatment over objection. Capacity doesn't necessarily guarantee respect for refusal. But Usually: Treatment over objection must be justified by lack of capacity. Patients with capacity can refuse any kind of care.

From Paternalism to Respect for Autonomy: Medicine Pre-1970s

Exclusive emphasis on beneficence. Long-term relationships. Solo practice. Fewer resource constraints. Monopoly over information.

Clinical Justice:

Fair allocation of health care resources, And equal treatment of similar cases. Recall Thomson's "decency v. justice." Justice = what we owe each other and are entitled to; Decency = the moral character of all our interactions with others. In general, justice—in contemporary discourse—is one virtue of institutions. Clinical justice, however, can refer to both institutions and individual actions.

Patient has no advance directive and no surrogate?

For routine care, attending physician can approve treatment. For major decisions, attending must consult others on team, and a second physician must concur. For withdrawal of life-sustaining treatment, sometimes two physicians can approve withdrawal; sometimes court order must be obtained.

Hard/strong paternalism:

Force, physical/chemical restraint.

Informed Consent

Full disclosure of relevant information. Necessarily requires physician action. Patient or surrogate has decisional capacity. Physician's legal and ethical responsibility; often requires action. Consent is voluntary. Entails negative and positive obligations for physician.

Surrogacy Priority for Adult Patients in NYS

Health care proxy/agent appointed by patient OR court-appointed guardian. Spouse or domestic partner. Adult child Parent Sibling Close friend

For legal questions:

Hospital's legal department—fiduciary responsibility to provide legal advice to physicians employed by the hospital. Hospital's risk management department—mission is to protect the hospital; no fiduciary responsibility to physicians. For physicians in private practice—malpractice insurer.

Introspective opacity

I am not aware that I hold these biases, and am shocked when IATs, startle eye blink tests, or semantic priming tests indicate their presence.

Dissociation

I sincerely and reflectively endorse the moral equality of all people, yet after many years of following the Yankees, I hold implicit biases against people from Massachusetts.

Elder abuse:

If patient has capacity, may not report without patient consent Other states vary

Domestic abuse:

If patient has capacity, may not report without patient consent. Other states vary.

What factor(s) automatically render a patient incapacitated?

Inability to meet the criteria for decisional capacity.

"Patients do not come to my office to exercise their autonomy."

Inherent power imbalance in medicine: Experience of physical infirmity. Knowledge differential. Medical decision-making involves more than decisions about values.

Intrinsically valuable?

Intrinsic (valuable in and of itself) v. Instrumental (valuable as a means to an end, an instrument used to achieve some other goal) Goldman claims self-determination is intrinsically valuable.

Advance Directive:

Legal document stating a person's wishes in the event that they cannot make decisions for themselves. Types of Advance Directives; 1) NYS Health Care Proxy (standardized form): Can be completed by the patient with or without legal assistance; designates person(s) who have legal authority to make decisions on the patient's behalf. 2) Living will: Can be completed by the patient with or without legal assistance; stipulates patient wishes for life-sustaining treatment, end-of-life care, and other major treatment decisions. 3) MOLST/DNR/DNI Orders: Medical order, signed by a physician, that instructs current and future health care providers about patient's wishes.

Definition: Conscientious Objection

Legally and professionally-sanctioned discretion to refrain from practices one finds morally objectionable. Based on metaphysical claims, religious views, or personal ethical stances. Differs from objections to or medically unwarranted treatments. Differs from clinical ethical dilemma (where two concepts/principles conflict or it is unclear what a concept/principle requires.)

What can diminish capacity?

Mental illness Intellectual disability Dementia Sepsis, uremia, delirium, etc. Confusion Pain Fear Denial Ignorance Lack of understanding Other factors that prevent patients from meeting the criteria for capacity.

Soft/weak paternalism:

Nudging, repeating, suggesting additional research, requesting family involvement.

Decision-making for Minor Patients

Parents/Guardians For minors in foster care: Form signed by parent granting consent for routine care. If no form signed, social services commissioner, director of foster care agency, or family court judge grants blanket consent. For procedures requiring informed consent, parents give consent. If they cannot/will not, it may be referred to a judge.

Patient has an AD and the surrogate's request contradicts it?

Patient's wishes must take priority.

Loewy (cont.)

Patients can best determine their own goals and values (usually). Doctors can help guide that analysis and best determine how to meet those goals. Patients often don't want to decide for themselves. They shouldn't be forced to do so. Cannot "abandon a patient to their autonomy."

Freud:

Patients' tendency to transfer feelings from childhood onto therapist.

A Potential Moral Justification for Paternalism:

Physicians may act paternalistically in the service of the patient's values. Premise 1: Physicians have superior knowledge of what is likely to hasten death, increase pain, or cause depression. Premise 2: Slowing death, decreasing pain, and preventing depression are either universally valued or at least rationally preferable. Conclusion: Paternalistic intervention to slow death, decrease pain, or prevent depression is justified. *Goldman thinks that (2) is false.*

Impaired physicians:

Professional and social obligation to report

Kipnis' Response:

Professional norms and practices must be disclosed. So if confidentiality can be breached, this must be built into a rule that patients know about in advance of clinical encounters. Duty to warn must be publicly advertised. What will happen if patients expect that confidentiality may be breached?

Abuse of adults without capacity or who are institutionalized:

Professional obligation to report

Child abuse:

Professional obligation to report.

What are some Concepts and Principles of Clinical Ethics?

Professionalism Beneficence/non-maleficence Respect for autonomy Justice Truth-telling Informed consent Assess Decisional Capacity Assess Surrogate Appropriateness Justified Paternalism Duty to Provide care Nonjudgmental regard Confidentiality Duty to warn Responsibility to peers/institutions Professional competence Evidence-based practice

When patients cannot make decisions for themselves:

Providers must consult other sources, including: 1) Advance directives 2) Health care proxies/Surrogate decision-makers

Mid-20th century:

Providers' projection of their own feelings and conflicts onto the patient in the form of judgments and intense emotions.

Decisional Capacity

Refers to a particular medical decision. Assessed by a physician. Incapacity caused by range of factors. Incapacity -> Someone else makes the particular decision on pt's behalf. Future decisions not necessarily implicated

Arguments Against Allowing Conscientious Objections (Schuklenk):

Requirement to refer patients to another provider not acceptable compromise for someone who has a genuine moral objection to a procedure. In practice, privileges the moral objections of a certain group. "Patients are entitled to receive uniform service delivery from healthcare professionals." Allowing CO causes disproportionate burdens in remote areas. Joining a profession requires adopting professional norms. Incompatibility Thesis: Allowing CO is incompatible with fair delivery of healthcare.

Appreciate

Requires that the patient have insight into their own condition. Requires connecting the information given with the patient's personal situation.

Rhodes & Non-Judgmental Regard:

Rhodes: "we expect doctors to promote the good of those with medical needs without first judging their worth. Physicians have to be: nonjudgmental in their allocation of caring concern and medical attention, and they have to try hard to avoid feeling frustrated by patient noncompliance or angered by patient deception, disrespect, or demandingness" *Rhodes: "We want doctors to attend to our loved ones' needs...regardless of their worth in the eyes of others."*

The Respect for Autonomy Argument Against Paternalism:

Self-determination has intrinsic value. 1)The right to decide for oneself does not depend on empirical predictions of benefit or harm avoidance. 2) The right to decide for oneself entails the right to make decisions that are not in one's interest. 3) This right respects not just individuals, but individuality itself.

Present day:

Similar to Mid-20th Century, but thought to yield useful clinical data.

Assess Surrogate Appropriateness:

Sometimes patients cannot make their own medical decisions because they lack decisional capacity

Critiques of The Beneficence Argument:

Sometimes, withholding might benefit a patient. If benefit/harm is difficult to predict, why should disclosure be the default? Withholding might not lead to erosion of public trust. So, the Beneficence Argument is not the most persuasive.

Goldman's View

Strong paternalism generally unjustified. Focus on withholding information/deception. *Two arguments:* Beneficence: Paternalism more likely to harm patients than benefit them. Respect for Autonomy: Even if paternalism prevents harm, avoiding that harm "does not permit exception to the right."

Standards for surrogate decision-making:

Substituted judgment: what the patient would have wanted. For adult patients who had capacity previously. Advance directives Patient's expressed wishes Surrogate's best guess Best interest: what the surrogate thinks is best for the patient. Minors Patients who have never had capacity

Recalcitrance

Suppressing or eradicating these biases is extremely challenging.

Who makes decisions for incapacitated patients?

Surrogate: "person selected to make a health-care decision on behalf of a patient" pursuant to state law. Health care proxy or agent: a surrogate who has been "designated by an adult" pursuant to state law. **In NYS, "power of attorney" is used for financial and legal decisions, not medical decisions. "Next of kin" is used for decisions about a deceased person and their estate. State laws vary.** (NYS Family Health Care Decisions Act, 2010) Surrogate Decision-maker ≠ Next of Kin

Confidentiality

The duty to protect confidentiality involves not disclosing and preventing the disclosure of patient information. Confidentiality is one of the distinctive professional responsibilities of medicine. *Confidentiality in medicine is mainly justified on harm reduction grounds.* *Respecting patient confidentiality is also a way of showing respect for the autonomy of the patient when the patient does have decisional capacity.*

Widespread effects on behavior

These biases influence my social choices, relationships with family members and colleagues, and my behavior in traffic.

Truth-Telling:

Thus, a physician must provide a patient with a diagnosis, prognosis, and information about the risks and benefits of any proposed therapies or diagnostic procedures. Physicians must not deceive patients by lying, misrepresentation, distortion, or withholding information. Truth-telling is important in maintaining trust in the physician-patient relationship and it is an element in showing respect for a patient's autonomy. When delivering bad news, truth-telling becomes an issue because the information may upset the patient. Nevertheless, the information must be disclosed. *A "therapeutic exception" to this rule is only justified (legally and ethically) when there compelling evidence to believe that the disclosure is likely to cause serious and imminent harm.*

Fiester: The Hateful Patient Reconceived

Traditional view of the cause of "hateful" behavior: psych illness or disturbance. But these behaviors are often a reasonable response to illness or the perception of ill treatment.

T/F? Minors who are parents, married, legally emancipated, or serving in the Armed Forces can consent to almost all health care.

True *Mature minors can, theoretically, consent to almost all health care. (Not explicit in NYS law.)*

Contemporary Justifications for Medical Paternalism

Urgency Seriousness Scarce resources Patient preference Lack of patient decisional capacity

Loewy's focus:

What, affirmatively, should doctors DO to facilitate and support patient decision-making?