Ethics Final Exam

Four Clinical standards for decision-making capacity

1. Decisions are consistent with the patient's values and goals. 2. Decisions do not result from delusions. 3. The patient uses reasoning to make a choice. 4. Assessments of decision-making capacity should take into account the clinical context.

Distinguish between ACT and Utilitarianism and RULE Utilitarianism:

ACT: Looks at consequences of each individual act. RULE: Looks at consequences of having everyone follow a particular rule.

Hard _________________ is analogous to the way that parents make decisions for their children. Medical decisions are based, in this model, upon the physician's medical judgment alone.

Paternalism

Weak/soft v. hard

Paternalism

When medical personnel override a person's known preferences to benefit that person, they are being __________________.

Paternalistic

What is it about PATIENTS that amplifies the need for this relationship of trust?

Patients are vulnerable and dependent.

Doctrine of Double Effect

Prohibiting one, allowing the other

Will doing what is right ever conflict with getting a good rating as an officer?

Yes

If a surrogate refuses CPR for the patient, this decision should be based upon the patients preferences or, if preferences are unknown, the patient's __________.

best interests

If you are lied to, you will likely feel __________ or manipulated.

betrayed

Define ethics

the study of right and wrong

which ethical theory is consequentalism applied to the benefit of the group

utilitarianism

List some Safeguards When Interventions are Considered Futile

1. Obtain a second opinion 2. Discuss the intervention with the patient or surrogate 3. Establish explicit guidelines on futility

What are some subsets of deontology?

1. Prima facie duty - at first sight Note: Categorical imperative

Reasons for respecting patient refusal

1. Respect for patient autonomy. 2. Imposing medical interventions would be unacceptable

The Nancy Cruzan case resulted in:

1. The increase in state legislation regarding advance directives. 2. The emplacement (December 1991 of the Patient Self Determination Act (PDSA).

What are the two categorical imperatives in Deontology?

1. Universal Law - unconditional commands that are binding on everyone at all times. 2. Respect - treat humanity never simple as a means but always at the same time as an end.

What are the criteria for evaluating ethical theory? Four "tools of reason"? (cpuj)

1. consistency 2. plausibility 3. usefulness 4. justification

The Terri Schiavo case highlighted the importance of advance directives. She had been in a vegetative state for over ____ years by the time of the removal of medically administered nutrition and hydration.

15

The Terri Schiavo case highlighted the importance of advance directives. She had been in a vegetative state for over _________ years by the time of the removal of medically administered nutrition and hydration.

15

Popular entertainment gives the viewer the impression that CPR is effective, sometimes miraculously so, in the majority of cases. Actual real-life cases in the hospital, however, give a different picture. What percentage of patients on whom CPR is attempted are discharged alive from the hospital?

15%

effective rate of CPR in hospital

15%

Statistics on CPR performed in hospitals show about a ____% rate for those who will be discharged alive from the hospital. Some of the discharged patients will suffer with lifelong ___________.

15% brain damage

How long after the brain injury can we determine with a high degree of confidence the irreversibility of the patient's vegetative state (in other words, the patient is now determined to be in a PERMANENT Vegetative State)? Anoxic ____________________ Traumatic __________________

3 months 12 months

Looks at the consequences of each individual act and calculates utility each time the act is performed

Act Utilitarianism

Why would we revisit the ethical question halfway through the decision making process (eg: see Army-Baylor HCA framework)?

After setting out the facts and taking a look at the contextual features you may discover that the ACTUAL ethics question is different than the original presenting question.

The principal theory of utilitarianism is...

An action is right if it produces the greatest balance of utility or good versus evil for a group of people.

Which theory "makes decisions based upon comparison and precedent?"

Analogical

Patients, even non-terminal patients, may refuse the following treatment (choose the best answer):

Any of the other listed answers for this question

A capable patient can change or reject an advance directive... (when?)

Anytime (verbally or in writing)

Persistent=

Approximately one month duration

Who created the golden mean?

Aristole

Who is associated with virtue ethics?

Aristotle

Define AAFN

Artificially administered food and nutrition

The patient takes the action to administer the lethal drugs. The physician assists with information and the means.

Assisted Suicide

Prima Facie literally means:

At first sight

Liberty and Agency are essential to personal ____________________.

Autonomy

Our pluralistic/diverse society tries to respect the various viewpoints of people as much as is possible. Much importance is placed upon patient __________________. __________ is not a one way street. Healthcare providers are not machines, but persons who also deserve respect and protection.

Autonomy

Patients have a right to be free of unwanted bodily invasions (even life-sustaining ones). Which principle of biomedical ethics most directly supports this right?

Autonomy

Promoting the patient's best interests may be in tension, at times, with which of the following principles of biomedical ethics?

Autonomy

Right to Die? BACKGROUND: A 25-year-old star outfielder for a major league baseball team (Mr. B.) is in an automobile accident. He suffers serious damage to his spinal cord, which causes paralysis of his body from the neck down. Mr. B.'s thinking, speech, and hearing remain unimpaired, but he has lost all movement of his limbs. He requires the constant assistance of attendants and technology to receive nutrition and expel wastes. After fifteen months of hospital care, his physicians conclude that he has no discernible chance of recovering lost functions and informs him of their conclusions. ISSUE: Mr. B. is an intelligent and thoughtful person and thinks a great deal about his future in the weeks that follow disclosure of this prognosis. During this time, he is visited by social and rehabilitation workers at the hospital. These personnel attempt to assure him that because he still possesses his mental QUESTION: By choosing to be discharged from the hospital, Mr. B. is exercising which of the following principles of bioethics?

Autonomy

There's tension between ___________ and best interests.

Autonomy

Unless vigorously resisted, the patient's vulnerability and the medical professional's knowledge and expertise tend to erode the patient's __________________.

Autonomy

Ethical concept:"Freedom to choose"

Autonomy of the patient (respect for autonomy) aka respect for persons

Identify the following framework for the systematic analysis of ethical dilemmas: 1. What is the problem or dilemma? 2. What are the medical facts? 3. What are the concerns, values, and preferences of the clinicians? 4. What are the concerns, values, and preferences of the patient? 5. What are the ethical issues? 6. What ethical guidelines are at stake? 7. What practical considerations need to be addressed? (Who's is it?)

Bernardo Lo's

In class we spoke of standards for decisions when patients lack decision-making capacity. Of the three standards discussed, which is the lowest standard?

Best Interests

Who is the expert in the patient/physician relationship?

Both

Define the Determination of Death

Brain Death -Permanent loss of brain function (cortex and brainstem); whole brain death -Clinical tests; coma, absence of brainstem function, apnea -Hypothermia and drug overdose must be ruled out (potentially reversible) -It may be helpful to confirm with EEG and imaging studies *Controversies -Higher-brain death -Disagreement on the concept of brain death -Legal status of brain death (UDDA) -Uniform Determination of Death Act -Irreversible cessation of circulatory and respiratory functions -Irreversible cessations of all functions of the entire brain, including the brain stem is dead **Note** Do not confuse vegetative state with a determination of death by brain criteria, not the same

Patients in a vegetative state have no cortical function, but have preserved ________________ function.

Brainstem

"Act only on that maxim through which you can at the same time will that it should become a universal law" is a statement of Kant's what?

Categorical Imperative

Absolute. No exceptions. "you must always do y"=

Categorical Imperative

If a rule applies to everyone all the time, what is it called?

Categorical Imperative

Universal/Universalization AND Respect

Categorical Imperative

We cover two versions of Kant's ______________. The key word of the first is UNIVERSAL. The key word of the second version is ____________ (this word is not spelled out, but summarizes the key idea).

Categorical Imperative Respect

If a rule applies to everyone all of the time, what is it called?

Categorical Imperative. Created by Kant. Or also known as Absolute. No exceptions. "You must always do y".

Freedom from what is one of the necessary requirements for informed consent?

Coercion

A 25-year-old star outfielder for a major league baseball team (Mr. B.) is in an automobile accident. He suffers serious damage to his spinal cord, which causes paralysis of his body from the neck down. Mr. B.'s thinking, speech, and hearing remain unimpaired, but he has lost all movement of his limbs. He requires the constant assistance of attendants and technology to receive nutrition and expel wastes. After fifteen months of hospital care, his physicians conclude that he has no discernible chance of recovering lost functions and informs him of their conclusions. ISSUE: Mr. B. is an intelligent and thoughtful person and thinks a great deal about his future in the weeks that follow disclosure of this prognosis. During this time, he is visited by social and rehabilitation workers at the hospital. These personnel attempt to assure him that because he still possesses his mental facilities, he would eventually accommodate to his injuries and develop some meaningful form of life in the future. Mr. B. finally decides on a course of action. He calls his physicians and requests that they discharge him. All parties, the patient included, understand that without hospital facilities death will ensue in several weeks. QUESTION: The hospital administrators believe that discharging the Mr. B. is the moral equivalent of allowing the patient to commit suicide. Furthermore, based upon the observations of both the hospital social worker and rehabilitative therapist, they believe that he has very good chance to live a productive life. In light of the prognosis, it is the view of the administrators that Mr. B. is allowing his fear of the future to make his decision for him and therefore he is not making a rational decision. The hospital believes that the only course of action is to take the matter to court. The judge will be asked to decide Mr. B.'s _____________

Competency

A Prima Facie obligation is binding unless it is overridden or outweighed by:

Competing moral/ethical obligation(s)

_____________ refers to "limits on the dissemination of information disclosed by a person within the doctor-patient relationship."

Confidentiality

The Right of _____________ protects people from participating in unethical actions.

Conscience

Ethical theory: What ought to happen?

Consequentialism (Utilitarianism & Egoism)

A patient has lost all brain function (entire brain including cortex and brainstem). There are no voluntary or involuntary movements except spinal reflexes. Pupils are dilated and fixed at mid-position. There is no reaction to aural irrigation or gag reflex. This patient can be determined, according to accepted medical standards, to be in what condition?

Death (by brain-criteria)

In the clinical setting, we look at the ability of the patient to make a particular decision about treatment. We try to determine their _____________________________.

Decision-making capacity

Beneficence

Defined: A moral obligation to act for the benefit of others. Good outcomes determined by balancing benefits with risks for harm or cost. General Rules (examples): -Protect and defend rights of others. -Prevent harm from occurring to others. -Help persons with disabilities. -Rescue persons in danger (minimal risk).

Which theory "makes decisions based upon absolute right and wrong?"

Deontological

Ethical theory: What is our duty?

Deontology

Study of moral obligation

Deontology

self-centered (ayn rand) Consequentialism applied to individual self-interest

Ethical Egoism

According to the US Supreme Court, appropriate high dose usage of opioids for the purpose of alleviating pain of the terminally ill is NOT _____________.

Euthanasia

If a patient requests that her life be terminated by the physician and the physician injects lethal chemical(s) into her, the following has taken place: (choose the one BEST option according to class lectures)

Euthanasia

A key sign of a lack of decision-making capacity is the patient's disagreement with the clinician's recommendations? True or False

False

Controversies over PVS are solely over technical/medical issues and do NOT pertain to personal, religious, transcendant or philosophical beliefs. True or False

False

Egoism focuses upon consequences to the group. True or False

False

Ethical issues regarding limitation of treatment are rarely encountered in the clinical context. True/False

False

Patients are to be treated solely as diseased bodies in need of repair by their healthcare providers. True or False

False

Refraining from the use of a ventilator is ok; stopping one on a still living patient is tantamount to murder. True or False

False

Rule Utilitarianism looks at the consequences of each individual act. True or False

False

The "best interests" standard is the highest standard that a surrogate decision-maker can use to make decisions for the patient. True or False

False

The discussion of CPR is something best delayed until the patient's condition progresses to the point where such a discussion is absolutely necessary. True or False

False

There is a significant difference, ethically, between withholding a medical intervention and withdrawing one that is already in place. True or False

False

True or False: A key sign of a lack of decision-making capacity is the patient's disagreement with the clinician's recommendations.

False

True or False: A proxy decision-maker cannot trump family members.

False

True or False: Controversies over PVS are solely over technical/medical issues and do NOT pertain to personal, religious, transcendent or philosophical beliefs.

False

True or False: Ethical issues regarding limitation of treatment are rarely encountered in the clinical context.

False

True or False: Once a patient has given informed consent, the patient cannot change his or her decision.

False

True or False: Once you know someone's culture (of origin) you should assume how much information that patient wants to know.

False

True or False: One can look forward to foresee a potential medical situation and, with a high degree of accuracy, envision what their choices would be in the midst of such a situation.

False

True or False: Patients may refuse ventilation buy may not refuse antibiotics

False

True or False: Persons with chronic health problems consistently rate their quality of life lower than their clinicians rate it.

False

True or False: Refraining from the use of a ventilator is ok; stopping one on a still-living patient is tantamount to murder?

False

True or False: Someone is determined to be dead when their cortex has irreversibly stopped functioning.

False

True or False: These features cannot possibly be that of the Persistent Vegetative State (PVS): -extensive brain damage -unconscious, no purposeful activity -wakefulness, cycles of sleeping and waking -may open and moves, blink move face, grimace, smile, yawn, and produce tears -breathing and circulation function normally

False

True or False: When CPR is strictly futile, clinicians MUST still perform CPR unless a specific DNR order is in place.

False

When CPR is strictly futile, clinicians MUST still perform CPR unless a specific DNR order is in place. True or False

False

True or False: The physician needs to get permission from the family in order to declare someone dead.

False.

True or False: The US Supreme Court declared PAS (Physician Assisted Suicide) to be a fundamental and constitutional right.

False. (Lower courts declared it, but the Supreme Court nixed it).

True or False: When it comes to ethical decisions that must be made in the clinical context, I need only be concerned with choosing what is ethically permissible.

False. Choose what is most desirable (providing the BEST that we can for our patients).

True or False: Discussing CPR with patients is like fine wine.

False. It does not get better with time.

True or False: A signed consent form is sufficient legal proof that the patient has given consent.

False. You must have a consent discussion. Document such discussion in the medical record.

True or False: When a patient refuses recommended treatment, that's the end of your responsibility.

False. You should ask for their reasoning and address their concerns (as possible).

Trust is at the root

Fiduciary

Which word means "holding in trust" and is essential due to the vulnerability and dependence of patients?

Fiduciary

Which word means "holding in trust"?

Fiduciary

True or False: A DNR order indicates that all treatment of all types should stop.

Flase.

The Terri Schiavo case originated in which state?

Florida

When we are asked the following question, what other question should immediately come to mind? "Does this patient have capacity?"

For which decison?

In Greek mythology the daughters of Danaus were condemned to carry water in leaky containers forever. What term relating to this comes from a Latin word for "leaky"?

Futility

When a treatment is not effective in producing a desired effect or end, this lack of benefit is called:

Futility

to do right because it is RIGHT

GOOD WILL

The following four principles (1. Respected; 2. Protected; 3. Cared for; 4. Treated Humanely) regarding the wounded and sick are at the heart of what?

Geneva Conventions

The following four principles 1) Respected 2) Protected 3) Cared for 4) Treated Humanely regarding the wounded and sick are at the heart of what?

Geneva Conventions

Who was the skeptic in The Myth of Gyges from Plato's Republic?

Glaucon

Middle between (two vices) Excess and Defect (the 2 extremes)

Golden Mean

What is the RESULT of good character?

Good Actions

Which federal regulation pertains to patient confidentiality?

HIPAA

The willing acceptance of a medical intervention by a patient after adequate disclosure by the physician of the nature of the intervention, its risks and benefits, and also its alternatives with their risks and benefits..

Informed Consent

What is defined as "the willing acceptance of a medical intervention by a patient after adequate disclosure by the physician of the nature of the intervention, its risks and benefits, and also its alternatives with their risks and benefits"?

Informed Consent

Who was a Rule Utilitarian and promoted the higher pleasures?

John Stuart Mill

A principle of biomedical ethics which emphasizes receiving what one is "due" or "similar care in similar circumstances" is called:

Justice

Who said "inherent dignity in each individual which must be respected, and the idea that certain courses of action must never be pursued, regardless of expected consequences to the many."

Kant

Name the version of this ethical theory upon which we will focus during this course that is not listed below: 1. ______________________ 2. Ross' Prima Facie Duties (not a pure form of Deontology)

Kantianism

A legal case concerning which woman put forth the idea of the right to decline or withhold treatment (covered in the slides)?

Karen Quinlan

This case reinforces the right to decline or withhold treatment

Karen Quinlan Case (1976)

An excellent clinician ____________ to patients.

Listens

Kant's theory lack an emphasis of _________?

Love

Kant's theory lacks an emphasis upon __________.

Love

Kantian Deontology lacks an emphasis upon what? (choose the BEST answer based on lectures/slides/notes)

Love

Triage and treatment decisions for enemy prisoners of war (EPW), civilian internees (CI), retained persons (RP), and other detainees (OD) under medical rules of care are based on...

Medical criteria alone

involves treating others based solely on urgency of medical needs. This also involves nondiscrimination. This idea is in tension with treating patients according to greatest need.

Medical impartiality

According to class slides on tube and intravenous feedings, artificial feedings are, in the legal realm, considered to be _______________________.

Medical interventions

___________ is a condition of those who have brain injury but progress to show some awareness of self and environment (e.g., respond to simple questions, show purposeful behavior, etc)

Minimally Conscious State (MCS)

Without constraints, utilitarian approaches will trample the rights of those ________ in the majority

NOT

What is a common example of a type of maxim that many people make for themselves at the start of the New Year?

New Year's Resolution

How many clinical virtues does Fletcher suggest?

Nine

Are ethics and law equivalent?

No

Artaxerxes II sent to Hippocrates for help in treating his soldiers who were dying of the plague. These soldiers were not allies, but enemies. Did Hippocrates help?

No

Is justice protected in Utilitarianism as a value and right in itself.

No.

Is justice protected in Utilitarianism as a value and right in itself?

No. Benefit of the group out-weighs individual Justice.

Do motives count for a Utilitarian

No. Only results count.

Do motives count for a Utilitarian?

No. Only results count.

The principle, which emphasizes that we avoid placing others at undue risk for great harm is _________________.

Nonmaleficence

The statement "Above all, do no harm," typifies which of the following principles?

Nonmaleficence

What biomedical ethics principle is primarily involved when confidentiality is overridden to protect their parties?

Nonmaleficence

Which main principle is involved when confidentiality is overridden to protect third parties?

Nonmaleficence (avoiding harm)

Which main principle is involved when confidentiality is overridden to protect third parties?

Nonmaleficence (avoiding harm).

The four principles of bioethics are...

Nonmaleficence; Justice; Autonomy; Beneficence

Type of ethics we study

Normative (applied ethics)

Which kind of statements express value judgments/use standards?

Normative statements

Which code condemned Nazis guilty of research-motivated abuse of people (abuse which happened during WWII)?

Nuremberg Code

Which code condemned Nazis guilty research-notivated abuse of people (abuse which happened during WWII)?

Nuremberg Code

What was Socrates' response to Glaucon?

One can remain just and choose to not allow himself or herself to be enslaved to one's desires. One can maintain rational control and thereby experience true happiness.

Define Universalizability

Our ethics should be based on reasons that can be generalized for others who are similarly situated- these moral laws should apply to all persons.

Define Universalizability according to Kant

Our ethics should be based on reasons that can be generalized for others who are similarly situated--these moral laws should apply to all person.

How long had Terri been in a vegetative state by the time the removal of medically administered nutrition and hydration had been authorized?

Over 15 years

WD Ross - At First Sight - based on intuitive moral knowledge

PRIMA FACIE DUTY

Define Decision-Making Capacity

Patient is of legal age and sound mind to understand the risks and benefits of treatment options and alternatives; patient can use reasoning to make choices

Decision Making Capacity 1. The patient makes and communicates a choice 2. The ________________ and appreciates its relevance

Patient understands pertinent information

What logically flows from the idea of informed consent?

Patients have a right to decline treatment

What is the fundamental idea about humanity that Kant communicates (particularly with the second version of his categorical imperative)?

People are inherently valuable and should therefore not be manipulated to achieve a goal.

What is the fundamental idea about humanity that Kant communicates (particularly with the second version of his categorical imperative)?

People are inherently valuable and should therefore not be manipulated to achieve a goal?

Prognosis in PVS:

Persistent: one month Prognosis of irreversibility can only be determined after some time: - Non-traumatic injury (anoxic brain damage): 3 months. - Traumatic injury: 12 months.

personal commitment - I will always serve my own best interests

Personal egoism

SOME doubt the ____________________ of a patient in a Persistent Vegetative State. Choose the best option that is most in accord with class lectures.

Personhood

Deontology (specifically the version of it called Kantianism) is an obligation-based ethical theory which tells us that...

Persons must not be treated solely as a means to our ends

Of the four sources of ethics, which are we focusing upon predominantly for this course?

Philosophy

FUTILE INTERVENTIONS Name the 3

Physiologic - Strict Probabilistic - Loose Futility comes from the Latin word - LEAKY

What do we use in the ethical theory of Kantian Deontology to develop rules

Practical reasoning

Nonmaleficence

Primum non nocere- "Above All [or first] Do No Harm" Hippocratic Oath: "I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or wrong them." Definition: Refraining from actions which may thwart, defeat or set back a person's interests or place them at risk of harm.

What are the problems with the doctrine of double effect

Problems a. People have multiple intentions. b. Seems to focus on what physicians say rather than on what they do. c. People are generally held accountable for consequences they foresee.

What is the approach to ethics and ethical dilemmas in patient care that emphasizes the dedication and special responsibilities of the clinician? This role involves special knowledge (advanced training) and agreed upon (to other members of the group) boundaries of practice.

Professional Approach

The Nuremberg Code, developed as a result of Nazi atrocities, is concerned with...

Protecting human subjects in research

Which abuses of the Red Cross sign are more serious (according to the reading assigned from Military Medical Ethics, Textbooks of Military Medicine)?

Protective

Which abuses of the Red Cross sign are more serious (according to the reading assigned from Military Medical Ethics, Textbooks of Military Medicine?

Protective

A ____________ decision maker is one who has been appointed using an advance directive; this person has been designated by the patient to make decisions on their behalf.

Proxy

This decision maker is appointed by the patient. This decision maker has the strongest legal and ethical claim to make decisions for the patient:

Proxy

What type of decision-maker has the strongest claim to make decisions for incapacitated patients?

Proxy

a surrogate appointed by a patient

Proxy

empirical doctrine - all persons act on what they perceive will produce their best interest/selfishly. No other motivations are ever present. (This is an observation of the way things are).

Psychological egoism

Which form of Utilitarianism related to color?

Racism

Which form of Utilitarianism relates to color?

Racism

"What a healthcare professional would disclose to reasonable patients in a similar situation" is known as the ...

Reasonable Patient Standard

The principle of nonmaleficence is concerned with...

Refraining from actions which may place a party at risk for harm

What is at the heart of clinical ethics?

Relationship between clinician and patient

(according to class lectures) Rules flowing from autonomy stem from the fact that we view human beings as equally deserving of ______________________. Choose the best answer.

Respect

HIPAA regulations define the value, scope and limits of confidentiality. As we look at confidentiality, a number of reasons support this practice: benefits to patients, benefits to the doctor-patient relationship; ________________, and prevention of stigmatization and discrimination.

Respect for Autonomy

HIPAA regulations define the value, scope and limits of confidentiality. As we look at confidentiality, a number of reasons support this practice: benefits to patients; benefits to the doctor-patient relationship; prevention of stigmatization and discrimination and _________________________ (one of the four principles put forth by Beauchamp and Childress).

Respect for Autonomy

What is the foundational reason (ethical principles) we give full disclosure to patients?

Respect for Autonomy

The foundation for thorough and truthful communication is ______________________________. This is the primary ethical grounding for truthfulness in clinician/patient interactions. In order for patients to participate in decision-making about their life they need clear and relevant information about their condition and all options. Choose the best answer as taught on slides.

Respect for autonomy

Looks at the consequences of having everyone follow a particular rule and calculates the overall utility of accepting or rejecting the rule.

Rule Utilitarianism

What BEST characterizes informed consent?

Shared Decision Making

What BEST characterizes the ideal result of informed consent?

Shared Decision Making

Informed consent should result in _______________.

Shared decision making.

What do we use in the ethical theory of Kantian Deontology to develop rules?

Simply put, we use practical reasoning

MATCHING: Match the following steps of the Army-Baylor Framework for the Systematic Analysis of Ethical Dilemmas to their correct sequence:

Step 1: Frame the question Step 2: Set out the medical situation Step 3: Note the context Step 4: Revisit/Reframe the question Step 5: Apply principles/identify conflicts Step 6: Weigh alternatives Step 7: Decide

Which of the following versions of futility would justify a unilateral decision to withdraw or refrain from treatment?

Strict

In a ________ (or hard) paternalism, the patient's autonomous choices are overridden.

Strong

The standard that focuses on what a specific, individual patient would need to know in order to understand the medical situation...

Subjective Standard

A treatment decision based on what an incapacitated patient would say if she/he could speak is an example of:

Substituted judgement

anyone who makes decisions for a patient lacking decision-making capacity.

Surrogate

________________ decision making - anyone who makes decisions for a patient lacking decision-making capacity.

Surrogate decision making

Which theory "makes decisions in order to reach a desired end state?"

Teleological

PVS for 15 yrs in Florida, Importance of advance directives (2005) (Who?)

Terri Schiavo

One common line of reasoning, though not universally accepted without qualification, is well-known and generally found to be helpful in resolving some ethical dilemmas. This line of reasoning deals with the unavoidable decisions we face in which desirable effects and undesirable effects are inextricably linked. We intend the good effects, such as the relief of pain, but the bad effects are undesirable (such as an increased risk of pulmonary infection). This argument affirms that an ethically permissible effect can be allowed, even if the ethically undesirable one will inevitably follow. However, the following conditions must be met: 1. The action itself is ethically good or at least neutral. 2. The agent must intend the good effects, not the bad effects, even though these are foreseen. 3. The morally objectionable effect cannot be the means to the morally permissible one. All of these conditions must be met. What is the name for this line of reasoning?

The Doctrine of Double Effect

CPR efforts can be, with some patients, highly unlikely to succeed and may very likely bring burdensome side effects. What medical goal can be achieved by putting DNR/DNAR orders in place?

The medical goal of a peaceful death

We do not know the goals, values or preferences of Ms. RT, an incapacitated patient. What do we base our treatment decisions upon in this case? [note: carefully read and think about the statement and the question]

The patient's best interest

The Karen Quinlan case (1976) reinforces which right?

The right to decline or withhold treatment.

A 25-year-old star outfielder for a major league baseball team (Mr. B) is in an automobile accident. He suffers serious damage to his spinal cord, which causes paralysis of his body from the neck down. Mr. B's thinking, speech, and hearing remain unimpaired, but he has lost all movement of his limbs. He requires the constant assistance of attendants and technology to receive nutrition and expel wastes. After fifteen months of hospital care, his physicians conclude that he has no discernible chance of recovering lost functions and informs him of their conclusions. Mr. B is an intelligent and thoughtful person and thinks a great deal about his future in the weeks that follow disclosure of his prognosis. During this time, he is visited by social and rehab workers at the hospital. These personnel attempt to assure him that because he still possesses his mental facilities, he would eventually accommodate to his injuries and develop some meaningful form of life in the future. Mr. B finally decides on a course of action. He calls his physicians and requests that they discharge him. All parties, the patient included, understand that without hospital facilities death will ensue in several weeks. After hearing the arguments from both sides, the judge rules that Mr. B is in fact making a rational choice. He cites the State of Georgia v. Larry MacAfee in which the Supreme Court of Georgia ruled in 1989 that absent conflicting state interests, competent adults have _______________________.

The right to refuse medical treatment.

What theme is frequently found in reading and viewing entertainment?

The theme of the enemy within.

What tends to happen to minorities (not in the majority) under a Utilitarian system?

Their rights and well-being get sacrificed to benefit the majority

What tends to happen to minorities (any who are not in the majority) under a Utilitarian system?

Their rights and well-being get sacrificed to benefit the majority.

Why are slow or show codes unethical?

They deceive patients and their families and confuse/create cynicism among clinicians.

Mr. DM suffered anoxic brain damage leading to his remaining in a vegetative state. After [how many] __________months can we determine with a high degree of confidence that this patient's brain damage is irreversible?

Three months

A patient's need for nutrition declines once she or he is in an advanced stage of dementia. True or False

True

Both humility and caring are included on Fletcher's list of clinical virtues. True or False

True

Hippocrates refused to help the soldiers of Artaxerxes II who were dying of the plague. True or False

True

In accord with the principle of respect for autonomy, patients have a right to be free of unwanted medical treatment (even if that treatment is life-sustaining). True or False

True

Medical impartiality involves treating others based solely on urgency of medical needs. True or False

True

Palliative sedation can be morally permissible in some cases and morally questionable (or outright wrong) in other cases. True or False

True

Sometimes (incorrectly) physicians equate euthanasia with the act of giving high doses (appropriately titrated) of medication intended for pain relief. True or False

True

True or False: "Preventative ethics" is better than a "crisis management" approach.

True

True or False: A patient's need for nutrition declines once she or he is in an advanced stage of dementia.

True

True or False: Adult patients can refuse lifesaving treatment based upon their religious beliefs.

True

True or False: Although physicians are urged to tolerate patient behavior they personally consider immoral, they are not obligated to carry out what they regard as an immoral action.

True

True or False: Both humility and caring are included on Fletcher's list of clinical virtues.

True

True or False: CPR is effective the majority of the time on TV.

True

True or False: Palliative sedation can be morally permissible in some cases and morally questionable (or outright wrong) in other cases.

True

True or False: Tube and intravenous feedings may prolong death and/or bring great indignity to patients suffering from advanced dementia or metastatic cancer.

True

Tube and intravenous feedings may prolong death and/or bring great indignity to patients suffering from advanced dementia or metastatic cancer. True or False

True

Another word associated with Fiduciary?

Trust

According to the ____________, appropriate high dose usage of opiods for the purpose of alleviating pain of the terminally ill is NOT euthanasia.

U.S. Supreme Court

Which act gives us a definition of death?

UDDA

With the Nancy Cruzan case, the ____________ supported the right of each state to establish safeguards for incompetent patients. They also acknowledged that administered nutrition and hydration is a ______________ intervention that can be removed at the patient's request/desire.

US Supreme Court medical

Which mentality, almost inevitable with a deployment environment, leads to an impairment of medical decision making?

US vs. THEM

Which Act gives us a definition of death?

Uniform Determination of Death Act (UDDA)

categorical imperative—what law?

Universal Law

The deontological idea that Kant put forth that teaches that our ethics should be based on reasons that can be generalized for others who are similarly situated (the moral laws we come up with should apply to all persons) is what? (Note: choose the best answer according to the lectures/notes/slides)

Universalizability

We can generalize our reasons for everyone, Action is our duty

Universalizability

absolute rules for moral rightness

Universalizable Maxim

consequentialism - focus on results - Happiness - Bentham

Utilitarianism

developed by John Stuart Mill, but Founded by Jeremy Bentham

Utilitarianism

What are two words (principles) that can describe 'good' for various Utilitarians?

Utility & Happiness

Ethical theory: Who ought we to be?

Virtue

Describe the concept of the Golden Mean

Virtue lies between two extremes (defect & excess) of a given quality.

If there are problems/weaknesses that can be found in all ethical theories, how can one manage to still benefit from them?

We can integrate some ideas without using all of them. We can amalgamate the strong points of each./

What question does Virtue ethics ask?

Who should I be?

According to class slides on Physician-Assisted Suicide (PAS) and Active Euthanasia, which of the following statements are FALSE?

Withholding and withdrawing medical interventions is the same as active euthanasia and assisted suicide.

Of the various standards used for making decisions for incapacitated patients, which type provides the most clear and convincing evidence of their wishes.

Written advance directives

Unconditional command that is binding on everyone at all times

You must do X

What are the three Problems with surrogates?

a. Emotional barriers to decisions b. Decisions inconsistent with the patient's preferences or values c. Conflicts of interest

Aspiration pneumonia and patient agitation are some of the _______ of tube feedings.

burdens

Define Ethical Theory

ethical theory is a philosophical tool that can be used to determine how we should think about ethics

What is the mean between two vices, excess and defect?

golden mean

To do something from duty is to do it with a ________. This is the indispensable condition necessary for happiness.

good will

which ethical theory is consequentialism applied to individual and personal pleasure

hedonism

Strictly speaking, only a court can declare someone _____________________.

incompetent

A lack of truth telling can lead to a patient being _____________ when they most need support.

isolated

Termination of the doctor-patient relationship is a _______ ___________.

last resort.

What are the sources of ethics? Which was this class concerned with?

law religion experience and philosophy. we were concerned with philosophy

Freedom from coercion or _______________ is a requirement for proper informed consent.

manipulation

Artificial feedings are ____________ interventions

medical

Definition of Ethics

morality, right and wrong

When providing care to the enemy it should be based on_________?

non-discrimination based solely of the urgency of medical needs (medical impartiality)

Try to understand the ____________ ___________.

patient's perspective.

Some doubt the _______________ of the patient in a PVS (Permanent Vegetative State).

personhood

Be _____________ in your communication with family members about these conditions in order to avoid confusion.

precise

Some Orthodox Jews, Native Americans and Japanese _____________ the concept of brain death.

reject

Consequentialism is concerned with?

results

If you break down the word autonomy, it literally means self _________.

rule

virtue ethics deemphasizes_______

rules and consequences. Focuses on the kind of person who is acting.

We use the standard of _____________ in the absence of advance directives. This assumes that someone who knew the patient (and their values) is available for this decision making.

substituted judgment

Define Physician-Assisted Suicide

the patient takes the action to administer the lethal drugs; the physician assists with information and the means

Another word associated with fiduciary is __________.

trust

Is deontology concerned with the type of act or the outcome?

type of act

Which ethical theory focuses on the person's character and moral traits?

virtue ethics

Which of the ethic is concerned with "who should be"?

virtue ethics

What is the Golden Mean?

virtue lies between two extremes (defect and excess) of a given quality

Because of the patient's dependence and vulnerability and the medical professional's knowledge and ___________ the tendency, unless resisted vigorously, is for the patient to lose some measure of autonomy.

vulnerability authority

Describe what must be done when one faces competing moral duties using Prima Facie ethical theory?

weigh the competing duties and determine which one is the actual duty.

Do not Resuscitate 1. Loosely futile 2. Strictly futile - ________chance of survival

zero

Discuss the Virtues Approach

"What kind of person should I be to do the right or good thing for my patient?" -Clinical Virtues (Fletcher) Technical Competence Objectivity and Detachment Caring Clinical Benevolence Subordination of Self Interest Reflective Intelligence Humility Practical Wisdom Courage

According to class slides, which of the following options pairs the correct ethical theory with the description/question?

(Actor/Character) Who out we to be? = Virtue Ethics

Providing Care to the Enemy is based on what doctrine?

**Based solely on urgency of medical needs (medical impartiality) Respect, protect, treat humanely, and provide medical assistance. -Tension between the commander's mission and this doctrine.

The Doctrine of double effect (necessary conditions)

- The action itself is ethically good or at least neutral - The agent must intend the good effects, not the bad effects, even though these are foreseen.. - The morally objectionable effect cannot be a means to the morally permissible one

Discuss Egoism

-Founder: Ayn Rand -Question Answered: What are the consequences to me? -Defined: (a form of consequentialism) Applied to individual self- interest Psychological egoism- all persons act on what they perceive will produce their best interest/ selfishly Personal Egoism- personal commitment; I always serve my own best interests -Strengths: Self fulfillment -Weaknesses: Focuses on personal best interests

Distinguish between ACT Utilitarianism and RULE Utilitarianism.

1. ACT: Looks at consequences of each individual act. 2. RULE: Looks at consequences of having everyone follow a particular rule.

3 necessary conditions in Doctrine of Double Effect

1. Action is ethically good (or at least neutral) 2. Intent is for the good effects 3. The morally objectionable effect not be the means to the morally permissible one

What are the three Standards for decision making

1. Advanced Directives 2. Substituted Judgments 3. Best Interests

When patients lack decision making capacity, what three things are considered

1. Advanced directives 2. Substituted judgment 3. Best Interest

Discuss the Principles Approach (Beauchamp and Childress) (bnaj)

1. Beneficence 2. Nonmaleficence 3. Respect for Autonomy 4. Justice

Name the two frameworks for analyzing ethical dilemmas?

1. Bernard Lo 2. Army Baylor grad program

1. What is the lowest standard of decision-making that we sometimes have to turn to when patients lack decision-making capacity? 2. Which principle of biomedical ethics primarily guides us as we make decisions using this standard?

1. Best Interests 2. Beneficence

What are the Informed Consent Guidelines (Fletcher)

1. Capacity 2. Voluntariness 3. Disclosure 4. Recommendation 5. Understanding 6. Decision 7. Authorization

Which ethical theory would NEVER pursue certain courses of action (and which would)?

1. Deontology 2. Utilitarianism

Which ethical theory would NEVER pursue certain courses of action?

1. Deontology 2. Utilitarianism

Name three types of Consequentialism and the focus of each?

1. Egoism - consequence to self 2. Utilitarianism - consequence to group 3. Hedonism - consequence to self pleasure

What are the steps of the Army-Baylor Healthcare Administration's Framework for the Systematic Analysis of Ethical Dilemmas

1. Frame the Question 2. Set out the Medical Situation 3. Note the Context (social, economic, familial, religious, legal issues, precedents..) 4. Revisit/ Reframe the Question 5. Apply Principles; Identify Conflicts 6. Weigh Alternatives 7. Decide

Bernard Lo - Know the 7 steps

1. Frame the question 2. Set out the medical situation 3. Note the context (social, economic, familial, religious, legal issues and precedents, ethical issues and precedents 4. Revisit/reframe the question 5. Apply principles/identify conflicts 6. Weigh alternatives 7. Decide

What are the sources of ethics?

1. Law 2. Experience 3. Philosophy 4. Religion

What are Some Types of Deception and Nondisclosure?

1. Lying- Least likely to happen 2. Deception- Intention 3. Misrepresentation- Lack of diligence or knowledge 4. Nondisclosure- could be done through evasion or not wanting to be harsh.

Of the following Brooks' versions of Socrates' question, which is better? (choose the best option)

"I'm a conscientious student who is seeking to learn and apply the class material in order to provide/coordinate excellent patient care in my vocation"

Discuss the Legal Rulings on Life Sustaining Interventions

*Karen Quinlan -The right to decline or withhold treatment -Motivated the development of hospital ethic committees *Nancy Cruzan -Advance directives -Patient self-determination act *Terri Schiavo -Importance of advance directives

The Schiavo Case

- Highlighted importance of advance directives - Disagreements among family members

Give components of Advanced Directives

-Designate surrogate and interventions should they lose capacity. -Can be oral or written (though written directives are preferred). -Living wills -Durable Power of Attorney for healthcare -Health Care Proxy (surrogate)

Discuss Deontology

-Founder: Kant Deontological theories: ethical theories that evaluate the type of act it is rather than the outcome of the act. Deontology focuses upon our duties. -Question Answered: Duty. What ought we do? -Defined: Makes decisions based upon absolute right and wrong. Evaluate the type of act not the outcome; duty. -Strengths: Discourages certain courses of action based on promotion of dignity and respect -Weaknesses: Does not account for love

The concept of brain death

-Permanent loss of all brain function (entire brain - cortex and brainstem). Whole-brain death. -Clinical tests: coma, absence of brainstem function, apnea. -Hypothermia and drug overdose must be ruled out (potentially reversible). -It may be helpful to confirm with EEG and imaging studies.

Know the 2 steps that are the same between Lo and Army-Baylor

1 & 2 frame the question and set out the medical situation

What are the Clinical Standards for Decision Making Capacity?

1. Patient makes and communicates a choice 2. Patient understands pertinent information and appreciates relevance 3. Decisions are consistent with the patient's values and goals 4. Decisions do not result from delusions 5. Patient uses reasoning to make a choice 6. Assessments of decision-making capacity should take into account the clinical context

What are two words (principles) that can describe "good" for various Utilitarians?

1. Utility 2. Happiness

Fletcher gives ____ guidelines for informed consent. Which is the last one listed?

7; Authorization

What kind of will are we seeking to have based on Kantian Deontology?

A Good Will

What kind of will are we seeking to have?

A Good Will

A patient has suffered brain damage. She is unconscious and exhibits no purposeful activity. She does exhibit cycles of sleeping and waking. During the wake cycles she can move her eyes, blink, move her face, grimace, smile, yawn, and produce tears. It has been 18 months since her original injury. The name for this medical state is:

A Persistent Vegetative State (PVS)

Immanuel Kant - Kantian - based on reason

Absolute commands

The physician administers lethal chemicals

Active Voluntary Euthanasia:

The term "Clinical" derives from the Greek word meaning:

Bedside

Beauchamp and Childress advocated a principles approach to biomedical ethics. The four principles for ethical decision making that they advocate include Justice, Respect for Autonomy, Nonmaleficence, and _______________________.

Beneficence

Ethical concept: "To help the patient"

Beneficence

A comparison of the good a treatment may do with the cost to the patient in pain and suffering is known as:

Benefit/Burden Test

What are the two frameworks for the systematic analysis of ethical dilemmas?

Bernard Lo's Army-Baylor HCA's

Which ethical theory focuses upon obligations resulting from a reasoning process (principles/rules focused)?

Deontology

Which of these theories most accurately reflects the following view: There is an inherent dignity in each individual which must be respected, and the idea that certain courses of action must never be pursued, regardless of expected consequences to the many.

Deontology (Kant)

Define Clinical Ethics

Derived from the Greek word for bedside; involves medical issues that arise at the bedside. It involves judgments in this setting about what is the right thing to do in a given situation. What CAN we do?= a technical question, What SHOULD we do= frequently an ethics question. Just because something CAN be done (medically), does not mean that it should be done.

Deontology

Duty-DO

Who brought the issue of battlefield wounded and sick to the forefront? This person was instrumental in the establishment of the Red Cross movement.

Henry Dunant

"If you want x, do y"=

Hypothetical Imperative

"if you want x, then do y" What imperative?

Hypothetical Imperative

In Deontology, this imperative, "If you want x, do y", is called?

Hypothetical Imperative

Types of Ethical Egoism

I. Psychological egoism II. Personal egoism Universal ethical egoism

Which person believes in exceptions moral rules, authoritative moral law, absolute necessity, and the preeminence of the use of reason to determine maxims?

Immanuel Kant

Only a court can declare someone _______________________________. This legal term describes a person unable to take care of herself or himself, including property management, entering into a contract, making a will, or standing for trial.

Incompetent

Question 21 Strictly speaking, courts declare someone ________________ when that person is determined to be unable to manage their own affairs. Choose the best option based on class slides/notes.

Incompetent

Which option do the following descriptors represent? Discussion of relevant information; agreement (or other decision) to plan of care (authorization); freedom from coercion or manipulation; capacity; recommendation; understanding.

Informed Consent

Once the patient has been informed, he or she has TWO valid options.

Informed Consent Informed Refusal

Informed consent. What's the OTHER legitimate possibility?

Informed refusal

Permanent=

Irreversible

Who founded the ethical theory of Utilitarianism?

Jeremy Bentham

Advance Directives and Patient Self Determination Act (1991) (Who?)

Nancy Cruzan

In dealing with conscientious objection by physicians it is important to protect whose autonomy? The patient or provider?

Protect patient autonomy in tension with caregiver autonomy Integrity: keep a good conscience

Which of the following is NOT a good approach to CPR and DNRs (or DNARs)?

Slow/Show codes

WHICH IS BETTER? I am a good person, but people think I am bad. OR I am a Bad person, but people think I am good (Who wrote it?)

Socrates' Question

Minimally Conscious State (MCS)

Some awareness (may be intermittent and limited)

Treatment appropriate for PVS

Some: Horrified to be kept alive without consciousness Some: Withdraw all interventions as they are no longer a person Some: Give all life-prolonging interventions (sacredness of life; believe conscious; will recover) - Interventions may be withheld or withdrawn on the basis of advance directives (or decisions by appropriate surrogates).

When we talk about normative ethics (the focus of this course), we are considering...

Standards of right and wrong

One of the reasons against assisted suicide and active euthanasia is linked to what professional role of the physician?

That of healer. These actions are incompatible with this role.

What should be looked at primarily in making a treatment decision

The benefit/burden ratio of the treatment

Confusing Ethical Distinctions

The difference between withdrawing and withholding interventions; not the same as active euthanasia or assisted suicide

Who is Nidal Malik Hasan?

The enemy from within. 2009. -Officer (Major) at Fort Hood. Psychiatrist. -Charged with 13 counts of premeditated murder and 32 of attempted.

Who is the direct agent of death with assisted suicide?

The patient

Describe what must be done when one faces competing moral duties.

Weigh the competing duties and determine which one is the actual duty.

Autonomy vs. Authority

What is it about the medical context that lends itself toward a loss of patient autonomy? How can we enable patients to make choices based on their own values and beliefs? Autonomy Rules: -Tell the truth -Respect the privacy of others -Protect confidential information -Obtain consent for interventions with patients -When asked, help others make important decisions

In relation to this subject, our respect for the patient's autonomy is often in tension with what other ethical guidelines?

acting in a patient's BEST INTERESTS

The Terri Schiavo case highlighted the importance of

advance directives

When domestic partners, the elderly, and ___________ are at risk you may override confidentiality in order to protect them.

children

With the Nancy Cruzan case, the Missouri Supreme Court was looking for a ______________ statement about the patient's desires for treatment/non-treatment.

clear and convincing (they wanted more than just a word from one person)

Patients in a vegetative state have no ____________ function, but have preserved brainstem function.

cortical

Observation, by medical personnel, of unusual cultural or religious beliefs/practices may lead these personnel to inaccurately assume the patient lacks _________________.

decision-making capacity

Which ethical theory makes decisions based on absolute right and wrong?

deontological

Rules flowing from autonomy stem from the fact that we view human beings as equally deserving of _______ and respect.

dignity

Which ethical theory is consequentalism applied to individual self interest?

egoism

What are some subsets of consequentalism?

egoism, hedonism, utilitarism

The Karen Quinlan case motivated the development of hospital _______________________.

ethics committees.

Which ethical theory makes a decision in order to reach a desired end state?

teleological

PVS (either Persistent Vegetative State or Permanent Vegetative State)

Clinical features, definition/description: - extensive brain damage -unconscious, no purposeful activity -wakefulness, cycles of sleeping and waking -may open and move eyes, blink, move face, grimace, smile, yawn, and produce tears -breathing and circulation function normally

Patient abandonment

"Abandonment, in the legal sense, means that a physician, without giving timely notice, ceases to provide care for a patient who is still in need of medical attention or when the physician is dilatory and careless (e.g., failure to see the patient at a time of urgent need or failure to judge the patient's condition serious enough to warrant attention."

Uniform Determination of Death Act (UDDA)

"Any individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards." ** Meet either cardiopulmonary or brain-death criteria.

Discuss what it means to Promote the Patient's Best Interests

1. Balance autonomy and the patient's best interests 2. Nonmaleficence - do no harm 3. Fiduciary - trust- nature of the doctor - patient relationship Do not make the situation worse. Problems: 1. Disagreements over what is best for a patient 2. Quality of Life 3. Medical Paternalism

4 Principles of Bioethics (bnaj)

1. Beneficence (a group of norms for providing benefits and balancing benefits against risks and costs.) 2. Nonmaleficence (a norm of avoiding the causation of harm.) 3. Autonomy - Respect for autonomy (a norm of respecting the decision-making capacities of autonomous persons.) 4. Justice (a group of norms for distributing benefits, risks, and costs fairly - treating similar cases similarly.) **Also known as Principlism: Tom Beauchamp and James Childress

What is the Doctrine of Double Effect?

1. Many interventions have intended effects and unintended side effects 2. Benefit to risk must be proportionate- 3. Bad effect must not be the means 4. Must be no less harmful means to the same end. 5. Necessary conditions - Action itself is ethically good or at least neutral -Agent must intent the good effects, not the bad effects, even though unforeseen. - The morally objectionable effect cannot be a means to the morally permission one. Problems with Double Effect 1. People have multiple intentions 2. Seems to focus on what physicians say rather than what they do 3. People are generally held accountable for foreseen consequences

What are Reasons Against Deception or Non-Disclosure?

1. Most patients want to know their diagnosis / options 2. Patients need info for decisions (autonomy) 3. Disclosure has more beneficial than harmful consequences 4. Deception and nondisclosure require more deception 5. Deception and nondisclosure might be impossible 6. Concealment of the truth, undermines the patient - physician relationship 7. Toleration of concealment by the physician may undermine the trust that the public should have in the profession

What is the "Right of Conscience"?

Acknowledge that problems exist Try to understand the patient's perspective Try to understand your own responses Try to negotiate mutually acceptable plans for continued care

Discuss the Caring Approach

Emphasizes relationships between professionals, patients, and families; recognizes human needs and interests

Define Active Euthanasia

Active Voluntary Euthanasia - the physician administers lethal chemicals; voluntary in the sense that the patient requests it *Reasons in Favor of Assisted Suicide / Active Euthanasia: -Respect for patient autonomy -Compassion for patients who are suffering *Reasons Against Assisted Suicide and Active Euthanasia -The sanctity of life -Suffering can almost always be relieved -Requests for assisted suicide are not autonomous -Fears of abuse -The physician's role -The physician's role

What are Advantages to Beginning a Treatment and then Withdrawing?

Additional information A time trial to see if it might work, then stop if it does not

Discuss the Casuistry Approach

Analyze clinical ethics by studying and comparing cases; bottom up reasoning; use accumulated experience

Justice

(Lat.) Jus= standard or due measure Definition: fair, equitable and appropriate treatment in light of what is due or owed persons Distributive Justice: fair, equitable and appropriate distribution of all rights and responsibilities in society (e.g., goods and services, political and civil rights) Commonly Held Material Principles: -To each person an equal share -To each person according to need -To each person according to effort -To each person according to contribution -To each person according to merit -To each person according to free-market exchange.

Discuss Prima Facie Duty

-Founder: W.D. Ross -Question Answered: "At first sight". What is my duty? -Defined: Combines deontology with utilitarianism; duty based; duties are morally binding and unbreakable. Ross recognized that sometimes Kant's absolutes conflict with each other and can be insensitive and he believed that there is absolute right and wrong, as well as the necessity to consider the consequences of individual choice. - Two conflicting duty - determine actual duty, the more important of the two. A Prima Facie obligation is binding unless overridden or outweighed by competing moral obligations. Initial Equal Importance: 1. Nonmaleficence - No harm to others 2. Reparation - Make reparation for harms 3. Fidelity - Keep our Commitments 4. Gratitude - Repay our Benefactors 5. Justice - Treat people as they deserve to be treated 6. Beneficence - To benefit others 7. To improve ourselves Strengths: All duties are initially equally important Weaknesses: 1. Not everyone agrees with what is right and wrong 2. Based on intuition and assumes everyone has same level of moral development.

Define Futile Interventions

-Latin word for 'leaky;' -Strict Definition - Unilateral (on your own) decisions by physicians to withhold or withdraw interventions are justified; interventions have no pathophysiologic rationale - clear indication all care should be withdrawn except comfort care (Note: AMA uses this definition.) -Loose Definition - The likelihood of success is very small; patient's quality of life is unacceptable; prospective benefit is not worth the resources required. They require value judgments and CANNOT be made unilaterally by physicians.

Discuss the Standards for Decisions When Patients Lack Decision-Making Capacity

1. Advanced Directives - designate surrogate and interventions should the patient lose capacity; can be written or oral *Advantages -Avoids uncertainty about who makes decisions -(in theory) POA appoints person who knows the patient's values, wishes, goals -promotes thought and discussion BEFORE incapacity *Limitations -Might not be informed -Patients might change their minds -Interpretations might be problematic -Might conflict with the patient's best interests 2. Living Wills 3. Health Care Proxy / Durable Power of Attorney for Healthcare 4. Substituted Judgments- must be used when specific preference are not known; the surrogate makes the best judgment of what that patient would have done in this situation - the surrogate uses their knowledge of the patient and their values 5. Best Interests - when an advance directive is not available and making a substituted judgment is impossible, we drop to the lower best interests standard; what do the surrogate and physician think is best for the patient; weigh the burdens and benefits of the intervention the intervention

What are the criteria for evaluating ethical theories? (cpuj)

1. Consistency - Internally and the recommendations it generates 2. Plausibility - Does it generate judgments that comport with our considered moral judgments? 3. Usefulness - Does the ethical theory lend itself to solving moral controversies? 4. Justification - How well grounded philosophically is the ethical theory

What are the Standards for Disclosure

1. Professional Standard- what a reasonable physician of ordinary skill would disclose. 2. Reasonable Patient Standard- what a reasonable patient would find relevant. 3. Individual Patient Standard- aka subjective standard- patient specific info tailored to that patients need for info and understanding.

What are the weaknesses of virtue ethics?

1. identifying the virtues 2. dealing with conflicting virtues 3. applying virtual theory to moral dilemmas

Discuss the Refusal of Treatment by Competent, Informed Patients

Does the physician's responsibility to help the patient ever override the patient's freedom to choose? -Reasons for Respecting Patient Refusal: -Respect for patient autonomy -Imposing medical interventions would be unacceptable -Scope of Refusal: -Any treatments -Beneficial treatments with few side effects -Not required to have a terminal illness -Initial Response to Refusals: -Tactfully ask why -Validate the patient -Give the patient a choice -Restrictions on Refusal: -Compelled treatment of pregnant women Communicable diseases

Discuss Do Not Attempt Resuscitation Orders

Justifications: 1. Patient refuses CPR 2. Surrogate refuses CPR 3. CPR is futile in a strict sense

The Nancy Cruzan Case:

Missouri Ruling; The US Supreme Court Ruling - Advance Directives - Patient Self Determination Act

Define PVS

Persistent Vegetative State - one month persistency of an irreversible prognosis; declared after 3 months for a non-traumatic injury, 12 months for a traumatic injury *Clinical Features -Extensive brain damage -Unconscious, no purposeful activity -Wakefulness, cycles of sleeping and waking -May open and move eyes, blink, move face, grimace, smile, yawn, produce tears -Breathing and circulation function normally *Controversy -Some horrified to be kept alive without consciousness -Some withdraw all interventions as they are no longer a person -Some give all life-prolonging interventions (sacredness of life, believe conscious, will recover)

Define Confidentiality

Refers to limits on the dissemination of information disclosed by a person within the doctor- patient relationship. Reasons for confidentiality= respect for persons, benefits patients, benefits dr/pt relationship, prevents stigmatation & discrimination. *HIPAA (HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT) -Exceptions Infectious Diseases Impaired Drivers Injuries Caused by Weapons or Crimes Partner Notifications by Public Health Officials Warnings by Physicians to Persons at Risk Violence by Psychiatric Patients Child Abuse Elder Abuse Domestic Violence

Discuss Surrogate Decision Making

Surrogate- anyone who makes decisions for a patient lacking decision-making capacity -(Can be prioritized based on state) -Court appointed guardians -Surrogates selected by the patients -Family members -Friends -Physician *Problems: -Emotional barriers to decisions -Decisions inconsistent w/ the patient's preferences or values -Conflicts of interest -Disagreements among potential surrogates *Proxy - a surrogate appointed by a patient *** proxy decision-makers have the strongest ethical and legal claim to make decisions for incapacitated patients

Define Informed Consent

The willing acceptance of a medical intervention by a patient after adequate disclosure by the physician of the nature of the intervention, its risks, benefits, and alternatives with their risk and benefit; results in shared decision making. It's a legal requirement and IT'S WISE AND ETHICAL.

The 4 principles of Bioethics are also known as______?

These four principles are also known as Principlism: Tom Beauchamp and James Childress

Vegetative state vs determination of death by brain criteria. Same or different?

They are NOT the Same

Rights of Conscience

This is the right of all persons to refuse to participate in what they believe to be unethical or immoral actions. This is to be distinguished from refusals based on prejudice, difficulty, inconvenience, or personal revulsion. Instead, these conscientious objections should be based upon strong moral or religious convictions.

Which ethical theory makes decisions based upon comparison and precedent?

analogical

What are the strengths of virtue ethics?

sets as the question as to what we ought to do/ concentrates what type of people we ought to be

Which ethic theory focuses on moral concerns?

virtue

Which ethical theory considers desirable character traits to measure good and bad?

virtue ethics

Discuss the Professional Approach

"What kind of person should I be to fulfill my professional obligations? -Characteristics of a Profession (Fletcher) Advanced Training A Well defined role Continuing Education Control over admission to the Profession Responsibility to specified individuals and to the particular group defined by the profession Devotion to Humanistic Ideals A well defined group of necessary virtues and moral rules that define the ethical parameters of the profession

What is Autonomy?

(Gk) autos (self) nomos (rule, governance, law) Two conditions essential to personal autonomy: -Liberty: Independence from controlling influences. -Agency: Capacity for intentional choice. Understanding. * Respect for autonomy does not supersede all other principles.

Discuss the Refusal to Care for Patients

*Doctor-patient relationship: ethical obligation to care for and not abandon patients *Right of Conscience - this is the right of all persons to refuse to participate in what they believe to be unethical or immoral actions; not to be confused with refusals based on prejudice, difficulty, inconvenience, or personal revulsion; providers still have an obligation to inform patients as far in advance as possible -Contraception -Abortion

Discuss Reason to Provide and Reasons to Withhold Tube and Intravenous Feedings

*Reasons to Provide: -Physicians can treat reversible causes of feeding problems -Withholding tube and intravenous feeding would starve patients -Tube and intravenous feedings are ordinary care -Withholding tube and intravenous feedings would lead to abuses *Reasons to Withhold: -Tube and intravenous feedings merely prolong dying -Such patients do not suffer if tube and intravenous feedings are withheld -Tube and intravenous feedings cannot be considered ordinary care -Tube and intravenous feedings have burdens and benefits -Caring should be provided directly, not through symbols -Slippery slope arguments are unpersuasive

Discuss some Ethical Dilemmas and Decisions in the Military Context

*Terms of Doctrine: Respect, protect, treat humanely, and provide medical assistance *Based solely on urgency of medical needs (medical impartiality) *Provide Care for: US Military, Allies, Civilian, Enemy *Problems treating the enemy -Refusal to treat -Tensions naturally arising from military service to Soldiers -Ethical Support: -4 Principles of Bioethics (Principlism)

The Karen Quinlan Case (1976)

- Life-sustaining interventions might be inappropriate in some situations (RIGHT TO DECLINE TREATMENT) - Patients, families, and physicians need not routinely involve court. - Motivated the development of hospital ethics committees. *** This case reinforces the right to decline or withhold treatment.

Discuss Consequentialism

-Consequentialism focused on the RESULTS, ethical theories that look at the overall balance of benefit over harm of the act, rather than the act itself. Consequences to self= Ethical egoism. Consequences to the group= Utilitarianism (act to produce the greatest amount of benefit to the greatest # of people. -Question Answered: What is the overall benefit? -Defined: When making a decision, the ends justify the means. Focuses on results

Discuss Virtue Ethics

-Founder: Aristotle -Question Answered: Who should I be? -Defined: Focuses on character and moral concern, someone having such virtues displays moral conduct. Moral traits that make for a good or a bad character. - Virtue ethics is an approach that deemphasizes rules, consequences and particular acts. It places the focus on the KIND of person who is acting and whether or not they are expressing good character. -Strengths: Focuses on who we should be -Weaknesses: Identifying the virtues; moral dilemmas

Discuss Utilitarianism

-Founder: Jeremy Benthem & John Stuart Mill -Question Answered: What ought to happen? -Defined: Consequentialist Theory. An action or practice is right if it produces the greatest balance of utility or good vs. evil for a group of people. (The Principle of Utility). We promote human welfare by minimizing harms and maximizing benefits aka The Greatest Happiness Principle. -Strengths: Promote human welfare by minimizing harms and maximizing benefits -Weaknesses: Does not account for motives, justice or other ethical virtues; results immeasurable

What are Reasons For Deception or Non-Disclosure?

1. Prevent Serious Harm to Patients (Severely Depressed, Suicidal) 2. Culturally Appropriate (Be careful not to assume) 3. Enhance Patient Autonomy (for patients who willingly choose to not know their diagnosis)

What are the Approaches to Ethics and Ethical Dilemmas in Patient Care?

1. Principles Approach (Beauchamp and Childress) aka Autonomy, Beneficence, Nonmaleficence, Justice 2. Casuistry Approach- analyze by studying and comparing cases, bottom up reasoning, using accumulated experience. 3. Virtues Approach- What kind of person should I be to do the right or good thing for my patient? Virtue provides motivation. Fletcher has 9 clinical virtues. 4. Caring Approach- emphasizes relationships between professionals, patients, and families. Recognizes human needs and interests. 5. Professional Approach- The clinician acts as a moral agent, "what kind of person should I be to fulfill my professional obligations? 6. Bernard Lo's Framework for the Systematic Analysis of Ethical Dilemmas 7. Army-Baylor Healthcare Administration's Framework for the Systematic Analysis of Ethical Dilemmas

What are the seven professional characteristics-flecher's (TRREAD on virtues and morals)

1. Training (advanced training) 2. Role (well defined role) 3. Responsibility to patients 4. Education (continued education) 5. Admission to profession (control) 6. Devotion to humanistic ideas 7. virtues and morals (defined group of virtues and moral rules)

Discuss Bernard Lo's Framework for the Systematic Analysis of Ethical Dilemmas

1. What is the problem or dilemma? 2. What are the medical facts? 3. What are the concerns, values, and preferences of the clinicians? 4. What are the concerns, values, and preferences of the patient? 5. What are the ethical issues? 6. What ethical guidelines are at stake? 7. What practical considerations need to be addressed?

Name the 5 approaches to clinical ethics (derived from greek for bedside)

1. virtue 2. caring 3. professionalism 4. casuistry 5. principle

Name the nine Fletchers clinical virtues (whit scob)

1. wisdom 2. humility* 3. intelligence (reflective) 4. technical competence 5. Subordination of Self-interests 6. caring* 7. courage 8. objectivity and detachment 9. benevolence (clinical)

What is the caring approach to patient care? Name two...

1.relationship between professionalism and patient is at the heart of clinical ethics 2. recognize human needs and interests

What is the concept of patient abandonment?

Abandonment, in the legal sense, means that a physician, without giving timely notice, ceases to provide care for a patient who is still in need of medical attention or when the physician is dilatory and careless (e.g., failure to see the patient at a time of urgent need or failure to judge the patient's condition serious enough to warrant attention." Jonsen, 99

Define MCS

Minimally Conscious State; some awareness, may be intermittent and limited

What is Respect for autonomy?

Respect for autonomy (a norm of respecting the decision-making capacities of autonomous persons.)

Which ethical theory combines deontology with utilitarianism?

prima facie duty