Medical Ethics Exam - Part 2

the good doctor:

"a certain technical/intellectual mastery coupled with a certain commitment to specific professional values" -some of these professional values include trustworthiness, confidentiality, beneficence, respect for patient autonomy, non-discriminating, conscientious of wellbeing of public

"Telling the Truth to Patients: A Clinical Ethics Exploration" - David C. Thomasma reasons for truth-telling

*1. right* -flows through the notion of autonomy; to be an autonomous decision maker, we need to have these options *2. utility* -persons need to make informed judgements about their actions -could also be a disutility if it serves to discourage people or if it is horrendous to deal with *3. kindness* -treating them as an adult human being - preserves their autonomy -necessary for the functioning of society

what do we use for moral reasoning:

*personal morality* - but it is hardly reliable. -who should we trust when it comes to questions of moral decision making? -there needs to be something more objective for moral reasoning (we can't just listen to anyone's personal opinions and morality)

special legal duties

*things we must do; embedded in our role as x* -parents have duty to save drowning child -lawyers cannot break confidentiality, that's why they often don't want to know -physicians must notify police if they see gunshot wounds -things we have no choice about; things we have to do

general legal duties

*things we ought to do; embedded in our humanness* -normative claim - a moral claim -things we should do because we're human beings -honour confidentiality with friends -save drowning child, even if you're late for a job interview -things we should do because we're part of community and we want to preserve these human relationships

Kipnis' defense of unqualified confidentiality: what does Kipnis ask?

Kipnis asks: so how are trustworthiness and confidentiality to be understood in relationship to medicine's commitment to diminish risks to third parties? -what would happen if the profession accepts that at times confidentiality may be broken to protect a third party?

common sense

a collection of childhood prejudices -common sense could come in handy in these absurd thought experiments, but much of it is a collection of prejudices

parens patriae

a legal doctrine that gives the state the authority to act in a child's best interest => guardians act in best interest of children: making decisions that attend to child's needs and wishes, but balancing that with beneficence => health care providers may appeal to health care authorities if the parent or guardian is choosing against best interest - appeal to child and family services if they think the parent or guardian is making choice that will harm the child

ethical problems arise when there is:

a) *a conflict between core values* (i.e. trust of Andrew and physician and beneficence, wellbeing of Wilma) -in this case, we need to weigh these problems and come up with priority rule => prioritize values that come into conflict when it comes to ethical dilemma b) *ambiguity with respect to preserving a core value* -we have to disambiguate these values with respect to professional responsibility

people make decisions based on...

common sense and other things... -but people do make ethical decisions based on other principles and not just common sense! acting based on virtue ethics, utilitarianism, etc. -we use normative ethics to make these decisions - not just based on the euphemism that we call common sense

what are the consequences of qualified confidentiality?

doctors must warn pts = pts. may not seek medical help and if they do seek help they may lie

difficulties with ethical relativism

not being able to talk about moral progress

deontology

rightness is not exclusively a function of promoting good consequences -school of ethical thought which focuses on *our obligations, rules and intention behind action* -we're *not interested in consequences* at all! look at the action. -*does not permit any variation* in any degree (i.e. white lies not permitted) -he arrives at the *categorical imperative*

categorical imperative

supreme principle -absolute duty without exceptions i.e. categorically, you must always tell the truth

professional obligations and personal morality:

-a major task for professionals is to *move beyond the various personal moralities embraced by practitioners* and to reach a responsible consensus on *common professional standards* -*upheld by all regardless of personal morality* (= someone's unique beliefs or opinions given various situations) -we shouldn't take on responsibilities that might conflict with personal morality => if they do, they need to be able to bracket their personal morality -can't let one's own political beliefs to get in way of autonomy of patient (i.e. referring for abortion) - *hindering someone else's liberty is a huge no-no*

multiculturalism

-a social-intellectual movement that *promotes the value of diversity as a core principle* and insists that *all cultural groups be treated with respect and as equals* -we strive for this -we need to be careful in health care to not be completely ethically relativists - *need to be open to cultural pluralism and need to be multicultural appreciative*

Formula of the Universal Law

-act only in accordance with that maxim through which you can at the same time will that it become a universal law -ask yourself: what if everyone did X? what if everyone threw their gum on the ground -considers the interest of all! -want to ensure quality (i.e. when you think of allocation of resources)

what do adult models presume?

-adult models presume that the patient is autonomous and has a *stable sense of self, established values, and mature cognitive skills*; these characteristics are undeveloped or underdeveloped in children -we still want to allow children some choice in a measure *appropriate to their level of development and experiences, to their values, cognitive skills, etc.*

mature minor in Canada

-any minor under the age of maturity (18 yrs)

overriding the truth: personal (in general relationships)

-are there values that are more important than one's rights, utility, and kindness? and are there reasons why telling the truth will not always ensure rights, utility, and kindness? -are there good social implications for overriding the truth? (could be sparing someone's feelings) -the truth in a relationship responds to a multivariate complexity of values, the *context* for which *helps determine which values in that relationship should predominate* -when we override the truth, we compromise respect for persons (i.e. in axe murderer case, you compromise his autonomy by lying to him) => the 3 values are always in conflict!

1. truth is contextual

-as the intensivist, you've never met Mr. P -> does this matter? how does this effect the healthcare trust relationship?

when in doubt, should we tell the truth according to Thomasma?

-Thomasma argues that when in doubt, the truth should be told! (truth management plan written out for health care team) -want everyone on health care team to be on the same page, so truth comes out in a planned out and controlled way

case: George VI

-cancer tumour found in left lung of king of Great Britain -heavy cigarette smoker -his lung and tumour were removed, and George recovered enough to continue with some of his work as kind until he died in 1952 -Queen Elizabeth took over some of his duties -everyone knew he wasn't in the best health; but George and his immediately family didn't learn until much later that he had lung cancer -they were all told by treating physicians that the operation was done to free a bronchial tube or airway in his left lung; not lung cancer -Winston Churchill (PM) has access to king's medical records - w help of his own doctor, Churchill figured out true diagnosis. Kept this info secret. -doctors knew George would want to carry on w his royal duties for as long as possible. also thought he would be better able to continue if he believed that he was recovering and would live for more than a short while longer -they chose what they thought would be best for the patient (and Britain) while keeping patient in the dark -Kant - this was immoral no matter what the motive -if George might die soon, then the government needed to prep for this and for a new person (Elizabeth) to take over these royal duties

how should I determine the appropriate role of a child in medical decision-making? b) primary-school children

-children up until age of 10/12 -may participate in medical decisions, but don't have full decision-making capacity. -they should be provided with info appropriate to their level of comprehension. -parents should authorize or refuse to authorize treatment, but the child's assent should be sought. *any strong and sustained dissent should be taken seriously*

Kipnis argument: confidentiality in medicine

-confidentiality in clinical medicine is far closer to an absolute obligation than it has generally been taken to be => Kipnis argues for absolute confidentiality

minor Jehovah's Witness patient

-courts almost always decide in favour of transfusing -almost always do this for children against religious beliefs of parents -some hospitals have Jehovah's liaisons in the hospital

what to do in the case of the woman with necrotic foot?

-ensure they understand the repercussions of not getting the surgery -if they do understand and still say no, then you can't do anything

utilitarianism

-form of consequentialism: rightness is a function of promoting good consequences => or promoting utility, and ensuring that there aren't too many disutilities -utilitarianism: right actions are those that maximize overall happiness of well-being -harm Principle: interference in the conduct of competent persons is only justified to prevent harm to other

do guardians have the right to make life-threatening decisions for persons who are unable to decide for themselves?

-freedom of religion doesn't include the right to act in a manner that will result in harm or death to others · -over-ride parents'/guardians' autonomy to promote beneficence -parents say no, but Child Services takes it upon themselves to do the surgery, even though the parents still dissent, then they return children under custody of parents => this avoids the parents and child from being ostracized in the community, bc not under parent's custody. a bit of a slight of hand

perspectives of health care workers and patients

-from the outset, the conceptual framework of bioethics has accorded paramount *status to the value-complex of individualism, underscoring the principles of individual rights, autonomy, self-determination,* and their legal expression in the jurisprudential notion of privacy => we hold autonomy to a certain standard. It always comes first; always trumps beneficence

ultimately, what would Kipnis say?

-Kipnis would say that under no circumstances should you break confidentiality

Thomasma's conclusions on truth:

1. truth is contextual 2. truth is a secondary good 3. truth is essential for healing an illness, but may not be as important for curing a disease 4. withholding the truth is usually only a temporary measure

substitute decision maker =

16 years or older in Canada

why is there "no justification for trimming back the obligation of confidentiality"?

-*bc doing so actually reduces protection to endangered third parties, increasing public peril* (danger) -in a way, by preserving this healthcare relationship, we ensure confidentiality -> *this ensures a good relationship btw the patient-physician relationship more broadly* -Wilma might be harmed by keeping confidence, but there's something larger at steak, which is this relationship -we still want people to come see physicians if they did something wrong or they're embarrassed (this is at stake if we start disclosing) -always keeping confidence and take a Kantian ethics line (especially the Universal line of deontology) -*act only on the maxim that you wish to be universalizable:* what would happen if everyone broke confidence? the whole system will suffer!

Treatment for Jehovah's Witnesses: Adults and Children - Ruth Macklin conflicts with Jehovah's Witnesses

-*conflict between autonomy and beneficence/non-maleficence* -*conflict btw duty of physician and religious autonomy of patient* => does the patient in a medical setting have the autonomy that we normally accord persons simply by virtue of their being human? or does one's status as a patient deprive him of a measure of autonomy normally accorded him as a non-patient person?

4. non-intervention cases

-*full disclosure* -EX: gene mapping -> can tell you of likelihood of developing different kinds of of diseases -the physician and healthcare team should fully disclose (Thomasma believes this) -people need to prepare for these potential diseases

family-centered approach

-*gold standard of decision-making for children* - for mature minors -considers the *effects of a decision on all family members, their responsibilities toward one another, and the burdens and benefits of a decision for each member*, while acknowledging the *special vulnerability of the child patient* -this doesn't say act in best interest of child; or to maximize/follow beneficence -*important to consider patients as being part of a system - a family* (looking back to Sue Sherwin) -who's taking care of them? will they lose their home bc they don't have the money to hire health care experts? => all of these questions need to be considered as well as the vulnerability of the child patient -they are especially vulnerable bc they might think that pain is never ending

Kants perspective on lies:

-*it always injures another (if not an individual, then mankind generally) since it vitiates (spoils) the source of justice* -to be truthful (honest) in all declarations is therefore a sacred unconditional command of reason, and not to be limited by any expedience

clinical case categories 1. intervention cases

-*managing the truth* -*where a family member (or proxy) intervenes and wants the health care team to keep the diagnosis secret* -often times the rationale that is given is to spare the emotions of the patients: "my mother will lose all hope" -we might instead set limits on how long the truth can be withheld from the patients - talk to family about why and set deadlines -truth can come out in little bits. this entails explaining the diagnosis and prognosis, but doesn't destroy life of the individual by not telling them or telling them all at once

"Ethical Relativism in a Multicultural Society" - Ruth Macklin ethical relativism

-*moral rightness and wrongness of actions vary socially; there are no absolute moral standards placed on all human beings at all times* -no moral principle held by all people at all times -moral rightness and wrongness will be *decided based on what's normal and what societies and cultures agree upon* -rather sexy bc *it allows for cultural pluralism* - allows to consider the cultural needs of others. a lot of people are persuaded by it! -there are things that we can all claim are morally troubling (the Holocaust) and morally great (not killing innocent people)

3. prevention cases

-*quality of live vs. need to know* -might withhold all the info -finding lumps and bumps all over the body: most of these are benign and will never manifest into anything -it probably doesn't make sense to investigate all these lumps and bumps, nor does it make sense to tell them about these abnormalities -not necessary to scare a patient unless you have reason to suspect its not benign (you'd have biopsy in this case)

case: Makayla Sault

-11-year-old aboriginal girl who had acute lymphoblastic leukemia -72% chance of survival if she continued with chemo -after 11 weeks, she experienced severe side effects that put her in the ICU. she begged for chemo to be stopped; the family agreed to her wish; Family Services in Ontario didn't consent the decision, and she died -most Aboriginal people seek care from health professionals - but nearly half also use traditional medicines -their beliefs (i.e. that there are multiple dimensions of health and relationships btw health, patient, community and environment) create expectations that Aboriginal patients bring to their health care encounters -usually health care professionals do concede if the child has attempted treatment for several week; *this might be a case where they are exercising their colonialism* -important to consider the history of Indigenous people in Canada - might have played a role in why they went forward!

case of 14-year-old Manitoba girl:

-14-year-old Manitoba girl hospitalized in Winnipeg suffering from Crohn's disease, which can cause GI bleeding, thus requiring blood transfusions -as a Jehovah's Witnesses, she refused treatment, but Manitoba Child and Family Services obtained a court order forcing the transfusion based on her doctor's recommendation -her lawyers claimed that this decision violated her constitutional rights and argued that decisions should be made on a case-by-case basis according to competence and not some arbitrary scale -Manitoba Supreme Court declared that such medical interventions are constitutionally sound. also declared that lower courts must consider minor's maturity and decision-making skills in all future enforced-treatment cases

Kant and our reasoning for moral decisions:

-Kant says: you can be held responsible if the decision is based on your own volition and is something you've reasoned through -for Kant, our reason is the foundation of everything. putting reason at the centre of his thinking allows him to arrive at firm moral principles; allows him to arrive at the categorical imperative. -even a white lie is morally egregious.

reporting patients in Canada

-governments, which have a responsibility to protect the public, have enacted *legislation that requires physicians, in specific circumstances, to violate a patient's confidence for the protection of others* -specific provincial legislation requires the *reporting of suspected child or elder abuse, transmissible diseases, or conditions that may impair a patient's ability to safely operate a vehicle* => Royal College of Physicians and Surgeons of Canada on Reporting Patients (Harm to Others) -in specific circumstances: this is so *ambiguous*! this allows for all sorts of *professional judgement*

case: Georgette Malette vs. Dr. Shulman

-head-on car collision killed her husband, left her unconscious when she arrived at the hospital -Dr. Shulman, her attending physician, determined that she was suffering from shock due to blood loss and that a blood transfusion was necessary to save her life -a nurse going through Mrs. Malette's purse discovered a card that identified the patient as a Jehovah's Witness and requested that no blood be administered under any circumstances -after getting a second opinion, Dr. Shulman accepted full responsibility for his actions, and administered the transfusions -Mrs. Malette successfully sued him for $20,000 -Dr. Shulman's appeal: "the card cannot be effective when the doctor is unable to provide the patient with the info she would need before making a decision to withhold consent in this emergency situation" -Mr. Justice Robins: a doctor isn't free to disregard a patient's advance instructions, even if the choice is contrary to the mandates of his own conscious and professional judgement -although the refusal wasn't verbally made, since there was no reason to doubt that the card validly expressed Mrs. Malette's desire to withhold consent to blood transfusions, the card was considered by Justin Robins as a legit advance directive

what could happen if you lie to the axe murderer?

-i.e. if you have by a lie hindered a man who is even now planning a murder, you're legally responsible for all the consequences. if you have strictly adhered to the truth, public justice can find no fault with you -if you lie and say the intended victim was not in the house and he had really gone out (though unknown to you), and the murderer met him as he went, and executed his purpose on him, then you might with justice be accused as the cause of his death -if you had spoken the truth as well as you knew it, perhaps the murderer while seeking for his enemy in the house might have been caught by neighbours coming up and the deed been prevented

the axe murderer problem

-if a sinister looked man carrying an axe knocked on your door and asked you where your best friend was, would it be morally acceptable to tell a lie? -Kant thought it wouldn't - due to the Categorical Imperative (an absolute duty; one without exceptions), which applies to everyone, whatever the consequences may be -Kant argued that if you told a lie, which by chance, led to the axe man finding your friend, that would be on your conscience -so if you tell the axe man that your friend is NOT in the house when he is, and your friend then sneaks out the back door and bumps into the axe man, anything that then happens is to some extent your responsibility -but if you told the truth, then the consequences for your friend, no matter how grisly, should not be on your conscience -contrast this to utilitarian's -> they'd think of the consequences of our actions

would it be appropriate for the physicians to make her decision?

-if they can't reach the daughter in emergency situation, they could do the operation -only time it would be appropriate is in emergency care

why are mentors important for virtue ethicists?

-important to have mentors who you respect - who have good bedside manners, interpersonal skills, etc. - so you can emulate them -how would they respond in the given situation?

what values come in conflict in case of infected spouse?

-in the case of the infected spouse, there's a conflict btw *beneficence (well-being of Wilma) and confidentiality* -Dr. might also be torn btw *trustworthiness to Andrew and well-being of public* (spreading HIV/AIDS - drains the healthcare system. We have limited amount of money and funding)

utilitarian perspective on the infected spouse:

-in the case of the infected spouse, utilitarianism would argue that the physician must disclose this information. The following disutilities in this case: A) disutility comes from telling Wilma and breach of confidentiality, losing Andrew as patient, lose the trusting relationship B) Disutility of NOT telling her - she ends up with deadly disease. => utility of disclosing = spare Wilma from having AIDS, which is a greater utility (high likelihood they will have sex, and she will get infected, and she will change her mind if she knew he was HIV+) -in this case of infected spouse, deontologists would apply the categorical imperative and not disclose this information. don't break promises from a deontological perspective -doctor did her best, tried to get Andrew to tell Wilma. she wanted him to agree to do this but now it out of her hands and it's up to Andrew to tell Wilma, we don't break promises -Kipnis argues that you SHOULDN'T disclose

-what would happen if the profession accepts that at times confidentiality may be broken to protect a third party?

-in this case, there would be no more assurance of confidentiality btw doctor and patient -this might cause people to be less likely to trust their doctors -people might not even go to physicians when they need help, or bring those that are vulnerable for help -what about patients who aren't willing to have a report filed? they may conceal their full condition. -*if we practice with no exceptions to confidentiality, we develop creative solutions to deal with them*

why is truth-telling necessary for the functioning of society?

-it is a kindness to be told the truth, a *kindness rooted in virtue* precisely because persons to whom lies are told will of necessity withdraw from important, sometimes life-saving relationships -similarly, those who tell lies poison not only their relationships but themselves, rendering themselves incapable of virtue and moral growth

3 additional elements are required to establish professional obligation:

1. attention to core values must be a part of professional education 2. core values must also be recognized as social values 3. obligation to develop a sound code of ethics (those aren't personal ethics, but things developed by your colleges) => not just about commitment between individuals but also to secure critical social values bc we expect physicians to do so => you have to consider what kind of doctor you are and decide what a virtuous doctor would do

questionable practices

-just bc something is normal or okay or good or right in a culture, doesn't mean that one has a duty to perform it -don't have to perform something that they find troubling (if the patient has asked for something) -*there's room for conscientious objection* -*tolerance must be distinguished from a judgment that the actions harmful to children should be permitted to continue. what puzzles me is the notion that 'cultural sensitivity' must extend so far as to refrain from providing solid education to these parents about the potential harms and the infliction of gratuitous pain* -*we ought to be able to respect cultural diversity without having to accept every single feature embedded in traditional beliefs and rituals* -kinds of cases that she's talking about = female genital cutting -we can hold this position of cultural sensitivity while not doing things that harm patients, particularly in case of children -you don't have to do anything that may compromise moral or professional integrity

how should I determine the appropriate role of a child in medical decision-making? c) adolescents

-many have decision-making capacity of an adult -*capacity will be determined for each patient*, and many will need assistance in developing an understanding of the issues and in demonstrating their decision-making capacity. -depends on their *maturity level*; can choose with some degree of independence bc of their *ability to assess the risk and benefits* -we can assess whether or not their wishes for treatments or against treatments are out-of-character or idiosyncratic. *this requires a set of values, which begin to solidify in adolescent years.*

virtue ethics

-morality is principally a *matter of realizing in action character traits (virtues) that express being a good person* -*tells us how to be, but not what to do* -does not slip into "personal morality" -remains *objective* -virtue ethics informs us that we should be asking ourselves - what would a virtuous person do? -we have capacity as human beings to recognize people who are virtuous (moral exemplars), and we should practice being virtuous => i.e. getting a sense of the type of doctor or person you want to emulate

what if parents or 2 guardians disagree with each other regarding treatment options?

-no black and white response -if there's a stronger voice, usually the other defers, and you get a sense that one of the guardians isn't happy with the decision -if there are 2 strong opinions that differ with respect to their decision of treatment for their child? => child and family services would be appointed to make this decision => have to prove that you've had these conversations, that you've brought in social workers, etc. - this is last resort!

overriding the truth: professional it used to be that a lot of physicians would withhold a lot of information from patients. why?

-non-maleficence; to do no harm. Didn't want to destroy patient's hope by giving them a damning prognosis -there are some cases where this argument is justified -in the 70s, we have shift away from paternalism towards autonomy => moving away from paternalism towards patient and family-centered care -we also have treatments - not all diagnoses are fatal -patients have right to their prognoses and diagnoses: this helps to lessen the hierarchy between patients and doctors -desire to ensure that patients and family have all the info and have the autonomy to make the decisions -Thomasma argues that the above is not always necessary ... he brings in some old school paternalistic line of thought

"Involving Children in Medical Decisions" - Harrison, Kenny, Sidarous, Rowell (Harrison et al.) given what we know about competence, why might it be difficult to involve children in medical decisions?

-part of brain isn't fully developed - can't expect to engage in process standard of competence with them -it depends on the age, but we can expect a minimal standard of capacity (which according to Buchanan and Brock, is their ability to show preference) -we need to take their preferences into consideration and need to ask them about these preferences -an expression of preferences may or may not account for interest or harm -this is different from consenting to treatment, but still important

personal values

-personal values include - authenticity, autonomy, competence, happiness, growth, learning, respect, wisdom, etc. -aren't necessarily ethical and we can't appeal to them to inform what one should do professionally -part of professional obligation is to understand what the other person values -when people let their personal morality get in way of decision making with patients, it could degrade the autonomy -or if the patients act in way contrary to personal values of doctor, it could cause moral distress, which is very uneasy bc you can't do anything about it -*we must learn to bracket law, but definitely bracket personal morality and values when we're reaching ethical decisions* - we must aim to be a *"good doctor"*

case of the infected spouse

-physician knows (with certainty the pt. is infected and infectious -physician knows that the spouse is not currently infected -infection is life-threatening -infection of spouse is highly likely -warning the spouse will likely affect her decisions (i.e. to have sex with her spouse)

what must we consider when determining the appropriate role of a child in medical decision-making?

-potential benefits and harms to the child -moral, spiritual, and cultural values of the child's family/community (a lot of time it comes down to financial concerns)

what are our legal (and institutional) obligations?

-professional obligations are NOT legal obligations -our professional obligations aren't about the law or personal values or moral codes -sometimes professional obligations aren't found to be part of legal obligations - sometimes these obligations come in conflict -often times, much of our professional obligations are legally sanctioned

Patient Self-Determination Act or Substitute Decisions Act:

-purpose is to *inform patients about their rights for their own medical care* -there are patients that believe that if you tell them their prognosis, that that's what's going to happen -you might tell the patient: how much do you want to know? *ask them how much they want to know* => they could ask you to withhold information or knowing everything! -this would mean *talking to proxy/substitute decision maker*, who would then make a decision with patient's values and beliefs in mind (i.e. what would my mother choose for herself?) -acting for a particular individual with their own values and beliefs - don't want to act in your own self-interest. *want to act in their stead; doing what the patient would choose for themselves* (sometimes this doesn't align with what would be in their best interest) -want to carry out informed consent conversation in a manner sensitive to their beliefs and values

how does virtue ethics remain objective?

-remains objective bc you always ask what a virtuous person would do in a given situation -what would a VIRTUOUS person do? -this way, it remains objective. not just personal values or morality - bracket all of this and put it aside to understand what the patient needs -*we can agree on traits that make doctors virtuous, and bc of this, it remains objective*

overriding the truth: professional

-should we think about rights, utility, and kindness?

Formula of Humanity

-so act that you use humanity, whether in your own person or that of another, always at the same time as an end, never merely as a means -*get the ultimate biomedical principle of autonomy* -*treat others as an end in and of themselves* -*this generally trumps beneficence* -need to respect dignity and humanity. what's particularly human is our ability to make decisions!

4. withholding the truth is usually only a temporary measure

-the truth will come out eventually -especially if prognosis changes -key is to consider relationship with the patient and the health of the patient with respect to hope and acting autonomously

2. truth is a secondary good

-this makes his thinking rather paternalistic -primary good = someone's wellbeing; preserving HOPE or FAITH (a powerful thing with respect to illness; both can have curative effects)

who is able to refuse medical treatment?

-to be legally valid, the refusal of medical treatment must be given by a person deemed capable of making health care choices, that is, capable of understanding the nature and consequences of the recommended treatment, alternative treatments, and non-treatment

the importance of thought experiments in philosophy

-to think about ourselves and the world in a different way than we typically do -side-step social conventions, prejudices, and all the things that have been meticulously programmed into us since birth -helps us try to get past social conventions and prejudices

3. truth is essential for healing an illness, but may not be as important for curing a disease

-we might be more inclined to full disclosure in case of an illness, but not necessarily in the case that the prognosis is bad

cultural pluralism

-when minority groups *maintain their unique cultural identities, values, and practices in accord with laws and values of the wider society* -something that we aim to do, but that we need to do better in health care => especially when our patients have diff cultural context, this is important! -ensuring that *practices and beliefs are preserved* as best as possible

2. dying patients

-withholding truth for actively dying pts. -please don't tell my family member that they only have 2 days to live (vs. don't tell them that they have 3 months to die: unless the patient tells you they don't want to know anything about the prognosis or diagnosis, then you should probably tell them this info in the latter case)

case of woman with necrotic foot:

-woman had necrotic foot and they were worried that she was going to get sepsis (= infection in body that grows so much that you can't fight it; multiple organ failure) -she was capable and she said that she wants her daughter to make all her decisions for her; I don't want to make any of my health care decisions -he called the daughter to make these decisions, and the daughter was planning a wedding. she didn't want to make the decision until after the wedding, in a couple of days. the mother was on the border of death.

what typifies a virtuous person/doctor?

-would a good doctor disclose the information to Wilma? for example. -a virtuous person, unlike the deontologist (who says to never break contract), says little white lies or big lies are sometimes okay, depending on the situation -you have to think about what a good and virtuous doctor do

Royal College of Paediatrics and Child Health, "Withholding or Withdrawing Life-Sustaining Treatment in Children" there are 5 situations where it may be ethical and legal to consider withholding or withdrawal of life-sustaining medical treatment:

1. *The "Brain Dead" Child* -no breathing, no heartbeat on its own -the whole brain is dead (brain stem death) 2. *The "Permanent Vegetative" State* -upper brain death 3. *The "No Chance" Situation* -disease so severe the treatment delays death without alleviating suffering 4. *The "No Purpose" Situation* -although the patient may be able to survive with treatment, the degree of physical or mental impairment will be so great that it is unreasonable to expect them to bear it 5. *The "Unbearable" Situation* -the child and/or family wish to have treatment withdrawn or refuse further treatment irrespective of medical opinion that it may be of some benefit => Royal College of Paediatrics and Child Health

moral issues in refusing treatment

1. *informed consent* o can't act contrarily to patients wishes. they often carry cards to let people know their beliefs o if they don't have card, you will transfuse in an emergency situation 2. *competence*

Tarasoff v. Regents of the University of California

o Potter met Tarasoff at a party and they ended up becoming friends. Saw each other weekly. He eventually made a move, kissed her and she rejected him o he got depressed and began to visit a psychologist in order to deal with this depression o during this time, Tarasoff was in Brazil and he told the psychologist that he planned on killing Tarasoff when she returned from her trip o psychologist alerted campus police and said he believed that Potter was dangerous o they admitted him to hospital, and they released him but didn't go back to therapy (relationship of trust was broken btw him and psychologist) o Tarasoff returned from Brazil and stabbed her o Her parents tried to sue university for failure to warn Tarasoff -> they LOST o They made their way up to supreme court of California, where they finally ruled that they therapist has the duty to warn o the psychologist type professions have this duty - but physicians DON'T have that same professional obligation in the way that therapists or social workers do o therapists and social workers can be sued for failure to warn, but not doctors

what typifies a good/virtuous doctor?

o bedside manners (= way that you care for the patients; viewing patient in humane way or for experimentation), honesty, full-disclosure, expediency, to try to see what is valuable to the patient and why

legal duties

obligations or standards of conduct toward other persons that are enforceable by law

unqualified confidentiality

patients should understand that no info about them obtained during treatment will be passed on to anyone else under any circumstances without patients consent

qualified confidentiality

patients should understand that some info about their treatment will be passed on to others under some circumstances without their consent (for not harming others, for law, or for benefiting public)

how should I determine the appropriate role of a child in medical decision-making? a) infants and young children

preschool children have no significant decision-making capacity - surrogate decision makers decide with child's best interest in mind -no level of decision making; depends on family and what family could bare

is it irrational for the Jehovah's Witnesses to refuse a transfusions? does their refusal warrant strong paternalism?

preserve autonomy of patient and dignity of physician

what do we do when we aren't capable of making a decision?

we often outsource (i.e. Religion) o i.e. acting in the way of religious leader or transcendental being - in a way, you can't be held responsible and don't have a choice