Clinical Ethics Test 1

Statutory Adult

In some states a minor can give consent for medical or mental health services involving diagnosis or treatment of venereal or other contagious disease, birth control, pregnancy, substance abuse, or out‐patient mental health treatment

Transparency model of informed consent

- Physicians avoid complex and contentfilled informed consents in favor of making transparent to the patient why they prefer and are recommending a given therapy, might mention a number of risks or even discuss an alternative modality, basically anything seen by the physician as significant factors in the physician's own decisionmaking process in a language the patient can understand. Also avoids hyperinforming ○ In general rejected for a variety of reasons: hard for physician to create recommendation without prior input from the patient, it ignores the possible personal choices of the patient, run the risk of the physician failing to include risks he finds normal but might cause patient to hesitate

Four main categories of surrogates:

1. designated proxies: previously designated by patient in living will or durable power of attorney for healthcare 2. family members 3. institutional committees: e.g. hospital ethics committees or volunteer committees for mentally ill patients with no families 4. the courts: last resort, can appoint surrogate to make decisions for patient

Biopsychosocial Model

The biopsychosocial model takes the commonly used biomedical model of describing patients in terms of diseases and adds physcological and social aspects of a person. Social, financial, spiritual, etc. aspects of patient are now just if not more important than actual disease itself.

Are there limits to patient autonomy?

Autonomy: · Respect of individual's views and rights as long as no harm comes to others · Rational individuals should be permitted to be self determining and to decide for one's self what to do, must be free from duress, coercion, force, manipulation (liberty of action), freedom of choice, and effective deliberation (informed consent) · Restrictions: The harm principle (prevent person from harming others), offense principle, the principle of paternalism (prevent a vulnerable person from harming self), extreme paternalism (act to benefit that person), principle of legal moralism (prevent a person from acting immorally), and the social welfare principle (act for benefit of others i.e. vaccines, STD treatment)

How does the Biomedical relate to the Biopsychosocial model?

Biopsychosocial is literally and addition upon the biomedical model. Biomedical model is looking at diagnosis, symptoms, treatment, etc. Biopsychosocial keeps the biomedical model but adds social, psychological, spiritual aspects into the interviewing and diagnosing process. Idea here is that diseases manifest themselves differently in people due to different aspects of a person's uniqueness; thus, they should be just as an important part of the process.

What is the difference b/t dmc in the clinical context and the notion of legal competence?

In the clinical context, 'decision making capacity' describes the functioning of sensory and mental powers to process data and draw conclusions. In the legal context, competence is the ability of a person to take care of him/herself and manage property; this is determined by a judge in court.

Persuasion

A patient is convinced to consent through the merits of reasons advanced by another person ○ ex) oWithin their recommendation of a plan of care clinicians almost always persuade the patient to some degree toward one choice based on knowledge and expertise.

What is the difference between withholding and withdrawing life‐sustaining treatments? Clinical differences? Ethical differences?

A preference for withholding treatment was also based on an argument that an important distinction lay between an "act" (leading to death) and an "omission" (leading to death). Withdrawing, in contrast to withholding, is seen as killing the patient. To withdraw seems to have more moral responsibility attached to it than to omit to act and let the disease take its course. Clinically: •Difference between engaging them removing a treatment vs. never starting it •Prohibiting withdrawal would influence decision to initiate treatment Ethically: •Relevance lies in the intentions of the agent and in the professional obligations of the agent

What are the primary components of the Hippocratic Oath? What is its core principle?

A promise: Of solidarity with teachers and other physicians. Of beneficence (to do good or avoid evil) and non-maleficence (from the Latin 'primum non nocere', or 'do no harm') towards patients. (In fact the well-known "first do no harm" phrase does not feature in the classical Hippocratic Oath.) Not to assist suicide or abortion. To leave surgery to surgeons. Not to harm, especially not to seduce patients. To maintain confidentiality and never to gossip. •Core principle: The physician should benefit the patient according to ability and judgment. •Components: •Help, or at least do no harm •Practicing as a physician is a calling •Oath of initiation: Loyalty to the professional group, handing down the knowledge to those who swore the oath Code: Three parts Dietetics Pharmacology Surgery: because back then it did more harm than good

Mature Minor

Adolescents have a right to participate to varying degrees, appropriate to their age and maturity in decisions about their health care. Legal

Are there limits to Beneficence?

Beneficence: · Duty to act in ways that promote the welfare of other people · Should not sacrifice your own selfinterest/welfare in providing beneficence, need to confer benefits/balance goods against harms

What are the guiding 'principles of biomedical ethics'?

Biomedical ethics: · Middle level principles: · Respect for autonomy - respect the capacity of individuals to choose their own version of the good life and act accordingly · Beneficence - foster the interests and happiness of other persons and of society at large · Nonmaleficence - refrain from harming others · Justice - act fairly, distribute benefits and burdens equally, resolve disputes by using fair procedures

What are the professional responsibilities defined by the charter on professionalism?

Commitment to professional competence · Commitment to honesty with patients · Commitment to patient confidentiality · Commitment to maintaining appropriate relations w/ patients · Commitment to improving quality of care · Commitment to improving access to care · Commitment to a just distribution of finite resources · Commitment to scientific knowledge · Commitment to maintaining trust by managing conflicts of interest · Commitment to professional responsibilities

What are the elements of competency/dmc?

Decision making capacity implies the ability to understand a situation and participate in deciding of the care and treatment. ○ Standards ■ Patient is judged capable based on the outcome of the decision. If decision reflects values that reject conventional wisdom, capacity can be called into question ■ Patient is judged capable based on his/hers category or status ■ Patient is judged capable based on his/hers functional ability as a decision maker ● Understand information relevant to the decision ● Communicate with caregivers about decision ● Reason about relative alternatives

DoctorCentered Interviewing

Doctor leads the discussion with the patient giving little thought to patients thoughts. More questioning on symptoms and treatments. Patient is object.

Behringer vs. The Medical Center at Princeton Informed consent

HIV‐positive surgeon who is also a patient because of his disease ■ As a patient, surgeon has the same rights to privacy as anyone else, and improper disclosure makes hospital liable. ■ As a surgeon, he must disclose his HIV‐positive status to patients during the informed‐consent process

If you had an HIV positive patient who was, through sexual contact, exposing an identifiable third party to the HIV virus, how would you respond?

I would respond by warning the third party. I would first give the patient an opportunity to tell the third party to tell the atrisk partner themselves with the understanding that if they did not cooperate I would inform them myself. It is ethical to breach confidentiality when there is serious and immediate danger to an identifiable third party.

How is a surrogate picked?

In most states have a set hierarchy to choose proxies. The first choice is always a designated proxy. The second choice is usually family members (spouse, adult child, parent, adult sibling...). If there is no family member act as a surrogate a surrogate may be appointed by the courts. As a last resort, judges can act as proxies.

Exceptions to Informed Consent

Legal requirements - public health laws or military directives Emergencies when there is no time for adequate disclosure and consent Waivers - when a patient leaves decision making to the physician or family member Therapeutic Privilege - controversial and rarely justified; the idea that giving people the truth about their diagnosis and expecting them to make an agonizing decision about treatment might devastate them.

Why does Mark Siegler argue that confidentiality in medicine is a decrepit concept?

Mark Siegler argues that confidentiality in medicine is a decrepit concept because the in the modern health care system many people have rightful access to a patient's medical records. Siegler estimates that at least 75 health professionals and hospital personnel have access to a patient's medical records. This is because the rise of health care teams, existence of third party payers and the expanding limits of medicine impact the level of confidentiality that can be maintained. No longer does a single physician is hold access to a patient's records and the responsibility to maintain confidentiality. Medical confidentiality still exists but not in the traditional sense.

When is it the duty of a psychotherapist to protect people who are not his/her patients (Tarasoff case)?

Obligation to nonpatient applies if the violence is foreseeable and a therapist can control the patient enough to prevent violence (to identified third party).

How​ ​are​ ​the​ ​terms​ ​'ordinary/extraordinary'​ ​treatment​ ​defined?​ ​Why​ ​are​ ​the​ ​terms 'proportionate/disproportionate'​ ​treatments​ ​preferable?​ ​How​ ​would​ ​you​ ​define​ ​'futility'? When​ ​is​ ​treatment​ ​to​ ​be​ ​considered​ ​futile?

Ordinary/extraordinary: •Morally required/obligatory vs morally expendable Proportionate/disproportionate: •Are the expected burdens proportionate to the expected benefits •More clear wording than (extra)ordinary terms; often used interchangeably though Futility: •The relationship among effectiveness, benefit, and burden of treatment in question

Define paternalism; is there a place for paternalism in modern medicine?

Paternalism: · Paternalism is some behavior that limits another person's liberty or autonomy for his or her own good and comes with an attitude of superiority. · As far as a place in modern medicine, a doctor should act paternalistic by serving the patient's best interests, but since physicians and patients don't necessarily share the same meanings and values, patient autonomy needs to be respected

PatientCentered Interviewing

Patientcentered interviewing puts the patient and not the doctor as the center point of the patientphysician visit. More humanistic.

What are the professionalism requirements of the Accreditation Council for Graduate Medical Education?

Professionalism requirements of Accreditation Council: · Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to: · Demonstrate respect, compassion, integrity, a responsiveness to the needs of patients/society that supersedes selfinterest, accountability to patients, society, and the profession, and a commitment to excellence and ongoing professional development · Demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices · Demonstrate sensitivity and responsiveness to patients' culture, age, gender, and disabilities

How is dmc determined?

Physician must understand determination of capacity is independent of diagnosis and that it can fluctuate ■ Ability to communicate choices in a committed fashion ■ Ability to understand relevant information ● Tell in own words information regarding situation ■ Ability to appreciate the situation and its consequences ■ Ability for rational manipulation of information ■ Capacity must be optimal with dangerous treatments as compared to easy, effective treatment ○ Depression, Children have other standards for capacity making ○ Incapacitation leads to a surrogate

Advantages/disadvantages of power of attorney

Power of attorney for healthcare: The capable patient appoints, in a written document, a surrogate decision maker, who the patient expects would make the same decision the patient would in a given clinical situation. The problem is, that there is an assumption that you've talked to the person who will be making these decisions. You want someone who is aware of your values, and you want them to know and accept the responsibility. When you designate another person to make your healthcare decisions, you risk their personal opinions influencing the decision‐making.

What are the main differences between principlism and casuistry?

Principlism: ethical decision-making that focuses on the common ground moral principles of autonomy, beneficence, non-maleficence, and justice Supports an abstract top-down decision making process Very mechanistic Deductive •Casuistry: reasoning used to resolve moral problems by extracting or extending theoretical rules from particular instances and applying these rules to new instances •Case by case or issue-based approach Encourages more of a bottom-up reasoning Builds on accumulated experience of dealing with a variety of cases Inductive

Main details of Tarasoff case

Prosenjit Poddar kills former girlfriend. Before so, threat was stated by him in a psychotherapy session with college mental health counselor. -Counselor followed standards and told superiors and attempted to get psychhold. ○ Court ruled therapist had duty to notify third party (Tarasoff), which was never done. ○ Courts made clear that central obligation is in confidentiality but that exception should have been made because of specificity of threat to identifiable third party. Thus, ruled confidentiality should have been breached and Tarasoff warned of threat

Tarasoff case impact on confidentiality

Radically altered the privacy and confidentiality considerations when the disclosure of the intent to act violently is made. ■ Traditional focus was on the patient, not the individual who has been threatened. Tarasoff flips this to the clinician having to consider how patient might be a threat to identifiable third party

What are the elements of informed consent?

Situation: an understanding of his/her medical situation ○ Treatment: an understanding of the treatment, its risks, and its benefits ○ Alternatives: a similar understanding of alternative requirements ○ No treatment: an understanding of the consequences of refusing treatment ○ Decision: an ability to define which values are important for him/her, weigh competing values, and reach a decision ○ Articulate a decision: an ability to communicate or be assisted to do so ○ Reasonable: the decision must be 'reasonable' ○ Durable: the decision must be durable

How did the Scholendorff v. Society of New York Hospital decision contribute to informed consent?

Specifics: Mrs. Scholendorff insisted that she didn't want surgery to remove a fibroid tumor, surgeon removed the tumor anyway while she was under anesthesia Importance: "Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient's consent commits an assault, for which he is liable for damages." Consequences: Made people aware of legal requirement for consent (however consent could still be misinformed or uninformed), nothing about knowledge. Could withhold info if you thought it might scare the patient

Salgo v. Leland Stanford Jr. contribution to informed consent

Specifics: Salgo suffered permanent paralysis after undergoing translumbar aortography. Sued his surgeon for failing to disclose the risk of paralysis. ○ Consequences: Court established the need for "informed consent" (for the first time in a major legal decision). Not complete success: The court tempered its ruling by acknowledging "physician discretion" in disclosing information. Discretion could not underlie info the pts. need to know to make a decision

Cantebury decision contribution to informed consent

Specifics: on the day after surgery he slipped and became paralyzed. US Court of Appeals was concerned that the surgeon might have failed to disclose the possible risks of paralysis ○ Importance: set forth the crucial aspects of informed consent in terms of telling patients about available treatments and their risk ■ Root premise: humans have right to determine what happens to body; surgeon required to disclose information necessary for an intelligent decision even if he is not asked ■ "Reasonable under the circumstances" release of information: whatever a reasonable person would find relevant to the decision ■ Allows for exceptions in emergencies and rare situations where disclosure would pose threat to pt wellbeing (latter referred to as therapeutic privilege) ex: severe depression or suicide

three main legal standards for surrogate decision making

Substituted judgment standard Best interests standard Reasonable treatment standard

Moore vs. Regents of the University of California Informed consent

Surgeon takes patients organs and uses for research ■ Court ruled that doctors have a duty to inform patients of research interests deriving from treatment. A person's consent to treatment requires complete information and physician has duty to disclose all information relevant to patient's decision.

How are patient-centered, doctor-centered, and biopsychosocial model related?

The biopsychosocial model can be looked at as the umbrella over which patientcentered interviewing falls under because they both include the patient with the disease, and the disease itself.

What must the physician discus and disclose

The medical diagnosis and prognosis if nothing is done All the medically accepted treatment options for their condition, as well as the risks, burden, and benefits, associated with each Recommendation for treatment plan and the reasons why they think it is best for the patient - necessary for shared decision making

Institutional/economic barriers to communication b/t clinicians and patients

The rapid emergence of managed care - pressure for shorter office visits, reduced physician utilization, termination of long standing clinician‐patient relationships and frequent changes in contracts and opinion ● Study of senior citizens revealed six barriers: anxiety, futility, time, reluctance to bother the doctor, language, and memory ● Race as a barrier: African Americans feel visits are less participatory ● Economic barriers: some patients can only afford to go to a research hospital where they feel they are being treated as guinea pigs. Because of this, a lack of trust is established between the physician and patient; personal histories or those of other patients have spread and lead to an uphill battle when decision making time arrives

Are there any exceptions to the right to refuse medical treatment?

Think of cases such as children of Jehovah's Witness parents refusing blood transfusions for a serious surgery · Social welfare principle - you need to act for the benefit of others. If not treating a patient will result in harm to society, you have an obligation to treat that patient (think STDs, Leprosy, etc.) · Finally, a patient can't refuse necessary medical treatment if he or she is not mentally capable of making an informed decision, i.e. under the influence of drugs, depression, effects of illness, etc. In this case, must instead act with the greatest benefit for the patient in mind

Discuss the use of placebos in medicine

Traditionally (before the 19th century), physicians would administer medicines that did not have physiological effect. However, with the rise of modern medicine, placebos fell out of standard practice. Today, it is usually unethical to prescribe a placebo to a patient, unless in the setting of a clinical trial. However, placebos have been shown to be effective against lowgrade chronic pain and mild depression.

Best interests standard

a. patient centered b. proxy decision maker weighs benefits versus burdens to make a decision c. considerations should include relief of suffering, preservation and restoration of function, and the quality and extent of life sustained d. applied to patients who have never been competent, such as children and patients with severe retardation, and patients whose opinion is not known e. goal of the proxy decision maker is to promote the welfare of the patient.

Substituted judgment standard

a. patient centered b. the patient's own values and definition of wellbeing are used to make healthcare decisions c. asks "what would the patient want?" d. The patient may have expressed a verbal or written prior directive or opinion about a similar healthcare situation which guides the surrogate's decision making

Reasonable treatments standard

a. provider centered b. used when proxy cannot either on substituted judgment or best interest standard c. e.g. proxy may decide to withdraw LST for a permanently unconscious patient

Manipulation

attempts to influence that are neither coercion nor persuasion ○ ex) Here the influence usually occurs with informational manipulation - playing with the data to change a person's understanding

Factors responsible for the shift in physicians' attitudes over the last 30 years toward truthtelling with cancer patients

availability of more treatment options for cancer (including experimental treatments) improved rates of survival from some forms of cancer fear of malpractice suits involvement of other disciplines/professions in healthcare altered societal attitudes about cancer increased attention to patient's rights, including the right to information overall, shift from paternalistic to patientcentered care

Harvard Criteria

criteria for brain death 1. unreceptive and unresponsive to all stimuli 2. no spontaneous movement of breathing a. persistent apnea after an interval of 3 minutes following discontinuance of mechanical ventilator 3. absent reflexes a. pupils fixed and dilated b. ocular reflexes and blinking absent c. no postural activity d. absent corneal reflex, swallowing, yawning, or vocalizing 4. isoelectric EEG a. repeated in 24 hours

whole brain death

irreversible cessation of all functions of the entire brain including the brain stem, no brain stem reflexes, no respiratory efforts after challenge, no responsiveness or voluntary movements

heart‐lung death

irreversible cessation of circulatory and respiratory function, no pulse or respiratory efforts, traditional standard recognized by law in all 50 states

higher brain death

irreversible loss of higher brain functions, these functions include: awareness/consciousness, ability to interact with fellow humans; permanently unconscious, permanently comatose, or those in a PVS; not recognized as a criterion for death

Emancipated Minor

minors who are married or who are not subject to parental control, definitions vary from state to state. In most states, this category includes college students and military personnel. Term also includes minors who are pregnant

Goals of medicine:

promotion of health/prevention of disease ● relief of symptoms, pain and suffering ● cure of disease; restoration of health ● preservation of life; preventing untimely death ● improvement of functional status or maintenance of compromised status'education and counseling of patients regarding disease and its prognosis ● avoiding harm to the patient in the course of care

Uniform Determination of Death Act

states that an individual who has sustained either irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain, including the brain stem, is dead

Coercion

when one person intentionally uses an actual threat of harm or force to influence another ○ ex) the threat of abandonment or refusal to do procedure X if procedure Y is not agreed to as well

Arguments for claiming that there is a difference between active killing and allowing to die:

the argument from beneficence: the consequences of the practice of permitting active killings would be worse than the consequences of permitting foregoing treatment the argument from the duty to avoid killing: there is something inherently wrong about killing the argument from autonomy and informed consent: letting die at the request of the patient or surrogate is always prima facie right because it is required to respect autonomy while respect for patient autonomy never calls for killing another

Arguments for claiming that that there is no difference between active killing and allowing to die:

the consequentialist argument: there is no difference because the results are the same

Persistent Vegetative State

total loss of cerebral cortical function with a functioning brain stem

Advantages/disadvantages of living will

‐Living will: Living wills may give instructions on limiting, withholding or withdrawing treatment, or instituting or continuing certain treatments when certain conditions are met. The problem with a living will is that it is a document. The wording is often ambiguous, leading to a lack of clarity and room for interpretation. If can feel like you are locking yourself into a decision and you must rely on your family or clinicians to make out your healthcare decisions. Living wills also do not cover all possibilities of your illness. They focus on LST, not holistic care.

Describe the practical problems that arise using the 'whole brain' oriented definition of death that is accepted by most states.

•Can fit criteria but still have EEG activity •Can fit criteria but not have permanent cessation of functioning of the entire brain •Test requires pt to not be hypothermic, but brain pts should be hypothermic •Difficult to diagnose in children (kids are 'more resilient') •Frequent HR and BP response to surgical incision •Some religious groups object

Hidding v. Williams informed consent

○ Patients signing a form of informed consent does not relieve the physician of liability if he failed to disclose significant risks of surgery ○ Surgeon's chronic alcohol abuse should be revealed to the patient, failure to make this disclosure constitutes violation of informed consent