Clinical Ethics 4480 midterm
Prima Facie
"Morally binding" duties unless in conflict with more important duties *Fidelity, Justice, Beneficence, Veracity
Nonmaleficence
-"Above all 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" 1) DO NOT kill 2) DO NOT cause pain or suffering 3) DO NOT incapacitate 4) DO NOT cause offense 5) DO NOT deprive others of the goods of life
Justice
-"Treating all individuals equally" In healthcare: 1)Proper distribution/allocation of resources *Due process 2)Equal benefits and burdens -3 types of Allocation of Resources 1)Distributive giving out resources that are scarce but desired by many 2)Compensatory loss is proportional to care 3)Procedural fairness in the process
Teleology/Utilitarianism Theory
-By Mill -Goal driven, assessing the context of the action [what is going on] -Ends count -"Most good, least harm overall" -An action is right if it promotes the best consequences most people -Means to an end -"CONSEQUENCES" -Maximize good for the greatest Ex: flu epidemic - we cant house everyone but can save some
Ethical Approaches: Ethics of Care Approach
-Making "real" contact -Building trust; building respect - "central" -Its about "the caring response"
Veracity
-Truth telling -Deontologists (Kant) holds veracity central; absolute to caring for the patient -Kant says; you MUST always tell the truth
Primary Principles of Communication
-autonomy -beneficence (make the situation better) -fidelity (faithfulness) -veracity (telling the truth)
What are the 3 questions a patient should ask?
1) "What is my main problem?" 2) "What do I need to do about it?" 3) Why is it important for me to do this?"
Fidelity
1) Faithfulness 2) Loyalty 3) Honoring Commitments Reasonable commitments = reasonable expectations 1)respect 2)competent 3)adhere to code of ethics 4)follow policies 5)honor agreements
Types of Communication
1) verbal 2) nonverbal 3) written 4) technological
Similes
A figure of speech that makes a comparison showing similarities between two things. Usually the words "like" or "as" are used in the comparison ex: She was as tall as a skyscraper
Ethical Dilemma
A situation that involves two (or more) morally correct courses of action BUT only one course can be taken
Step 5: Complete the Action
"ACT" Another critical point -"engage" -ask yourself what would happen if you did not act -need to identify concrete steps you need to take, then -need to ask why is my solution the best solution? -which one of the alternatives conveys the most convincing argument? How do I do this? -You need courage and resolve to proceed as you feel is ethically right
Step 2: Identify the Type of Ethical Problem
Moral distress = barriers *type A or type B Ethical Dilemma = 2 correct choices *doing something right; *also doing something wrong Locus of Authority = WHO *professional, institutional, traditional, authority of experience Value of this step: -being able to describe the type of problem, who the moral agent is, and the desired outcome help us to determine the details of the problem and what the potential conflicts are -provide support How do I do this? -Identify the moral agent, the course of action and the desired outcome
Moral Residue
Moral distress that tends to linger "that which each of us carries with us from those times in our lives when in the face of moral distress we have seriously compromised ourselves or allowed ourselves to be compromised"
Moral Distress Type B
Not sure what to do but you know something is wrong
Appreciate why communication can be hard for patients
Patients fear that providers won't like them if they ask too many questions. They may feel ashamed to admit not understanding certain medical terms or concepts. And, as I and many others know, when faced with health challenges, it's exceedingly difficult to think quickly and communicate clearly when feeling vulnerable and exposed. In other words, it's very hard to communicate when naked. (Osborne pg. 29-30) a. It is hard to think of questions to ask when you are exposed in a gown b. Many fear if they ask too many questions the providers will not like them so they don't ask them c. They feel ashamed to admit not understanding certain medical terms or concepts
If humor is used inappropriately...
Quickly apologize and let the other person know that you are not trying to be hurtful (Osborne pg. 79)
If in doubt, don't say it
Should be used in small doses, not to converse away from treatment and care There are times when humor is not appropriate, such as when people hear bad news, are angry, or are struggling emotionally. People may need to cry before they can laugh (Osborne pg. 78)
Six-Step Process
Step 1) Get the story straight: gather relevant information Step 2) Identify the type of ethical problem Step 3) Analyze the problem(s) Step 4) Explore the practical alternatives Step 5) Complete the action Step 6) Evaluate the process and outcome *Evaluation is important to see where you made mistakes and to learn from those mistakes
Health Literacy
The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions
Paternalism
What principle directly conflicts with Autonomy?
Fiduciary Relationship
a relationship in which a person has placed a special trust or confidence in another person who is required to act in good faith and in the interest of that person
Plain language
a. It is not about dumbing down the language but rather providing information in ways that MOST everyone can understand b. Use common one-syllable or two syllable words c. Be consistent d. Be conscious of value judgment words such as rarely and moderate; these words will have different meanings for different people e. Limit the use of contractions as they can be confusing
Texting/Email and Text messaging
a. Recognize not everyone might use it or feel comfortable using it b. Obtain consent to discuss medical information over email or texting c. It is not to be used for Emergencies
Know your audience: Older Adults
a. older adults are increasingly being diagnosed with acute illnesses and chronic conditions, emotional issues b. Hearing and vision are often impaired; speak slowly, clearly and concisely introducing one concept at a time c. CONFIRM. CONFIRM. CONFIRM UNDERSTANDING with feedback d. Ensure materials are readable; assess reading ability informally with red flags
Pay attention to the Ads: Direct-To-Consumer (DTC) Advertising
about medication is an example of how the popular media can affect clinical practice. Help your patients appreciate the influence of ads, such as how the picture of a cute teddy bear or sleeping baby on the label of children's medication may encourage parents to buy it (Osborne pg. 74)
Battery
act of offensive touching without the consent of the person being touched, however benign the motive or effects of the touching
Why should one not use family or friends as interpreters?
can lead to problems, as when an untrained interpreter inadvertently misinterprets a term or interjects his or her own opinion another concern is about violations of privacy and confidentiality children especially should not interpret for their parents of other family members - as doing so can place them in the midst of health conversations they shouldn't be a part of (Osborne pg. 82)
Durable Power of Attorney
documents designed to enable patients to specify a surrogate or proxy decision maker who they want to make the treatment decisions when they are no longer able to make them -surrogate who knows the patient's values, wishes and life plan -only for medical issues (not financial) -Usually notarized
Living Wills
documents designed to enable patients to specify the types of treatments they would want to have and, more importantly, not have -activated if terminal and incapacitated -can be rescinded at any time
Advanced Directives
general idea is to allow persons while still competent to make their wishes known regarding decisions that will be made at a time when they become legally incompetent, especially in illness that will end in death types: -living wills -durable power of attorney documents
Purpose of using Interpreters
help bridge language gaps between provider and patient (Osborne pg. 81)
Health Insurance Portability and Accountability Act (HIPAA)
identified as confidential pieces of information: -identification (name, address, gender, occupation, date of birth, martial status, etc.) -medical info (diagnosis, condition, medications, treatment details) -social info (family/social relationships, housing, occupation) -psychological info (emotional state)
Question Asking
is a learned skill it is important to "insist" that patients ask questions
Humor and Healing: purpose of Humor in health care setting
occasions when a dose can: -help build rapport -facilitate learning -improve understanding a powerful tool that providers can use to enhance communication and demonstrate compassion and humanity (Osborne pg. 78)
Implied Consent
patients in need of emergency treatment -situation must be life threatening or pose a risk of significant physical injury if procedures not performed -only procedures that are absolutely necessary can be performed
Idioms
phrases that mean something different from their actual words; generally have a special meaning to people from a certain region or culture ex: "an arm and a leg," "out cold," "under the weather"
Assault
placing someone in immediate fear or apprehension of harmful or unpleasant touching without the person's consent to commit; a person must be aware, or fearful that you are about to touch him or her
Why do health care providers use acronyms?
refer to shortened ways of referring to longer, more complicated terms can be very efficient when talking with peers or entering data into medical charts usually take the first letters of each word in a phrase to create something new
Compensatory Justice
refers to the extent to which people are fairly compensated for their injuries by those who have injured them -to justly compensate is to provide a replacement that is "proportional" to the loss "compensation" -to make up for -assumes equitable distribution of resources should be based on more than just medical need -acknowledges that some persons are socially disadvantaged in ways that puts a moral claim on the larger community -assumes a deep interdependence of people in society -involved those members of society who are dismissed or even disdained by members of mainstream society even though they contribute in ways that society needs for its overall well-being Compensatory justice *medical need >lifestyle >societal position
Distributive Justice
refers to the fair, equitable, and appropriate distribution of resources -comparative treatment or allocation of benefits and burdens to group or individuals (tangible)
Communication
the most common procedure in medicine YET the most common reason for ethical issues is due to lack of communication vital to the delivery of comprehensive healthcare a learned skill
Informed Consent
the right of every competent adult to make their own decisions regarding his or her body and medical care protects against paternalism
Privacy
the right of individuals to keep information about themselves from being disclosed
False Imprisonment
the unlawful detention of a person, in which that person is deprived of personal liberty of movement against his or her will and without any authority to detain a) restraints 1) chemical - medication 2) physical - tie someone down
Purpose of Communication
to SHARE information involves active listening, responding, validating, educating, collaborating, coordinating, decision making and partnering maintains trust and dignity
Homonyms
words that sound alike and may or may not be spelled the same way, but have very different meanings ex: "stool," "gait," "dressing"
Telling stories in health care
*Stories typically have a beginning, middle and end* Takes practice to be good at it Ensure the story is relevant to the situation
Paternalism
-"Intentional overriding of one person's known preferences or actions by another where the person [moral agent] who overrides justifies the action by the goal of benefiting or avoiding harm to the person whose preferences or actions are overridden [patient]." -Limitations: 1)"Value" judgments should be made by the patient - Quality of Life 2)Assumes you have the right to make a choice for the patient bc health professionals have more knowledge 3)Conflict between patient's choice and professional judgment *belief that patients can't make wise medical decisions *but if the are informed then..... 4)Physicians might seek to override a patient's wishes bc of his/her psychological and emotional reactions to a case
Deontology/Duties
-Absolute *Duties binding at all times *avoid wrong doing others, treat people as equals, and promote the good of others -Prima Facie -Conditional *Obligated to perform a duty only after certain conditions are met
Autonomy
-Allowing an individual the freedom of choice and action: "self-rule" , "self-determination" -A legitimate moral right, independence, freedom -Intentional -"Justifies the doctrine of informed consent" -It is at the heart of the patient-centered care -NOT ABSOLUTE *Limitations on exercising - impact of patient's decisions; on society-is it rational? Do they understand the implications
Virtue Theory
-An action is right if it is what a virtuous agent would do in the circumstances -A virtuous agent is one who exercises his or her virtues -People (moral agents) -Aristotle -Primary idea behind this theory is whether the person acting is expressing good character or not -They are "second nature" -"Right action, Right motive" -Virtues are our character traits; desirable, admirable, "feel good" -Socially approved
Talking to patients about what they learn from the media
-As a healthcare provider it is important to stay current; keep up with news especially information related to health care *pay attention to the news *pay attention to the ads *pay attention to the shows *pay attention to spikes in phone calls
Deontological Theory
-By Kant -Duty Driven -Rights, Respect, Duties -An action is right if it is in accordance with a moral rule or principle -Morality is grounded in reason, not tradition, intuition, conscience, emotion or attitudes -Since we cannot control the outcome of our actions...the morality of an act must be judged based on the motive or intent of the actor -Act "it is your duty" -Focused on autonomy -Everybody counts
Moral Distress
-Like a blockade -"A knot in the pit of your stomach" -Due to a hinderance -Founded by nursing -Issue: a sign that ethical issues are not being addressed adequately -Addressing requires identification of social and organizational issues, and questions of accountability and responsibility -"Occurs when...one knows what is best for the patient but that course of action conflicts with what is best for the organization, other providers, other patients, the family, or society as a whole. Thus ______________ occurs when the internal environment...health professional values and perceived obligations -- are incompatible with the needs and prevailing views of the external work environment" Characteristics: -Constraints on their behavior; lead to compromise -Conflicts -Emotional Constraints- FEAR, frustration, and anger -Isolation -Devalued, unheard -Positive effects: increase your awareness of ethical problems -Negative effects: moral residue, burnout, suicidal ideation, depression
Standards of Care
-Medical guidelines or psychological guidelines and can be general or specific -specific "appropriate" treatment protocols based on scientific evidence, and collaboration between medical and/or psychological professionals involved in the treatment of a given condition
Ethical Approaches: Storytelling/Case Approach
-Narrative -Emphasizes relationships *Patient-centered *Power differences -Relevant information *How do you decide what is relevant information? *2 CONSIDERATIONS 1) Story will vary depending on WHO tells it 2) Power - How does power affect a narrative?
Health Literacy: Why is it important?
-Patients need to understand health information quickly bc they have less face-to-face time with their providers -Patients, along with their family members and other caregivers, are expected to correctly accomplish a wide array of health-related tasks -Patients must be active learners -Patients are increasingly seen as active consumers rather than passive recipients of treatment and care
Key points about the Teach Back Method
-Recognize that individuals remember approx. 50% of what they are told in a health encounter -Body language, eye contact, and tone of voice are also important in communication
Beneficence
-Reflects responsibilities to contribute to the welfare of the patient by simply doing good, being proactive and "preventing further" harm when possible "Try to make it better"
Locus of Authority
-WHO should have the authority to make an important moral decision -WHO is the best person to make the decision? The patient is always the best person to make the best decision
When confronted with news in the media:
-confirm what is true especially if the information pertains to DTC (direct-to-consumer) advertising -write a message that you will provide to everyone who calls with concerns about the information; ensures everyone obtains the same information
Benefits of blogging
-this type of media reaches traditionally undeserved populations two new populations are "jumping online" 1) non-college-educated 18-to 30-year-olds who are connecting via mobile phones rather than computers 2) older adults (60 years old and over) who are becoming more interested in and comfortable with technology, especially computers
Results of using media for health care
-unrealistic expectations -DTC advertising
Health Literacy: Red Flags
1) Consistently have "headaches" or chronically "forget" their eyeglasses when asked to perform reading tasks 2) Often say their hands hurts and will fill out paperwork at home 3) Regularly ask family members, friends, or others to read written materials aloud 4) Identify medications by looking at the pills themselves, rather than reading prescription labels 5) Ask a lot of questions about topics already covered in handouts and brochures
Ethical Approaches: Principle-Based Approach
1) Nonmaleficence 2) Beneficence 3) Autonomy 4) Fidelity 5) Veracity 6) Paternalism 7) Justice -Guidelines that offer support for the best decision. Guidelines that will give you the confidence to know that the course of action you have chosen is the right one
Teach Back Method (Interactive Communication Loop)
A way to assess and confirm whether patients truly understand the provider's spoken words Providers can use this technique to assess a patient's recall and comprehension of important concepts just discussed. If the patient does not understand a concept correctly or completely, then the provider restates or tailors the message to make it more accessible. The provider again assesses the patient's comprehension and continues this process until it is clear that the patient understands. (Osborne pg. 41) -- Hence the alternative name
Metaphors
A word or a phrase that is used to make a comparison between two people, things, animals, or places Save metaphors for those times when you are teaching something that is unfamiliar or hard to understand ex: I have too much on my plate
Burnout
Long-term exhaustion and diminished interest, usually related to work Characteristics: -inability to cope with emotional stressors at work -excessive use of energy leading to feeling of failure and exhaustions
Analogies
Both metaphors and similes are types of analogies. An analogy is a similarity between like features of two things.
Step 4: Explore practical alternatives
Brainstorm -confer with colleagues Ask yourself: -which option will produce the most good and least harm? (Utilitarian approach) -which option best respects the rights of all who have a stake? (rights such as autonomy) -which option treats people equally? (justice) -which option best serves the community? (Utilitarian approach) -which action leads me to act as the sort of person I want to be? (virtue approach, deontological approach) How do I do this? -Use your life experiences and creativity to figure out what to do
What does CHAT stand for?
Choosing Health plans All Together
Communication vs. Confidentiality
Confidentiality is about HOLDING information Communication is about SHARING information
Step 3: Use Ethical Theories or Approaches to Analyze the Problem(s)
Deontological *Scientific *Narrative *Interactive *Conditional *Pragmatic *Ethical Teleological/Utilitarianism Principles *Autonomy *Justice *Beneficence *Nonmaleficence *Paternalism *Fidelity *Verasity Value of this step: -using ethical theories help us explore the situation in more detail. It is still too soon to make a decision. In fact, after analyzing the different elements of the problem, we do additional brainstorming and may determine new pathways of actions which occurs in the next step How do I do this? -Remember your ethical principles (justice, autonomy, etc.) and take means and ends into account
Help patients ask questions
Encourage patients to anticipate questions they want to ask. You can help by giving patients tools like notepads to write down their questions about diagnoses, treatment, and medical instructions. Make sure to leave room for patients to also write down your answers. And please provide a pen, pencil and clipboard or other hard writing surface as these items are increasingly hard to find in examining rooms today (Osborne pg. 30)
Interpreters vs. Translators
Interpreters convert the spoken word from one language to another Translators convert the written word - can include translating discharge instructions, patient's rights, informed consent documents, medical bills, and even sign or maps that help newcomers find their way around unfamiliar places (Osborne pg. 81)
Step 1: Get the story straight/gather relevant information
THE MOST CRUCIAL STEP -be specific -be objective -examine problem from several perspectives -clarify known facts and beliefs Value of this step: -if enough information is not gathered, we may end up making a wrong assumption which would make it difficult to come to a caring response that would fit this particular situation 1) first ask is situation is ethical, legal or medical 2) is the situation related to me and what i am doing 3) is the situation related to the client? 4) is the situation related to the institution and their policies and procedures? Possible ways to gather this information: -narrative reasoning -scientific reasoning -interactive reasoning what are the medical facts? what are the medical professions concerns? what are the patients and family concerns? How do I do this? -Pay attention to the details for ethical content
Why use stories in health care?
They are powerful health communication tools: increases awareness and brings connection to the situation through facts and emotions
Moral Distress Type A
Unable to do what you know is right
Step 6: Evaluate the Process and Outcome
You will never learn from a situation unless you evaluate it because every situation involving ethical issues is different BUT these issues can and will happen again Ex: Rounds (M&M) Value of this step: -to see what you did well, what you want to repeat -DO NOT WANT TO RE-INVENT THE WHEEL How do I do this? -Reflect on the situation, decisions and outcome. Decide if you could have handled the situation better and what can be learned from this situation for next time
Know your audience: Children and Youth
a. Use humor, real-life examples to help prepare the child for a test, procedure b. Encourage laughter using favorite TV characters or pop singers c. Play games or use puppets as part of an exam d. Use age appropriate ways for children to participate in health