Clinical Ethics Midterm

Withholding vs. Withdrawing LST

-Withdrawing life sustaining treatments may be more emotionally difficult and feel more active than withholding them because the HCP performs an action that hastens death -The distinction is often meaningless (withdrawing G-tube vs. withholding nutrition) -Ethical relevance lies with the intentions and professional obligations of the agent -Prohibiting withdrawal of LST would influence the decision to initiate such treatment; trials of therapy

specific exceptions (rare) for use of a placebo (3)

-the condition is known to have a high placebo response rate -the alternatives are ineffective and/or risky -the patient has a strong need for some prescription

Futility

-the relationship among effectiveness, benefit, and burden of the treatments in question -Effectiveness = assessment of the capacity of the procedure to alter the natural history of the disease at this point in time -Benefit = determined by the patient's/surrogate's assessment of the value or desirability of the treatment's result -Burdens = costs, discomfort, pain, inconvenience of the treatments in question experienced by the family

President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research (definition of functional standard)

-Understand the information relevant to the decision -Communicate with caregivers about the decision -Reason about relevant alternatives, against a background of reasonable stable personal goals and values

Principle of Human Dignity

-The intrinsic worth in every human being (rooted in Imago Dei) -Basis for human rights

Appelbaum and Grisso (definition of functional standard)

-Ability to communicate choices -Ability to understand relevant information -Ability to appreciate the situation and its consequences -Ability to rationally manipulate information (CUMA)

Principle of Respect for Person

-All people are presumed to be free and responsible persons and should be treated in proportion to their ability -Those with reduced autonomy are entitled to protection via human dignity and justice

What Must be Disclosed? (7)

1. The nature of the therapy 2. The purpose 3. The risks and consequences 4. The benefits 5. The probability that the therapy will be successful 6. The feasible alternative 7. The prognosis if the therapy is not given

Higher Brain Death

-An individual dies when there is irreversible loss of higher brain functions -Loss of ability to interact with other humans, awareness/consciousness, reason, memory, act morally, feel, imagine -Death occurs when unconsciousness is irreversible Includes: -Permanently comatose, PVS, and anencephaly

Uniform Determination of Death Act

-An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all function of the entire brain including the brain stem is considered dead -A determination of death must be made in accordance with these accepted standards

Living Wills

-An advanced directive that reveals what kinds of treatments a would or would not want in certain circumstances -Most are vaguely worded limitations of treatment, while others have specific desires for treatment Issues: -Often not helpful for making specific decisions -The condition encountered is often not addressed in the living will -Person may have previously written against a treatment, but actually would choose the treatment when faced with the actual situation -Reserved for only terminally ill patients -No penalties legislated if providers choose to ignore them -Document may be a forgery

Durable Power of Attorney for Healthcare

-A document in which a person designated someone they would trust to make treatment decisions if the patient were to lose capacity -The document is the principle, the designated person is the agent Issues: -Does the agent actually know what the patient wants? -The principle document may or may not contain treatment wishes

Whole Brain Death

-An individual dies when there is irreversible cessation of all functions of the entire brain (including the brain stem) -No brain stem reflexes, no respiratory efforts, no responsiveness or voluntary movements -Endorsed by AMA, Law in 48 States

Statutory adult

-A person who has attained the age of majority -The age of majority is the legally defined age at which a person is considered an adult, with all the attendant rights and responsibilities of adulthood -The age of majority is defined by state laws, which vary by state, but is 18 in most states -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

Medical Care Directives

-A written directive indicating the type of care an individual wants, should they become incapacitated -Considers what type of medical condition may occur, what treatments are available, and what treatments are desired Issues: -It is impossible to anticipate every medical problem -They are depressing to create -A patient would need hours of instruction to understand all the possibilities

Differences in Decision Making Capacity (Medical Context)

-"Capacity/Incapacity" are used to describe the functioning of the sensory and mental powers to process data and draw conclusions -Incapacity can be either developmental or pathological

Differences in Decision Making Capacity (Legal Context)

-"Incompetence" - when an individual is judged by a court to be completely unable to take care of themselves and manage property -"Incapacity" - used to describe an individual whose physical or mental limitation do not entirely restrict their cognitive abilities or life activities

Heart-lung Death

-A cardiopulmonary oriented definition -Permanent/Irreversible cessation of the flow of vital body fluids -No pulse or respiratory efforts -No one can suffer clinical death and recover -Traditional Standard, Recognized in 50 states Pronouncing death: -Ascertain code status, check for hypothermia/drug OD, check for respirations or heart tones, check corneal reflexes, document TOD

Biopsychosocial Model

-Articulated by George Engel in 1977 -The biopsychosocial model proposes that biological, psychological, social, and structural processes operate in a matrix of nested and connected subsystems that influence all aspects of mental and physical health. -The biopsychosocial model is the only model that sufficiently meets the demands of compassionate care

Casuistry

-Case-based Reasoning -Coined by Jonsen and Toulmin -Describes a case-based approach to ethical conflict -Stresses the pivotal role of the particularity of cases -De-emphasizes the role of theory/routine appeal to principles -Begins with typology/grouping of cases around a paradigmatic instance of a moral rule or principle -Weight lies in the details -Inductive, Bottom Up

Older, largely rejected meanings of 'ordinary v. extraordinary'

-Common v. uncommon -Simple v. complex -Cheap v. expensive

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

-Efforts to preserve confidentiality in the way it was previously defined are doomed to failure, as many as 100 health professional read medical records during hospital stays -Rather than to perpetuate the myth of confidentiality we would be better off determining which of the original aspects of confidentiality are worth retaining

Determining capacity

-For easy effective treatments that are not dangerous and are in a patient's best interest, awareness and assent may be all that is required -For less certain treatments, when the diagnosis is doubtful, the condition is chronic, or the treatment is more dangerous or less effective, the patient must be able to understand the risks and benefits of the options and make a decision -For dangerous treatments and treatments that run counter to professional and public rationality, the patient is required to show the highest standards of understanding and judgement

How does the biomedical model relate to the biopsychosocial model?

-In contrast to the biomedical model, which focuses solely on physiology, the biopsychosocial model of illness supposes that a dynamic interaction of the biological, psychological, and social variables accounts for the predisposition, onset, course, and outcome of all illness. -Molecular Biology is the hub science of the biomedical model. -The biomedical model assumes that disease is completely explained through biological variables and neglects the social or psychological dimensions of illness.

White (definition of functional standard)

-Informability (receive information, recognize relevant information, remember information) -Cognitive and affective ability (relate situations to oneself, reason about alternatives, rank alternatives) -Resolution and resignation (select and option) -Recount one's decision-making process

Inadequate reasons for claiming there is a difference b/w active killing and allowing to die (3)

-Intuitively feels like there is a difference -Active killing is illegal in all jurisdictions -Physicians have strong reservations about active killing

Principle of Material Cooperation

-It is impossible for an individual to do good in the world without being involved in some evil -Cooperation must be mediate material, never formal or immediate material -Mediate Material cooperation occurs when the cooperator participates in circumstances that are not essential to the commission of an action, such that the action could occur even without this cooperation

Paternalism: is there a place for paternalism in modern medicine?

-Locus of decision-making = health care professional; has moral authority; parental or priestly model (active vs. passive, order vs. obey) -Patient autonomy = patient agreement -Once the dominant model of health care (shift to shared decision making) -Shift due to increased respect for patient autonomy -Competent patients have the right to refuse treatment -Physicians and patients don't necessarily share meaning and values -Interaction ensures that patients receive the intervention that best promote their health and well-being BUT assumes shared objective criteria for determining what is best

Problems with 'Whole Brain' Death

-Many who fulfill the criteria still show EEG activity -Many who fulfill the criteria do not have a permanent cessation of functioning of the entire brain -Tests require that patients not be hypothermic, but brain-dead patients should be hypothermic -Difficult to diagnose in children -Frequent response to surgical incision with rise in HR and BP -Counterintuitive - 'Not Dead Yet' -Some religious groups object - where does consciousness objection fit in? What makes a person?

Emancipated Minor

-Minors who are married or who are not subject to parental control -They may be self-supporting and living on their own -In most states, this category includes college students and military personnel -Minors who are pregnant or married are often considered emancipated and able to consent for themselves and their children

Mature minor

-Person younger than 18 years of age, who nonetheless possesses an understanding of the nature and consequences of proposed treatment -Adolescents have a right to participate to varying degrees, appropriate to their age and maturity, in decisions about their healthcare

Principlism

-Principles approach -Coined by James Childress -Describes any principle-based approach to resolution of ethical conflict -Principle are generally derived from traditional ethical theories -Deductivist, Top-down Advantages: -Each principle is consistent with a number of moral theories -No one principle enjoys automatic supremacy, weigh and balance principles in each case Disadvantages: -Too mechanistic and principles need to be interpreted to give meaning -No pre-established theoretical weights

The Transparency Model

-Proposed by Brody as a model for disclosure in informed consent not based on previous standards -The clinician discussed why the treatment is recommended over the alternatives, the patient is allowed to ask questions suggested by the disclosure of the clinician's reasoning, and those questions are answered to the patient's satisfaction. -Disclosure is adequate when the clinician's basic thinking has been rendered transparent to the patient.

Manipulation

-Represents attempts to influence that are neither coercion or persuasion -The influence usually occurs with informational manipulation - playing with the data to change a person's understanding

What are the limits to beneficence?

-Should individuals sacrifice their own self-interest and welfare to do good for others? -Conflicts between medical and non-medical benefit

Selecting a Proxy

1. Designation by the patient before decision-making capacity is lost 2. Common law practice of designating family members as proxies 3. Friends, significant others 4. Court appointment of a legal guardian: -When there is a disagreement among the family -When there are no family members or friends available -Court procedures become adversarial proceeding and complex 5. Judges as proxies

Exceptions to the Requirement of Informed Consent (5)

1. Emergency -When the patient is in a life-threatening situation and unable to consent 2. Incapacity -When the patient is unable to consent, the process must include a surrogate decision maker 3. Patient Waiver -When the patient waives the right to know, the physician must be sure that this is what the patient wants 4. Therapeutic Privilege -When fully informing the patient poses a significant threat to the patient's well-being, not because it will make the patient feel upset or depressed (only used in rare circumstances) 5. National/State Waivers -When the federal or state government waives informed consent for vaccination programs, newborn genetics screening, and so forth (NIPET)

Various Types of Advanced Directives

1. Living Wills 2. Medical Care Directives 3. Durable Power of Attorney for Healthcare

What are the primary components of the Hippocratic Oath?

1. Oath of Initiation: a vow of allegiance to physician's teacher, a pledge to loyalty and secrecy 2. Code/Prohibitions -Prohibition on surgery -Prohibition on Giving Deadly Drugs -Prohibition on Abortifacients

Guiding Principles of Biomedical Ethics (4)

1. Respect for Autonomy -Respect the capacity of individuals to choose their own version of the good life and act accordingly 2. Beneficence -Foster the interests and happiness of other persons and of society at large 3. Nonmaleficence -Refrain from harming others 4. Justice -Act fairly, distribute benefits and burdens is an equitable fashion and resolve disputes by means of fair procedures (Resting B*tch New Jersey)

What are the Legal Standards for Disclosure?

1. The Professionalism Standard -Requires that the physicians disclose only what other physicians would disclose in similar situations, paternalistic. 2. Reasonable-person Standard -If an average, reasonable person would decline to proceed with treatment in the face of fully disclosed risks, the physician who fails to make appropriate disclosures can be liable for any injuries that follow the treatment provided. -Considered impossible to satisfy

What are the basic goals of medicine (5)?

1. The prevention of disease and injury and the promotion and maintenance of health 2. The relief of pain and suffering caused by maladies 3. The care and cure of those with a malady and the care of those who cannot be cured 4. The avoidance of premature death and the pursuit of a peaceful death 5. The education and counseling of patients regarding disease and prognosis

When does the duty of a psychotherapist to protect people who are not their patient apply?

1. The implication of this ruling is that a duty to warn third parties of imminent threats trumps a duty to protect patient confidentiality, however, it is usually difficult for a therapist or health care provider to accurately ascertain the seriousness and imminence of a threat. 2. Tarasoff has subsequently been interpreted to endorse the provider's duty to warn when a patient threatens an identifiable victim. 3. State law requires the report of certain communicable/infectious diseases to the public health authorities. In these cases, the duty to protect public health outweighs the duty to maintain a patient's confidence.

Professional Responsibilities Defined by the Charter (3)

1. The primacy of patient welfare 2. The primacy patient autonomy 3. The primacy of social justice

Factors Causing a Shift in Physicians to Truth-Telling (8 factors)

1. Availability of more treatment options for cancer (including experimental treatments) 2. Improved rates of survival for some forms of cancer 3. Fear of malpractice suits 4. Involvement of other disciplines/professions in healthcare 5. Altered social attitudes about cancer 6. Increased attention to patient right, including the right to information 7. Better understanding of the death process and effective communication with the dying 8. The impact of medical literature encouraging frankness

Exceptions to the Right to Refuse Medical Treatment (6)

1. Children, can't decide for themselves, parents can't deny live-saving treatments for children 2. Adolescents, lack life experience and decision-making capacity 3. Parents of solely dependent children 4. Pregnant Patients, rights of fetus 5. Patients who are Incompetent, lack decision-making capacity or suffer from mental illness 6. Surrogates, when their decisions contradict the patient's best interests (CAPIPS)

Professional Requirements of the ACGME (3)

1. Demonstrating Professional Conduct and Accountability -How physicians present themselves to their peers and patients -Dress appropriately and have cleanliness -Be honest, accountable, admit errors, be ethical 2. Demonstrating Humanisms and Cultural Proficiency -Honor the humanity of the patient, be respectful, display empathy -Maintain privacy of the patient 3. Maintaining Emotional, Physical, and Mental Health, and Pursues Continual Personal and Professional Growth -Physicians should set an example for their patients -Life-long learning approach to the practice of medicine

Who Makes the Decision? (4)

1. Designated Proxies -The patient may previously and voluntarily designate a proxy in a living will or durable power of attorney 2. Family Members -Family members are generally concerned with a patient's interests and is aware of the patient's values and goals -The NJ Supreme Court suggest that family members are the best surrogate for the patient 3. Institutional Committees -Act as formal, informal, or advisors to decision makers -NY State volunteered this as a system of surrogacy for mentally ill patients with no family 4. The Courts -Often cumbersome, unfamiliar with patient's goals, and heavily favor the physician's viewpoint -NJ Supreme Court finds that the courts are not a substitute for surrogacy, but a last resort

Elements of Informed Consent (3)

1. Threshold Elements (Preconditions) -Capacity (to understand and decide) -Voluntariness (in deciding) 2. Information Elements -Disclosure (of material information) -Recommendation (of a plan) -Understanding (of disclosure and recommendations) 3. Consent Elements -Decision (in favor of the plan) -Authorization (of the chosen plan) (TIC)

The Main Institutional and Economic Barriers to Effective Communication

1. We reward action and not communication. Communication among care providers is not always encouraged or fostered. 2. Six Issues that Negatively Affect Communication in Patients -Anxiety (feeling intimidated) -Futility (unable to make a difference in the relationship) -Time (the doctor is always busy) -Reluctance to bother the doctor -Language (medical jargon) -Memory (forgets to talk about an issue) 3. Race and ethnicity 4. Complexity of the Modern Health-care system, Tertiary-care centers

Is it justifiable to deceive a patient with a placebo?

The deceptive use of placebos is not ethically justifiable. There is strong moral obligation to honesty and truthfulness. It poses danger to the physician-patient relationship.

Saikewicz

Background: -(1977, Mass) -The patient was 67 and profoundly mentally retarded. -He was diagnosed with leukemia. -The court appointed a guardian to determine whether the patient should receive the chemotherapy treatment. -The guardian argued against the treatment since it is less successful in older patients. -The treatment is painful and debilitating and the patient would not be able to understand or withstand the treatment. -The court agreed. Implications: -The court pointed out that incompetent patients should not be denied the right to refuse treatment. -In this instance, since the patient's desires are not known, the best interest standard should be followed.

Herbert

Background: -(1983, California) -Doctors Nejdl and Barber where charged with murder following the death of Herbert. -Herbert went into cardiac arrest following surgery, was on a respirator for three days, and the respirator was eventually removed along with nutrition with the family's consent. The patient died days later. Implications: -The charges against the doctors were dismissed. -The courts stated that in the case of a permanently unconscious patient decisions should be based on whether potential benefits outweigh the expected burdens. -The courts also found that family members can act as appropriate surrogates.

Linares

Background: -(1989, Illinois) 8-month-old, Linares swallowed a balloon and suffocated. -He was placed on a ventilator. -He was comatose and likely PVS. -Against the wishes of the parents, the hospital refused to take Linares off the respirator. -At gun point, the father held back hospital staff and police and unplugged his son and he later died. -The father was charged with murder Implications: -The grand jury threw out the murder charges. -This cased deals with surrogate decision-making for minors.

Wanglie

Background: -(1991 Minnesota) -86-year-old patient in a PVS on a ventilator. The husband did not accept the irreversibility. The staff proposed the cessation of treatment, but the husband refused. Implications: -Court ruled that guardianship should rest with the husband as "the most suitable and best qualified person" to make decisions for the patient -Case was important due to guardianship decision. -Court did NOT rule on the merits of "futile care"

Patient-centered interviewing

Focuses on four principal dimensions of patients' experiences: their ideas about what is wrong with them; their feelings about their illnesses, especially their fears; the impact of their problems on functioning; and their expectations about what should be done

Baby K

Background: -(1993, Virginia) -The baby was born with anencephaly and was permanently unconscious. -The baby did have primitive reflexes. -The baby was placed on a ventilator. -The hospital encouraged a DNR order and to discontinue ventilation treatment, but the family refused. -The baby was eventually weaned from the ventilator but relapsed. -The hospital filed suit to allow future refusal to provide Baby K with LST (ventilator) and not violate Emergency Medical Treatment and Active Labor Act (EMTALA) Implications: -The court ruled against the exception for the EMTALA act because the court refused the hospitals assertion that such stabilizing treatment is futile or inhumane -By withholding the ventilator, the hospital would violate the Rehabilitation act and the ADA act -Hospitals, in accordance with EMTALA, must provide care if the patient or surrogate desires such treatment even if the hospital feels that the treatment is futile

Schiavo

Background: -(1997, Florida) -The wife was found unconscious due to potassium deficiency. -She was PVS and the wrote a DNR order. -The husband petitioned the court for the removal of the ANH tube on the basis that the wife would not have wanted LST. -In 2000, the court approved the removal of the feeding tube, based on the clear and convincing evidence that Terri had specifically expressed a desire to refuse LST. -The wife's parents opposed, claiming there was no PVS and that the wife would want LST. Implications: -The Supreme court ruled for the withdrawal of ANH, but the state governor reversed the decision. -This was the first time the legislative or executive branch and not the judicial branch made the decision. -the patient ultimately can decide whether to have life sustaining treatment removed

Quinlan

Background: -(NJ, 1976) -Quinlan was in a coma from alcohol and drugs. -She required feeding from a nasogastric tube and breathing required a respirator. -She was diagnosed as being in a persistent vegetative state, PVS. -Family wanted to disconnect the ventilator; the hospital refused. Implications: -Initial ruling rejected the argument that there was a difference between ordinary and extraordinary means to sustain life and sided with the hospital. -The NJ Supreme Court ruled that there is a distinction between ordinary and extraordinary efforts to preserve life, and that the ventilator constituted extraordinary means and could be removed -Majority now agree that ethics committees have little authority and must respect the decision-making authority of patients, surrogates, and family.

Wendland

Background: -(2001, California) -Wendland was profoundly brain-damaged from a car accident. -He emerged from a 16-month coma with major cognitive impairments and no bowl control. -He could not communicate. -Physicians believed that he would not improve. -He was receiving artificial nutrition and hydration (ANH) through a J-tube. -The family asked for the tube to be withdrawn and let Robert die with the support of the hospital. -The mother however opposed it and sued. Implications: -The judge ruled that the proof of Robert's wishes was not sufficient enough to terminate LST. -Court created the Wendland standard, which is, a conservator (legal guardian in CA) prove by clear and convincing evidence that conservator's decision either tracks the conservatee's own previously stated wishes precisely or that stopping treatment is in his best interest -The Wendland standard is practically impossible to meet; therefore, in cases with an incompetent patient, medical decisions withdrawing life sustaining treatment can practically only be made if a DPAHC is in place

Cruzan

Background: -(MO, 1990) -Cruzan was in a serious car accident and pronounced dead by police, but later resuscitated by paramedics. -She was in PVS, but her parents wanted to remove the artificial hydration and nutrition that kept her alive. Implications: -Court ruled in favor of parents, but Missouri Supreme Court overturned lower court, thus preventing parents from removing feeding tube, ruling that, in the case of incompetent patients, clear and convincing evidence of the patient's wishes, such as a living will or DPAHC, made while patient was competent, must be present for the legal guardians to remove life sustaining treatment Legal Standards of Evidence: -Preponderance of Evidence -Clear and Convincing evidence -Beyond a reasonable doubt (the subjective standard) WITHDRAWING A FEEDING TUBE IS NOT DIFFERENT THAN WITHDRAWING ANY OTHER LST

Persuasion

A patient is convinced to consent through the merits of reasons advanced by another person

Physician-centered interviewing

Includes asking specific questions in order to establish the diagnosis. Most of the conversation is done by the physician. This approach in most cases ignores important personal information about the patient, his or her personality, and emotions. It is evidence-based.

Principle of Double Effect

An action may have both intended good and unintended bad effects

Elements of Decision-Making Capacity

Any determination of capacity must relate to the following: -The individual abilities of the patient -The requirement of the task at hand -The consequences likely to flow from the decision Capacity Standards (ofc): -Outcome - a patient is judged capable based on the outcome of their decision -Category - a patient is judged capable based on their category of status -Functional - recognizes the patient's functional ability as a decision-maker Functional standard Determining capacity

What is a placebo?

Any substance given to a patient with the knowledge that it has no specific clinical effect, yet with the suggestion to the patient that it will provide some benefit

Hidding vs. Williams

Background: -A malpractice action in which the patient agreed to surgery in the absence of informed consent. -Louisiana Court of Appeal found that the physician failed to obtain informed consent from patient before performing spinal surgery which resulted in the patient's loss of control over his excretory system Implications: -The fact that the patient signed a form for informed consent did not relieve the doctor of liability when he failed to disclose the risks of the surgery to the patient -The surgeon's chronic alcohol abuse should have been revealed to the patient, and violated the requirement of informed consent

Salgo Decision

Background: -California 1957 -Salgo consented to a trans-lumbar aortography to locate the cause of chronic pain in legs, but the operation resulted in his paralysis. Outcome and Implications: -First major legal decision about informed consent (the hospital was found guilty of not providing info about the risks of the operation to the patient) -Weighed the right of patient to know vs. the right of physicians to use discretion in telling patients about risks -Consent is not enough, it must be informed

Canterbury Decision

Background: -DC 1972 -Patient after myelogram and surgery slipped off his hospital bed and became paralyzed Outcome and Implications: -Patients need the information necessary to make an intelligent and informed decision, the physician has a duty to disclose information that is not even asked for -It set forth the crucial aspect of informed consent by giving some principles to guide physicians in telling patients about available treatments and their risks

Behringer vs. Medical Center at Princeton (informed consent)

Background: -Explored the status of someone who was both a surgeon and HIV positive -The surgeon has the same right to privacy of everyone else, but the court rules that the hospital had the right and the duty to disclose his condition to patients during the informed consent process. Implications: -How much is a clinician obligated to tell the patient about personal issues that may put the patient at risk? Everything, due to informed consent.

Tarasoff Case

Background: -In 1969 Poddar was a voluntary outpatient receiving therapy at Cowell Memorial Hospital. Poddar told his therapists he was planning to kill his former girlfriend, Tarasoff. Poddar was taken into psychiatric custody but found to be rational and was released. He later killed Tarasoff. Impact: -Prior to Tarasoff, patients with threats of violence were either voluntarily or involuntarily committed to prevent harm to others and to protect their confidentiality. -Post-Tarasoff, the clinician is routinely required to consider how the patient might be a threat to an identifiable third party. -The courts have determined that the Tarasoff obligation applies when the threatened violence is foreseeable and a therapist can't control the patient enough to prevent the violence.

Moore v. Regents of the University of California (informed consent)

Background: -Moore was diagnosed with leukemia and consented to a splenectomy. -The physician obtained portions of the spleen and used it for research without informing the patient. -The court ruled that the patient had no property interests in the spleen, but the doctor had a duty to inform the patient of the research interests derived from the treatment. Implications: -Physicians have a duty to disclose all information that is relevant to a patient's decision even if it is not normally disclosed in practice. -In respect to the principle of autonomy, patients must be told whatever they reasonably want to know.

Gilgunn

Background: -(1989, Mass) -71-year-old Gilgunn had several years of injuries and suffers from Parkinson's and several strokes. -In 1989, she suffered severe brain injury from seizures before receiving surgery -She was comatose. -Joan, the surrogate, said that the patient would have wanted everything medically possible done. -However, the doctor wrote and DNR order and disregarded the family's opinion. -The doctor later revoked the DNR. Later, a new doctor wrote a DNR and began weaning the patient from the ventilator. -He was correct in expecting the patient to die. -The family sued. Implications: -The jury voted in favor of the hospital arguing that the resuscitation would have been futile despite patient wishes. -LST can be withheld despite patient wished when the treatment is considered futile.

Schloendorff Decision

Background: -1914 -The patient insisted, despite the doctor's recommendation, that she did not want her tumor removed. -She agreed to an abdominal exam under anesthesia, but then the doctor removed the tumor anyways. She sued. Outcome and Implications: -She didn't win the case since no harm ensured, but there was an important determination about consent. -Every human has the right to determine what is done with their own body and anything a doctor does without a patient's consent is assault and they shall be liable in damages. -Made people aware of legal requirements for consent, but said nothing about informed consent

Harvard Criteria

Body Criteria: -Unreceptive and unresponsive to all stimuli -No spontaneous movement of breathing - persistent apnea after an interval of 3 minutes after stopping ventilation -Absent reflexes - pupils fixed and dilated, ocular reflex and blinking are absent, no postural activity -Isoelectric EEG, repeated 24 hours later -Criteria are based on loss of nearly all brain functioning, extremely conservative criteria -No one declared dead by these criteria has ever regained consciousness -Few potential organ donors meet Harvard Criteria

Arguments for no difference b/w active killing and allowing to die

Consequentialists may argue that there is no difference because the results are the same

Persistent Vegetative State

Definition: -total loss of cerebral cortical function with a functioning brain stem Characteristics: -Sleeplike coma for a few days to weeks, then eyes open and sleep-wake cycles begin -Eye-open unconsciousness, eyes move randomly -Unintelligible groans, screams, grimacing, chewing without purpose -Many reflexes are present -Gross involuntary reflexive, purposeless movements -Use PET Scan Prognosis: -After 3 months, prognosis is essentially zero -If caused by cerebral hypoxia, prognosis can be established at 1 month -Even if 'recovered', severe neurologic deficits, including locked-in syndrome

Coma

Eye-closed unconsciousness

What are the limits to patient autonomy?

Liberty-limiting principles (possible justification for infringement on autonomy): -The Harm Principle: prevent the person from harming others -Offense Principle: prevent offense to society -Principle of Paternalism: to act to the benefit of that person -Principle of Legal Moralism: to prevent a person from acting immorally -The Social Welfare Principle: act for the benefit of others (SHLOP)

When is a treatment considered futile?

Quantitative: -5%, 10%? Inconsistent definitions - many reasonable physicians do not agree Qualitative: -What is the quality of life criteria? Medical Futility: -Wicclair - 1993 -Physiological futility -Futility in relation to the patient's goals -Futility in relation to the standards of professional integrity = medically inappropriate Brody's Definition: -The probability of benefit is unacceptably low -The magnitude of benefit is unacceptably low -The harm is much too great relative to any benefit

Arguments for a difference b/w 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 (consequentialism) The argument from duty to avoid killing: -There is simply something inherently wrong about killing (deontological) 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

What is the Hippocratic Oath's core principle?

The physician should do good and no harm

How is the Decision Made?

The substituted-judgement standard: -Ideally the surrogate reaches the same decision that the patient would, if competent The best-interest standard: -What will be best for the patient, avoid doing the patient harm -Reserved for those that were never competent, never expressed an opinion Other standards: -Professional Standard -Reasonable Treatment Standard

Principle of Totality

The well-being of the whole person must be taken into account when deciding about any medical intervention, overall benefit for the person

Coercion

When a person intentionally uses an actual threat of harm or force to influences another

Proportionality

a single, better term combining both uselessness and net burden; a medical treatment is morally expendable if the expected burdens are disproportionate to the expected benefits

Extraordinary

morally expendable

Ordinary

morally required, obligatory