Ethics Final- Dr. Helgeland
JUSTICE
JUSTICE
DRUG SHORTAGES lending drugs in short supply
Justice (fairness/allocation of resources)-lend it versus Fidelity to institution? potential pt? this pt?- do not lend it Real Pt: beneficence/nonmal to pt that needs Potential pt beneficence/ potential nonmal to potential pt at your facility can we have fidelity w/ a potential pt? Justice: allocation of resources medical utility- best prospect of success Utilitarianism: greatest good for greatest number- give drug deontology- duty- do the right thing..what is the right thing? may go either way Veatch- Strong moral claim to real person
*FAIRNESS is most closely linked to which ethical PRINCIPLE*
Justice :D
*What is the "slippery slope"?*
Justify something like termination of unwanted pregnancies due to disabilities leads to one bad decision leads to another, then another if we allow certain things to occur, at some point we may have mandates for certain things to occur societal slippery slope: the fear of allowing assisted suicide may lead ot mwhat has happened in netherlands (dr deciding when to euthanize) or abortions leading to infanticide
MATTERS OF CONSCIENCE
MATTERS OF CONSCIENCE 1) right to refuse to dispense
Utilitarianism defining statement limits -ex:
Maximize the "good"; (avoid pain and seek pleasure, pleasure, health, knowledge, friendship) do the greatest good for the greatest number. Limits: -can be hard to calculate level of good -individual rights overlooked for collective good -good should be favorably moral -we don't know outcomes ahead of time ex: robin hood; taxing the rich to give to the poor -who says what is 'good'?, rules are not binding, outcomes are unknown REMEMBER THIS IS THE SAME AS CONSEQUENTIALISM
NONMALEFICENCE
NONMALEFICENCE
PLACEBOS
PLACEBOS
PRIVACY
PRIVACY
suicidal
PT ends life on own Ex: pt OD on own prescriber may or may not be involved in states where legal: this would be assisted suicide
the function of Informed Consent
-to avoid pt exploitation -to protect pt autonomy
the false necessity trap
"Necessity is an interpretation, not a fact." overestimating the cost of doing the right thing and underestimating the cost of doing the wrong thing
what are the major parts of veracity code of ethics? violates upholds
"telling the truth" AND "adequate disclosure" code of ethics: a pharmacist acts with honesty and integrity in professional relationships (tell truth) lying and deception- VIOLATES disclose information like R vs B- UPHOLDS
Deontology (aka) -definition -problems
(non-consequentialism) DUTY independent OF GOOD (means should be good or bad and less concerned w/ outcomes) -Duty before anything else; lying is wrong, duty to tell the truth regardless of the outcome; less concerned with the outcome hope that by doing right that in the long run the best thing will happen (maybe not even in their lifetime) Problems: 1) might not happen in this lifetime 2) right things can conflict -what is right differs between diff people; could be more than one "right thing" or they can conflict; how does a deontologist determine what is right and wrong? 3) tell truth versus keeping promise 4) someone has to decide what's right
parts of autonomy
*"self-rule"* we have the right to choose own actions and make own decisions individual rights due to dignity
*******NEW MATERIAL*******
*******NEW MATERIAL*******
*define: "BOUNDED ETHICALITY"*
*BOUNDED BY RATIONALIZATIONS* Systematic and predictable psychological processes that lead people to engage in ethically questionable behaviors that are inconsistent with their own preferred ethics. develop protective cognitions that regularly and unwittingly lead them to engage in behaviors that they would condemn upon further reflection or awareness this perspecitve explains how an executive can make decisions that not only harms others but is inconsistent with beliefs and preferences we don't try to improve either cause we think we are ethical
*therapeutic privilege*
*extremely rare* withholding information in an attempt to benefit the patient. overrides the pt's autonomy and is a violation of veracity times we don't want to tell certain information that may upset them so they don't make a rational decision rare, narrow times, extreme caution (exception to this in informed consent?)
Rules of conduct: who makes them and *why* code is a combo of these 3 things:
*standards set by MEMBERS of the PROFESSION (we don't want the general public or courts to establish our code that way we dictate the standards of our profession) * 1. Aspirational codes 2. Educational Codes 3. Regulatory Codes
When asked to evaluate a situation based on principles or rules what do we need to look at
- uphold/follow - violate -potentially violating --> consequences? (theories) what did they do, didn't do, consequences also consider potentials for violating/upholding
Principles
-Autonomy -Non-maleficence -Beneficence -Justice
name 3 Theories
-Hippocratic -Consequentialism (Utilitarianism) -Deontology (non-Consequentialism)
Rules
-Veracity -Privacy -Confidentiality -Fidelity
*Living will vs HC proxy- which is "better"*
-Will is a declaration of specific wishes, if possible (if irrev mental state, incurable condition, terminal, permanent unconsciousness, brain damage) -nutrition, hydration, resusciation, ventilation, abx, pain vary by state depending on laws (rehydration and feeding tube in SD if no advance directive, some only apply to terminally ill pts) -doesn't give someone the right to make decisions for you -have to predict your demise -Proxy is the designation of a person to carry out your wishes. type of durable power of attorney (other-financial etc) documented, -hope they are consistent w/ your wishes May have both *most say proxy better (hard to predict-living will)*
*Common Law Doctrine of Necessity*
-that which is not lawful is made lawful by necessity. -*ignoring the law when obeying the law would cause harm to the patient* The ETHICAL THING may be ILLEGAL if patient has anginal attack and you give ASA and NTG (when no rx on file, and not your patient)
*STUDENTS SHOULD BE ABLE TO ASCRIBE ONE OR MORE EHTICAL RULES AND OR PRINCIPLES TO EACH PART OF THE PHARMACIST'S CODE OF ETHICS* I. A Pharmacist respects the covenantal relationship between patient and pharmacist (1)...A pharmacist promises to help individuals achieve optimum (2) benefit from their medications (3). II. A pharmacist promotes the good of every patient in caring compassionate, and confidential manner (4, 5).A pharmacist places concern for the well-being of the patient at the center of professional practice (6). In doing so, a pharmacist considers needs stated by the patient as well as those defined by health science (7)... a pharmacist is dedicated to protecting the dignity of the patient (8)... with a caring attitude and compassionate spirit, a pharmacist focuses on serving the patient in a private (9) and confidential (10) manner. III. A pharmacist respects the autonomy and dignity of each patient.(11) ...a pharmacist promotes the self-determination and recognizes individual self-work by encouraging patients to participate in decisions about their health (12).... A pharmacist communicates with patients in terms that are understandable (13 (maybe 2 more))... In all cases, a pharmacist respects personal and cultural differences among patients (14/15) IV. A pharmacist acts with honesty and integrity in professional relationships (16)...a pharmacist has a duty to tell the truth to act with conviction of conscious (17)... a pharmacist (18 ) avoids discriminatory practices, behavior judgment, and (19) impair professional judgment, and actions that compromise dedication to the best interest of patients. (20/21) V. A pharmacist maintains professional competence... (22) A pharmacist has a duty to maintain knowledge and abilities as new medications, devices, and technologies become available and as health information advances. VI. A pharmacist respects the values and abilities of colleagues and other health professionals...(23) When appropriate, a pharmacist asks for the consultation of colleagues or other health professionals or refers the patient. A pharmacist acknowledges that colleagues and other health professionals may differ in the beliefs and values they apply to the care of patient. VII (none) VIII (health resource allocation 24)
1(fidelity) "covenant" 2(fidelity) "promise" 3(beneficence). "benefit" II. 4 "good of every pt" beneficence 5 confidentiality 6) "well-being"(beneficence) 7) "needs stated by pt" (autonomy) 8) "dignity"(autonomy). 9(privacy) 10 (confidentiality) III. 11 "autonomy, dignity" (autonomy) 12 self-determination/self-worth (autonomy) 13 Veracity (stretch to autonomy and beneficence) 14 justice/15 autonomy "cultural diff" "respect" IV. 16 (veracity) 17(veracity) "conviction of conscious(professional autonomy) 18 (justice) avoids discriminatory practices 19 (beneficence...potentially upholding non-maleficence- for the good of the pt) 20 beneficence 21 nonmaleficence (autonomy?) V. 22( beneficence/non-maleficence) VI. 23 (beneficence/non-maleficence—patient centered) VII. VIII. 24 (justice)
*microallocation of resources: name/differentiate 3 proposed criteria for screening*
1) constituency factors (geography, country) ex: brookings hospital so full, they won't tx anyone from anywhere else or state hospitals not tx anyone from out of state 2) progress of science (pts in research program-we exclude others) some better candidates than others (inclusion/exclusion criteria) 3) prospect of success (scare resource-like to use on someone w/ reasonable change of success (medically acceptable) SUBJECTIVE- related to nonmaleficence ex: use droug on someon who isn't going to die liver transplant not for alcoholic who will likely not do well with it anyway
Is full disclosure always necessary what if disclosure harms the patient to what degree does one need to inform the patient
1) does NOT always apply (emergency, can't find family and incompetent, named guardian is incompetent) 2) it is best to give all information (rare circumstances- therapeutic privilege) 3)Varies (professional and patient- fidelity, veracity, autonomy come into play) common and serious- provider dependent- veracity some argue if we don't tell all the info is readily available anyways
other considerations for justice 1) forfeiture of health care 2) age criteria 3) organ donation conclusion
1) forfeiture- if you are ivdu, ride bike w/o helmet, smoke, alcoholic wanting new liver these people use more of the pie- should they pay the difference 2) at what point do we stop tx or not tx for the first time (cost of dialysis-stop covering after certain age?) 3) expensive issue, regional access, more national now conclusion: no conclusions about what we should do: philosophy, politics, societal views of justice differ politicians really should not use the term"fair"
3 criteria for a decision to be autonomous
1) intentional action (NOT accidental) 2) awareness (informed and knows what they are doing) 3) free choice (no coerced)
final selection process considerations
1) medical utility (how urgent is their need- prospect of success; obligatory versus ordinary) 2) chance (flip a coin) 3) social utility (potential of person or worth- determine who gets something-subjective things and try to be ojective (try to avoid bias)- value to society, past efforts/results, or future potential)
*6 spectrum components of euthanasia*
1) passive 2) semi-passive 3) semi-active 4) accidental (DOUBLE EFFECT) 5) suicidal 6) active
arguments for non-disclosure or violations of veracity
1) placebos 2) pt harm 3) time 4) pt not take med (benevolence through deception) 5) pt doesn't want to know (how do you know) 6) not able to tell all so why start
Medical experimentation 7 requirements for research trial to be ethical
1) social or scientific value AND 2) scientific validity (justice/nonmal and autonomy- scarce resources/ nonexploitation ) 3) fair subject selection justice 4) favorable R vs B ratio: nonmal, beneficence, autonomy 5) independent review 6) informed consent (autonomy) veracity-full disclosure 7) respect for potential and enrolled subjects (autonomy)
violating ethical principles 1) mercy killing 2) passive euthanasia autonomy?
1) violate non-mal (actively causing harm) 2) may or may not non-mal; may violate beneficence if death is considered a harm autonomy- pt wants it (advanced directive) do we violate and go against their wishes
Explain the 2 consent elements
1) voluntariness _ cannot be coerced (ex-free care..etc) 2) consent- is there signed or documented consent
AMA positions on healthcare
1)* prioritization *of hc services must take place 2) dr have obligation to provide care to *those in need* 3) individuals responsible for *own health* (do we need to tx those who do not take care of themselves?) 4) NO pt deprived of Necessary care (what's necessary, can they pay?) 5) Fair opportunity ( "adequate" not perfect level of care) 6) NO societal obligation to equal care or all possible care to all (do not have to provide everything - collective protection-firefighters) terms not defined what do we tx or not tx and to what extent
*Veatch's 3 characteristics of ethical "Evaluations"*
1. *Ultimate(um)*- a decision had to/must be made 2. *Universality*- it could be applied to anyone under the same circumstances 3. Treat good of everyone alike *(Welfare)*- promote and protect human welfare; account for the points of view of everyone involved
Rules of Conduct 1. Aspirational codes: 2. Educational Codes: 3. Regulatory Codes:
1. Aspirational codes: "practice ideals" = doing the best we can; we strive for.... optimal practice would be... 2. Educational Codes: how you interpret the problems in prof practice 3. Regulatory Codes: the rules you should follow (laws) governing professional conduct
autonomous decisions MUST be...
1. Intentional actions - cannot be accidental 2. Awareness- conscious decisions 3. Free Choice- pt must not be coerced towards a decision
*3 Disclosure standards*
1. Professional practice standard (*professional judgement* of pharmacist or professional on how much to provide- all rph would do this (could withhold info) 2. Reasonable person standard *type and amount of info would disclose what a "reasonable person"* would want to know (hypothetical person) *3. Subjective disclosure standard* beyond what a reasonable person would want to know PATIENT SPECIFIC info to make decision
1. Professional practice standard: 2. Reasonable person standard: 3. Subjective disclosure standard:
1. paternalistic; giving info based on prof judgment; common until the 70's. 2. disclose what a reasonable person would want to know. 3. requires HC personnel to disclose all info that is material to the counseling of a particular patient; what the pt would need to know to make an informed decision
*Argument for placebo*
1. positive outcomes 2. is it deception? YES, but saying this *MAY* help you is not untrue. The purists would say we are leaving a bad impression 3. Deontology: may be acceptable in very very rare situations 4. utilitarian: Good outcome=OK
*Argument against placebo*
1. pt dignity: deceiving pts is not Tx'ing them with respect, violates autonomy 2. deception: *Deontology*=deception is wrong; *Utilitarianism*: is ok if outcome is good, however if pt loses trust, outcome of harming relationship(trust) may be worse than the good done by the placebo.
*5 elements of informed consent*
1. threshold elements a) competence 2. information elements a) disclosure b) understanding 3. consent elements a) voluntariness b) consent
potential for competence: is the person able to... (x4)
1. understand his/her position? 2. understand the disclosed information? 3. express a preference? 4. give rational reasons based on risk/benefit? NEED yes for all 4 to be competent
*2 fundamental Q's ethics seeks to answer*
1. what should we do? 2. Why should we do it? (essentially discernment AND discipline) Done for justification- not just because but choose amounts multi right decisions for what is hopefully the most ethical
ADVANCED DIRECTIVES
ADVANCED DIRECTIVES
ALLOCATION OF RESOURCES UNDER JUSTICE
ALLOCATION OF RESOURCES UNDER JUSTICE
social media and hc professionals professional purposes? AMA
AMA discourages INTERACTION on social media policy- do NOT practice medicine online general health info okay quality research ethical responsibility to point out if inappropriate use medical advice-discouraged using company time to surf net
AUTONOMY
AUTONOMY
*what is authenticity*
Authenticity- what the person usually would think, do,etc. IT IS CONSISTENT with who they are and not with the less than optimal state they are currently making decisions in READ below for more detail: authenticity has been proposed as an alternative foundational principle to autonomy The principle of autonomy fails to do what it is commonly supposed to do: provide a criterion of distinction that can be invoked to settle moral controversies between patients and providers. The existentialist concept of authenticity is more promising in at least one crucial respect: *It acknowledges that the essence of human life disappears from sight if life's temporal character is reduced to a series of present decisions and actions. This also implies that the very quest for a criterion that allows physicians to distinguish between sudden, unexpected decisions of their patients to be or not to be respected, without recourse to the patient's past or future, is erroneous.*
INTRO TO ETHICS IN HEALTHCARE PRACTICE
INTRO TO ETHICS IN HEALTHCARE PRACTICE
BENEFICENCE
BENEFICENCE
*what is the placebo effect*
CHANGE in condition attributable to THE INTERVENTION (not to a specific pharmacologic effect) usually if give we see a response, see noncompliance too, modifies labs even if they know its a placebo can still work some percent of active drug has this effect (DRUGS OF ANY KIND WILL WORK BETTER IF WE SUPPORT)
CONFIDENTIALITY
CONFIDENTIALITY
Communicable disease do we notify hc workers? patients? suicide? forfeiture of rights to hc disclosure/privacy issues
CONFIDENTIALITY AND PRIVACY ISSUE: (review HIV case) do we need to know before we give someone a shot if they have hep C? patients: HC worksers ARE NOT obligated to disclose their info to pts (cdc - somethings they shouldn't be involved in or should let pt know- finger, needle, poor visual type things) suicide- Not legal to have assisted sucide forfeit rights: if you participate in risky behavior (relates to cirrhosis and transplant)
CONTEMPORARY ISSUES
CONTEMPORARY ISSUES
resusictation
CPR code, no code or slow code (staff determines) should not be different from other life-sustaining efforts unless advanced directive
forced treatment -psych issue
DEPENDS on STATE LAWS nonemergency -threat to others (staff or pts)may be only time we do competency to deceide on tx (competent after meds or before?) other tx available-less risky thing to try? side effect- permanent? atypicals
nonmaleficence define uphold/violate what type of action conflicts of what is harm
DO NO HARM UPHOLD/VIOLATE most of what we do upholds nonmaleficence if harm occurs we violate Nonmaleficence if harm could occur but hasn't we potentially violated nonmaleficence (we violate Beneficence but may not violate nonmaleficence) TYPE: 1) MAY be DELIBERATE or UNITENTIONAL 2) May go BEYOND PHYSICAL harm to patient (mental, psych, social) ex: if we uphold veracity and tell HIV pts partner about the HIV we may violate nonmaleficence on social aspect by harming relationship and uphold beneficence if they seek tx 3) OMISSION (don't do something we should have) OR Commission (did wrong thing and shoudn't have-hopefully unintentional) surgery we gain consent to perform painful procedure---> OKAY BECAUSE WE DO FOR THE GREATER GOOD OF THE PATIENT "shouldn't.....but" Conflict (shouldn't hurt patient but with surgery we do for better good; same thing with immunizations)
the concept of justice societal obligations to justice?
FAIRNESS=DESERT (get what you deserve) negative or positive or NOT getting something you don't deserve depends on the society ex: dictator (decides justice) US: rules of society, personal property, characteristics Cultural pressure/shame payday lenders: can take advantage of someone if both follow the rules
FIDELITY
FIDELITY
Justice assingments Fallacy of Fairness thomas sowell Advances in Medicine have caused health care crisis - willard gaylin 1) according to gaylin the only solution to our nations health care crisis is ____ 2) the concept of health has been expanded t/f 3) good medicine increased the percentage of people in the population w/ illness t/f 4) what does "death w/o dying mean? 5)once impairments are no longer perceive as inevitable, they become curable impediments to health functioning t/f pro/con of right (entitled to health care) is health care a right? walter williams the killing will not stop/john will's aptitudes - George Will 1) slippery slope 2) down's syndrome patient has better or worse qol 3) do we owe downs patient more less or same as everyone else
Fallacy of fairness- the word "fair" is a handicap in logic and an advantage in politics; life is unfair -tests measure results; if society says somehting is fair -then obligated to uphold it 1) health care must be rationed 2) True 3) true 4) grow old gracefuly, life long time w/o effects of aging 5) True 1) slippery slope- see before 2) can't look through our eyes- they may be super happy QOL we cannot decide for others 3) same - we do not tx different if all relevant factors are equal we do not discriminate if we tx differently we would violate justice
medical/political issues - vaccination HPV? health care workers?
HPV vaccine- make it mandatory? can we mandate that hc workers get immunizations- (flu in sufu) religious or contraindications herd immunity (justice-) public health vs individual rights (autonomy) (confidentiality) -asking about kdis for exposure purposes if kids sick then send home
HIV case: do you tell pts girlfriend what rules does it violate, uphold, or potentially violate
Patient: if you don't tell uphold privacy (stay out of personal life) uphold confidentiality uphold fidelity (he is your pt and you have a relationship) (violate veracity w/ girlfriend) Girlfriend: if you do tell uphold veracity uphold autonomy (prinicple but here for completion sake) uphold fidelity (if she is your pt or you have relationship) violate privacy (her private life)
semi-active
STOPPING the Ventilator (stop mechanical not natural item) ex: stable vegetative state, on vent, based on medical knowledge they won't come out of it (note: this is NOT terminal) probably no hope of regaining consciousness and geting back to normal state
THEORIES
THEORIES
What are the HEW (now HHS) guidelines
US guidelines for informed consent fair explanation of procedures disclosure of dicomforts/adrs description of benefits disclosure of alternatives statement that patient can w/draw at anytime staff should answer all questions at anytime
VERACITY
VERACITY
Psychiatric issues mental institution
Violation of confidentiality - esp because stigma is stronger and could be more damaging Patients Choice? informed consent (choice or forced; competent?) just because they have a mental illness does NOT mean they are not competent AUTONOMY -caregiver or assigned by state when does the patient have the right to refuse medications? can we force them? placeboes- no different than before - do not trick just because they have psych disorder access to records- family members have right. no different then else where (if different-more strict)
Theoretical approaches (X and Y)-Beauchamp and Childress
X has obligation to Y if and only if: -Y is at risk of significant loss/damage -X's actions needed to px loss -X's actions has a high probability of px the loss -X's actions would NOT present sig risks, costs, burden to X -the benefit to Y outweighs the risks, costs, burdens to X MUST HAVE ALL 5
Do patients have the right to know EVERYTHING that pertains to their care?
YES (according to veracity and autonomy) do the best we can to communicate they do have the right but we would not have the time to go through everything with every patient so w e pick and choose
*As a pharmacist, does OBSERVING UNETHICAL behavior make you a participant and confers responsibilities, even if you haven't done anything wrong?*
YOU HAVE OBLIGATION to report unlawful behavior it is part of your MORAL RESPONSIBILITY
Pharmacist most likely involved in which type of euthanasia
accidental (verify order) maybe: suicidal if aware of intent when filling
Ethics applies to comes from
applies to SPECIFIC GROUP conscious REFLECTION of morality -standard of practice clarify organize and critique THOUGHT AND REASON
what is distributive justice
are things distributed fairly in society not big deal until scarcity of resources tradeoffs- weight R/B and costs, who bears that cost
if unsure about pt competence, u should...
assume the pt is competent
principle most closely related to dignity
autonomy we have intrinsic worth
accidental what is the double effect
based on intent (not truly euthanasia) ex: terminal pt w/ pain give opioid for comfort but cause resp depression and death (intent not to kill) desired effect AND undesired harm
fidelity-
being faithful and not cheating keeping promises and looking out for the pt's welfare don't abandon them in clinical research we should have more fidelity to pt than to study may have fidelity to the system (employer etc)- if future pts will have ramifications than will have fidelity to org over pt its a relationship (may be closer than the one they have w/ provider) should give all pts same?? based on time with them?
*most of what we do in pharmacy probably supports which ethical principle?*
beneficence most of what we go -we want to do good it is not enough to simply mind our own buisnes- morality and ethical conduct would have us go farther than just respecting others autonomy, and refraining from harming them
*why is pharmacy considered a MORAL PRACTICE?*
the goal is to advance the interests of the patients (put the PTS' interests ABOVE our OWN
Beneficence versus autonomy *PATERNALISM* wk versus strong paternalism
beneficence used to be overriding now autonomy autonomy may override or at least needs to be included if pt--> not making solid decisions competence may be questioned w/ autonomy) weak paternalism- pt judgement is impaired- would be acceptable till they are no longer in that state (then give choices) strong paternalism- rarely defensible - violates autonomy
clashes between autonomy and beneficence
beneficence- do good autonomy- do good but on their terms
describe understanding part of the information element
can they comprehend the information you disclosed some argue they can't even understand so why give info but we should error on the side of TOO MUCH info
what is necessary to have autonomy
competence
what is the threshold element for informed consent
competence (recall 4 steps of competence) related to autonomy can be via caregiver, guardian, or health care proxy
2 contemporary theories
consequentialism (utilitarianism) non-consequentialism (deontology)
cost versus access in healthcare market vs soical vs compromise
cost, access and quality- desired properties (cannot have all 3 at highest level market- want free market social- want access need cost containment what is fair for society to do for its people everyone has some level of access on their own medicare/medicaid-beyond basic services
truthful management of information
counsel- communication depends on UNDERSTANDING and used for decision making what a reasonable pt would want ot know pts don't know what they don't know provide MORE rather than less for our pts
What word is most closely related to fidelity or vice versus?
covenant -very strong tie/agreement
what are the 2 information elements of informed consent
disclosure understanding
postfertilization effect
disclosure of information? impossible to tell all, hard to know pt preferences (subjective disclosure standard) must try our best pharmacist or prescribers duty to tell pt?
acceptability of violating autonomy
do not memorize the pt is at risk of illness or injury risks of paternalism not substanital benefits to pt outweigh risk no alternative to paternalistic action and it is the least possible action only minimal infringement on autonomy (if all true- may be okay to violate autonomy)
Right to refuse to dispense based on conscience ethical principles/rules involved
do not want to violate nonmaleficence and beneficence (to embryo) the person has autonomy to make decision (we violate if we don't dispense) -ben/potential nonmal to mother autonomy- violate professional autonomy fidelity (to pt or unborn child) veracity (uphold by telling pt info)
define beneficence
doing good for benefit of others Hippocratic oath- benefit pt according to providers ability and judgement-paternalism
active
dr admin fatal dose w/ intent ama says this violates nonmaleficence
describe competence
elements influencing decision making (family, cost, facts, culture, provider, prior knowledge, mental state and emotions) there are varying degrees of competency aging is associated with decreased competency but depends on person (no specific time when age means you are not competent)
clinical pharmacist pt wants to know why they are sick and rph knows its hiv due to blood transfusion
fidelity to system may outweigh fidelity to patient violate veracity, autonomy, fidelity of patient by not telling
Euthanasia when does it fit under nonmaleficence AMA position
for those that feel it is wrong- it would fall under nonmaleficence AMA: it is MORALLY JUSTIFIED to w/hold or w/draw "EXTRAORDINARY means to prolong life of the body when there is IRREFUTABLE evidence that biological death is IMMENENT" as along as pt/family w/ the advice and judgement of dr makes the decision
Hippocratic where is it from key points
from hippocratic oath (older,less common) -only service to patient welfare is relevant -do good and do no harm *- view of practioner (Up to them)*
describe paternalism
healthcare providers traditionally felt that they know best and decide for the patient may not be right hippocratic theory
biotechnology: genes knowledge of what genes a person has can lead to 1) 2) 3) 4) 5) 6)
human genome project-mapped human gneome 1) abortion- based on risk of fetus (huge percent aborted before birth if problems known) 2) sterilization- mandatory sterilization if someone carries a gene that passes on problems to offspring 3) employer/insurance knowledge of genes*CONFIDENTIALITY* issue -law passed to prohibit and protect them from discrim (justice) 4) AUTONOMY- right to choose behaviors -do we take it away if we know they are predisposed to a condition (ex-big mac and heart disease) 5) mandatory screenings - everyone screened for genes (employer/insurance cannot but government could) 6) choosing offspring- based on genetics-make perfect human; aborting non-ideal fetuses
Refusal to dispense DES
if grossly unethical- we have to refuse few situations when no other others 1) right refuse 2) patient right to access (autonomy)
Cultural difference: the balance between autonomy and beneficence
in most cases we go with autonomy beneficence must be considered if there culture is a huge part of who they are using different terms- may be violation of veracity consent?-pt versus family fidelity- if prior relationship rabi giving advise or actually using religion watch paternalism- not just a feeling
what is situational information
includes data regarding: - values and perspectives of principles involved -their authority, -verbal and nonverbal communication including language barriers -cultural/religious factors -setting and time constraints -relationship of those immediately involve in the case jehovah's witness case (not talk while parents in room, etc)
Right to refuse to dispense based on conscience *ARGUMENTS FOR*
independent judgement (we are not robots, part of team, duty to care for pt and/or fetus- autonomy to make decisions and do not have to follow orders if harm to pt etc) professionals should NOT forsake own moral as condition of employment (moral distress) right to refuse to participate in american tradition (freedom of religion)
ethical issues vs Ethical dilemma vs Ethical outrage
issue- pt welfare (role of pharmacist involved) -ethics will be involved *dilemma: reasonable people may DISAGREE on the issue outrage: reasonable people would AGREE on the issue* (ex- diluting chemotherapy to make money)
US healthcare
it is very expensive is it a right or a privilege? (see article that weighs both sides)
what is an advance directive?
living will or health care proxy are examples documents drafted in writing and signed while pt still has facilities to spell out wishes wishes in advance- autonomy -even if not competent
*Market justice versus societal justice*
market justice (focus on liberty-fair but don't take away liberty of others; gov involvement takes away individual's liberty open market for social goods, not social planning by government SOCIETY is NOT morally obligated to provide healthcare for others (unfortunate when someone cannot afford hc but NOT unfair social justice "social protection" reason to give hc public responsibility -goverment controlled what we do as a society if for the collective social protection-not the individual "fair opportunity" -should not be denied based on disadvantageous properties
psych issues medical records communication skills
medical records should not be leaked to general public (see this in politics) - no one should know unless person lets it out communication -no different talk at their level (veracity) and find level that works
AMA definition of mercy killing killing versus allowing to die
mercy killing- the INTENTIONAL termination of life of one human being by another (not necessarily supported by AMA) allowing to die: may NOT violate non-mal causing death: VIOLATES nonmaleficence
off-label use of drugs
modafinil- for concentration- used even though it doesn't work well
What is our obligation for beneficence? How far should we go? What are the limits?
moral obligation to act (traditionally) how far should we go? (injury, pain, tx disease) sometimes we have to do something to violate autonomy of veracity to give info ideal versus practical specialists and knowledge
*Standards of DUE CARE*
more than just legal aspects of pharmacy things needed for negligence/malpractice (recall from law) if we follow STANDARDS of CARE we reduce risk of violating nonmaleficence 1) professional duty 2) duty breached 3) affected party is harmed (substantial) 4) harm is caused by breach (proximate cause)
Stem cell research
most of stem cells come from aborted fetus that is what makes it controversial we are trying to make drugs from them some may not want to use drugs procured this way
*natural lottery versus social lottery*
natural lottery Properties from birth either good or bad looks, iq, etc much HARDER to OVERCOME social lottery social aspects - social class, school system, assets or deficits of where you start out we don't give things to people just because they are wealthy or withhold because they are poor SOCIAL aspects can be OVERCOME
gene therapy where do we draw the line? cost/benefit analysis who recieves the drugs? non-approved us of biotech drugs
need regulation to set where we draw the line- could end up someone trying to breed the perfect race very expensive to use, should these technologies be on formulary? will tey be beneficial? save a lot of lives? how do we decide who gets them (insurance? can pay?) blood doping for performance enhancement HGH-used for things other than indicated law of unintended consequences?
employee of a chemical company got sick due to inhaling vapors with at his job other employees
need:job company found another job with same pay and qualifications merit: others have been there longer, maybe have more training equal opportunity: one is a minority makes decision more complicated
DNR=
no CPR. (not no tx) other Tx may be given to sustain life, just do not resuscitate
lethal injection
no medical process should not paricipate
Fair Opportunity
no should be GRANTED social benefits on the bases of undeserved advantaging properties and no one should be denied social benefits on basis of underserved disadvantageous properties a) natural lottery b) social lottery unjust NOT to give developmentally disabled something you would give to everyone else WE should provide FAIR SHARE but NOT necessarily a LARGE share (use society's resources)
DISTINCTIONS between nonmaleficence and beneficence
nonmaleficence-DO NO HARM one ought NOT INFLICT evil or harm beneficence: TO DO GOOD one OUGHT to PREVENT, REMOVE, DO/PROMOTE good
Gifts and funding from pharmaceutical industry
not done as much as they used to fear of influencing prescribers more gifts received--> more likely to believe it doesn't influence their behavior subconsciously sense of indebtedness repay in kind food, flattery, friendship if it influences you- conflict of interest seeing now that companies are paying for things like CEs and have smaller budgets
ethical relativism-
nothing is objectively right or wrong; the definition of right or wrong depends on the prevailing viewpoint of the individual, culture or time period therefore-bioethicists differ in views
*obligatory treatment versus optional treatment*
obligatory = ordinary ethically obligatory means MANDATORY or REQUIRED things that have REASONABLE hope of benefit and can be obtained or used w/o excessive expense, pain, or other inconvenience optional=extraordinary 1) extraordinary- tx cannot be obtained or used w/o excess (above) OR which it would NOT offer a reasonable hope of benefit 2) BURDEN outweighs BENEFIT tx may prolong indefinietly but burden (pain/suffering) lead to deciding it is optional -depends on pts age, condition 3) POINTLESS TX - where irreversible death or imminent dnr
addicted health professionals
okay to send back to work on buprenorphine etc?
passive violate? examples
only one that may be acceptable under nonmaleficence allow to die based on conditions not tx someone who is terminal in some way allowing them to die or die of something else *DNR* - dying of something, they're terminal so we do not resuscitate examples: (DNR, erminal pt, advanced alz pt where we don't treat pneumonia or sepsis)
*when does the obligation to treat not always hold?* ethical principles involved
optional situation - does NOT violate non-mal not doing obligatory would violate non-mal autonomy- advance directives come into play if previously stated QOL: pt having a meaningful life (DEFINED BY PATIENT AND NOT PROVIDER)- (may also see justice) watch out-->not an argument (who is to judge-at least palliative care)
parts of confidentiality
other parts of HIPAA besides marketing give info only to those who NEED TO KNOW
practical issues where autonomy and beneficence clash
patient choice (maybe we don't know what that choice is, things happen w/o consent like side rails -implied consent)
legal perspectives on refusal to dispense
pharmacy law- valid script fill unless reason not to (overdose, interaction) if no clause-board would have to decide if beliefs are valid-depends on state employment law- wrongful discharge suits if they fire after you tell them your belief (prob won't hold up in court unless you signed saying something before hand0 conscience clauses- vary by state- between professions, hospital might have own discrimination- cannot discrim based on religion BUT don't have to make MASSIVE accomodations
Types of privacy
privacy is defined as PHYSICAL PRIVACY or INTRUSION IN PRIVATE LIFE Physical: having a "private" area for counseling etc private life: marketing restrictions, database of information used for other purposes
digging into a pt's records to use for another purpose is a _____ violation.
privacy. if the information was shared with another person who did not need to know, it would also be a breach of confidentiality.
Right to refuse to dispense based on conscience *ARGUMENTS AGAINST*
professional autonomy has LIMITS (should not supercede the pts autonomy) we are in a moral profession-put good of pt above our own not sure if preg has taken place we don' t know hard to study- what the product does is the issue might negatively impact pts health (burden on pt (rural areas))-cannot get elsewhere potential for abuse: areas for discrimination (JUSTICE) - dispense HIV drug to IVDU viagra to single man o/c to single women (Note plan b should not be used for regular birth control)
professional autonomy Pt's rights
providers have the right to make a decision that is in the pt's best interest; providers do not have to be forced to do something (like assisted suicide) Pt's have the right to refuse that decision
What should we do to avoid bounded ethicality
recognize biases look at what we want to do versus what we should do and do what we SHOULD DO
placebos
rely on power of the imagination prescribing inert substances
*what is "Ethics of self-interest"?*
risk-reward decision making - motivated to make ethical decisions for self-interested ex: cheat on exam or lie on resume If risks are high- we will act ethically if risks are low and reward high- moral principles succumb to expediency
autonomy summary
self rule intentional, aware, informed, free choice pre-eminent (some clashes) pt can give up autonomy to provider and that is fine
what options does the pharmacist have ama/apha say
should mention when getting job decline job if they will make you go against morals we are passive roles linked in a process code of ethics says we should promote good- autonomy apha/ama 1) right to refuse 2) pt has right to access
patient expectations? what if no placebo is there still an effect?
some tell dr to do what they need to do others- want to know everything w/o placebo- may use w/ drugs to boost use- violates autonomy for most
*What does it mean by pharmacy is a professional practice guided by human values? how are they integrated into pharmacy practice*
the profession is based on compassion/empathy, dignity, justice, truth our success is based on our relationships rather than our competence (ideally we would have both) we integrate these values into practice (things are rarely free of value so sometimes there are clashes- however with pharmacy practice changing to more patient-centered care our encounters may become more value based) Code of ethics
Motivational Blindness-
the tendency to not notice the unethical actions of others when it is against our own best interest not to notice
Spelling test: 3 theories 4 principles (2 for this exam) 4 rules
theories 1) hippocratic 2) consequentialism (utilitarianism) 3) deontology (nonconsequentialism) principles: autonomy non-maleficence beneficence Justice rules: veracity privacy confidentiality fidelity
acceptable confidentiality violations
unless required by law: -inspection/audit - communicable disease -other providers involved in care do in patients best interest and error on side of too little info cannot give spouse to spouse info unless "agent or okayed" may violate confidentiality to yield rights of others -duty to warn (ex-psych threat-killed) -must notify spouse of HIV/AIDs(other not unless pt agrees but to have sex w/o telling in manslaughter)
Is autonomy the pre-eminent principle
used to be beneficence many feel it is now the pre-eminent prinicple
Consequentialism aka? defining phrase
utilitarianism "the end justifies the means" ACTIONS are right and wrong BASED ON CONSEQUENCES what we do doesn't matter as much as the outcome more at the INDIVIDUAL level- (ex- if we w/hold truth but pt gets better than its okay, however if the pt doesn't get better it is violated and the deception is bad)
ways that research trials may be unethical
violate privacy- use database to contact for study nonmaleficence-if you do something you shouldn't beneficence (not a lot here but potentially to future pop) veracity - tell them what is going on fidelity- TO PT NOT TO STUDY
semi-passive
violates from here on withholding nutrition or hydration in someone who is terminal (these are things they would naturally do on own) some state law says we have to give food and water even if coma and terminal state so w/holding would be passive
changing "inappropriate behavior" duty
w/o consent (autonomy) is wrong (ex-homosexuality) Duty is with the individual and not the institution do what is best for the patient
*what are "RELEVANT PROPERTIES" with regards to justice?* DISCRIMINATION?
what is relevant? a) what information is TRULY relevant (important) to the situation b) somethings are relevant in some situations but not others c) may differ from community to community, and even w/in healthcare Discrimination- looks at what is relevant and not relevant DISCRIMINATION VIOLATES JUSTICE (race, religion, color, socioecon, gender, etc) THOSE that are EQUAL in ALL RELEVANT properties SHOULD be Tx EQUALLY if diff we can tx differently ex: we tx "normal" the same as a developmentally disabled person