MH001

Decision making through 3 Ethical Viewpoints

Virtue Ethics: focus on the actor. Argues that what we do is usually less important than why we do it and the effect it has upon us and others. They would say that the best way to think about ethical decisions is to start with the people involved - with their characters, and their motives and their beliefs.

Deontology: focus on actions - some basic rules that are universally true. Ex you shouldn't kill.

Consequentialism: focus on outcomes that result from action. A well known form of this is utilitarianism

MH001

 5 approaches on decision making in a clinical setting

First approach

1. Principlism
2. Virtue Theory
3. Ethic of Care
4. Feminist Ethics
5. Casuistry

Four key principles of principilism:
1. Respect for Autonomy

• Give people all their options
• Give them the information they need to understand the options
• Respect their decisions
• Help them act on their decisions
  Challenges:
• How informed can patients be?
• How clearly do we think when we are sick?
• What constitutes controlling interference?
• Do we always say (or even know) what we want?
• Some cultures/religions do not see individual as the most important unit

2. Beneficence

• A moral obligation to act for the benefit of others
• Need to consider and balance the potential benefits and risks

3. Non-maleficence

• An obligation not to inflict harm intentionally 
  Primum non nocere - first do no harm
  Challenges:
• Defining goods and harm
• Challenge of paternalism

4. Justice

• “Fair, equitable and appropriate treatment in light of what is due or owed to persons”
• Treat equals, equally, and unequal unequally
  Challenges:
• Confusion between allocation and true scarcity
• Fiduciary duty vs gate-keeper
• Personal responsibility for health choices

MH001

Feminist Theory

 Virtue Theory

Ethic of Care

Casuistry

Feminist Theory:

• Certain groups are systematically suppressed and their opinions are not given equal consideration
• Being in a position of power creates blind spots
• We need to make greater efforts to hear all voices and recognize their value

Virtue Theory: always act with compassion, trustworthiness and integrity.

Ethic of Care: act to support and strengthen our relationships. More rational than principilsm (less emotional).

Casuistry: compare ethical decisions to those that occurred in the past. Problem arises when people argue that in previous cases, the wrong decision was made.

MH043

Fiduciary Relationship

Our unequal relationship with patients arises from... (4)

Fiduciary Relationship

• A fiduciary is someone who has undertaken to act for and on behalf of another in a particular matter in circumstances which give rise to a relationship of trust and confidence.
• Resolve conflicts of interest in favor of the patient

Our unequal relationship with patients arises from...

1. Knowledge
2. Control of resources
3. Patient is ill
4. Intimate knowledge and exams

MH043

What is a Conscientious Objection?

Elements of an Informed Choice (5)

Conscientious Objection:

• Treatment is legal and professionally acceptable but individual physician is unwilling to participate on moral or religious grounds
• Active debate within medical community as to acceptability and standards
• Ex. Abortion

Elements of an Informed Choice:

1) Decision-making capacity (DMC)
2) Disclosure of relevant information
3) Understanding of information by patient
4) Voluntary decision (not coerced)

MH005

Components of decision-making capacity

When should we assess it?

Components of decision-making capacity:

1. KNowledge of the options
2. Aware of consequences of the options
3. Consistent Choice - consistent with values and consistent over time

When should we assess it?

1. Lack of comprehension
2. Lack of organization/participation
3. Mismatch between values and choice

Not just because we disagree

MH005

Decision Making Capacity

Disclosure

Therapeutic privilege

Advanced Directives

Challenges associated with AD

Competence

Decision Making Capacity: ability to understand and work with information provided. Assess the patient’s knowledge of options, understanding of consequences, ability to make a value consistent choice. This is not an all or nothing determination, but a spectrum (more important decisions require more capacity). In cases where DMC is not acceptable, patients should be protected by a substitute decision maker, someone who can reflect the patients ideals and goals. It is important when asking for informed consent, that you get the patient to explain why they are choosing one option over another.

Disclosure: should explain a procedure, what it is designed to do, list other options, and explain risks involved, uncommon ones if they are significant, patient specific risks need to be inquired (model’s fear of scar).

diagnosis
plan
risks
benefits
alternatives
can revoke without jeopardy
opportunity for discussion

Therapeutic privilege: withholding information to not upset patient. Rarely done now

Advanced Directives: written statement where patient identifies an individual to make decisions on their behalf, or treatments that they do not want. Must have statement, signature and date.
   

Challenges associated with AD: sometimes instruction is unclear, substitute decision maker is named but disagrees with the AD, sometimes AD is not followed simply because there was no knowledge of its existence.

Competence is a legal term and is all or nothing unlike capacity (which is a spectrum) and refers to people’s inability to carry out certain activities of daily living

MH005

Exceptions to Consent

Not Exceptions to Consent

Exceptions to Consent

True emergency
      with incapable patient and prior wishes not known
Public health

Not Exceptions to Consent

Impaired Capacity
Waiver
“Therapeutic Privilege”

MH007

Legal Hierarchy of

Substitute Decision Makers

• A guardian of the person as appointed by the court.
• When there is no suitable relative or friend
• Someone who has been named as a proxy in an advance directive
• Spouse, partner or relative in the following order:
• spouse or partner
• child if 16 or older; custodial parent (who can be younger than 16 years old if the decision is being made for the substitute’s child); or Children’s Aid Society
• parent who has only a right of acces
• brother or sister
• other relative.

Appointed/proxy > spouse > child over 16 > parent > CFS > sibling > other relative

MH007

What are Futile Treatments?

1.    Treatment will not work for medical problem.
2.    Unfair allocation of resources.
3.    Treatment causes harm that outweighs benefit.
4.    Outcome remains the same.
5.    Poor quality of life.

MH011

The Belmont Report

outlined the ethical foundation of good research

Three key ethical principles:

1. Respect for Persons – this means both that we recognize those who are autonomous and allow them to make informed decisions about participating in research 
2. Beneficence – this describes an obligation to maximize possible benefits and minimize possible harms. In research this should be applied to the individual research subject, as well as to the entire group or community of potential research subjects involved in any given study. While we usually think of this calculation as a balancing act (will the potential benefits outweigh the potential harms) there must also be some absolute limit to the amount of risk any one individual (or group of subjects) can be exposed to, even if it may result in tremendous benefit to others. 
3. Justice – there must be a fair distribution of the benefits and burdens of research. This means that subjects should not be chosen simply because they are easy to recruit, or unlikely to refuse. Also - if participants are exposed to the risks of research, they must also be able to participate in the benefits. (e.g. using poor patient as subjects to study expensive drugs they would never be able to afford is unjust

Three important applications of these principles:

1. Informed Consent - Similar to informed consent for treatment, however, in research the standard in each of these areas is even higher than in informed consent for a clinical procedure since a research subject is agreeing to undertake additional potential risks with no guarantee of benefit.
2. Assessment of Risks and Benefits (follows from Beneficence) – The study question must have value and the study design must be able to answer the research question in order for benefits to be realized (bad science = bad ethics). Assessment of risk must include both the magnitude and probability of risk, and should include such potential risks as psychological distress, breaches of privacy and confidentiality, and social harm. As potential benefits increase, greater risks are also allowable – however there is a limit to risk beyond which we say that no amount of benefit can justify the study
3. Selection of Subjects (follows from Justice) – Researchers must ensure they are fair in the selection and treatment of individual subjects, and that their research does not propagate societal injustice and discrimination.

MH015

Principle of Formal Justice

Material Principles of Justice

“Equals must be treated equally and unequals must be treated unequally”

Material Principles of Justice

An equal share
According to need
According to effort
According to contribution
According to merit
According to free-market exchange

MH015

Utilitarian Theories

Libertarian Theories

Communitarian Theories

Egalitarian Theories:

Utilitarian Theories

• Just actions are those which create the greatest good for the greatest number
• Problem: Cut up 1 person to save 5?

Libertarian Theories

• The free-market should determine how benefits and burdens are distributed
• Get what you earn, and earn what you get
• Government’s job is to protect liberty and property rights
• Problems -  what about differences that are not person’s fault - “Lottery” of life - accidents, family money

Communitarian Theories

• We all have collective and individual responsibilities
• The community owes something to each individual, and individuals to the community
• Justice is a reflection of community values
• Problem: Different values within the community - how are they weighted and balance

Egalitarian Theories:

• Justice is promoted through the equal distribution of:
• goods
• means of distribution
• John Rawls "Veil of Ignorance" fits here

MH015

In our health-care system, resources are allocated at three main levels. These are:

Two key factors that should play a central role in virtually every allocation decision made in health care:

1) The Macro level – governments at the national, provincial and municipal levels decide how much to give to health care, and how much to other areas 
2) The Meso level – Administrators at hospitals and in charge of other health-care programs decide which programs to fund and at what level  
3) The Micro level – clinicians and clinical programs decide how to allocate resources to individual patients

Two key Factors:

1)    The need for the treatment
2)    The ability to benefit from the treatment

MH015

AAPA Code of Ethics (9)

1. PAs shall be committed to providing competent medical care
2. Deliver care without regard to sex, age, race, creed, socio-economic or political status
3. Adhere to laws regarding informed consent
4. Provide only those services for which they are qualified
5. Not misrepresent themselves
6. Uphold the doctrine of confidentiality
7. Strive to maintain and increase the quality of health care
8. Place service before material gain and guard against conflicts of interest
9. Strive to maintain a spirit of cooperation

MH041

Why respect Confidentiality?

Exceptions

1) Autonomy: allow each patient to control their own personal and private information.
2) Physician-patient relationship: doctor needs to acquire personal information to benefit society and patient, but must first respect the trust that the patient has placed in us.
3) Patient is more likely to seek treatment and be truthful

Legal Implication: criminal charges or could be sued. PHIA outlines penalties.

Exceptions:
1) Legally mandated:

i) Suspected child abuse or neglect: don’t need proof.
ii) Suspected abuse of a person in care: Protection for Persons in Care office.
iii) dangerous and communicable diseases: AIDS, TB, syphilis, etc.
iv) Health conditions that imply a danger to drive, fly, etc.
v) Other: medical errors, births, deaths, gunshot, stab, subpoena (court relevant)

2) A Duty to Warn: if there is an imminent risk to an identifiable person or group.

3) A Personal Judgment: rare, significant consequences, should go to consulting body.

MH041

SPIKESS: breaking bad news

S: Setting should be optimized.
P: Perceptions of the patient, ask what they know already.
I: Invitation to give information, provide a warning that info is coming.
K: Knowledge that needs to be given, state the bad news very clearly.
E: Explore emotions and empathize.
S: Strategy
S: Summarize

MH009

Quality End of Life Care (3 factors)

1) Control of pain and other symptoms:
These symptoms may be physical, emotional, psychological, spiritual or some combination of the above.

2) Establishing goals and making treatment decisions
Some of the issues that should be addressed include: reaching consensus around diagnosis and prognosis, engaging in advance care planning, establishing goals for care, and discussing life-sustaining treatments – including resuscitation and Do Not Resuscitate (DNR) orders.

3) Providing support for patients and their families
This is largely patient defined, but includes such goals as: maintaining hope, preserving dignity, facilitating closure, and strengthening relationships. While we have an individual responsibility to help patients and families work towards these goals there are also structural and systemic issues that play an important role.

MH009

Euthanasia and For and Against

Assisted suicide

Euthanasia:

a deliberate act with the intention of ending the life of another person to relieve that person’s suffering, where the act is the cause of death. Illegal in Canada.

For:
a) autonomous individuals should be able to determine what happens to them, including choosing the time and manner of their death.
b) euthanasia allows a person’s death to occur in a predictable manner, and with the smallest likelihood of experiencing distressing symptoms such as pain and shortness of breath.
c) policies permitting euthanasia will not have a negative impact on society if developed and administered appropriately   
Against:
a) people do not have the “right” to end their own lives – there are limits to autonomy
b) good palliative care can minimize the distressing symptoms patients feel at the end of life
c) permitting euthanasia will have a negative impact on society as a whole and particularly on specific at-risk populations

Assisted suicide:

the act of intentionally killing oneself with the assistance of another who deliberately provides the knowledge, means, or both. Also illegal.