Transcript Dr David Smith, Associate Professor of Health Care

ETHICAL DECISION-MAKING
Prof David Smith
INTRODUCTION
• FOUR PRINCIPLES
• THE FOUR QUESTION
APPROACH
• THE FOUR-TOPIC PARADIGM
PRINCIPLES OF BIOMEDICAL
ETHICS
(1979; 2013)
• Four principles govern
clinical research &
clinical medicine
regarding human
persons:
1) Respect for Autonomy
2) Nonmaleficence
3) Beneficence
4) Justice
FOUR PRINCIPLES*
Beneficence
Justice
*Beauchamp & Childress, Principles of Biomedical Ethics
Respect for Autonomy
Nonmaleficence
(1979; 7th ed. 2013
FOUR PRINCIPLES APPROACH
• The four principles plus scope approach claims that
whatever our personal philosophy, politics, religion,
moral theory, or life stance, we will find no difficulty
in committing ourselves to four prima facie moral
principles plus a reflective concern about their
scope and application.
• The fours principles plus attention to their scope of
application, encompass most of the moral issues
that arise in health care.
RESPECT FOR AUTONOMY
• Etymology: The word autonomy derives from the
Greek words autos = self and nomos = rule,
governance, law
• Definition of Autonomy:
• The right of persons to make authentic choices about
what they shall do, and what shall be done to them
and, as far as is possible, what should happen to
them.
• Deliberate self rule is a special attribute ascribed to
all moral agents
RESPECT FOR AUTONOMY
• Ability and tendency to think for oneself, to make decisions for
oneself about the way one wishes to lead one’s life based on
that thinking, and then to enact those decisions—is what makes
morality—any sort of morality—possible.
• Respect for autonomy is the moral obligation to respect the
autonomy of others in so far as such respect is compatible with
equal respect for the autonomy of all potentially affected.
RESPECT FOR AUTOMONY
The principle of Respect for Autonomy incorporates two aspects*:
(i) Respect for Autonomy – which requires that those who are
capable of deliberation about their personal choices should be
treated with respect for their capacity for self determination.
(ii) Protection of persons with impaired or diminished
autonomy – which requires that those who are dependent or
vulnerable be afforded security against harm or abuse.
RESPECT FOR AUTONOMY
DOCTOR’S OBLIGATIONS
PATIENT’S RIGHTS
The obligation to maintain patient
confidentiality.
The right to have one’s medical
information kept confidential.
The obligation to presume the
capacity of the patient to
consent/refuse treatment, OR if
indications to the contrary, to
assess incapacity.
The right to self-determination
through choice and action i.e. to
make an autonomous choice.
The obligation to provide all
necessary information for
informed consent.
The right to receive all the
information necessary for
decision-making.
The obligation to get consent /
refusal prior to treatment.
The right to consent/refuse
examination, procedures etc.
CASE STUDY
• Mr. A. has intermittent abdominal pain. Investigations reveal
gallstones, and the cause of the pain is thought to be due to this.
Mr. A. gives consent for the operation involving removal of the
gallbladder, and also for anything else to be done that is thought
necessary. At operation, the surgeon finds that, although there
are gallstones, the cause of the pain is probably a carcinoma,
which he discovers at the head of the pancreas. The surgeon
removes not only the gallbladder but also the pancreatic
carcinoma.
Question:
• Has the surgeon acted correctly?
*Hope T, Savulescu J, Hendrick J, (2008) Medical Ethics and Law: 75.
The principle of
BENEFICENCE
• Principle of Beneficence refers to a statement of moral
obligation to act for the benefit of others.
• Principle of Beneficence requires that an agent take positive
steps to help others, not merely refrain from harmful acts.
• Attending to the welfare of patients – not merely avoiding harm
– embodies medicine’s goal, rationale, and justification.
Beauchamp & Childress (2013) Principles of Biomedical Ethics: 202ff.
BENEFICENCE
• The traditional Hippocratic moral obligation of medicine is to
provide net medical benefit to patients with minimal harm, that
is, beneficence with non-maleficence.
• To do this we must respect the patient’s autonomy for what
constitutes benefit for one patient may be harm for another.
• Beneficence is vital in all medical and health care professions.
BENEFICENCE
• Promoting the welfare of patients – not merely
avoiding harm – embodies medicine’s goal,
rationale, and justification.
• The health care professional’s primary obligation
is to act for the patient’s medical benefit.
• Potential conflict between what the patient
determines to be in their best interest and what
the health care professional believes to be in
their best interest.
BENEFICENCE
• Although there are some general norms of human needs,
benefits and harms, people vary in their individual perceptions
and evaluations of their own needs, benefits, and harms.
• Jehovah’s Witnesses attitudes to blood are a vivid illustration of
this variability.
• Thus even to attempt to benefit people with as little harm as
possible requires, where possible, discovery of what the
proposed beneficiary regards as a benefit, regards as a harm,
and regards as the most beneficial and least harmful of the
available options.
BENEFICENCE
• The obligation to provide net benefit to patients also requires us
to be clear about risk and probability when we make our
assessments of harm and benefit.
• Need empirical information about the possibilities of the various
harms and benefits that may result from the proposed health
care interventions.
• Moreover even if the person agrees that one available
intervention would be more beneficial than another, he or she
may simply wish to reject the beneficial intervention.
BENEFICENCE v PATERNALISM
BENEFICENCE
• The ethical obligation to
act for the benefit
patients.
PATERNALISM
The intentional overriding of a
patient’s preferences by:
Manipulation of information
Nondisclosure of information
Deception
Lying
Coercion
and justifying this action by:
•Reference to the patient’s best
interests;
•Preventing harm to the patient;
•Mitigating harm to the patient.
CASE STUDY
Mrs. B. has acute abdominal pain. A diagnosis of appendicitis is
made and Mrs. B. gives her consent for surgery, including removal
of her appendix. At operation discovers that in addition to an
acutely inflamed appendix, Mrs. B. also has an ovarian tumour.
This tumour is not likely to have contributed to her acute abdominal
pain. The surgeon considers that it is in Mrs. B’s best interests for
the ovary containing the tumour to be removed. He therefore
removes it.
Question:
•Is the surgeon acting in the best interests of Mrs. B?
*Hope T, Savulescu J, Hendrick J, (2008) Medical Ethics and Law: 75.
THE PRINCIPLE OF
NONMALEFICENCE
“Do no harm”
DUE CARE
ABSENCE OF DUE CARE
Taking sufficient and
appropriate care to
avoid causing harm, as
the circumstances
demand of a reasonable
and prudent person.
NEGLIGENCE –
intentional or unintentional.
PROFESSIONAL
MALPRACTICE – not
following professional
standards of due care.
NONMALEFICENCE
“Do no harm”
The concept of harm
• Hippocratic Oath
• “I will use treatment to help the sick according to
my ability and judgement, but I will never use it to
injure or wrong them.”
NONMALEFICENCE
• What do we mean by harm?
• In medical terms, pain, disability, suffering,
death
• Specification of non-maleficence might mean
–
–
–
–
–
Do not kill
Do not cause pain or suffering
Do not incapacitate
Do not cause offence
Do not deprive others of the goods of life
NONMALEFICENCE
“Do no harm”
Standard of Due Care
• Due Care: taking sufficient and appropriate
care to avoid causing harm, as the
circumstances demand of a reasonable and
prudent person.
• This standard requires the health goals
pursued justify the risks – grave risks require
commensurate goals
• Professional malpractice happens if conduct
falls below accepted standard of care
NONMALEFICENCE
“Do no harm”
Negligence: the absence of due care
• Intentionally – imposing unreasonable risks
of harm
• Unintentionally – but carelessly imposing
risks of harm
.
NONMALEFICENCE
“Do no harm”
Professional malpractice
An instance of negligence that involves not
following professional standards of care
The principle of
JUSTICE
The principle of justice refers to the obligation to provide fair,
equitable and appropriate treatment to patients.
BUT: By which principle of justice should healthcare be
distributed?
DISTRIBUTIVE JUSTICE
TYPES OF ALLOCATION
• Partitioning the comprehensive social budget
• Allocating within the health budget
• Allocating within the health care budget
• Allocating scarce treatment for patients
RATIONING – AS CRITERIA
FOR ALLOCATING
• Rationing of healthcare to those who cause their own
ill health
• Smokers
• Obese People
• Over consumption of alcohol
• Risky sexual behaviour
• Risky activities in life
• Known genetic predispositions
CASE STUDY
There are three patients in your clinic. They all need coronary artery bypass surgery.
But only one of them can have it due to limited resources.
Aziz is 50 years old and has a wife and three small children. He has been taking his
medication sensibly for the past 5 years. However, he is still a heavy smoker and has
two pints of Guinness a day. He is a neonatologist.
Bertie is an 8O-year-old man who served in the Second World War and was
commended for his bravery. His wife recently died and he does not have any
children. He has also been compliant with his medication. He has never smoked and
only has the occasional whisky.
Chloe is a 30–year–old woman with a genetic disorder that has caused learning
disability and early heart disease. She lives in a care home and is visited often by her
family. She is much loved by everyone who knows her and is often seen in her local
village selling cakes for charity.
Question:
•Who should you prioritize to receive the surgery?
PRINCIPLES CAN CLASH!
Respect for
patient’s
autonomy
Beneficence
USING THE FOUR
PRINCIPLES
SPECIFICATI
ON
narrowing the
scope by the
addition of
content from a
specific case
BALANCING
finding
reasons about
which moral
norms should
prevail.
JUDGEMENT
resolution of
ethical
dilemma
STRENGTHS OF THE FOUR
PRINCIPLES
Culturally neutral.
Universal appeal – give us a common moral
language.
Enable us to avoid moral imperialism & moral
relativism.
WEAKNESSES OF THE FOUR
PRINCIPLES
CLAIMS & NAMES:
They are only a collection of names and don’t fulfil the claims they
make.
CRUDE, NOT COMPLEX:
(i) They fail to capture the complexity of real life.
(ii) They make ethical debate boring.
WESTERN PRINCIPLES:
The primacy of ‘respect for autonomy’ indicates a lack of respect for
community values & cultural autonomy.
THE FOUR QUESTION
APPROACH
• Goran Hermeren “Human stem-cell research in
gastroenterology: Experimental treatment, tourism and
biobanking” Best Practice & Research Clinical Gastroenterology
28 (2014) 257-268
• The idea is to begin with three questions:
– What do we know?
– What do we want?
– What are we able to do?
• Variations may have to be considered, depending on who ‘we’
are in each particular case. Then we can move on to the fourth
question:
– What ought to be done?
The Four-Topic Paradigm
Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics: A Practical
Approach to Ethical Decisions in Clinical Medicine, 7th ed. New York:
McGraw-Hill, 2010.
• Medical Indications
• Principles of Beneficence and Nonmaleficence
1. What is the patient’s medical problem? Is the problem acute?
chronic? critical? reversible? emergent? terminal?
2. What are the goals of treatment?
3. In what circumstances are medical treatments not indicated?
4. What are the probabilities of success of various treatment
options?
5. In sum, how can this patient be benefited by medical and
nursing care, and how can harm be avoided?
The Four-Topic Paradigm
• Patient Preferences
• Principles of Respect for Autonomy
1. Has the patient been informed of benefits and risks,
understood this information, and given consent?
2. Is the patient mentally capable and legally competent, and is
there evidence of incapacity?
3. If mentally capable, what preferences about treatment is the
patient stating?
4. If incapacitated, has the patient expressed prior preferences?
5. Who is the appropriate surrogate to make decisions for the
incapacitated patient? 6. Is the patient unwilling or unable to
cooperate with medical treatment? If so, why?
The Four-Topic Paradigm
• Quality of Life
• Principles of Beneficence and Nonmaleficence and Respect for
Autonomy
1. What are the prospects, with or without treatment, for a return
to normal life, and what physical, mental, and social deficits
might the patient experience even if treatment succeeds?
2. On what grounds can anyone judge that some quality of life
would be undesirable for a patient who cannot make or express
such a judgment?
3. Are there biases that might prejudice the provider’s evaluation
of the patient’s quality of life?
4. What ethical issues arise concerning improving or enhancing a
patient’s quality of life?
The Four-Topic Paradigm
5. Do quality-of-life assessments raise any questions regarding
changes in treatment plans, such as forgoing life-sustaining
treatment?
6. What are plans and rationale to forgo life-sustaining treatment?
7. What is the legal and ethical status of suicide?
The Four-Topic Paradigm
• Contextual Features
• Principles of Justice and Fairness
1. Are there professional, interprofessional, or business interests
that might create conflicts of interest in the clinical treatment of
patients?
2. Are there parties other than clinicians and patients, such as
family members, who have an interest in clinical decisions?
3. What are the limits imposed on patient confidentiality by the
legitimate interests of third parties?
4. Are there financial factors that create conflicts of interest in
clinical decisions?
5. Are there problems of allocation of scarce health resources that
might affect clinical decisions?
The Four-Topic Paradigm
6. Are there religious issues that might influence clinical
decisions?
7. What are the legal issues that might affect clinical decisions?
8. Are there considerations of clinical research and education that
might affect clinical decisions?
9. Are there issues of public health and safety that affect clinical
decisions?
10. Are there conflicts of interest within institutions and
organizations (e.g., hospitals) that may affect clinical decisions
and patient welfare?
RECOMMENDED READING
Primary sources:
Beauchamp T L & Childress, J F (2013) Principles of Biomedical Ethics. 7th edition. Oxford
University Press.
Beauchamp, T L, ‘Methods and principles in biomedical ethics. J Med Ethics 2003; 29: 269-274.
Childress, J.F., ‘A Principle-based Approach’ in A Companion to Bioethics. 2nd ed. Ed. H.Kuhse &
P. Singer. (Wiley-Blackwell: 2012) 67-76
RECOMMENDED READING
Secondary Sources:
Campbell, A V, ‘The virtues (and vices) of the four principles. J Med Ethics 2003; 29: 292-296.
Clouser, K D., and Gert, B., ‘Morality vs. Principlism’ in Principles of Health Care Ethics edited by
R. Gillon. John Wiley & Sons; 1994: 251 – 266.
Clouser, K D., and Gert, B. (1990) ‘A critique of principlism’. Journal of Medicine and Philosophy
15: 219-236.
Gillon, R, ‘Ethics needs principles – four can encompass the rest – and respect for autonomy
should be “first among equals”’. J Med Ethics 2003; 29: 307 – 312.
Gillon, R, ‘The Four Principles Revisited – a Reappraisal’ in Principles of Health Care Ethics
edited by R. Gillon. John Wiley & Sons; 1994: 319 – 333.
Harris, J, ‘In praise of unprincipled ethics. J Med Ethics 2003; 29: 303 – 306.
Nicholson, R H, ‘Limitations of the Four Principles’ in Principles of Health Care Ethics edited by
R. Gillon. John Wiley & Sons; 1994:267 – 275.
Sommerville, A, ‘Juggling law, ethics and intuition: practical answers to awkward questions.’ J
Med Ethics 2003; 29: 281- 286.