Transcript Bioethics and Moral Hazard in Short-Term

Transplant Ethics
ANTH 3301: Health, Healing & Ethics
Prof. Carolyn Smith-Morris
Challenges to Ethical Care
1. Culture and Language
• Communication breakdowns and cultural differences are
ubiquitous
• Less likely to receive care
• Less likely to be compliant
• Greater risk of
experiencing medical
errors
• Respect for autonomous
individuals requires providers
to acknowledge and honor a
patient’s ability to consent
for treatment.
Challenges to Ethical Care
2. Lack of Adequate Time, Resources
• Triage – identifying medical needs and likelihood of
benefit.
• The principle of justice obligates medical personnel to
consider the medical utility and prospect of success as
factors in the decisions about how to allocate resources
• The Utilitarian Approach
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To do the most good for the most people
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To offer the best possible care (for the community? for the individual?)
with available medications and equipment
Challenges to Ethical Care
3. Chronic Care and Elective Surgery
• Nonmaleficence requires physicians to consider what
care should not be offered.
• Without the ability to provide long-term follow-up
care, avoid chronic care medication and elective
surgery. (Jesus 2010: 19)
Case 1
(Sargent & Smith-Morris 2006)
A young adult male is brought to the ER having swallowed a
Pentium 4 computer chip. He has a history of psychotic episodes. He
now has bowel obstruction but refuses surgery, apparently wants to
keep the mechanism. A Psychiatry consult determines that he is not
competent to make decisions and he is sent to surgery.
Once there, an OR authority questions him to determine if he is
“oriented X 3.” He knows his name, the day, and the president. The OR
nurse then overrides the surgery decision, having determined to her
own satisfaction that he is competent.
In an ethics consult to discuss the decision-making process in this
case, the psychiatry residents mention that while the patient is mildly
retarded, this was not a factor in their determination that he lacked
the capacity to make a decision about surgery. The OR nurse then
vigorously states that if she had known he was retarded, she would
have never questioned the psychiatry decision.
Cultural Reification of the
Individual
Principles can reinforce cultural notions
about:
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the target of care
the definition of the patient
responsibilities of the various parties involved
“out of touch” with multi-cultural settings
What can ethnography or cultural analysis add
to ethical care?
(Sargent& Smith-Morris)
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Individual versus family (or collective) focus of decisions
Religious interpretations
Discussions of death
Truth-telling norms
Distributive justice
Patriarchal family and customary gender roles
Cultural constructs of mental illness
The authority/implications of a diagnosis of “retardation”
The authority/implications of a diagnosis of “psychotic”
What it means to be delusional vis-à-vis decision-making capacity
The limits of personal autonomy
Legal
Institutional
Cultural
Impact of authoritative knowledge and structural violence
The Common Morality:
Transplant-Specific Challenges
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Individual orientation
Linear time
Universality of truth-telling
Informed consent
Definitions of personhood
Ownership and transplantation of body parts
Withholding or withdrawing life-sustaining treatments
Explanatory Models for
Transplant Decision-Making
Descriptive Level
Who else, if anyone, has been or should be involved in your
care?
Conceptual Level
In cases like yours, what family or friends usually are
involved in decisions?
How are decisions about health care made in your
family/culture/neighborhood?
What do you feel doctors/hospitals should provide in these
cases? (What are your expectations?)
Personal Level
Would you like to express any preference for who is
involved? – for how decisions are made?
How do you want me to handle information about your
health?
Case 2: A case study of the Ethics of Risk (“Maria Hernandez”)
Future Behavioral Risk
• As a Mexican seeking care in the U.S. on a B-2 Visa
(Beneficence)
• As a Mother (Autonomy)
International Organ Transplant
• Economic Responsibility and International Ethics (Justice)
Wealthy “Tourist” versus Poor “Migrant”
“Organ Risk or Just a Migrant”
Challenges to Ethical Care
4. Bioethics and Free Market Medicine
• Certain experiences (e.g., dialysis) are increasingly viewed as
“unacceptible suffering”
• Medicalization
• A narrative of “global scarcity” is created.
• (Scheper-Hughes) The free market requires a divisible body
• Detachable, dymystified organs
• Market dilemmas
• Corruption and malfeasance (e.g., Dr. Shapira)
• Unequal market power (e.g., supply driving down kidney fees)
• Outdated laws, poor regulation
Can Ethical Dilemmas be resolved by the market?
Jesica Santillan Case
• February 2003
• 17 year old Mexican immigrant
• Two consecutive heart/lung transplants
(the first failed because of the wrong
blood type)
• Immigrant threats to the nation/national
resources (Leo Chavez)
• The culture of transplant; bioavailability
(Nancy Scheper-Hughes)
• The Experimental Imperative, especially
for children (Lesley Sharp)
Remedies & Strategies:
Kleinman’s 8 questions:
a.k.a. Explanatory Models
OBJECTIVE: for clinicians and patients to negotiate treatment and expected
outcomes, as therapeutic allies.
ADDRESS:
• etiology
• onset of symptoms
• pathophysiology
• course of illness
• treatment
REFLECT: social class, cultural beliefs, education, occupation, religious affiliation,
past experience with illness and health care.
(Arthur Kleinman, M.D., Leon Eisenberg, M.D., Byron Good, Ph.D, Annals of Internal
Medicine 88:251-258, 1978)