Transcript Ethics for Transfusion Medicine Residents

Ethics for Transfusion
Medicine Residents
Dr. Jerry Growe
Prof. Michael McDonald
Stop
there
and look around:
are Ethical matters of
concern in Transfusion
practice.
Part I. What is ethics?
 Ethics
as the systematic study of human
conduct and moral judgement, including



good/bad,
right/wrong
virtue/vice
 Critical
reflection on moral beliefs and
practices


What are people’s moral beliefs?
What choices should we make?
Moral psychology (Rest)
4 Components of Moral Behaviour
1.
Ability to recognize a situation as having a moral
component
2.
Ability to make a judgement as to which action is
right, fair, just, appropriate
3.
Commitment to morally appropriate action
4.
Possession of appropriate personal qualities
(perseverance, courage) to carry out morally
appropriate actions

James Rest
Acquisition of moral values
 Many
values are “caught” rather than
“taught”



Importance of peers and workplace
Socialisation and acculturation
Life experiences
 Reflective
engagement
Ethical judgements






Centre on important values
Based on reason, not authority
Override self-interest to assure mutual benefit
Based on impartial considerations
Special words and emotions
“All things considered judgements”


Not optional add-on judgements
Integrative or holistic
Learning objectives

Identify and discuss


Some ethical issues in transfusion medicine
Methods for resolving ethical issues

Offer resources
 Ethical Issues in Transfusion Medicine; aabb

Ethical framework
• http://www.ethics.ubc.ca/people/mcdonald/decisions.htm

Ethics lit search
• http://bioethics.georgetown.edu/
Ethical judgements & principles

Ethical judgements involve a dual test:



“Are the means acceptable?” AND
“Are the ends worthwhile?”
Consensus principles in bioethics





Treat people with respect
Do no harm
Do good
Act fairly
Be caring
Part 2. Ethics & Transfusion
 Clinical
practice ethics centres on patient
care
 Requires


Patient (or guardian) consent
Fairness to other patients
 Within

institutional parameters
Licensing, medical appointment, general
health care system authorisation
Clinical Case #1
You received a phone call from a donor
asking why a "Coombs" test, (DAT), or
an HTLV test was done and reported
positive to her. Should the donor be
surprised? Did the donor truly give
informed consent to the test?
Clinical case 2
The Special Services Nurse has brought cases to
you on several occasions as he has wondered
about your colleague's interpretation of the
medical data, and the acceptance of the
donors involved. You also have been informed
through the grapevine that he frequently is
unavailable by pager when on call and, as a
result, three plateletpheresis donors have been
disqualified. What should you do?
How does CBS manage the
Altruistic Gift of Blood?
 Obligations



Not to harm the donor
To use the donation appropriately
To ensure privacy and confidentiality
 Obligations


of the CBS:
of the Donor:
To answer all questions truthfully
Not donate if engaged in any risky activities
Research ethics basics

Research involving humans is a privilege, not a
right!
 Those who conduct research involving humans
must meet norms for ethical research
 The onus is on those who conduct, house or
sponsor research to show these norms are met.
Three central questions
Does the research meet relevant
scholarly/scientific standards?
1.
•
•
Bad science is bad ethics
Is the science honestly done and accurately reported?
Will the likely net benefits of the research will
outweigh overall harms?
Does the research respect the rights of the
research subject, including
2.
3.
•
•
Protection from undue harm &
Informed consent?
Norms for clinical research
1.
2.
3.
4.
5.
6.
7.
Socially valuable research
Scientifically sound research
Fair subject selection
Favourable risk-benefit ratio
Independent review by an REB
Informed consent
Respect for actual and potential research subjects
in the conduct of research
Emmanuel et al. JAMA 2000
CBS REB
 RESEARCH
REGISTRATION
 RESEARCH ETHICS BOARD
APPLICATION
 GUIDANCE DOCUMENT
Research case

A physician-researcher you know at the
provincial cancer agency asks that you provide
her with left-over blood from routine medical
tests of patients with a certain type of tumour in
order to test a research hypothesis she has
about tumour growth. She also asks that you do
a chart review of these patients. She offers you
co-authorship on the resulting publication. What
should you do? Are there are any special rules
and procedures to follow with the use of blood
for research purposes?
Blood Contingency Planning in BC
 To
ensure a consistent and coordinated
approach to blood shortages.
 Guidelines
 PBCO
activated at Red Alert phase.
and CBS will coordinate.
Principles from BC Plan


All patients in BC should have equal access to the available blood
on the basis of need. No hospital should stockpile blood for “its”
patients.
When available resources are exceeded, the focus should shift from
doing the best for the individual patient to the public health goal of
doing the greatest good for the greatest number.


May include suspension of prophylactic transfusions and elective
procedures and cessation of transfusion support in terminal or moribund
patients
Blood inventory transparency is essential in a shortage. Decisionmakers need to know what inventory is available in the province,
regardless of whether it is at CBS or hospitals.
Assumptions from BC Plan

The supply of blood is insufficient to meet current or
anticipated demand, despite ongoing efforts to increase
the available supply.
 Hospitals and CBS will share inventory information.
 During a blood shortage, blood use will be triaged to
ensure the most urgent cases receive the available
supply.
 Measures to ensure appropriate blood use and reduce
waste during non-shortages contribute significantly to
blood contingency preparedness.
Further Points to Consider
Guidelines for “stopping principles”
 How to operationalize guidelines





Under what circumstances will guidelines come into
effect?
What is the decision-making process?
Who will make decisions?
How will process and decisions be communicated?
• To attending physicians, staff, families

How will process and decisions be documented?