Transcript Practical Ethics

Practical Ethics
Stuart Sprague, PhD
Practical Ethics
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Some see this as an oxymoron
Ethical realists think ethics stands
above practice
• Ethics is fixed and unchanging,
regardless of practice
• Changing ethics in light of practice
smacks of cultural relativism
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Other post-modern views allow for
ethics which rises out of practice
Solidarity
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Idea from Richard Rorty, and others,
that moral progress is possible
• Changes in moral standards over time
reflect common human experiences of
pain, humiliation, pity and benevolence
• Reason can give “ideals,” but practice
shows us an equilibrium between
principles and practice.
Practice of Resuscitation
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Devised in modern medicine as a response
to body systems arrest or failure
Seen as something anyone can learn
Has a common sense appeal that it should
be given to everyone who experiences
cardiac or pulmonary arrest-”Why would
you not do it?”
Unlike other medical procedures, it
becomes a default assumption. Must
write order not to do it.
Autonomy
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Highly valued principle since the
Enlightenment
One of four basic principles of
medical ethics
Key element of physician-patient
relationship
Essential component of informed
consent
Autonomy
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Not an absolute
Two persons in dyad, each of whom
has autonomy
• Professionalism demands subjection to
the interests of the patient
• AMA Code of Ethics says no physician is
required to give treatment simply
because it is requested
Resuscitation II
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Common assumption that CPR is
always beneficial challenged in era of
debilitating chronic illness
Requests for CPR may not be based
on fully autonomous choice
• Full autonomy requires full knowledge
• Substituted judgment of surrogate adds
a layer of separation from full autonomy
Recent AMA action
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Opinion 2.035 (AMA Code of Ethics)
“Physicians are not ethically obligated to
deliver care that, in their best professional
judgment, will not have a reasonable
chance of benefiting their patients.
Patients should not be given treatments
simply because they demand them.”
Annual Meeting 2011 saw request to CEJA
“for practical ethical guidance to help
them refuse inappropriate requests while
maintaining positive relationships with
patients.”
Back to Practical Ethics
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Physicians commonly refuse patient
requests for inappropriate treatments:
narcotics ,antibiotics, cesarean sections et
al.
What are reasons for acceding to requests
for inappropriate CPR?
• Fear of legal repercussions
• “This is different; it’s life or death.”
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Would solidarity of action create new
guidelines from which to operate?
Potential Problems
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Could be seen as effort only to save
money.
It would require a new perspective on CPR
in the mind of the public.
• It is a major medical intervention requiring
skill and judgment rather than something
anybody can do and everybody ought to have.
• Guidelines needed will vary among patients.
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It would require true solidarity among a
variety of institutions and perspectives.
Buy in from the top is crucial.
Advantages
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Patients would be spared suffering
from invasive therapy of little or no
value.
Staff would experience less moral
distress.
Valuable resources could be devoted
to other, more urgent needs. (e.g.
shortages of epinephrine, etc.)
Strategies
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Work with ethics committees to raise
discussion of a new approach.
Work with policy making entities to
develop new policies.
Do in-service with staff
Develop role plays to practice the
language of a new approach.
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