Transcript Introduction to Ethics

Introduction to Ethics
Toby L. Schonfeld, Ph.D.
Preventive and Societal Medicine
Today’s objectives
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To describe ways that values shape ethics and to
give some examples of these in health care;
To identify ways in which considerations of law and
ethics often converge in health care;
To explain how the contextual features of a case are
central to its adequate resolution;
To state three or four goals of medicine and give
examples in which each goal dominates as a
priority;
To demonstrate how patient’s values influence
patient decisions and how a provider’s values
influence provider choices
Elliot J.
Ethics 101
 Two fundamental questions
 Process of Rational Reflection
 Position + Reasons = Moral Argument
 Medical Ethics: developing, analyzing, and
reforming moral arguments about health care
in support of a particular position
 Goal of ethical analysis: a right answer, a
choice, a recommendation
Rationing and Public Health
 Assume that an influenza epidemic was
evolving in Omaha. The ICU in each hospital
was full and nearly all ventilators were in
use.
 Two patients arrive in the emergency room
simultaneously.
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One is 40 years old, has had influenza for 2
days, and is rapidly evolving into respiratory
failure.
The second is 50 years of age, was in a car
accident 20 minutes before arriving in the
Emergency room, and has respiratory failure
from multiple fractures of his ribs causing
ineffective respiratory function.
 Finally, there is only one ventilator available in
the hospital that was being reserved for an 80
year old man requiring coronary by-pass
surgery the following morning.
 What are the ethical dilemmas in this case?
 What questions are asked and what should
be considered in a deliberation about how the
ventilators are used?
Values 101
 Values = the fundamental building blocks of
our moral system
 Sources: parents, culture and society,
religion, law
 One goal of medical ethics: to identify,
assess, and respect values in health care
 Principles: respect for autonomy,
beneficence/nonmaleficence, justice, virtue,
listening to silenced voices
How might these additional factors
influence the decision?
 The 40 year old with influenza does not have
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insurance coverage.
The 50 year old in the car accident was driving drunk.
The 40 year old with flu is an undocumented
immigrant living in an apartment with 8 other family
members.
The 80 year old is a major benefactor to the
organization.
The 50 year old in the car accident is the primary
guardian for his 16 and 14 year old grandchildren.
Law
 Limits range of permissible action
 Enforcement of rights and liberties
Case Study
Pregnancy and Privacy: where questions
of law and questions of morality seem to
conflict
Pregnancy and Privacy
 May 30, 2002: slain baby found in trash
outside Storm Lake, Iowa
 Autopsy failed to reveal information about
boy’s race, cause of death, or whether he
was born alive
 Police had no leads
Legal maneuvering
 County officials want to find baby’s mother
(presumably for prosecution)
 June 17, 2002: District Court judge ordered:
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Hospitals & clinics
Planned Parenthood
to turn over names of women with positive
pregnancy tests between 8/15/01-5/30/02
 Deadline: August 17, 2002
Planned Parenthood
 Planned Parenthood refused to comply
 Appealed case to Iowa Supreme Court
 Week of December 9, 2002: Court was
scheduled to hear arguments
Legal conclusion
 County withdrew the case because of a “lack
of time and resources to fight a case that
could drag on for years”
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Was this the real reason, or was there another
motive?
 May 2004: Storm Lake couple filed a lawsuit
against a hospital that released their records
2 years earlier
Ethical Considerations
 Is the information about pregnancy being requested
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private or confidential?
What justifies a breach of confidentiality?
What is to be gained from this information?
Will this information be adequate to reach the stated
goals?
Why assume the baby’s mother is responsible?
Is there a way to get this information that is less
invasive of individuals’ privacy?
Legal considerations
 Court order for records was obtained legally
by county attorney
 Planned Parenthood went through legal
channels to quash the subpoena and
challenge its validity
 Was someone criminally liable for the death
of the child, or merely for the disposal of a
body?
Ethical Considerations
 Is the requested information about pregnancy private
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or confidential?
What justifies a breach of confidentiality?
What is to be gained from this information?
Will this information serve the alleged purpose?
Is there a way to get the desired information that is
less invasive of individuals’ privacy?
Why assume the baby’s mother is responsible?
Final thoughts
 We will return to this case in our
confidentiality unit, but for now this will serve
as an example of where the requirements of
the law and the requirements of ethics may
differ. It is important, therefore, to consider
legal and ethical questions separately when
evaluating a case.
Back to Elliot J.
 Case analysis consists of:
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(Medical) Facts
Contextual Issues
Goals: case, patient/family, medicine
Values
Resources
Resources
 Supervisor, colleagues
 Professional Code of Ethics
 Institutional/organizational policies
 Consultation services (ethics, etc.)