Transcript Ethical Considerations for Medical Decision Making

Medical Ethics 101
Balancing obligation, outcomes, and risk
in clinical decision-making
Jill Ann Jarrell, MD, MPH
Complex Care Program, Academic General Pediatrics
Texas Children’s Hospital, Baylor College of Medicine
Disclosures

Dr. Jarrell has no relevant conflicts of interest to
disclose
Patient-Provider Relationship
Patient-Healthcare Team Relationship
What is “Ethics”?
“Ethics is a branch of philosophy; the
formal, rational, systemic examination
of the rightness and wrongness of
human actions.”1
What is “Medical Ethics”


Evaluating the rightness and wrongness of human
actions in medicine
Bioethics
Principles and Duties of Medical Ethics
Principles
Duties
• Autonomy
• Veracity
• Justice
• Confidentiality
• Beneficence
• Role Fidelity
• Nonmaleficence
• Respect for Societal
Institutions
Ethical Principles
Autonomy
•
Individual liberty, dignity, and capacity
Justice
•
What is fair or deserved
Beneficence
•
An obligation to do good
Nonmaleficence
•
An obligation to not harm
Ethical Duties
Veracity
•
Truth telling
Privacy and Confidentiality
Role Fidelity
•
Professional responsibility and autonomy
Respect for Societal Institutions
•
Life, culture, family, religion
Hot Topics in Ethics
•
Surrogate or substitute decision-making
•
Advanced care planning
•
Principle of double effect
•
Informed consent
•
Futility
Decision-Making Capacity
Able to understand medical treatment and
make informed decisions.
Incapacitated
Unable to understand the benefits, risks,
alternatives to treatment.
Surrogate Decision-Maker
Individual with authority to consent to
medical treatment for an incapacitated
patient.
Surrogate Decision-Makers
•
•
•
•
•
•
Spouse
Adult child with POA or majority of adult
children
Parents
Clearly identified individual
Nearest living relative
Patient’s clergy
Surrogacy in Minors
Parents available
•
•
•
•
Natural parents
Adoptive parents
Sole managing conservator
Possessory conservator (non-invasive
procedures during possession)
Surrogacy in Minors
Parents not available
•
•
•
•
Grandparent
Adult sibling
Adult aunt/uncle
Educational institution with written
authorization
Surrogacy in Minors
Parents not available (cont’d)
•
•
•
•
Adult with custody and written
authorization
Court with jurisdiction
Adult with care of child subject to
juvenile court
Peace officer
Schizophrenic Child
With Absent Family
History
• 17 yo male with paranoid
schizophrenia
• Attempted suicide
• Survived - multiple orthopedic and
internal injuries
Conflict
• Poorly compensated from a
psychiatric perspective
• Mother quit visiting/answering calls
• Patient turned 18 during care
Who is in charge?
Who is the decision-maker?
• Patient
• Mom
• CPS/APS
• Legal Guardian
Ethical challenges
• Beneficence
• Autonomy
• Social Responsibility
Pregnant patient with
terminal cancer
Pregnant Patient With Cancer
• 30 yo woman
• 24 weeks gestation
• Stage IV breast cancer
Pregnant Patient With Cancer
• Intractable pain
• Progressive encephalopathy
• Previously told her OB/GYN she wanted
to “have this baby”
Pregnant Patient With Cancer
• Patient’s condition declined
• Patient’s mother asked for hospice care for
her daughter
Pregnant Patient With Cancer
Two patients?
Pregnant Patient With Cancer
Who is the decision-maker?
•
Patient
•
Mother
•
Healthcare team
Pregnant Patient With Cancer
Ethical Challenges?
•
Beneficence
•
Nonmaleficence
•
Social responsibility
•
Role Fidelity
To trach or not to
trach…
History
•
5 yo with Trisomy 21, repaired CHD, CP
admitted for pneumonia
•
PICU, intubated, difficult wean, trach
was discussed with family
•
Palliative care consulted on HD 55 to
discuss “options”
Conflict
•
Palliative care recommended not to trach and
for medical team to collectively advise palliation
•
ENT “just a technician” and uncomfortable
•
PCP and CCM wish to proceed with trach
•
Ethics committee consult requested
Ethical challenges
•
•
•
•
•
Benificence
Non-maleficence
Respect for family
Autonomy (but how much?)
Role fidelity
Skills for Resolving Ethical Dilemmas2
•
Listening
•
Conflict resolution
•
Tolerance for ambiguity
•
Ability to apply ethical principles and
carry out duties
Framework for Ethical Decisions 3
•
Medical indications
•
Patient preferences
•
Quality of life
•
Contextual features
Take Home Messages
• Continue to LEARN about your discipline
and the ever-changing milieu in which it
is practiced
• COMMUNICATION and
COLLABORATION between care team
members and decision-makers is key to
success
Questions?
References
1.
Pellegrino, E. Toward a Reconstruction of Medical Morality. The
American Journal of Bioethics 2006; 6-65-71
2.
“Legal and Ethical Issues” Physician Board Review Course in Hospice
and Palliative Medicine, MD Anderson Cancer Center, 10/12/2010.
3.
Jonson A, Seigler M, Winslade W. Clinical Ethics: A Practical Approach
to Ethical Decisions in Clinical Medicine. 6th ed, page 11.