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Alexa Miranda

Biomedical Ethics
Chapter 5: Professionalism and the Internal Morality of Medicine
Medical Futility:

Futile= ineffective/ incapable of producing any result.

Physiologic Futility:

Futile in achieving its physiologic objective and offers no physiologic


benefit to the patient
EX: CPR on a patient with rigor mortis (p.123)

Qualitative Futility:

An act that has important physiologic effects that medical judgment


concludes are non beneficial to the patient as a person.
EX: artificial feeding for patients in a vegetative state.

Quantitative Futility (Probabilistic Futility)

Act that is very unlikely to produce either a desired physiologic effect


or personal benefit.

Medically futile because improbable

EX: when physicians conclude that the last 100 cases a medical treatment
has been useless they should regard the treatment as FUTILE
Wanglie Case:

86 yr. old ventilator dependent woman in permanent vegetative state


(PVS)
Physicians told family the mechanical ventilation was non beneficial to
her as a person and should discontinue it.
Family rejected idea (hoping for miracle) & claimed she wouldve
wanted treatment
Hospital appointed an independent conservator to decide if the
ventilator use was beneficial (found that it was not beneficial)

Went to court, hospital decided not to discontinue ventilator support


Mrs. Wanglie died 3 days later of sepsis-induced multi system organ
failure.

Baby K Case:

Female anencephalic infant born in Virginia.


Had perinatal respiratory distress & was intubated & mechanically
intubated
No treatment existed for anencephaly & mechanical ventilation served
no therapeutic or palliative purpose
Mom refused to consent to DNR
Ethics committee concludes ventilator support was FUTILE, mom
disagreed
Hospital takes legal action, guardian appointed to represent Baby K
Guardian decides ventilation is futile too,
At the end, EMTALA law: states hospitals are required to provide
stabilizing treatment to any person who comes to an emergency room
department with a emergency medical condition. & Futility does not
apply with this.

Gilgunn Case:

Catherine Gilgunn, 71 yr. old woman with Parkinson disease, diabetes,


and heart disease, one-year status- post cerebrovascular accident and
a mastectomy for breast cancer.
Went into surgery for hip fracture in Massachusetts General Hospital
Developed extensive & irreversible brain damage resulting in coma.
Daughter said her mom wouldve wanted Everything done thats
medically possible
Drs go against that b/c CPR would be medically contraindicated,
inhumane, and unethical.
They put DNR on Gilgunn & wean her off of ventilator, they didnt
monitor blood gasses because they knew she would not survive on her
own.
3 days later, she died
Daughter sued hospital & lost because CPR and mechanical ventilation
was seen as futile.

Health Care Professional Duty:

HCP generally under no obligation to provide medically futile


treatments.

Medical futility is all about professional duty but professional duty is


not about medical futility.

Internal Morality of Medicine:

Goals & means of medicine = internal morality


Professional integrity of physicians constituted by allegiance to this
internal morality.
Acts promoting no medical goal violate internal morality
When the means employed are not legitimate medical means, the act
violates the internal morality of medicine because of means of
illegitimacy!

Goals of Medicine:
4 Goals of Medicine

prevention of disease and injury and promotion & maintanence of


health
relief of pain & suffering caused by maladies
care & cure of those with a amlady & care of those who cant be cured
avoidance of premature death and rhe pursuit of a peaceful death

Goals Made By:

Diagnosing the disease or injury (appropriate treatment depends on


proper diagnosis)
Reassuring the well worried that they have no disease or injury
o The RELEVANT GOAL/END = the one intended by the HCP.
Cases when HCP action has more than 1 effect (principle of
double effect is applicable).

MEANS OF MEDICINE: (4)- PAGE 128


Means-End Fit: PAGE 129

Knowledge:
Organized body of information
Medical Knowledge:
Organized body of medical information
Skill:
Ability to do something well
Something done diligently:
Something done with care and effort
Care:
Serious attention and thought or caution to avoid damage or loss

Medical professionalism focuses on the character of medical


professionals

Parsonian Model of Professionalism:


Characterized by the following elements
1. Expert authority of the professional

2. Professional as the mediator between individuals in society


3. Professional motivations
4. Acts of Profession

CHAPTER 6: Confidentiality
Doctrine of confidentiality is a foundational principle in medical ethics.
Hippocratic Oath: What I may see or hear in the course of the treatment or
even outside of the treatment in regard to the life of men, which on no
account one must spread abroad, I will keep to myself.
4th principle of Medical Ethics:
A physician shall . Safeguard patient confidences within the constraints of
the law
o 1 of 10 professional responsibilities = commitment to patient
confidentiality
Confidentiality Problems:
1. Widespread use of electronic information systems for compiling patient
data & increasing availability of genetic information.
o Guidelines for Ethical Conduct for the Physician Assistant Profession
o PAs should maintain confidentiality, by that they respect and protect
their patient from discrimination based on medical conditions.
o Patients confident their privacy is protected = MORE LIKELY TO SEEK
MEDICAL CARE & discuss their problems candidly.

RIGHT OF PRIVACY:
Right against appropriation of ones name or likeness
Right against intrusion upon ones solitude or seclusion
Right against being painted in a false light in the public eye
Right against public disclosure of private facts
(Most important for our purposes in this chapter)
Gert, Culver & Clouser:
An individual or group has privacy in a situation with regard to others is and
only if in that situation the individual or group is normatively protected from
intrusion, interference, and information access by others.
Confidential communication:
statement made under circumstances showing that the speaker intended
the statement only for the ears of the person addressed.
Example:
Communications between spouses
physician-patient
Attorney-client
Confessor-penitent
The law protects these confidential communications from forced disclosure
on the witness stand at the option of the witness patient, client, penitent.
Confidentiality refers to a duty within a private situation
You have the responsibility not to divulge information to inappropriate
parties.
Privacy is INVADED but confidentiality is VIOLATED- that is, the duty of
confidentiality is violated.

RATIONALES FOR THE DOCTRINE OF CONFIDENTIALITY IN THE


MEDICAL CONTEXT
1. UTILITARIAN:
Knowledge that the HCP owes them a moral and legal duty of confidentiality
encourages persons to seek medical care.
Ex: Having a genital rash that person would less likely seek medical attention
if they knew their HCP was free to share that information with the public.
(Shamed)
2. PRINCIPLE RESPECT FOR AUTONOMY:
The patient decides whom to disclose their medical information to.
LEGAL PROTECTION OF CONFIDENTIALITY:
Includes both common law protections and statutory protections.
Common law: a body of law that develops and derives through judicial
decisions, as distinguished from legislative enactments.
Breach of patient confidentiality = unprofessional conduct
CASE 6A:
Video posted on YouTube with doctors and nurses laughing and joking in a
operating room. Patient had a 6 inch canister in his rectum and once it was
removed they joked babys out! There were at least 10 people in the room.
ANALYSIS OF CASE:
These HCPs and student nurses all breached their professional conduct. 10
people in an operating room was an invasion of the patients privacy. The
HCP responsible for precepting and serving as a role model failed miserably.
The making of the video without the patients consent ran afoul of the
principle of respect for autonomy and of the right to informed consent
/refusal.
FEDERAL PRIVACY REGULATIONS: HIPAA
Impose an obligation to maintain the confidentiality of individually
identifiable health information on certain covered entities which include
health plans, healthcare clearinghouse, and health care providers who
transmit health information in electronic form during certain transactions.

THESE ENTITIES MUST


1. Adopt internal procedures to protect the privacy of protected health
information
2. Train employees regarding privacy procedures
3. Designate a privacy officer
4. Secure patient records that contain protected information
5. Ensure that agreements with other entities (business associates)
include terms requiring the protection.

A violation of the regulations may result in a significant civil penalty or


criminal liability or BOTH.

LIMITS OF CONFIDENTIALITY: THE DUTY TO WARN OR OTHERWISE


PROTECT THRID PARTIES
Under certain circumstances, violations of moral rules may be justified.
Example: prohibition against killing yields to the right to defend oneself
against the use of deadly force.

CHAPTER 9: BATTERY AND CONSENT


Battery:
Intentional tort and is defined as intentional and wrongful physical contact
with a person without his or her consent that entails some injury or offensive
touching.
In care of patient, you will be touching people with their consent
Tort:
Legal wrong committed upon the person or property independent of
contract
MONETARY FINES
Standard: probable, more likely, etc.
In Crime: guilty
Example: oj Simpson found not guilty in criminal court but in civil court
found guilty and paid fine to deceases family.

Stature of Limitations:
Certain amount of time. Prevents burden to HCP from causes of actions of
past patients.
Case 1:
Case 2:
Case 3:

Why each are ruled differently is because of jurisdiction based


(Conservative/Liberals) and FACT BASED
Informed Refusal
Truman v. Thomas Case
30 year old mother died of cervical cancer. Dr. Thomas, a family physician
saw Mrs. Truman frewuently but never performed a Pap Smear. Her two
children sued him. He stated he did not specifivallly inform her of the risks
involved in refusing to undergo such a test but told her You should have a
Pap Smear I am sure we discussed it so much that she knew we wanted
her to have the examination. The case looks like negligence at 1st but we
find out that Mrs. Truman refused to consent to it.
Johnson v. Kokemoor

Hilding v. Williams

Albany Urology Clinic v. Cleveland

HIV INFECTION:

Estate of Behringer v. Medical Center at Princeton