MEDICAL ETHICS III

Ethical Decision Making

Maria Zoila G. Carandang, MD | 10 August 2018
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OUTLINE Factors in Influencing Decision Making
 The circumstances surrounding the
Context
I. Ethics/Morality issue
II. Ethical Systems  Derived from personal belief
a. Teleological Values  Are grounded in traditional sources
b. Deontological such as family, religion and school.
c. Virtue Theory  Sometimes derived from external
sources
d. Relativism
Principles such as institutions or ethical
III. Principles in Medical Ethics theories,
IV. Four principles approach provide guidance.
V. Ethical Decision Making Model  Important part of the process of
VI. In Emergency Medicine justifying a
VII. Clinical Ethics: A Practical Approach to Ethical Decisions in particular action.
Clinical Medicine Ethical Systems  Right and Wrong, Bad and Good
are
determined by a particular
philosophical
ETHICS AND MORALITY foundation.
 Discipline dealing with what is good and bad and  A way of viewing the world
with moral duty and obligation  A particular frame of reference or
o There is no perfect system Perspective "lens" through which certain
principles are filtered and applied
o Systems develop and evolve to relationships between self and
 Paternalism others
 Autonomy and the Nuremberg
Trials ETHICAL SYSTEMS
 Social Justice and the medical Teleological Theory
insurance plans in the early 80’s  "teleos" = purpose
 Focus is on the consequences or end. One example is
What Makes an Agent Moral in Doing An Act? utilitarianism, which advocates maximizing the amount of
 Freely acting - acceptance that one is a moral agent "good" for the largest group.
 Motives  Sometimes, answer the question “Does the end justify the
 A morally right action mean?

Moral Dilemma Deontological Theory

 Conflicts between moral requirements  “deonto” = duty
 Conflict between values and ethical principles that support  Inherently right or wrong as often defined by religious
different courses of action tenets or professional codes of behavior

Criteria and Resources Virtue Theory

 Reason  System focuses on the motives and intentions of the
 Experience individual
 Tradition/Culture  Asks what a "good person" would do
 Experts  Ancient Greeks, Thomas Aquinas and Kant
 Religion/Scripture/Holy Spirit
 Relativism
 No universal truths
 Only codes that vary from one group to another

THE PRINCIPLES IN MEDICAL ETHICS:

HIPPOCRATIC OATH (review)
LOVE - incarnate, giving and being given, universality, community - The Principle of Beneficence
incarnate, giving and being given, universality, community.  Do only that which benefits the patient
 Patient’s welfare as the first consideration
Steps in Decision Making
1. Explore the issue thoroughly The Principle of Maleficence
2. Identify key ethical questions  First do no harm
3. Bring source to bear upon the problem  Calculated risk or risk benefit.
4. Prayerfully seek the guidance of the Holy Spirit o Informing the patient about the risk and benefits of
5. Decide on a course of action drug or procedure to be done
6. Place you decision before the bar of public scrutiny
The Principle of Autonomy
 Right to self-determination.
 Right to information.

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 MEDICAL ETHICS III
Ethical Decision Making
 Free and informed consent human life begin?
 Free will and accord - intentional participation in treatment. o Can we assess
 Respect and dignity maintained another person’s
 Other key points: quality of life?
o Capacity to think, decide, take action. Totality  An individual has the right to
o Mental incompetence = no autonomy remove, cut off or
o Autonomy vs. Paternalism mutilate any defective or
 When patient not autonomous – no worn out nonfunctioning part
clash of his body if it is for the
o When patient autonomous – clash general
well-being of the whole body.
The Principle of Paternalism Cooperation  Any physical or moral
 The act of being fatherly to someone. concurrence or
 Personal - a person decides on the basis of one’s best participation with the
knowledge on what is good for another principal agent in an
 State - refers to the control exerted by legislature, an agency immoral act.
or other governmental body over particular practices and  Formal: external and internal
procedures in medicine. concurrence
 Material: immediate and
mediate
The Principle of Justice and Social Responsibility
Double Effect  Situations in which a good
 Actions are consistent, accountable and transparent
effect and an evil one will
 Does not to discriminate on age, sex, religion, race, position
result from one cause
or rank
 Under certain conditions,
 For the greater good of Society
some evil effects that are
 Respect for the Law voluntary in cause may be
 Equity and Distribution of Burdens & Benefits allowed to occur

The Principle of Veracity CONDITIONS:

 Truth telling  The act itself must be good
 Obligation to full and honest disclosure or at least indifferent
 If you override this principle:  The good effect is not
o You endanger doctor-patient relationship which is produced by means of the
based on trust bad effect
o You offend against the principle of autonomy  Only the good effect and not
the bad is directly intended
The Principle of Confidentiality  There is a proportionate and
 Based on loyalty and trust sufficient reason for allowing
 Maintain the confidentiality of all personal, medical and the bad effect to occur.
treatment information
 Information to be revealed only with consent and for the THE FOUR PRINCIPLES APPROACH
benefit of the patient
 Except when ethically and legally required 1. Beneficence
 Disclosure should not be beyond what is required 2. Non-Maleficence
 Exceptions to Medical Confidentiality: 3. Justice
o Patient gives a written and valid consent 4. Autonomy
o To other participating professionals
o Statutory requirements Questions
o Ordered by Court  Beneficence-Non-Maleficence → Justice-Autonomy
o Public interest  Is the patient your only concern? (possible conflict with
o Approved Research utility)
 Do we always know what is good for the patient? (patient’s
Other Principles in Medical Ethics view may differ from ours).
 Natural Law and Thomas Aquinas  Constraints on Beneficence:
 Fundamental claims: o Need to respect desires of the patient.
o There is a natural order or rule in the universe o Need to ensure health is not bought at too high a
o This natural order or rule is accessible to human price.
reason o Need to consider rights of others
 Human beings are merely o Ex: The need for a doctor to uphold the principle of
caretakers Beneficence vs. the Quality of life of the patient
 Responsible for protecting
and cultivating bodily
Steward-Ship and spiritual functions Limitations of Principles Approach
 Accountability is to God  Risk of oversimplification
 We are also accountable to o There are no absolutes
our families and as well  Risk of favoring one principle to outrank others.
as to our patients.  Requires balancing several principles.
Preservation of  The value of life is sacred  There is no formula for prioritizing.
Life because it comes from God
o At what stage does

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 They do not provide an account for the "casuistic" nature of
moral analysis - absolutes in right or wrong.
AN ETHICAL DECISION MAKING MODEL
Step 1: Identify the problem.
Step 2: Identify the potential issues involved.
Step 3: Review relevant ethical guidelines.
Step 4: Know relevant laws and regulations.
Step 5: Obtain Consultation.
Step 6: Consider possible and probable courses of action.
Step 7: List the consequences of the probable courses of action.
Step 8: Decide on what appears to be the best course of action.
Strategy for Solving a Moral Problem
Step 1.  Determining whether
Define the a problem is on the
problem so the one hand a matter of
dilemma is clearly poor communication,
understood by all failure to appreciate
parties cultural or religious
differences, or
represents a genuine
difference in values
and principles means
closely examining the
issues involved.
 Some issues are
readily addressed
simply by clarifying
the nature of the
disagreement.
 There may also be
more than one
problem, which
means prioritizing.
Step 2.  Accurate,
Collect as much comprehensive
information about information is
the problem as you important and seems
can before beginning at the outset like it
to think about a should be a 1.
solution straightforward task.
 However, even the
facts can prove to be
contentious.
 Consider how
different witnesses
view the
same automobile
accident. 2.
 Equally important is to
understand personal,
religious, economic
and cultural beliefs
which are key
components of the
context framing the
conflict.
Step 3  Values are grounded
Identify the in beliefs which may
important values and be held consciously
principles for you and or unconsciously and
the others who are are sometimes highly
involved charged with emotion.
 For instance, a belief
in God may
predispose one to
value human life as
the most important
value.
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 Though sometimes
difficult to articulate
and not necessarily
derived from a
reasoning process,
beliefs have a
legitimate place in
making a decision.
Step 4.  Motive can be
Reflect on personal distinguished from
motives & intentions intention in that
in light of different motive can be thought
courses of action & of as the "why", and
consequences to self, intention the "what".
others & society.  What outcome is
wanted and why is
this desirable?.
 Both of these
questions apply to the
individual's character.
Step 5.  Consider that
Prioritize conflicting deciding to NOT
values and make a make a decision
responsible decision represents one form
of choice which has
real consequences.
 This is best
demonstrated by an
example illustrating
how the information is
integrated and a
course of action might
be chosen.
ETHICS MANUAL
A CASE METHOD TO ASSIST CLINICAL ETHICAL
DECISION MAKING
Define the ethics problem as an "ought" or "should"
question.
 Example: "Should we withhold a respirator for this
unconscious adult man with AIDS, as his partner requests,
or use it, as his parent’s request?"
O Not: "This man with aids is an ethics problem."
O Not: "Is it better for terminally ill patients to die with or
without a respirator?"
List significant facts and uncertainties that are relevant to the
question. Include facts about the patient and caregivers (such
as Intimacy, emotional state, ethnic and cultural background, faith
Traditions, and legal standing).
 Example 1: "This man and his partner have been living
together for 10 years and purchased a house together. The
partner has been a caregiver throughout the illness. The
patient's parents have been unaccepting of his lifestyle and
orientation and have been distant from him."
O include physiologic facts
 Example 2: "The patient is irreversibly unconscious and
Incapable of making decisions; thus, he cannot now be
consulted about who should speak on his behalf about his
preferences for treatment."
O include significant medical uncertainties (such as
prognosis and outcomes with and without treatment).
 Example 3:"Antibiotics can be given for the current lung
infection, but we do not know whether the patient can be
weaned from the respirator given the advanced disease. It
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seems more likely than not that he will eventually be weaned requirement for informed consent and respect the patient's
from the respirator. The patient has an estimated life span of goals and preferences."
3 to 9 months, but it may be much shorter or somewhat
longer." 7. Propose and critique solutions, including multiple options for
O include the benefits and harms of the management treatment and alternative providers.
 Example: "The physician could provide palliative care to a
 Example 4: "The respirator will prolong life, but it is a person who has respiratory therapy who elects not to receive
burdensome and invasive treatment and will confine the a respirator or seek to expeditiously transfer the patient to
patient to a highly medical setting." someone who can provide such care (the latter course would
disrupt a relationship between this physician and patient).
3. Identify a decision maker. If the patient is competent, the The physician, in protecting the interests and values of this
decision maker is the patient. If the patient is incompetent or lacks patient who cannot speak on his own behalf, must serve as
decision making capacity, identify a proxy decision maker as the patient's advocate to the parents of the patient."
specified by court appointment, state law, a durable power of
attorney for health care, living will, or the persons who are best 8. Identify and remove or address constraints on solutions (such as
situated by virtue of their intimate, loving familiarity with the reimbursement, unavailability of services, laws, or legal myths).
patient.  Example: "The parents in this case asserted that the doctor
 Example: "This is a 32-year-old adult who has lived away had to obey them because they were family members. A
from home for 14 years and who has had only occasional check with the hospital attorney showed that this was not
contact for 14 years and who has had only occasional true in this state."
contact with his parents, mainly on holidays. He does not
have a living will or a durable power of attorney but has IN EMERGENCY MEDICINE
spoken often with his partner about his preferences for  Each ethical dilemma may be approached by assessing the
health care as his disease has advanced. His partner has issues, naming the dilemma (conflicting ethical principles),
accompanied the patient to clinic and cared for him as he considering alternative courses of action, implementation,
has become increasingly debilitated." and evaluation.
4. Give understandable, relevant, desired information to the decision 1. Assess the issue Assessing issues helps to clarify
maker and dispel myths and misconception interests and to organize
 Example: "The respirator and antibiotics will prolong life and preferences. Ask the following
may allow for treatment of the lung infection, but they will not questions:
reverse the underlying severity of the patient's condition. No  What is the medical
treatments exist at this time that can affect this patient's situation? This question
underlying condition. If the respirator is started, it can be is about emergency
discontinued if the patient does not respond to treatment. If physicians' goals as
the respirator is not used, medications can be given to caregivers.
assure that the patient is comfortable even if his lungs are  What is the appropriate
failing." medical intervention?
 What is the benefit to
5. Solicit values of the patient that are relevant to the question.
the patient?
These include the patient's values about life; place in the life
 What are the patient's
cycle; relation to community, health care, and health care
preferences? These
institutions; goals for health care (for example, palliation,
may be ascertained by
enhancement of function or independence, prolongation of life, or
determining the
palliation without prolongation of life) and conditions that would
patient's goals.
change goals; and specific preferences about health care or proxy
Patients' wishes on
decision makers that are relevant to this situation.
how they want to live
 Example: "This patient made many statements to his partner
their lives may differ
about wanting exclusively palliative care at this time and
from those of the
Specifically declined further anti-HIV therapies, as noted in
emergency physician.
the medical record. He stated that he wanted no life-
For example, the
prolonging treatments of any kind if he could not
possibility of losing use
communicate with his partner, which his present
of the hands may
unconscious state prevents him from doing."
cause a patient to
refuse a neuropathy
6. Identify health professional values. Values include health
inducing
promoting goals (such as prolonging life, alleviating pain,
chemotherapy.
promoting health, curing disease, rehabilitating an injury,
Assessing the patient's
preventing harm, providing comfort, empowering patients to make
values and needs,
choices, and advocating for patient). Values that pertain to
whether the patient is
patient-physician communication (truth telling, confidentiality, non-
informed, the patient's
discrimination, requirement for informed consent, and tolerance of
expectations, the
the diversity of values) are also included, as well as some values
patient's competency,
that extend outside of the patient-physician relationship (such as
and whether consent is
protection of third parties, promotion of public health, and respect
voluntary is important.
for the law).
 What are the
 Example: "Although the physician may feel that a respirator
consequences of
is indicated for this person with respiratory failure, this
accepting or refusing
patient has articulated different goals for health care. The
the intervention? How
physician is obliged to respect the diversity of values and the
will quality of life be
affected (eg, maintain,

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restore, improve)? Advance Directives?
 Will patients be able to 6. Is the patient unwilling or
pursue their own unable to cooperate with
goals? medical treatment? If so,
 What are the external why?
issues involved? 7. In sum, is the patient's
Issues outside of medical fact that right to choose being
both appropriately and respected to the extent
inappropriately impact the possible in ethics and
decision-making process include law?
family and social pressures,
economics, emotions,
interpersonal conflict, legal
issues, communication, and time
pressure.
2. Name the dilemma Take the time to clearly identify
the issues in conflict that have led
to the dilemma being addressed. Quality of Life Contextual Features
Look over the glossary of terms The Principles of Beneficence The Principles of Loyalty
for a list of basic ethical terms and Nonmaleficence and and Fairness
and issues. Respect for Autonomy 1. Are there family issues
3. Consider alternative List the alternative courses of 1. What are the prospects, with that might influence
courses of action action focusing on the pros and or without treatment, fora treatment decisions?
cons of each choice so that the return to normal life? 2. Are there provider
decision is most consistent with 2. What physical, mental, and (physicians and nurses)
medical opinion and the patient's social deficits is the issues that might
values and goals. patientlikely to experience if influence treatment
4. Implement the action Once a plan of action is created, treatment succeeds? decisions?
it must be implemented. 3. Are there biases that might 3. Are there financial and
5. Evaluate the outcome An evaluation component is prejudice the economic factors?
important in the overall process of provider'sevaluation of the 4. Are there religious or
solving ethical dilemmas, patient's quality of life? cultural factors?
particularly when formulating 4. Is the patient's present of 5. Are there limits on
plans to be utilized in future future condition such thathis confidentiality?
situations. or her continued life might be 6. Are there problems of
During evaluation, include judged undesirable? allocation of resources?
assessment of the actual 5. Is there any plan and 7. How does the law affect
outcome in regard to patient's rationale to forgo treatment? treatment decisions?
goals, values, needs, and 6. Are there plans for comfort 8. Is clinical research or
interaction with external and palliative care? teaching involved?
pressures and issues. 9. Is there any conflict of
interest on the part of the
providers or the
institution?
CLINICAL ETHICS: A PRACTICAL APPROACH TO
ETHICAL DECISIONS IN CLINICAL MEDICINE
Medical Indications Patient Preferences REFERENCES
The Principles of Beneficence The Principle of Respect for Ethics Trans 1.1 Batch 2019
and Non-maleficence Autonomy
1. What is the patient's medical 1. Is the patient mentally
problem? capable and legally
Diagnosis?Prognosis? competent? Is there
2. Is the problem acute? evidence of incapacity?
Chronic? Critical? 2. If competent, what is the
3. What are the goals of patient stating about
treatment? preferences for
4. What are the probabilities of treatment?
success? 3. Has the patient been
5. What are the plans in case of informed of benefits and
therapeutic failure? risks, understood this
6. In sum, how can this patient information, and given
be benefited by medical and consent?
nursing care, and how can 4. If incapacitated, who is
harm be avoided? the appropriate
surrogate? Is the
surrogate using
appropriate standards for
decision making?
5. Has the patient expressed
prior preference, e.g.,

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