D r. G uia Tan E thic s YL7:04.

09 09/23/2015

 
Ethical Decision-Making: A Review
GASTROINTESTINAL – ETHICS

OUTLINE III. DECISION-MAKING PROCESS

I. Case: CP’s Prescription Dillema IV. The Ethical Lens
II. Tool: Angeles Model for Ethical V. Important Notes A. STEP 1: GATHER THE FACTS
Reasoning
III. Decision-Making Process
A. Step 1: Gather the Facts • Gather and clarify the facts of the case in question
B. Step 2: Who are the • Separate fact from fiction
stakeholders → Do not project your own emotions onto the players involved
C. Step 3: Articulate the → Sometimes, you tend to project and think that what you think is the
dilemma
D. Step 4: List the alternatives
same as what your friends are thinking or that how you will react is
E. Step 5: Compare the similar to how they will react. You need to be wary.
alternatives with the values • We have a tendency:
F. Step 6: Weigh the → To make assumptions
consequences → To rush judgments
G. Step 7: Make a decision → To use intuition
→ To look at only medical facts
• Questions that should be asked are:
I. CASE: CLERK PADUA’S PRESCRIPTION DILEMMA
→ “What do we know?”
→ “What else do we need to know?”
• Francis Padua, clinical clerk, currently rotating at a government • The facts from the case
hospital. → I am a clinical clerk, an undergrad in training
→ Patient comes who is 20/M with loose bloody stools. Patient is → The patient asking for the edited prescription is being seen at a
diagnosed with amoebiasis. Patient was prescribed 1 week charity hospital
Metronidazole 500 mg BID. Resident told the clerk to make the → He definitely needs the medication
prescription and the resident will just sign with his PRC number. → The senior citizen discount will allow him to maximize his
Patient asked to have the prescription written under the aunt’s resources
name to avail of her senior citizen’s discount. The resident agreed. → The senior citizen discount is really only for the seniors. if I write it,
• Often patients request for prescriptions to be written in the name of it will cause the loss of 20% to the lawful recipient
relatives who are senior citizens so they can avail of 20% discount → The residents usually accede to the request, “bilang tulong na lang
• The culture is that generally the residents accede to the request sa kanila”; tells me to do it
“bilang tulong sa kanila” → Do I have all the facts I need to know to give him advice?
• The PRC license of the resident is used but it is the clerks and interns
who write out the prescription [normal practice] FACTS RELATED TO THE CASE
• FP is bothered because it seems obviously wrong and yet his seniors
say it is an act of compassion • What is the financial standing of the patient’s family?
• Should he adapt to the practice while he is there? → Class D - Php10,000 per month for a family of six
• What is the patient’s occupation? Is he employed?
II. TOOL: ANGELES MODEL FOR ETHICAL REASONING → Patient is trying to look for a job but unemployed at the moment
• Does the family have health insurance?
→ He has PhilHealth but it got discontinued when he left his last work
1. Gather the facts
• Is there a different source of the medication that offers it at a cheaper
→ Find out about everything that is happening in the case price?
→ Ask more questions, if necessary • Are there alternatives to the medication prescribed by the doctor?
2. Identify the stakeholders → Metronidazole is the drug of choice for Amoebiasis so no
3. Articulate the dilemma. What are the competing values or issues in the alternatives
case? • How much is the drug?
→ Ask yourself: “Why am I bothered or burdened?” → RiteMED Metronidazole 500 mg tablet - Php8.96/tablet
4. List the alternatives -- what are the options? • Are there any other possible sources of support?
→ Gut reaction doctors would immediately identify options once they → His mother earns Php1,200 per week by washing clothes three
obtained the facts about the case but in Ethics, you need to take a times a week
step back and ask if you have already obtained all the facts that • Does the local health center provide this medication?
you need to know before you make a decision which can → No
sometimes be anti-intuitive • What are their usual household expenditures?
5. Compare the values behind the options → Bulk of expenditures are for transportation and food
→ Ask yourself: “Why am I doing it? What are the things that are • How long does the patient need to take the drug?
pushing me to do it? What are the things I’m going to sacrifice if I → One week
do it?” • Who covers for the 20% discount for senior citizens?
6. Weigh the consequences behind the options → The drug company, together with the pharmacy, covers for the
→ Ask yourself: “Will I really get what I want when I do it?” 20%
7. Make a final decision • What does the student handbook say about situations like this?
→ Hospital guidelines are usually followed; however, it does not
stipulate any specifics about cases like this
• Are there other government agencies that can be approached? What
about PCSO?
T E N A C IO U S : A N G E L E S , A R A Y A , E S G U E R R A , G E L V E Z O N , G U A R IN , H E R N A N D E Z , H E R R A D U R A , L A C B A W A N , M E D IN A , M IJ A R E S , P O O N , S A R T E ,
YL7: 04.09 1OF4
 
SY
• Is it a life or death situation? Table 1. Stakeholder’s Analysis
→ No
• Will there be consequences if the patient does not take the drug? Stakeholder Stake Viewpoint Power
• What are the consequences if the student does not follow the
resident? Patient Seeks better Ally (supports High
→ Social repercussions but the student will not get penalized; life can health at a prescription
be made difficult for the student in the hospital lower cost using his aunt’s
• Are there consequences when they find out that the drug is not for the 20% senior
aunt but for her nephew? citizen discount)
→ Withdrawal of the privilege can happen
• If the patient gets the discount, the money saved will be used for what Aunt Wants her Ally No evidence to
purpose? nephew to get use as basis
• Are there other dependents for Philhealth? well;
→ Spouse Volunteered the
→ A child below 21 years old is considered a dependent use of her
• What is the case rate for Amoebiasis? senior citizen
→ Php4,200 discount
→ Not relevant to know, however, because case rates are only
applicable for in-patients Mother Good health of Probably an No evidence to
• Are there other qualifications for discounts? her son ally, but no use as basis
• Is the patient under any barangay discount? evidence from
→ No, their barangay does not offer such discounts the video
• Is the patient a member of 4Ps?
→ No Pharmaceutical Covers for the Against Low
• Does the family have any other expenses due soon? companies 20% discount
→ Rent - Php2,000 including water and electricity
• Is the family really incapable of paying for the 20% or do they just Pharmacies Covers for the Against Low
need to save the money? Do they need to borrow money to be able to 20% discount
buy the medication?
→ No, they don’t need to borrow but other things will suffer because
of the additional expense (i.e. less amount for food) C. STEP 3: ARTICULATE THE DILEMMA
• Does the patient have other comorbidities that warrant more
expense? • “What is the question that needs to be answered?”
• Is the doctor willing to make an out-of-pocket payment to cover for the • Why am I bothered?
20%? → Distress shows that values are being violated or threatened
• Is the patient willing to forego certain things to be able to pay for his → If you are not in distress, it’s either you don’t feel violated or you
own medications? feel like you’re in control or there’s something that matters to you
→ Patient is willing to forego communication and transportation that’s holding you back
expenses (i.e. mobile phone load and willing to walk longer than • Which values are at play in the case?
ride the jeepney, etc.) → Your hierarchy of values become clear to you through the decisions
• Are there people siding with the clerk or are there possible allies that you make. The end result or final decision would reflect what
will support him if he decides to disobey the resident? matters most to you.
→ No allies; groupmates think it’s wrong but they’re not willing to • If you list them, then it could be clear which values weigh more and
stand up to the resident most heavily to you
• Do other members of the family need medical support? • Make a “dilemma” statement
→ None, they’re all well. → “Do I do as they do when in that hospital?”
• Does the patient have reserved money for illnesses or emergencies? → How do I respond to his request?
→ He has Php100 from his last job • Value deliberation
• Is this the first time the patient had Amoebiasis or is it recurrent?
→ Yes Table 2. Conflicting Values
• What ethical framework is the clerk using in deciding? Conflicting Values
→ Kantian framework Beneficence for patient (savings, Nonmaleficence to me (my
• Did the aunt know that her name will be used for the prescription? access to medicine) integrity is not compromised)
→ Aunt was the one who suggested it be done Beneficence to the patient (primal
Beneficence for patient’s relatives
• Are there other requirements to avail of the 20% discount? value of integrity Beneficence to
(savings)
→ Prescription the patient (primal value of
→ Booklet integrity)
→ Senior Citizen ID Beneficence for me (“compassion”) Beneficence to pharmacy,
• Is the patient going to comply and actually take the drug? pharma companies (Autonomy
→ Yes, the patient will comply because his condition has been upheld)
bothering him for some time now Beneficence to the government..
MISSINGBeneficence to
B. STEP 2: WHO ARE THE STAKEHOLDERS government and society
(integrity upheld)
• In a dilemma, many people who all seem to have valid positions are
involved • As for Clerk Padua, his two conflicting values are:
• Who are involved and affected in this case? → Beneficence for me (compassion) and Non-maleficence to me (my
• What are the stakes for them? What are their interests? integrity not compromised).
→ He said that he wanted to be compassionate to the patient but he
• Do they have any “power” to do anything about the situation?
also does not want to ever lie.
• The stakeholders in this case:

YL7:04.09
 
ETHICAL DECISION-MAKING: A REVIEW 2OF4
• Important points from Dr. Guia Tan: Alternatives Values Upheld Values Sacrificed
The
→ As ASMPH doctors, we must always consider the viewpoint of the Consequences
society even though it does not have a direct effect to our Beneficence to me, - Beneficence to me - Patient will feel
society, (“not let down, may let
decisions.
government and compassionate”) you feel his
→ The Philippine society operates on the conventional level of moral patient (integrity) - Beneficence for disappointment
development. Nonmaleficence patient - He will not get
→ We do not have a unifying philosophy as one nation, unlike other and autonomy for the discount
Refuse the
countries who can identify themselves with communism, liberalism, the pharma - You will keep
request
and many others. company and your integrity
pharmacy - You may feel
→ Following Maslow’s hierarchy of needs, Filipinos as a nation do not
bad
have yet the luxury to focus on self-actualization until all the other - You protect
basic needs have been satisfied. ideals of
liberalism
Table 3. Template - Nonmaleficence - Nonmaleficence to - You help patient
for me and myself (financial financially
What is a dilemma pharmaceutical “harm”) - Uphold free
Refuse the
company enterprise
Facts of the request but
- Integrity - You keep your
Dilemma give him the
preserved integrity but you
The values in a conflict 20%
- Beneficence for lose money
difference
society
- Beneficence for
Autonomy Justice patient
- Beneficence for - My integrity - You help patient
The Stakeholders the patient - Nonmaleficence financially
Write the - Beneficence to and autonomy of the - Industry loses
Beneficence Nonmaleficence Lola’s name me (preserve pharmaceutical - You don’t
standing, avoid company uphold the law
demerit)
Table 4. Conflicting values for the case
The Dilemma: How do I respond to his request? G. STEP 7: MAKE A DECISION
The Values in Conflict
Autonomy Justice • There are no easy and painless solutions to ethical dilemmas
- Pharma company and - Those who have pay more than • The decision should reflect your values
pharmacy’s right to free enterprise those who have not • Vet your final decision -- Ask these questions:
Beneficence Nonmaleficence → Does your course of action best fulfill what you designated as the
- Beneficence for patient (savings, - Nonmaleficence to my (my most important value?
access to medicine) integrity is not compromised) → Does your course of action cause the least sacrifice of the good
- Beneficence for relatives - Nonmaleficence for the drug values?
(savings) company, pharmacy (protection of → Is it fair, responsible, permissible, praiseworthy?
- Beneficence for me (virtue of the right to free enterprise)
compassion)
IV. THE ETHICAL LENS
D. STEP 4: LIST THE ALTERNATIVES • Expanded from the UNESCO framework for bioethical decision-
making and combined with Laura Nash’s “Ethics without the Sermon”
• Sometimes it helps to just brainstorm and then eliminate untenable • Subject your decision to three tests:
options → Test of publicity
• There are usually two extreme alternatives in a dilemma → Test of non-harm
• Think creatively… come up with other options → Test of consistency (or time)
• The solutions should reflect the values articulated in the dilemma → [Test of legality] - least important among the four
→ Your solution should reflect values that are most important to you
• It helps to talk to trusted friends about the case From UNESCO’s Universal Declaration of Bioethics and Human
• Make a 3-column matrix Rights, Article 18, October 2005
1. Fact Deliberation
E. STEP 5: COMPARE THE ALTERNATIVE WITH THE VALUES 2. Value Deliberation
○ Identify the moral problem
○ Choose the main problem
• Match alternatives with values
○ Identify the values at stake
• Eliminate alternatives if moral values they uphold are not that
3. Duty Deliberation
important to you
○ Extreme course of action
• If we create a matrix where values are matched with options. It
○ Intermediate course of action
becomes clear to us what values are behind options or solutions
○ Best course of action: will best promote the value
→ Why do you make a worksheet? When you name it, you control it
that is important or will least negate or impede that
and you will be able to manage it better. That’s why you name
value
what’s the autonomy, harm, etc. so that you can make better
4. Tests of Consistency
decisions about your dilemma.
○ Test of legality, publicity, and time
F. STEP 6: WEIGH THE CONSEQUENCES 5. Final Decision
○ Well thought-out
• What are the consequences of alternatives to key stakeholders? ○ Best course of action
• Short term and long term ○ Promotes best the fulfillment of values
• Consider both positive and negative consequences ○ Infringes least upon the values at stake
○ Fair, responsible, permissible, praiseworthy
Table 4. Values Upheld, Sacrificed and Consequences of the Source: ASMPH 2018 YL5 trans 1.05
alternatives
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ETHICAL DECISION-MAKING: A REVIEW 3OF4
 V. IMPORTANT NOTES

• Gather the facts

→ Find out about everything that is happening in the case
→ Ask more questions, if necessary
→ Separate fact from fiction
• Identify the stakeholders
→ Who are involved and affected in this case?
→ What are the stakes for them? What are their interests?
→ Do they have any “power” to do anything about the situation?
• Articulate the dilemma. What are the competing values or issues in the
case?
→ “What is the question that needs to be answered?” Make a
“dilemma” statement
→ Ask yourself: “Why am I bothered or burdened?”
→ Which values are at play in the case?
• List the alternatives -- what are the options?
→ Brainstorm and eliminate untenable options
→ Solutions should reflect the values articulated in the dilemma
→ It helps to talk to trusted friends about the case
→ Make a 3-column matrix
• Compare the values behind the options
→ Ask yourself: “Why am I doing it? What are the things that are
pushing me to do it? What are the things I’m going to sacrifice if I
do it?”
→ Match alternatives with values
→ Eliminate alternatives if moral values they uphold are not that
important to you
• Weigh the consequences behind the options
→ Ask yourself: “Will I really get what I want when I do it?”
→ What are the short and long-term consequences of alternatives to
key stakeholders?
→ Consider both positive and negative consequences
• Make a final decision
→ No easy and painless solutions to ethical dilemmas
→ Decision should reflect your values
→ Vet your final decision -- Ask these questions:
§ Does your course of action best fulfill what you designated as
the most important value?
§ Does your course of action cause the least sacrifice of the good
values?
§ Is it fair, responsible, permissible, praiseworthy?

YL7:04.09
 
ETHICAL DECISION-MAKING: A REVIEW 4OF4