Bioethics Flashcards
Midterm exam
Decisions of ending life or hastening death for cases of incapacitated patients
An incapacitated patient is one who is temporarily or permanently unable to make decisions due to acute medical conditions, such as being in a coma or suffering from an acute mental health crisis. The distinction between incompetence and incapacitation is important because the incapacity may be reversible, and the patient’s ability to make decisions might return.
End-of-Life Decisions for Incapacitated Patients:
Temporary Nature of Incapacity: In cases where the incapacity is temporary (e.g., due to anesthesia or a coma), the patient’s preferences cannot be known during the period of incapacity, and decisions are made based on their previous wishes (if documented) or best interests.
Family or Medical Team Decisions: For patients who are temporarily incapacitated, the healthcare team may provide the necessary life-sustaining treatments until the patient regains capacity. If a decision must be made in the interim (such as withdrawing life support), the family or a surrogate decision-maker would typically be involved.
Ethical Considerations: There is tension between the preservation of life and allowing natural death. While life-saving treatments are generally given, when the prognosis is poor, some argue that forcing life-sustaining treatment on an incapacitated patient may violate autonomy.
Decisions of ending life or hastening death for cases of incompetent patients
- Incompetent Patients
An incompetent patient is unable to make their own medical decisions, often due to conditions like dementia, mental illness, or severe brain injury. When a patient is incompetent, they cannot express their preferences regarding end-of-life care.
End-of-Life Decisions for Incompetent Patients:
Substitute Decision-Makers: If a patient is incompetent, decisions about hastening death or end-of-life care typically fall to a surrogate decision-maker (often a family member, legally designated agent, or healthcare proxy). The surrogate is expected to make decisions based on the patient’s best interests or, in some cases, based on what the patient would have wanted (i.e., substituted judgment).
Advance Directives: If the patient has previously expressed their wishes through an advance directive, living will, or durable power of attorney, those documents guide decision-making. These documents may specify the patient’s desires regarding life-sustaining treatments or instructions about euthanasia or withdrawing life support if they become incompetent. If the patient had previously expressed a desire to end their life in a specific way (such as no CPR, or refusal of life support), the surrogate should honor those wishes, as long as they align with the legal and ethical standards in place.
Ethical Dilemmas:
What if an incompetent patient’s prior wishes conflict with the surrogate’s judgment of what the patient would want in the current situation?
Should surrogates be allowed to make decisions that hasten death or withdraw life support when there is no clear, previously expressed wish from the patient?
Decisions of ending life or hastening death for cases of competent patients
End-of-Life Decisions for Competent Patients:
Autonomy and Informed Consent: A competent patient has the right to make decisions regarding their end-of-life care, including the choice to refuse life-sustaining treatments or request euthanasia or physician-assisted suicide where legally permitted.
Right to Refuse Treatment: Even if a treatment is life-saving, a competent patient can choose to refuse it if they believe that the burden outweighs the benefit, or if they wish to avoid a prolonged dying process. The right to die with dignity is grounded in the principle of autonomy.
Physician-Assisted Suicide and Euthanasia: In jurisdictions where physician-assisted suicide (PAS) or active euthanasia is legal, a competent patient has the right to request assistance in ending their life. In PAS, a physician provides the means (usually medication) for the patient to self-administer, whereas in euthanasia, the physician actively administers a lethal dose. Ethical considerations: Is it ethical to honor a request for euthanasia? This brings up questions about the moral obligation to preserve life versus respecting a patient’s autonomy.
Examples:
A terminally ill patient with unmanageable pain and a poor prognosis chooses to undergo physician-assisted suicide.
A competent patient suffering from chronic illness chooses to stop receiving life-sustaining treatment, such as a ventilator, because they believe it prolongs suffering without a meaningful improvement in their quality of life.
Be prepared to critically evaluate a case study pertaining to… IVF
Psychological and Social Considerations
What were the emotional and psychological impacts of IVF on the individuals or couples involved? IVF can sometimes lead to significant stress, disappointment, or emotional strain, particularly if multiple cycles are needed or if the procedure fails.
Were the potential social implications considered, such as family dynamics, the expectations of society, or stigma
Parental Responsibility and Future Considerations
What responsibilities do the intended parents have, both toward the child born via IVF and toward any embryos that may have been created but not implanted?
If the IVF resulted in a genetic child, was there a consideration of whether the intended parents were ready for parental responsibility, etc.
Legal Considerations
Were all legal requirements followed? IVF may involve complex issues related to parental rights, especially if donor gametes (sperm/eggs) were used, or in cases of surrogacy. Was there clarity regarding who has legal rights to the child (e.g., biological vs. intended parents)? etc.
Be prepared to critically evaluate a case study pertaining to… IVF
When critically evaluating a case study related to In Vitro Fertilization (IVF), several ethical, legal, medical, and personal factors must be considered. These include issues related to patient autonomy, accessibility and fairness, embryo rights, parental responsibility, and social implications.
Patient Autonomy and Informed Consent
Was the patient fully informed about the IVF process, its success rates, risks, and potential complications?
Did the patient provide informed consent after understanding the medical, psychological, and financial implications of IVF?
Consider whether the patient was free from any coercion or external pressures
Medical Considerations
Were the medical indications for IVF appropriate? For instance, IVF is often considered when there are issues with fertility, such as blocked fallopian tubes, low sperm count, or unexplained infertility.
What were the medical risks for both the mother and the baby, including the likelihood of multiple births (twins, triplets) and associated complications like preterm birth, low birth weight, or birth defects? etc.
Ethical Issues Related to Embryo Handling
How were embryos handled? IVF often involves the creation of multiple embryos, some of which may not be implanted. Ethical concerns arise regarding the disposition of unused embryos. Were they frozen, donated for research, or discarded? etc.
Access to IVF and Social Justice
Was the IVF process accessible to the intended parents in a fair and equitable manner? Consider whether IVF was affordable, especially in cases where insurance or public funding was involved.
Did the case address potential issues of accessibility for people from different socioeconomic backgrounds, ethnic groups, or countries? Is there fairness in access to reproductive technologies?
What does non-futile medical care refer to?
Treatments that are likely to produce meaningful benefits for the patient.
What is involved in determining whether care is futile?
Clinical judgment, which may include consultations with ethics committees or discussions with the family.
How can futile care conflict with patient autonomy?
If the patient or their family insists on continuing treatment that is clearly ineffective.
What ethical concerns may arise with futile medical care?
It may violate principles of beneficence (doing good) and non-maleficence (avoiding harm).
What is an example of high burden, low benefit treatment?
Administering chemotherapy to a patient with advanced terminal cancer who is near death.
What does high burden, low benefit mean in the context of futile care?
The treatment may cause harm or discomfort without providing any measurable improvement.
Give an example of futile medical care.
Continuing life-sustaining interventions like mechanical ventilation in cases of irreversible organ failure.
In what situations is futile medical care commonly seen?
In cases where patients are at the end of life or suffering from a terminal condition where recovery is impossible.
What is a key characteristic of futile medical care?
Lack of therapeutic benefit, meaning the treatment does not improve the patient’s condition.
What does futile medical care refer to?
Treatments or interventions that are unlikely to produce any meaningful benefit for the patient.
What is the distinction between futile and non-futile medical care?
It pertains to the effectiveness of treatments in achieving intended outcomes, especially in terminal illness situations.
What is a concern regarding the interpretation of advance directives?
Advance directives may be misinterpreted or misunderstood by family members or healthcare providers.
How can rigid adherence to prior directives undermine patient autonomy?
It may not respect changes in a patient’s preferences, especially as they near the end of life or experience new insights.
What does Dresser say about the changing nature of patient preferences?
Dresser critiques the assumption that a patient’s previous testimony or written directives should be held as sacred or unchangeable, emphasizing that values can shift over time.
Why might advance directives not reflect a patient’s evolving sense of dignity or quality of life?
Medical circumstances can vary greatly, and what seems acceptable at the time of writing the advance directive might not feel right when faced with a new reality.
What is the issue of contextual inflexibility in advance directives?
Advance directives can’t account for the contextual nuances of a particular situation, leading to misalignment with the patient’s current wishes.
How might a patient’s preferences change regarding life-sustaining treatment?
A patient who, when healthy, expresses a desire to refuse life-sustaining treatment may change their mind if they experience a terminal illness.
What is Dresser’s critique regarding the predictability of future decisions in advance directives?
Dresser argues that it’s challenging for individuals to predict how they would feel or what they would choose when faced with specific medical circumstances in the future.
What ethical limits does Dworkin recognize in patient decision-making?
A patient’s decision must not undermine the well-being of others, and the provider’s duty to minimize harm must be balanced with respecting the patient’s wishes.
What does Dworkin’s approach call for regarding informed consent?
Comprehensive informed consent, ensuring patients fully understand the consequences of their choices.
What must medical professionals consider when discussing treatment options?
The unique values and beliefs of each patient, rather than imposing their own values.
What role do values and beliefs play in Dworkin’s conception of patient dignity?
Each individual has a unique set of values and beliefs that guide their decision-making.
How should healthcare providers respond to a terminally ill patient’s wish to refuse life-sustaining treatment?
Respecting their decision is a way of honoring their life plan.
What does Dworkin emphasize about the integrity of life plans?
People should be allowed to make choices that align with their long-term values, goals, and conceptions of a meaningful life.
What must healthcare providers ensure regarding patient autonomy?
Patients have the freedom to make informed decisions based on their personal values and life goals.
What does autonomy refer to in the context of patient dignity?
The right of individuals to make decisions about their own lives, including medical decisions.
What is Dworkin’s conception of respect for patient dignity?
Respect for Autonomy
what is critical interest
Definition: Critical interest, on the other hand, focuses on analyzing, questioning, and critiquing the larger structures or systems that shape or influence individual experiences and decisions.
Focus: It is concerned with examining the underlying reasons, power dynamics, policies, and ethical frameworks that govern decisions, often from a social justice perspective. This interest looks at broader societal factors, including inequality, systemic bias, and healthcare policy.
Example: A critical interest might involve questioning how social determinants like race, class, or gender affect a patient’s access to healthcare or the fairness of medical decisions made by institutions or professionals.
what is experiential interest
Experiential Interest
Definition: Experiential interest refers to the perspective or concerns that are based on personal experience or the lived experiences of individuals.
Focus: It centers on what individuals actually feel, perceive, and go through in their everyday lives, particularly in relation to their health, suffering, and well-being.
Example: A patient’s experiential interest would include their experience of pain, discomfort, or emotional distress due to an illness. This is often used in bioethics to ensure that patient care is sensitive to the subjective experience of the person involved.
what is the difference between experiential and critical interest
Experiential Interest – This is a direct, personal engagement with something, focusing on emotions, sensory experiences, or participation. For example, someone who enjoys reading novels for the pleasure of storytelling or listens to music because it evokes emotions is demonstrating experiential interest.
Critical Interest – This involves a more analytical or evaluative approach, where one examines, critiques, or deconstructs a subject based on logic, knowledge, or expertise. For example, a literary critic analyzing themes, style, and structure in a novel or a musicologist studying the composition and historical influences of a song is engaging in critical interest.
what is the difference between physician assisted suicide, active euthanasia and passive euthanasia
Physician-Assisted Suicide (PAS)
Definition: The doctor provides the patient with the means (e.g., medication) to end their own life.
Key Point: The patient self-administers the lethal dose.
Active Euthanasia
Definition: The doctor directly administers a lethal substance to end the patient’s life.
Key Point: The doctor causes the death through direct intervention.
Passive Euthanasia
Definition: Life-sustaining treatments (e.g., ventilators, feeding tubes) are withheld or withdrawn, allowing the patient to die naturally.
Key Point: The death is allowed to occur without direct intervention.
what is passive euthanasia
Passive euthanasia refers to the withholding or withdrawing of life-sustaining treatments, which allows a patient to die naturally, either by the progression of their illness or condition. It does not involve the direct administration of lethal substances but rather stopping medical interventions that are keeping the patient alive.
Key Characteristics of Passive Euthanasia
Withholding Treatment – Not starting or continuing medical procedures (e.g., ventilators, dialysis, or feeding tubes) that could extend life.
Allowing Natural Death – The patient dies naturally due to the lack of life support, as opposed to being directly caused by medical intervention.
Decision-Making – Typically, the decision is made by the patient (if they are able) or their family, often when the patient is terminally ill or in a persistent vegetative state, and there is no hope for recovery.
Examples of Passive Euthanasia
Withholding life support: A doctor may decide not to place a patient on a ventilator or take them off it after consultation with the family, knowing that the patient’s condition is terminal.
Discontinuing life-sustaining treatment: A doctor may stop chemotherapy or other life-extending treatments if the patient’s prognosis is hopeless and they have chosen to die naturally.
Legal and Ethical Context
Legally Permissible: Passive euthanasia is legal in many countries, including the U.S., where it’s often seen as the right to refuse medical treatment.
Ethical Debate: Passive euthanasia is generally considered less controversial than active euthanasia because the cause of death is not an intentional act. The ethical focus often shifts to respecting patient autonomy (the right to refuse treatment) and ensuring informed consent.
what is active euthanasia
Active euthanasia is the deliberate act of directly causing a patient’s death through medical intervention, typically to end suffering from a terminal illness or severe pain. This usually involves administering a lethal dose of medication.
Key Characteristics of Active Euthanasia
Intentional Act – The doctor or another person takes direct action to end life (e.g., injecting a lethal drug).
Purpose – Typically performed to relieve unbearable suffering when a patient has no hope of recovery.
Distinction from Passive Euthanasia – Unlike passive euthanasia, where life-sustaining treatments are withheld or withdrawn, active euthanasia involves direct intervention to cause death.
Types of Active Euthanasia
Voluntary Active Euthanasia – The patient explicitly requests it (e.g., terminally ill patients in unbearable pain).
Non-Voluntary Active Euthanasia – The patient cannot consent (e.g., in a coma), and someone else makes the decision.
Involuntary Active Euthanasia – Performed against the patient’s will (widely considered unethical and illegal).
Legal & Ethical Status
Legal in Some Countries – Netherlands, Belgium, Luxembourg, and Canada allow voluntary active euthanasia under strict conditions.
Illegal in Most Places – In the U.S., active euthanasia is illegal, though physician-assisted suicide (PAS) is legal in some states.
Ethical Controversy – Debates focus on autonomy, the sanctity of life, and the role of physicians in causing death.
what is physician assisted suicide
Physician-assisted suicide (PAS) is when a doctor provides a patient with the means (typically a prescription for lethal medication) to end their own life, usually in cases of terminal illness and unbearable suffering. The patient, however, must voluntarily administer the medication themselves.
Key Characteristics of PAS
Patient Autonomy – The patient makes the decision and takes the final action.
Physician’s Role – The doctor provides the necessary medication but does not directly administer it.
Legal and Ethical Debate – PAS is controversial, with arguments for and against its moral and legal status.
Distinction from Euthanasia
PAS: The patient self-administers the lethal dose.
Euthanasia: The doctor directly administers the lethal substance (illegal in most places except a few countries like Belgium and the Netherlands).
Legal Status
PAS is legal in certain jurisdictions, including:
United States: Legal in states like Oregon (Death with Dignity Act), California, and Washington.
Other Countries: Legal in Canada, Switzerland, and parts of Australia.
Ethical Arguments
In Favor:✔ Respects autonomy – Allows patients control over their death.✔ Reduces suffering – Provides an option for those in extreme pain or distress.✔ Compassionate choice – Recognizes dignity in death.
Against:✘ Sanctity of life – Some argue life should not be intentionally ended.✘ Slippery slope – Fear of abuse or expansion to non-terminal cases.✘ Medical ethics – Conflicts with the physician’s duty to “do no harm.”
How did Canterbury v. Spence influence modern informed consent laws?
It helped define modern informed consent laws and patient rights.
It shifted medical ethics toward patient-centered care and strengthened the legal obligation for doctors to inform patients.
It shifted medical ethics toward patient-centered care and strengthened the legal obligation for doctors to inform patients.
What are the exceptions to full disclosure established by the court?
The exceptions are emergency situations and therapeutic privilege.
What are material risks in the context of informed consent?
Material risks are any risks that could influence a patient’s decision and must be disclosed.
What standard was rejected by the court in Canterbury v. Spence?
The court rejected the ‘professional standard’ which was based on what other physicians would disclose.
What is the physician’s duty regarding disclosure of treatment information?
Doctors must provide sufficient information about risks, benefits, and alternatives to a proposed treatment.
What must a doctor disclose according to the reasonable patient standard?
A doctor must disclose all information that a reasonable patient would find significant in making a healthcare decision.
What legal standard for informed consent was established by Canterbury v. Spence?
The case established a patient-centered standard for informed consent.
what are the advantages of Brody’s transparency model of informed consent
Advantages of the Transparency Model
More practical than expecting full patient comprehension.
Respects autonomy while allowing trust in medical expertise.
Reduces information overload that may confuse patients.
Brody’s transparency model of informed consent
Bernard Brody’s Transparency Model of Informed Consent is an alternative approach to traditional informed consent, aiming to balance patient autonomy with practical communication between doctors and patients.
Key Features of the Transparency Model:
Focus on Physician Disclosure, Not Patient Understanding
Instead of ensuring patients understand every detail, the doctor must be transparent about their reasoning for recommending a treatment.
The goal is not exhaustive detail but to ensure the patient can ask questions and engage in the decision-making process.
Reasonable Disclosure Standard
Physicians should explain their thought process as they would to a colleague, making their reasoning clear.
Patients don’t need to understand every medical term but should grasp the core reasons behind a recommendation.
Patient-Driven Inquiry
The model allows patients to seek more information if they wish.
If a patient does not question the doctor’s reasoning, it is assumed they trust the recommendation.
The value of informed consent
Respects Patient: Autonomy
Patients have the right to make decisions about their own bodies and medical treatments.
Without informed consent, a patient’s autonomy is undermined, turning medical care into a paternalistic process.
Promotes Trust in the Patient-Doctor Relationship:
When doctors provide full transparency, patients feel respected and valued, fostering trust and collaboration in healthcare decisions.
Reduces Medical Harm and Ethical Violations:
Ensures patients understand potential risks, benefits, and alternatives before agreeing to a procedure.
Protects patients from unnecessary harm (non-: by ensuring they are aware of possible complications.
Legal and Ethical Safeguard
Informed consent is a legal requirement in most healthcare systems. Performing procedures without consent can lead to lawsuits for medical malpractice.
Ethically, informed consent ensures that no patient is subjected to unwanted or unexpected medical interventions.
Encourages Shared Decision-Making
Moves away from traditional paternalism and towards patient-centered care, where medical professionals guide but do not dictate decisions.
Essential Elements of Informed Consent:
For informed consent to be valid, it must include:
Disclosure – Full information about the procedure, risks, benefits, and alternatives.
Comprehension – The patient must understand the information provided.
Voluntariness – The decision must be free of coercion or pressure.
Competence – The patient must be mentally capable of making the decision.
The four core ethical principles in biomedical ethics
Autonomy:
Respecting a patient’s right to make their own informed decisions about their health and medical treatment.
Requires informed consent, ensuring patients receive all relevant information to make voluntary choices.
Example: A patient refusing chemotherapy despite a doctor’s recommendation must have their decision respected.
Beneficence:
The duty to promote the well-being of patients and act in their best interests.
Requires healthcare providers to take positive steps to prevent harm and enhance patient health.
Example: A doctor recommending a life-saving surgery to a critically ill patient.
Non-Maleficence:
The obligation to do no harm or minimize harm as much as possible.
Healthcare interventions should avoid unnecessary risks or suffering.
Example: Avoiding prescribing a high-dose medication with severe side effects when a safer alternative exists.
Justice:
Ensuring fair distribution of healthcare resources and treating patients equitably.
Includes fair access to treatment, avoiding discrimination, and making ethical decisions in resource allocation.
Example: Prioritizing organ transplants based on medical urgency rather than social status.
Problems with this traditional model of the medical professional relationship grounded in.. Value pluralism
Value pluralism is the idea that multiple, conflicting values can be equally valid and that no single moral framework can dictate the “right” answer in all cases. The traditional paternalistic model of the medical professional-patient relationship faces significant challenges when viewed through the lens of value pluralism
The Shift to a Value-Pluralistic Model
Recognizing value pluralism encourages a shared decision-making approach, where doctors respect diverse patient values and involve them in choosing treatments.
Instead of assuming a single “best” course of action, the physician provides medical expertise while allowing patients to make choices aligned with their personal beliefs.
The traditional paternalistic model of the medical professional-patient relationship?
The traditional paternalistic model of the medical professional-patient relationship is based on the idea that the doctor, as a medical expert, makes decisions on behalf of the patient, assuming that they know what is best for the patient’s well-being. Physician Authority – The doctor takes an authoritative role, making treatment decisions with little or no input from the patient.
Limited Patient Autonomy – The patient’s role is largely passive, expected to comply with medical advice without questioning or fully participating in decision-making.
Beneficence Over Autonomy – The primary ethical principle is beneficence (acting in the patient’s best interest), often at the expense of respecting the patient’s right to make their own choices.
Restricted Information – Doctors may withhold certain information if they believe it would distress the patient or lead to poor decision-making.
Example:
A doctor diagnosing a patient with a serious illness may choose not to disclose the full details or may prescribe a treatment without discussing alternatives, assuming that this will reduce the patient’s anxiety and lead to the best outcome.
Criticism & Shift Toward Shared Decision-Making:
Critics argue that the paternalistic model disrespects patient autonomy and fails to consider individual values and preferences.
what is weak vs strong paternalism?
Weak Paternalism:
Justified only when a person’s decision is not fully informed or voluntary (e.g., due to misinformation, coercion, or impaired judgment).
Protects individuals until they can make a fully autonomous choice.
Example: A doctor temporarily stopping a patient from refusing a life-saving treatment because the patient was misinformed about the risks.
Strong Paternalism:
Justified even when a person is fully informed and competent but makes a decision that is deemed harmful to themselves.
Overrides autonomy for the person’s own good, even if they knowingly accept the risks.
Example: Forcing a competent patient to undergo life-saving surgery despite their refusal.
what is the difference between normative vs. non-normative account of ethics?
Normative Bioethics: It provides moral guidance and establishes ethical standards that ought to be followed.
Evaluative: It assesses what is right or wrong and makes recommendations based on ethical theories
Non-Normative Bioethics: Instead of prescribing what should be done, it focuses on describing ethical beliefs, practices, and reasoning within different cultures, traditions, or institutions. It studies how people actually behave in bioethical situations without making moral judgments.
