Bioethics 3 Flashcards
How does public health balance the interests of individuals with the interests of the broader public?
The only purpose for which power can be rightfully exercised over any member of a civilized community against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant.
What are 5 examples of public health influencing individual choices?
- Quarantine of patients with infectious disease
- Banning smoking in public places
- Fluoridating public water supplies
- Taxes on health-harming goods, such as sugary beverages and tax breaks on health-promoting goods
- Food labeling or media campaigns
What is an example of how strategies based on education, information, and individual choice can reproduce or even exacerbate health disparities between more and less advantaged groups?
Education initiatives are most effective for individuals who have the time, interest, motivation, and resources to act on the information and opportunities made available. People who work long hours or double shifts, or who lack access to affordable gyms or safe spaces to walk or exercise, for example, may not have the time, energy, or financial resources to change habits that are embedded in ways of life.
Can medical treatment ever be provided against a patient’s will?
The ethical justification for treatment of a patient against his will is based on balancing the risk to the public versus respecting the patient’s personal freedom. If the magnitude of risk to the public is great, many states allow for involuntary treatment. Health care providers have obligations, however, to use the least restrictive means to achieve the therapeutic goal. An involuntary hospital stay is the most restrictive, necessary only when there is high risk of infecting others as well as evidence of non-adherence to outpatient treatment. A less restrictive approach utilizes directly observed therapy, in which a designated provider or case worker observes the patient taking his medications at home or in another outpatient setting.
What are the 3 general ethical principles applied to research with human subjects?
- Autonomy
- Beneficience
- Justice
How to design ethical research studies? 5
- The primary concern of the investigator should be the safety of the research participant which requires the investigator to use all available information to identify potential risks to the subject, to establish means of minimizing those risks, and to continually monitor the ongoing research for adverse events experienced by subjects (in which case the research study should be stopped)
- Informed consent from each research participant must be obtained in writing . This should be obtained in writing after the participant has had the opportunity to carefully consider the risks and benefits and to ask any pertinent questions
- The investigator must protect the subjects’ privacy and confidentiality
- The investigator must consider how adverse events will be handled. In particular, it must be established a priori who will provide care for a participant injured in a study and who will pay for that care.
- The investigator must strive for clinical equipoise. A true null hypothesis should exist at the onset regarding the outcome of the trial, that is, if a new intervention is being tested against the currently accepted treatment, the investigator should be genuinely uncertain which approach is superior
What are the 6 components of ethically valid informed consent for research?
- Disclosure that the study is a research study, and not clinical therapy, of the nature and purpose of the research, the procedures to be used, the expected benefits to the participant and/or society, the potential of reasonably foreseeable risks, stresses, and discomforts, and alternatives to participating in the research, confidentiality measures, compensation and care in case of injury
- Understanding of what has been explained and opportunity to ask questions and have them answered by someone fully conversant in the study particulars. The informed consent document must be written in lay language, avoiding any technical jargon. The potential participant must be able to read and/or understand the language in which the consent form is written.
- Voluntariness: The participant’s consent to participate in the research must be voluntary, free of any coercion or inflated promise of benefits from participation. Care should be taken that the consent form is administered by someone who does not hold authority over the participant. Ideally, the potential participant is given the opportunity to discuss their participation in the study with family, trusted friends, or their physician before reaching a decision.
- Competence to give consent
- Consent and authorization for participation in the research study, preferably in writing. Children who cannot read or write should still signal their willingness to participate by an affirmative act (for example, nodding their head). Consent by minors is referred to as assent.
- Exculpatory language: No informed consent may contain any exculpatory language by which the participant waives any legal rights or releases the investigator or sponsor from liability for negligence.
Is deception of subjects allowed when doing research?
Usually not, but there are some exceptions.
For example: a study of how the decision-making practices of physicians affect their practice of medicine might be presented as a study of “communication behaviors.” The IRB will carefully review any proposal that suggests using deception or misrepresentation. They will require an in-depth justification of why deception is necessary for the study and the steps that will be taken to safeguard participants, including a plan to debrief subjects at the end of the research.
What rules guide rationing decisions? 4
- Likelihood of medical benefit
- First-come, first-served
- Seriousness of need
- Closeness to the organ
Why is the “social worth” criteria unacceptable in rationing? 2
- This sort of evaluation proved very difficult and troubling, since it leads to highly discriminatory judgments, such as “Popular” people over unpopular, school graduates over the uneducated, devout over unreligious, etc.
- A patient with social issues (like substance abuse) could overcome these issues with the right support
Are there ethical criteria for making triage decisions?
- Serve persons whose condition requires immediate attention and, if this attention is not given, will progress to a more serious state
- During disasters or war: attend first to those who can be quickly and successfully treated in view of a speedy return to the battlefield, or to treat commanders before troops in order to assure leadership. This sort of disaster triage is applied to civilian disasters by treating persons, such as firefighters or public safety officers, who can quickly return to duty and help others
Can I make allocation decisions based on judgments about “quality of life”?
YES AS LONG AS:
- First, who is making this quality of life judgment, the care team, the patient, or the patient’s family? Several studies have shown that physicians often rate the patient’s quality of life much lower than the patient himself does. If the patient is able to communicate, you should engage her in a discussion about her own assessment of her condition.
- What criteria are being used to make the judgment that the quality of life is unacceptable? These criteria are often unspoken and can be influenced by bias or prejudice.
Why is it important to attend to spirituality in medicine?
Religion and spiritual beliefs play an important role for many patients. When illness threatens the health, and possibly the life of an individual, that person is likely to come to the physician with both physical symptoms and spiritual issues in mind. Many are comforted in the face of a health-crisis with an inner calm that is founded on their deep trust in God’s loving care for them in all situations. Attending to spirituality ensures the physician is caring for the whole person.
Referral of these patients to the chaplain, or appropriate clergy, to help them work through these issues may ultimately improve clinical outcomes
What is the physician’s role with regards to spirituality?
Briefly screen patient’s spiritual needs as they relate to health care and to refer to the chaplain (a specialist in pastoral care), as appropriate
How should I take a “spiritual history”?
Say: “As physicians, (or, as physicians-in-training,) we have discovered that many of our patients have spiritual or religious beliefs that have a bearing on their perceptions of illness and their preferred modes of treatment. If you are comfortable discussing this with me, I would like to hear from you of any beliefs or practices that you would want me to know about as your care giver.”
If the answer is no, ask: “do your family members have spiritual beliefs or practices?” in order to better understand the family context and anticipate concerns of the immediate family
What is the HOPE way of taking a spiritual history?
(H) Where do you find comfort or hope in this time of illness? When things are tough, what keeps you going?
(O) Does organized religion have a place in your life, or in your family’s life?
(P) Are there spiritual practices or beliefs that are important to you personally?
(E) Are there ways that your personal beliefs affect your health care choices or might provide guidance as we discuss decisions about your care near the end of your life?”
What does spirituality mean?
The search for meaning
When is it justifiable to discontinue life-sustaining treatments? 2
- If the patient has the ability to make decisions, fully understands the consequences of their decision, and states they no longer want a treatment, it is justifiable to withdraw the treatment.
- Treatment withdrawal is also justifiable if the treatment no longer offers benefit to the patient.
Does depression or other history of mental illness mean a patient has impaired decision making capacity?
Patients with active mental illness including depression should have their decision making capacity evaluated carefully. They should not be presumed to be unable to make treatment decision.
What are you supposed to do if a family member tells you he will handle all medical decisions for the patient and you should not tell the patient what disease he/she has?
If I had to manage this situation alone, I would want to better understand the reasons why the family member thinks knowledge about his mother’s possible illness “will kill her.” His motives are commendable since he is trying to protect his mother from news that might negatively impact her life. His approach may also reflect a cultural, ethnic, or religious belief regarding medical decision making, so I would make sure to be culturally sensitive in speaking with him. Withholding unpleasant information from the patient without a justifiable cause can foster mistrust and lead to poor delivery of care and lack of patient empowerment. Asking him for clarification would allow me to assess whether there is evidence that disclosing the truth to his mother would cause her harm or whether he holds beliefs that are influencing his approach. If his mother is severely depressed and suicidal, then my duty would be to protect her by withholding information. This is referred to as my therapeutic privilege and should only be exercised in exceptional cases in which subsequent harm to a patient is indisputable. If there is not enough evidence suggesting that the anticipated harm to his mother is reasonable, then I would reassure him that we would inform his mother together in a compassionate, respectful, and sensitive manner. I would express my understanding of his concerns, would explain that his mother needs information to make informed and personalized medical decisions and that it is important that I build a strong, trusting relationship with his mother so that we can work as a team. If the son still wishes to hold back information, then I would explain that I will need his mother’s stated consent that I should communicate with him only regarding medical decisions about her health. In this case, it would be my responsibility to respect the patient’s decision not to be informed.
Can you prescribe a patient a placebo?
PROS: promoting the placebo effect might be one of the most effective treatments available for many chronic conditions and can be accomplished without deception (by saying: “There’s no evidence, but some people say it helps.”)
CONS: involves deception and therefore violates patients’ autonomy and informed consent
OVERALL: Intention matters. Prescribing a placebo because you think it may help a patient is one thing. Prescribing it to simply appease a difficult patient is something else entirely.
Stem cell research: pros and cons?
PROS: medical benefits in areas of regenerative medicine and therapeutic cloning, huge potential for finding treatments and cures to a vast array of diseases including different cancers, diabetes, spinal cord injuries, Alzheimer’s, MS, Huntington’s, Parkinson’s and more. We can now use iPSCs or umbilical-derived stem cells.
CONS (only for ESCs): involves the destruction of blastocysts formed from laboratory-fertilized human eggs. For those who believe that life begins at conception, the blastocyst is a human life and to destroy it is unacceptable and immoral.
What to do if a patient comes into my pharmacy to buy needles? Overall and step by step.
OVERALL: need to look out for the best interests and the safety of the patient and do not judge them and shun them away if they are a drug user
- Check the policy of the pharmacy or institution you work at
- If there is no policy, ask the patient why he wants needles.
3a. If the patient says it’s for diabetes or another medical condition that requires needles ==> ask for how long they have been receiving treatment and check their record for accuracy ==> ask for prescription or insulin bottle if this a recent diagnosis
3b. If the patient says it’s none of my business ==> ask them to please be honest, and let them know you do not feel comfortable selling them without a reason and that whatever they tell you will remain confidential
3c. If the patient says it’s for drugs ==> it’s very difficult to get patients off of IV drugs, and it will be safer for them and society to use clean needles (decreases spread of diseases) ==> refer them to a needle exchange program where drugs users can bring used needles for new ones and refer them to resources for addicts
What are 3 reasons against deception of a third party other than the physician or patient?
- Undermines social trust
- Patient will lose trust in physician
- Public will lose trust in physician and profession
3 steps to handle deception situations involving 3rd parties?
- Is there a health benefit at stake? If so, how important is the health benefit?
- Can the situation be resolved without deception?
Consider other options carefully - Gently discuss the situation with the patient, including the consequences of deception for all parties involved, including patient, physician, and third party
What is a good argument for not postponing delivering good news?
There may never be a good time
What are 6 reasons why you should never deceive a physician?
- Violates physician code of ethics
- Patient will lose trust in physician
- Public will lose trust in physician and profession
- Emotional distress caused by discovery of deception
- Failure to respect or enhance patient’s immediate autonomy
- Initial deception may lead to further deception
How to convince a colleague to disclose an error made?
Tell them we all make errors and give an example of an error I’ve made
What are 2 good reasons to tell the attending physician about a medical error made?
- If I do not tell the attending then he cannot do his job properly which could negatively impact the patient’s health
- It will allow for a discussion about the reason why the error took place, which is a great learning experience
4 things to do when handling an angry patient?
- Re-state why he is angry to show you understand and validate it
- APOLOGIZE
- Fix the issue, and in the meantime ask if you can do anything else (is he hungry? comfortable? enough pillows?)
- THANK the patient for sharing concerns and for giving me the opportunity to make it better
2 things to do when a patient is mad at me for being late?
- Apologize
2. Provide a valid reason
When you are addressing something an employee did wrong, what is important to do?
- Focus on the actions, not on who your colleague is as a person
- Offer time off if the person is going through a hard time
- Offer a solution and ask them if it sounds reasonable
- Express faith and trust in them as an employee
What is a pro of pharmaceutical companies giving gifts to patients?
Free meds for patients who cannot afford them
What to do if parents want to use frozen eggs of dead daughter to make babies?
Encourage family to wait until enough time passes before making such an important decision
What do some states require if you help a family member in an emergency medical situation?
Document it
What are 2 exceptions for treating family members or friends?
- Emergency
2. They do not have access to healthcare (eg: no insurance)
What is an important thing to say to a patient who wants to use CAM?
Tell them you are glad they are taking such an active interest in their health and researching possible treatments
If asked to make up a policy, what should you always do? 3
- Engage all stakeholders and relate it to PCORI
- Make a policy based on science and facts
- Make the policy and process transparent
Should you deny an organ transplant to someone who is alcoholic?
No. They may be genetically pre-disposed
Should we restrict non-citizens from obtaining transplants?
NOPE since we let them donate them
Benefit for early genetic test of Alzheimer’s?
Advanced directives before cognitive impairment
6 steps to handling a “non-compliant” patient?
- Discuss the noncompliance in a non-judgmental manner and use open ended questions to begin (EG: you haven’t been able to take your medication - are you having a problem taking it?)
- Assess the patient’s understanding of the medical problem and risks to health if the problem is not treated
- Determine if the patient has any concerns or questions about the recommended treatment
- Determine if the patient has been considering or using other treatments
- Make non-compliance a shared problem
- Ask the patient about strategies he/she thinks might be effective (EG: what can I do differently to help you?)
Is it ethically appropriate for doctors to opt out of caring for Ebola patients? 3 points
- Professionals acquire specialized knowledge and skills that others do not and cannot have. Having these skills creates a presumptive obligation to use them. However, such an obligation is tempered by the likelihood that intervention will actually benefit patients by either curing them or relieving pain and suffering. The extent of professionals’ duty to assume risk must take into account the rights of the providers to receive appropriate training and resources to protect themselves.
- Second, a policy could reasonably include or exclude professionals on the basis of their relevant clinical experience. Students have relatively little related experience. However, by the end of several years of postgraduate training as residents or fellows, many, though not all, physicians and surgeons, even those still in formal training programs, have sufficient clinical experience to competently learn and use Ebola precautions.
- Some situations warrant respecting informed professionals’ choices to opt out of caring for patients with or at-risk for Ebola. For example, clinicians who have increased vulnerability to infection because of medical conditions or immunosuppressive treatment could reasonably refuse to assume the risk. Pregnant women who might pass the virus onto their fetuses should also have the option of declining participation. Within these categories, competent adults could choose to opt in and participate in the care of these patients, provided they do so knowingly and voluntarily, understanding the risks and benefits, and being reassured that no penalties would accrue from a decision to opt out.
