Clinical Ethics Flashcards
According to Fox’s survey, what is the primary goal of CEC? Who does ethics and how?
protect patient rights. Most common model was one of small team - about 4 people doing each consult. only about 20% of people have formal ethics training. very little quality control/
Dangers of ECs
tempation to abrogate moral decision making to ethics ppl, may take over DM process, may not have enough diversity, may overemphasize legal protections, may have loyalty to institution, may impose own values
models for CEC
pure committee model, committe member as consultant (person goes, reports to committee), post-facto committee review (request ot consultant, who makes recs, reviews with committee), pure consultation model (request goes to consultant, never to committee)
According to Singer, Pellegrino, and Siegler, how do you measure the success of CEC?
the goals is to improve patient outcomes. This is measured not just by mortaility, but also by pt sat, functional status, and cost.
2 arms of the development of clinical ethics
ID dialogue, abuses in research
10 goals of CEC according to Fox
protect patient rights, resolve conflict, improve quality pt care, improve pt satisfaction, educate staff, prevent ethical problems, address needs of staff, suspect unwanted/wasteful trtmt, reduce legal liability, moral support of staff
3 branches of philosophy
ontology, epistemology, ethics
According to Kanoti and Younger (encyclopedia), what is the CE consultant and what sources contribute to EC?
an expert with special skills/knowledge, a facilitator, or the moral police/God squad.
-legal norms, moral philosophy, theo and religion, psychiatry and psychology
According to Scofield, should ethics be professionalized?
no, bc ethicists already have too much power and impose their values on others. they knowledge is incomplete and unrepresentative, they are plagued by vice. they should have to function under IC and should focus on education – how to approach adn think through problems.
According to Casarette, Daskal, and Lantos, does the ethicist have expert authority?
Ethicists build consensus. The ethicist is mediaator and moral expert. But expertise is gained through the consensus building. Here, they rely on Habermas - consensus is not a way to avoid rigorous moral theory, but to bring theories together to a joint theory. “The EC’s moral auth depends on her ability to construct consensus”
According to Agich, does the ethicist have expert authority?
The ethicist should be ‘in authority’, not ‘an authority.’ she gains authority through epistemic and competence qualities, and her authority is grounded in the subject matter of clinical ethics and skills that illustrate her competence. it’s not authority by nature of her position, but by her personal performance.
origin of authority: AUGERE - to augment, enrich, increase, tell about. this is role of the ethicist.
According to Rasmussen, does the ethicist have expert authority?
Ethicist has ethics expertise, not moral expertise. thie ethics expert doesn’t rely on metaphysical claims about moral facts or on the ability to make universal recs. expertise is located in particualr contexts and in the engagement of particular knowledge of rel, ethics, law with circumstances at hand.
- ETHICS EXPERTISE: command of moral arguments behind law, knowledge of consensus/dissensus, understanding of main religious groups, historical moral foundations of clincal practice. (FE, right to abortion comes from legal right to privacy) much more MODEST. doesn’t claim priviledged access.
- MORAL EXPERTISE: moral expert has the ability to resolve disputes on moral issues through a decisive opinion. usually done by rel leaders. includes unique access to moral truth.
According to Rasmussen, what do ethics experts distinctly contribute?
1, identify clearly wrong answers, 2, bettera ble to reason from moral premise to implications, 3, better able to idnetify full range of moral values/stakeholders, 4, better able to offer creative solutions to clinical dilemmas.
According to Erica, what are 3 main approaches within moral philosophy?
principle based, virtue, casuistic
Skillsneeded for EC
ethical theory and analysis, clinical medicine, hospital structure, politics, professional ethos of clinicians, communication and interpersonal skills, cultural competency
According to Rasmussen, why can’t we have moral experts in CEC?
we disagree over facts (metaphysical), disagree over the good (epistemology), and we need complete autonomy in making decisions (conceptual, we can’t be neutral)
4 steps to CEC certification, 4 part certification for CEC (Smith et al)
- -training progs, credentialing by hospitals, code of ethics, certification process.
- -written exam, case portfolio, case simulations, 2 hour oral exam
Acording to the CECA, what is necessary to demonstrate competency?
exam (written and oral), mock consults, evidence of consult experience, graduate degree, CEC training, letter of rec
According to Jim, what kinds of ethical problems are there?
volitional (know right thing), cognitive (what is right thing?), social (know right thing and want to do it, but socially problematic)
According to Jeff, Joe and Mark, should we standardize CEC?
No. standarization relies on procedural goods, impinges on goods internal to the practice of CEC and reduces irreducible intersubjective encounters. ethics is diverse and local. “It purchases agreement at the price of reduction.” –their point is that standardization will reshape what CEC is. combining quality improvement and evidence based medicine leads to CEC that could be standardized…and the CEC will create this standarization, then she will be created by them, but then she will be policed by them. “Expertise is a self-fulfilling, circular project.”
According to Engelhardt, is credentialing desireable?
No. it will inc probability that people will misunderstand what CECs are and associate them with authority, expertise, and a false sense of moral consensus.
VA approach to ethics
Clarify consult request, assemble relevant info, synthesize info, explain the synethesis, support the consult process with follow up and self-review
Siegler and Winslade 4 box method for CEC
4 considerations for analysis that correspond to principles: medical indications (beneficence, nonmaleficence), pt preference (respect for aut), QoL (ben and nonmal and respect for aut), contextual features (loyalty and fairness)
(Check to make sure authors are correct. D said this was Jonsen)
Miller, Fletcher, Fins - method for CEC
principle based DM is too abstract, not practical. they propose four step model - CLINICAL PRAGMATISM. -assessement of facts, context, org, preferences, power; -moral diagnosis of problems and options for resolution; -goal setting, DM, implementation via democratic and deliberative process; evaluation of results. ///principles matter, but they are not ultimate or the best way to define a problem.
According to Dubler, what is mediation?
private, voluntary and informal process in which an impartial 3rd person facilitates negotiation btw ppl in conflict and helps them to find sol that meet their needs and interests
According to Dubler, what is the goal of CEC?
principled resolution: a plan that falls within clearly accepted ethical, legal, and moral boundaries and facilitates a clear plan for future interventions
According to Dubler, what do mediators need?
knowledge of ethical/legal principles, vocab of clinical med, law, ethics, policies, understanding process of mediation, knowledge of particular workings of their institution
According to Dubler, what are the five principles of negotiation?
separate people and the prob, focus on interests/not positions, generate options for mutual gian, use objective criteria, know your BATNA (Best alternative to a negotiated agreement).
Stages of bioethics mediation
assessment and prep, begin the mediation, introduce the patient, present/refine medical facts, gather info from parties, problem solve, resolution, follow-up
technique for mediationg a dispute (Dubler)
STADAsit with fam, tell me about your mama, admire the family’s committment and who pt was, discuss medical facts/options, ask what would mama want
**Focus on summarizing, reframing. practice stroking, allow silence, talk to certain people before meetings, encourage abandonment of extreme positions.
Why are chart notes important and how do you write them? (Dubler)
they communicate agreement, explain resolution, and elucidate process for staff not present. —– time/place of consult, medical and social history, consult description, ethical problem, ethical analysis, summarize the process, make recommendations, style (review it for appropriate and neutral language)
Sandra Johnson on Cruzan and Quinlan
bc of these cases, we rely on theory of highly individualized inquiry into pts precise condition, wishs, identity…rather than what reasonable person would want. These cases are not just legal standards, but about “how decisions are made in a democratic society.”
Quinlan vs. Cruzan
Q decided 1976 NEw Jersey - vent withdrawn, she breathed on her own, died 9 years later
——– C decided 1990, Missouri. PVS, wanted to remove anh. Supreme court said that states can require clear and convincing evidence
historical trends in cultural competency
began in 1990s bc there was desire to alleviate barriers to effective hc and address misunderstandings that emerged in cultural distance. More recently, it’s justified by aim to eliminate racial and ethnic disparities.
According to Gregg and Saha, what is culture? does cultural competency have a role in HC?
culture is defined in CC movmeent as “a fixed, knowable entity that guides ind’s behavior in linear ways.” they say culture is much more complex, cultures are not discretely bounded wholes; people belong to many cultures.
- -CC has a role, but should stress:
- culture matters so you need to understand ind’s beliefs, -bridging cultural distance isn’t only or most imp way to < disparities, culture race and ethnicity are entangled and distinct, culture is mutable and multiple, context is critical and includes social/econ
According to Betancourt, why train people in cultural competency?
-improves outcomes and cost, includes diversity in leadership and services, populations are diverse,increases access to quality care, traslates into services like translation, helps eliminate disparities. (just know some of these)
ethnography
doesn’t have a trait list, but emphasizes engaging with others in order to understand other’s local world
Kleinman and Benson - explanatory models approach
cultural competency is not foundational to good patient care. the life of the patient and meaning of suff are most important. rather than CC, focus on that. So, in the exp models approach, 6 steps: -ask about ethinic identity/how it matters, evluate whats at stake for pt with illness, get understanding of meaning of illness to pt, consider psychosocial probs, see who culture shapes relationships, be aware of side effects of attn to cultural diff (perceived as intrustivE)
Lo: requirements for IC
nature of treatment, benefits/risks/consequences, alternatives/totally forgoing and their ben/risks, volunatry agreement.
Lo: Exceptions to IC
lack of capacity, emergencies, therapeutic priviledge, waiver
Lo: clinical standards DMC
makes/communicates choice, pt understands info and its relevance, decision is consistent w pts values/goals, decision is not delusional, pt uses reasoning
Lo: Standards of disclosure
professional standard (what would reasonable phys find relevant to disclose), pt standard (what would reaosnable pt want to know), subjective standard (what would this pt want to know)
Berg, Applebaum, and Lidz on IC
emerged in legal processes over decades, therefore is unclear and inconsistent. — IC is best envisaged as a process cultivate in pt-prof rltshp.
consent as event = event provides all info, embodied in consent form. consent as process - exchange of info takes place throughout rltshp. Stages of process of consent:: est rltshp, define prob, asecertain goals of trtmt, select approach, follow up.
Quill and Brody on IC
HC moved away from paternalism of 1970s to another extreme of ind choice.
2 models of IC: 1) independent choice model - phys primary role is to inform pts ab options, don’t bias pts. 2) enhanced autonomy model - dialogue btw pt and phys enhances aut; this model is relationship centered rather than pt centered
Sulmasy on IC
Cath/sec IC appear the same. but secular mixes up freedom and morality. Catholic reasoning based on dignity and an objective moral order that precedes choices. ITs IC without absolute aut. this is what society should adopt. it’s a NL approach. Dignity is not unencumbered choice, but capacity for free choice within objective limits.
Kuczewski on DM
distinction btw ind and fam is blurier than legal and IC norms suggest. ind is embedded in the family. so we need a deliberative model of IC that acknowledges role of family. pt aut is a goal, not presupposition. ——– interpretive model = phys and fam assit pt in interpreting values and translating into decisions. assumes well developed, individualstic, stable values; deliberative model = fundamental layer of necessary values is lacking, needs to be developed. fam’s role is to help restore pt’s thinking by presence/interaction. pt doesn’t have access to already formed vlaues. others help uncover, create, give meaning - self discovery.
traditional approach to DM for surrogates
pt’s known wishes, substituted judgments, best interests
–Berger et al argue that this is too simplistic. based on W notions of personhood and ind. need a mutlidimensional notion of aut that accomodates value of and integrity of family.
Dresser and Robertson - current interests approach
currently, w incompetent pts the orthodox approach prioritizes, ADs, sub judgement, best interests. Should be best interests first.we should first ask about pt’s current interests, which is really about QoL. we should think about person’s situation and subjective existence.
Brock - moral grounds for family DM authority
1democratic (family members have formal rights), 2self-determination of patient, 3someone must decide, family is best, 4 family will be most affected so they should decide, 5 distributive justice - effects on family, 6 fami is ind moral unit w DM capacity.
Fagerlin and Schneider
ADs are prob bc: people don’t sign them, people have unstable preferences, ppl can’t predict preferences for unpecified future and condition, ppl can’t articulate preferences in docs, we lose the docs, proxies don’t interpret ADs correctly, ADs don’t actually alter pt care.
living wills fail bc of human nature and they’re not justified.
Baby Doe Regs
1985 limits decisions to withhold med trtmt from disabled infants <1
**Kopelman says these are inconsistent with AAP guidelines that rec individualized DM by clin and fam.
AAP on IC/LSMT
IC doesn’t fit exactly the same in peds context. Parental permission and patient assent are crucial to IC. —— phys and parents should give weight to kids wish to forgo lsmt. seek third part when there’s conflict btw parent and child. you can’t forgo kids’ care for religious reasons. **Whereas Ross says parents are best situated to make decisions for kids. third party involvement undermines parental authority.
Weir and Peters on teens
we should extend use of ADs to 14-17 year olds. competent teens should be able to override parents.
Hardwig on Futility
reducing demands for futile care requires preventative approach that addresses spiritual needs of the family. futile care is an iatrogenic problem.
Sulmasy on Double Effect
action with 2 effects, one good and one bad, permited if: act is good, intent is good, does not achieve good through bad, proportionate reason. **Dan argues that DE shows PAS is wrong and gives credibility to use of pain meds. Many misues DE: effects have to follow on one action, immediately. the correct use of DE in case of PAS is cooperation. DE is not for removing life support, and it has to specify particular effects (not relieve suff). the principle is grounded and useful, even if it has religious origins.
Griff on futility
goal, action aimed at that goal, virtual certainty it will fail. our disagreements are about goals, more than achieving them. he argues that bc medicine is inherently social, the locus of authority rests in the GMC (Royce) resolving futility conflicts requires deliberation, conversation and consensus building through a public philosophy. Griff - GMC doesn’t have consensus on trtmt of pvs pts.
Griff on futility
goal, action aimed at that goal, virtual certainty it will fail. our disagreements are about goals, more than achieving them. he argues that bc medicine is inherently social, the locus of authority rests in the GMC (Royce) resolving futility conflicts requires deliberation, conversation and consensus building through a public philosophy.
GMC
ideal moral subcommunity (but not utopian standard). it’s a historically contingent best approximation of flourishing humanity, predicated on historical, cultural, and scientific facts and engendered by our response to current probs. this is the locus of authority in clinical medicine. for medicine, gmc requires sound philosophy of medicine that articulates human goods that medicine aims to achieve.
