Core ethical principles - informed consent - consent of minors- decision making capacity Flashcards
core ethical principles
- autonomy
- beneficence
- nonmaleficence
- justice
core ethical principles - AUTONOMY
Obligation to: 1.to respect patients as individuals (truth-telling, confidentiality). 2. to create condtitions necessary for autonomous choice (informed consent). 3.to honor their preference in accepting or not accepting medical care
core ethical principles - BENEFICENCE
Physicians have a special ethical (fiduciary) duty to act in the patient’s best interest
Beneficence may conflict with
- autonomy (an informed patient has the right to decide)
2. what is best for society (traditionally patient interest supersedes)
core ethical principles - NONMALEFICENCE
do not harm
Nonmalleficence must be balanced agaist….
explain
beneficence
if the benefits outweigh the risks, a patient may make an informed decision to proceed (most surgeons and medications fall into this category)
core ethical principles - Justice
to treat persons fairly and equitably. This does not always imply equally (triage)
informed consent is not just a
document/signature
informed is a process (not just a document/signature) that requires:
- disclosure: discussion of pertinent information
- understanding: ability to comprehend
- capacity: ability to reason and make one’s own decision (distinct from competence, a legal determination)
voluntariness: freedom from coercion and manipulation
informed consent - patients must
- have an intelligent understanding of their diagnosis and the risk/benefits of proposed treatment and alternative options, including no treatment.
- be informed that he or she can revoke written consent at any time even orally
informed consent - exceptions (and explain)
- patients lacks decision capacity or is legally incompetent 2. implied consent in an emergency
- therapeutic privilege: withholding information when disclosure would severely harm the patient or undermine informed decision - making capacity 4. Waiver-patient explicitly waives the right of informed consent
a minor is generally –>
any person under 18
parental consent-health-state
Parental consent laws in relation to health care vary by state in general, it should be obtained unless emergent treatment is required (eg. blood transfusion) even if it opposes parental religious/cultural beliefs, or if a minor is legally emancipated (eg. married, self supporting, military)
parental consent - in general, it should be obtained unless
- emergent treatment is required (eg. blood transfusion) even if it opposes parental religious/cultural beliefs
- if a minor is legally emancipated (eg. married, self supporting, military)
- sex (contraception, STIs, pregnancy)
- Drugs (addiction)
situations in which parental consent is usually not required:
- sex (contraception, STIs, pregnancy)
- Drugs (addiction)
- emergency/trauma
parental consent - physician should always encourage
healthy minor-guardian communication
emancipated minor
at least one: 1. self-supporting 2. military 3. married
4. have a child for whom he or she cares
decision making capacity - Physician must determine whether
the patient is psychological and legally capable of making a particular health care decision
decision making capacity - components
- patients>=18 years old or otherwise legally emancipated
- patients makes and communicates a choice
- patient is informed (known and understands)
- decision remain stable over time
- decision is consistent with patient’s values and goals not clouded by mood disorder
- decision is not a result of altered mental status (delusions, delirium, hallucinations)
Advance directives?
instructions given by a patient in anticipation of the need for medical decision –> Deatils vary per state law
Advance directives - types
- oral advance directive
- living will (written advance directive)
- Medical power of attorney
oral advance directive?
Incapacitated patient’s prior oral statements commonly used as guide
oral advance directive - disadvantages
variance in interpretation
oral advance directive - when is more valid
- if patient was informed
- directive was specific
- patient made a choice
- decision was repeated over time to multiple people
living will (written advance directive)?
describes treatments the patient wishes to receive or not receive if he/she loses decision-making capacity
living will (written advance directive) - usually
patients directs physician to withhold or withdraw life-sustaining treatment if he/she develops a terminal disease or enters a persistent vegetative state
Medical power of attorney?
Patient designates an agent to make decision in the event that he/she loses decision-making capacity. Patient may also specify decision in clinical situations. Can be revoked by patient if decision-making capacity is intact –More flexible than living will
Medical power of attorney vs living will (written advance directive) according to flexibility
Medical power of attorney is more flexible
Surrogate decision maker?
If a patient loses decision-making capacity and has not prepared an advance directive, individuals (surrogates) who know the patient must determine what the patient would have
Surrogate decision maker: priority of surrogates (in order)
first: spouse –> adult children –> parents –> adult siblings –> other relatives
confidentiality?
respect patients PRIVACY and AUTONOMY
confidentiality if patient is not present or is incapacitated
disclosing information to family and friends should be guided by professional judgement of patient’s interest
confidentiality - special characteristic
the patient may voluntarily waive the right to confidentiality (eg. insurance company request)
General principles for exceptions to confidentiality
- potential physical harm to other is serious and imminent
- Likelihood of harm to self is great
- No alternative means exists to warm to protect those at risk
- Physician can take steps to prevent harm
Examples of exceptions to patient confidentiality
- Reportable disease (STI, TB, hepatitis, food poisoning) - physician may have a duty to warn public officials, who will then notify people at risk
- Child and/or elder abuse
- Imapired automobile drivers (eg. epileptics)
- Suicidal/homocidal
- The Tarasoff decision
The Tarasoff decision?
California Supreme Court decision requiring physician to directly inform and protect potential victim from harm
core ethical principles - AUTONOMY is the obligation
- to respect patients as individuals (truth-telling, confidentiality). 2. to create condtitions necessary for autonomous choice (informed consent). 3. to honor their preference in accepting or not accepting medical care
a competent patient patient request cessation of artificial life support?
both legal and ethical for the physician to do it
causes of impaired physicians - types and management
- substance abuse
- physical or mental illness
- old age
Reporting is an ethical requirement because patients must protected and the impaired physician must be helped
Most and least likely specialist that sued for malpractice
Most –> surgeons and anaesthesiologists
Least –> psychiatrists and family doctors
recently there has been an increase in number of malpractice claims due to
breakdown of the traditional physician patient relationship
For malpractice claim, the patient must prove that the physician demonstrated
- dereliction (or negligence)
2. a duty that caused damags directly to the patient
malpractice - crime
malpractice is a tort, or civil wrong, NOT A CRIME. A doctor may be required to pay money to compensate the patient for suffering as well as for medical bills and lost income
if you are not sure about patients competence –>
assume that he is competent
