E&P Midterm Flashcards
Profession
self-defineself-defined group of specialized workers whose expert knowledge and skills earn it the right to function as an independent semiautonomous group
Professionalism
extent to which members of a profession maintain a level of conduct above an ethical threshold determined by the profession
consequentialism
no type of action is automatically wrong
morally right action. Morally right action is the one that maximizes good consequences
actions are morally wrong because of the consequences they have
primary focus is ACTION
decision procedure: greatest happiness principle
Deontology
some types of actions are just wrong, independent of consequences they may have
primary focus is action
decision procedure: categorical imperative
(act in way that you treat humanity as an END and never simply as a means (to do should rob them of dignity)
Virtue ethics
actions/feelings should be guided by a virtuous character
purpose internal to the profession of medicine provides moral guidance
beneficence
doing good for patients
respect for autonomy
honoring pt’s prima facie right to make decisions regarding their own life and body
non-maleficence
primus non-nocere (first, do no harm)
justice
protecting patients from discrimination and exploitation
balancing interests of other parties addicted by the decision
postnatal genetic diagnosis
non-symptomatic (carrier states), pre-symptomatic (genetic risk) or symptomatic individuals (genetic diagnosis, precision or personalized medicine)
Prenatal genetic diagnosis
post-implantation (abortion decision) vs. pre-implantation with IVF
prenatal genetic selection and modification
identify or create embryos with desirable genes prior to implantation
genetic screening
genomic profiling of a population
Genome-wide sequencing (GWS)
statistically significant correlations between SNPs and increased susceptibility of disease; analytic validity is high but clinical utility remains LOW
Genetics Information and Non-Discrimination Act (GINA)
prohibits insurers and employers from collecting and using genetic information
does NOT protect against possibility of discrimination in life, disability, or long-term care insurance
Are physicians required to inform patients or their affected relatives about the transferability of genetic risk>
There is legal precedent requiring physicians to inform patients about the transferability of their genetic risk BUT informing affective relatives is directly controversial and raises issues of respect for autonomy, beneficence and justice
Explain a proxy
Proxy –> a legally designated person
All it says is “if I lose decision making capacity, this person can speak for me”
Does NOT say physician is legally obligated to do what the proxy says
strict futility
no physiologic rationale; allows for unilateral withdrawal or withholding of intervention
No law holds you to act contrary to your professional judgement – unilateral withdrawal is allowed
loose futility
very low probability of success, no worthwhile goal, unacceptable quality of life; unilateral withdrawal or withholding unjustifiable (alternative term - “potentially inappropriate treatments”)
Physicians determine __________; courts determine ________
Physicians determine decisional capacity; courts determine competency
Patients with certain mental illnesses are more likely to lack decisional capacity, but having such an illness does not …
a priori preclude decisional capacity
Decisional capacity
ability to (1) communicate choices, (2) understand relevant information, (3) rationally manipulate that information, (4) appreciate the situation and its consequences
substituted judgement
Proper surrogate –> supposed to BE the person. Sources of evidence (living will, fam/friends who know pt) help guide surrogates
In cases of a dispute, the decision of a legally appointed ___________________________ takes priority over family members not so designated
power of attorney (POA) or health care proxy
Advance care planning
includes POA empowered to serve as a health care proxy; living will helpful for guiding decisions, but no making them
Surrogates are not legally bound to follow the instructions in a _________ (in most states)
living will
______ forms recommended for documenting a detailed plan for last year of life
POLST forms
Physician Orders for Life Sustaining Treatment
Peds
Parents given wide latitude in decision making on behalf of children. In rare cases of conflict, peds physician responsibility is to ped patient indep of parent’s wishes
respect for autonomy=decision making capacity of child
exp of tx w/o parent consent –> sexual health, substance use, mental health
Primary duty to pediatric patients
Beneficence
Respect for autonomy is commensurate with developing decision making capacity of the patient (informed assent vs informed consent)
Physicians cannot refuse patients on basis of…
ethnic background, race, gender, religious beliefs, personal dislike, smoking/alcohol/substance abuse/non adherence to meds
but can refuse based on bad attitude or attraction (?)
problematic pt-physician relationships
accepting valuable gifts
secret info from relatives or others
sexual relationships of any kind with current or past pts
Virtue ethics
Aristotle
primary focus: character
decision procedure: what would virtuous person do?
ethics=skill, practice makes perfect
downplay strict rules, instead develop skills, learn from wise, be guided by purpose of your profession
Solutions to challenges to the moral integrity of clinicians
negotiate
refer, if compromise not reached
disclose practice limitations PRIOR to establishing physician-pt relationship
The best interest standard is most closely aligned with the principle of _____ rather than _____.
beneficence rather than non-maleficence.
Only patients themselves can ultimately determine what is in their best interest, assuming they have the capacity to freely make and express this determination. If they do not, physicians should not rely solely on their own judgement, but should first turn to patients’ designated health care proxies or family members to help clarify what the patient would have wanted under the circumstances.
Physicians are under no ethical obligation to order any intervention (diagnostic or therapeutic) that is not…
medically indicated, irrespective of the wishes of their patients. Acquiescing to patient demands for unnecessary tests often fails to reassure them, leads to additional requests for further testing, and risks false positive results, which may cause harm.
It is currently ____ in the US to base hiring decisions on the results of an applicant’s genetic screening results
ILLEGAL
For which of the following single-gene mutations would you be LEAST compelled to breach patient confidentiality?
a. BRCA 1 b. Huntington’s disease c. hereditary non-polyposis colon cancer d. cystic fibrosis
Unlike the other conditions, the gene for cystic fibrosis is transmitted in an autosomal recessive pattern. Therefore, the greatest harm to the sisters would be a lack of knowledge regarding their potential carrier state, which is unlikely to affect anyone. Since genes for the other conditions are autosomal dominant, each sister would have a 50% risk of possessing a given gene should the patient screen positive for it. Though their penetration is variable, such information would have major implication for the sisters and their children.
Who would the utilitarian put on his lifeboat?
As a utilitarian, the ship’s captain is most interested in saving as many lives as possible. Recognizing that he is unable to save everyone, he must make a decision (and if necessary enforce it with his weapon) that will maximize the number of passengers likely to survive. Since rescue is unlikely to arrive prior to the storm, selecting the best rowers carries with it the greatest probability of increasing the total number of survivors compared to the other options listed. Were the captain to give up his place to one of the other passengers, the lives of the remaining survivors would be further imperiled having lost their leader.
You dx viral infection, but mom of pt wants abx for child despite your discussion of why that would be ineffective… rx abx?
You have fulfilled your beneficent obligation by correctly diagnosing your patients and recommend appropriate tx. The addition of abx, which have no clinical utility, may actually cause harm (e.g., acute diarrhea, allergic reaction). Exposing the child to unnecessary risk would, therefore, violate the principle of non-maleficence.
You are seeing a patient referred to your surgical practice. She has a large uterine fibroid (a benign condition) causing abnormal vaginal bleeding. While some fibroids respond to medical management, many require surgical excision for symptom resolution. Pt demands surgery even though, in her case, its risks outweigh its benefits…
The principles of non-maleficence and beneficence prohibit surgeons from actively and unnecessarily placing patients at risk even if they choose to place themselves at risk.
