Elliot: Medical Ethics, Limits and Boundaries

Question 1

Lab tests indicate that your patient has developed Hep C. What do you say?

Answer 1

h

Question 2

What are professional values?

Answer 2

First, do no harm (nonmaleficence)
Respect the pt (autonomy)
Benefit the pt (beneficence
Use scarce resources wisely (justice)
Be honest

Question 3

What makes the execution of professional values complicated?

Answer 3

DR-Pt relationship:

How do I tell her so she will hear?

If she is difficult to care for–can I fire her?

Question 4

What are Dr Pt Relationships based on?

Answer 4

ethics of personal and professional values

reflect a locus of POWER in a decision

• paternalistic
• informative
• deliverative

Question 5

When can I DECLINE to tx?

Answer 5

1. scope of practice (legal and ethical)
2. clinical skills (legal and ethical)
3. exposure to infection (legal; not ethical)
4. torture/execution (legal and ethical?)
5. Can’t refuse to refer (not legal or ethical)
6. reproductive health (conscience clause) (legal and ethical)

Question 6

What are conscience clause for reproductive health?

Answer 6

legally permits professionals to NOT provide certain medical services, based on MD’s personal beliefs (abortion, BC, Stem cell rx)

Question 7

Guardian or conservator

Answer 7

appointed by the court—trumps proxy/surrogate

Question 8

What is substituted judgement?

Answer 8

decisions based on pt preferences

sources of guidance for SJ (written documents, discussion, life story, biographic knowledge)

Question 9

What does best interests mean?

Answer 9

decision based on what is best for the patient

Question 10

What are sources of guidance for BI?

Answer 10

• pain and suffering

- functionality, prognosis

Question 11

What is EMTALA?

Answer 11

Legal obligation to treat and stabilize

-you are not obliged to do everything possible, but if they present unstable, then you are obliged to stabilize

Question 12

When do you not need informed consent?

Answer 12

• EMTALA
• children
• good samaritan (ethical and legal)
• best interests criteria vs default of full care

Question 13

Where is the death with dignity act (PAS) legal?

Answer 13

oregon
washington
montana
vermont 
new mexico

Question 14

Is euthanasia legal in the US?

Answer 14

NO

Question 15

What are hte ethical issues surrounding PAS?

Answer 15

Intent–> counter air hunger (ok)
double effect
autonomy
beneficence

Question 16

What is double effect?

Answer 16

Cancer tx + kill fetus

Question 17

What is futility?

Answer 17

NON-beneficial care

• professionals are NOT obliged to provide care they judge to be non-beneficial
• limits pt autonomy: pt cannot demand care/can refuse care

Question 18

How do you assess futility?

Answer 18

Look at the goals of care

• clinical prognosis (MD assessment)
• social, spiritual, personal, family goals
• costs and benfits ratio

Question 19

What are ethical issues associated w/ futility?

Answer 19

• high cost outliers
• use expensive options selectively
• monitor benfits

*HCV, CRC

Question 20

What is disproportionate or extra-ordinary care?

Answer 20

Disproportionate to benefit

• can be declined

Question 21

When can you forgo medical interventions?

Answer 21

When an intervention is likely to offer little benefit to a pt
-cpr, feeding tube, ventilation

Question 22

What are the ethical issues are associated w/ forgoing medical interventions?

Answer 22

• first, align autonomy and beneficence
• understand/explain w/ non-maleficence (do no harm)

*facilitated by dr-pt relationship

Question 23

How do you resolve conflicts in clinical medicine?

Answer 23

ethics committees

Question 24

How can request an ethics committee for a case?

Answer 24

ANYONE

• no cost
• findings are advisory (more than one)
• multidisciplinary

Question 25

How do you cope with competing issues?

Answer 25

can arrange to do BOTH

-have assistand do informed consent to avoid coercion

Question 26

How do you cope w/ conflicting interests?

Answer 26

doing ONE impacts other

• financially: investment in drug under investigation
• intellectually: interest in publication

Question 27

Is the government involved wtih privacy?

Answer 27

NO

Question 28

is government involved with confidentiality?

Answer 28

NO

Question 29

What are exceptions to confidentiality?

Answer 29

Public health reporting
Tarasoff (known risk to others–> POLICE)
impaired professionals
emancipated minors
patients/others at risk (incl. driving)
Child and vulnerable adult abuse
domestic abuse (ethical, depends on state)
Impaired pts (unsafe drivers, public safety)
infectious conditions (legal)
genetic conditions (legal)

Question 30

When should you report impaired professionals?

Answer 30

1. illness
2. drugs, alcohol
3. chronic infectious conditions (HIV, hepatitis)

HPSP- public safety, rehabilitation

Question 31

What are exceptions for legal statuses and minors?

Answer 31

1. specific care issues (BC,STI, mental health concerns, drug abuse)
2. legal marriage
3. consenting as parent
4. military
5. court ordered emancipation

Question 32

What are sources of legal liability?

Answer 32

1. risk management–keep hospital protected
2. scope of practice/competence
3. informed consent
4. negligence
5. medical errors
6. harm