Exam 1 Flashcards
Ethics
-Moral Philosophy
-Concerned with questions of how people ought to act and the search for a definition of right conduct and the good life
Three levels of Rest Kohlberg’s Theory of Cognitive Moral Development
Level 1 = Pre-conventional Morality
Level 2 = Conventional Morality
Level 3 = Post-conventional Morality
Level 1 Pre conventional Morality
Around 9 years and younger
NO personal code of morality
Moral code shaped by standards of adults
Focus is on consequencesof following or breaking rules
Stage 1 = Obedience and Punishment Orientation
Stage 2 = Individualism and Exchange
Stage 3 = Good interpersonal relationships
Example:
Pharmacist may provide a very low level of patient care if the costs of doing more outweigh the benefits
Level 2: Conventional Morality
- Most adolescents and adults
-Begin to internalize the moral standards of valued adult role models
-Reasoning based on norms of social group
Stage 4: Maintaining the social order
Example:
Conventional pharmacist would attempt to provide a level of patient-focused care consistent with state and federal laws
Level 3: Post Conventional Morality
-Very small amount capable of this level of abstract thinking
-Individual judgement based on self-chosen, “universal” principles
-Moral reasoning based on individual rights and justice
Stage 5: Social contract and individual rights
Stage 6: “Universal” principles
Example:
The post-conventional pharmacist would probably provide a high level of patient care, despite being faced with moderate situational pressures
Why is moral reasoning important
Higher levels of moral development seem predisposed to behaving in a more professional manner concerning clinical decision-making and greater inclination to providing patient-centered care
Better performance if you have the skills vs if you don’t
Charactarisitics of a profession
- Specialized knowledge and training
- Commitment to provide important services or information to patients, clients, students, or consumers
- Maintain self-regulating organizations
- Control entry into occupational roles through formal certification
- Specify and enforce obligations of their members
Professional Obligations
Moral Ideals (saints and martyrs) = very extreme
Special relationship obligations (professional obligations, Family/Friend/Partner)
General Moral Obligations (stranger to stranger) = I don’t care what you do
Differences between 1852 and 1994 pharmacist codes of ethics
1852
-More focused on buisness principles, and making money
-Archaic terms to refer to pharmacists (druggists)
1994
-More focused on interacting with patients and being a professional
-More modern terms used
Ethical situation
One in which the rights and/or welfare of people are impacted
Ethical dilemma
A situation in which it is unclear what to do because each action can be viewed as right according to a different ethical principle or set of principles
*very common in pharmacy
Socialization
Process by which people selectively acquire the values and attitudes, the interests, skills and knowledge –> The culture
Primary socialization vs Secondary socialization
Primary:
-Religious rituals or initiations
-First job
Secondary:
-Learning the work culture of an occupation
-Pharmacy (characteristics for success)
Why is socialization important?
Layer of work culture
For most of pharmacy’s history, it was learned through apprenticeship
Origin of apothecaries
-Arose during golden age of islam
-Baghdad was a new city built
-Allowed for rise of apothecaries because of trade routes which allowed for new drugs, new vehicles, and new preparations
-State appointed inspectors came about (Muhtasib)
-Idea spread across Islamic sphere
Pharmacists role in western civilization
-Shopkeeper
-Natural philosopher
-Alchemist
-Pharmaceutical expert
-Agent of social order
(assures quality of drugs and medicines)
(collects taxes and controls dangerous drugs)
Paradigm shift in pharmacy practice to clinical pharmacy
“New Professionalism”
-An ideology combining traditional professionalism and science
-Movement to clinical pharmacy because retail pharmacy fell behind and fell short of expectations for graduates
-Shift from product orientation to patient orientation
-Little to no compensation for advanced services (managed care)
The disenchantment problem lessened in recent decades
-Graduates became more experienced and opportunities expanded
Educational shifts in pharmacy
Before 1920 most pharmacists trained as apprentices with the pharmacist from being a young boy for 4-5 years
-In 1821 Philadelphia College of Pharmacy was built
-Mostly taught at night until late 1800s
-Low graduation rate at first
How did American Pharmacy evolve?
Pharmacists worked in 1-2 person drug shops and practiced pharmacy as an art
-Transitioned to be trained formally at a university
-State laws were passed in the late 1800s that required licensure
-Pharmacy school diploma requirement spread after 1910
Change after 1950:
-PharmD became advocated for in order to elevate pharmacy as an educated profession
-Use “pharmacist” over “druggist”
-Growth in Hospital Pharmacy which caused innovation
Virtues
Morally good traits that everyone either may possess or can learn
Dictate how the individual ought to behave or ought to be
Cardinal Virtues:
-Temperance
-Prudence
-Fortitude
-Justice
-Charity
-Faith
-Hope
Health care professional virtues
-Care: Emotional commitment to and willingness to act on behalf of persons with whom one has a significant relationship
-Compassion: Active regard for another’s welfare combined with empathy; the capacity to feel sorrow for another’s suffering
-Discernment: Ability to make appropriate judgements and reach decisions without being unduly influenced by extraneous considerations
-Trustworthiness: To merit confidence in one’s character and conduct
-Integrity: Soundness, reliability, wholeness, and integration of moral character; objectively, impartiality, and fidelity to moral norms
-Conscientiousness: Being motivated to do what is right because it is right, trying with due diligence to determine what is right, intending to do it, and exerting appropriate effort to do so
How are health care professional virtues present in the Pharmacist Code of Ethics?
-Discernment and Trustworthiness were represented in V because a pharmacist has to not only have trust in them self but they have to make decisions as well
-Compassion for VI because you have to understand other peoples perspective and respect their values
How are virtues and ethics related?
By living according with virtue a person will be good and happy and as a by product will be a naturally ethical person
Empathy
The ability to recognize, understand, and share the thoughts and feelings of another person
*Crucial for establishing relationships and behaving compassionately
*Involves experiencing another person’s point of view
*Enables helping behaviors that come from within
Two aspects of empathy
Affective: Range of emotional responses to what others feel or the situation they are in
“Emotional resonance”
Cognitive: Capacity to understand another person’s state of mind from their perspective
“Perspective taking”
Similarity Bias
-Tendency of the empathizer to empathize better and deeper with those who resemble and/or are close to you
*Appearance, Family and friends, spatial proximity, temporal proximity
-The challenge is in extending the same depth of empathy to those who are dissimilar or distant –> empathy is neither universal nor automatic
Psychological distress
Compassion fatigue: The psycho-emotional distress that originates because of long term self sacrifice
Burnout: Syndrome comprising emotional exhaustion, depersonalization and a reduced sense of personal accomplishment
*Some level fo emotional fatigue is inevitable for empathetic interaction
The expert of the patient’s experience
You can usually imagine what it is like to be in someone else’s position
-You can never know what it is like to be in someone else’s position
-You can never be the expert in what the patient is experiencing; only the patient can know this
-Decisions based on assumed knowledge and expertise can harm the patient-provider relationship
Fake empathy
Standardized set of expressions and procedures that tries to simulate genuine and accurate empathetic understanding
Autonomy
An autonomous individual acts freely in accordance with a self-chosen plan
-No controlling interference from others
-No limitations that prevent meaningful choice
As a right:
American Law recognizes that all persons have a fundamental right to control their own body and the right to be protected from unwanted intrusions
Steps of informed consent
Informed consent: Individuals autonomous authorization of a medical intervention or of participation in research
1. Competence=ability to perform a task
-Patient is able to communicate their wishes freely to caregivers
2. Disclosure=provision of information by healthcare provider
-Provider gives the nature and limits of consent as an act of authorization
3. Understanding=acquired pertinent information and have relevant beliefs about the nature and consequences of their action
4. Voluntariness=person wills the action without being under control of another person or condition
5. Consent=person’s verbalized agreement to course of action
Patient centered care
Care that is respectful of and responsive to individual patient preferences, needs and values
-Respect for patient autonomy is the foundation of patient-centered care
Shared decision making
The process by which the optimal healthcare decision may be reached for a patient involving, at minimum, a clinician and the patient
This process is distinct from the formal process of informed consent but incorporates many of the same elements and encourages autonomous decisions.
How does shared decision-making incorporate autonomy?
Patient decision aids
-Decision aids are tools used in shared decision-making that describe the options and help patients think about these options from a personal view
Most useful when there is more than one option and:
-None is clearly better or the options have benefits and harms that people value differently
EX: pamphlets, videos, web-based tools
Patient decision aids benefits
-Improved knowledge of options
-Feel better informed
-Clearer understanding about what matters most to them
-More accurate expectations of benefits and harms
-More participation in decision making
-Achieve decisions more consistent with their informed values
-More likely to talk about the decision with a health care provider
They DO not:
-Worsen health outcomes
-Sway patients to one decision
Restricting autonomy
Can be justifiedly restricted when:
-The choice endangers public health
-The choice potentially harms innocent others
-The choice requires a scarce resource
Paternalism
The intentional overriding of one person’s preferences or actions by another person, where the person who overrides justifies this action by appeal to the goal of benefitting or of preventing or mitigating harm to the person whose preferences or actions are overriden
-Restricts autonomy
Ex: blood transfusion after patient refusal
Soft paternalism
Interventions intended to prevent or mitigate harm or to benefit a person when the person has not made an autonomous decision
-Temporizing measure that provides health care professionals time to help a patient gain more autonomy
-Long term goal is to help patients make their own autonomous decisions in the future
Hard paternalism
Interventions intended to prevent or mitigate harm or to benefit a person despite the fact that the person’s risky choices and actions are informed, voluntary, and autonomous
When is hard paternalism justified?
- A patient is at risk of significant, preventable harm
- The paternalistic action will probably prevent the harm
- The prevention of harm to the patient outweighs risks to the patient of the action taken
- There is no morally better alternative to the limitation of autonomy that occurs
- The least autonomy-restrictive alternative that will secure the benefit is adopted
Patient rights in autonomy
Not every patient wants to participate in shared decision-making
-Patients have the right to share and receive the information they want
-Patients have the right to delegate decision-making
Tacit consent
Consent which occurs silently or passively through omssions
Presumed consent
Type of implied consent based on what is known about a particular patient’s choices in the past and known preferences
Implied consent
Consent inferred from actions
Beneficence
The bioethical principle of acting in order to benefit or promote the good of other persons
-Preventing harm
-Rescuing others or removing harm
Beneficence in health care
Implicit assumption of beneficence in all medical and health care professions
-Embodies the goal, rationale, and justification of medicine
Obligations of beneficence
-Nonobligatory beneficent actions (kid is in building but it would endanger your life)
-Professional Obligations (family, partner, friend obligations)
-Obligatory beneficent actions (stop kid from running into burning building to save dog)
Rules of obligatory beneficence
- Protect and defend the rights of others
- Prevent harm from occuring to others
- Remove conditions that will cause harm to others
- Help persons with disabilities
- Rescue persons in danger
Unless…
-Requires severe sacrifice
-Requires extreme altruism
-The action is unnecessary
-The action is unlikely to cause the good intended
Nonmaleficence
The bioethical principle to not cause harm (unlike beneficence because it’s not prevention)
Primum non nocere = Above all do no harm
Malficence
The doing of evil or harm
-The quality or state of being maleficent or harmful
Malfeasance
The performance by a public official of an act that is legally unjustified, harmful, or contrary to law; wrongdoing (used especially of an act in violation of a public trust)
Nonmaleficence as part of the pyramid
-General moral obligation
Rules of Nonmaleficence
-Do not kill
-Do not cause pain or suffering
-Do not incapacitate
-Do not cause offense
-Do not deprive others of the goods of life
-Follow the principle of nonmaleficence means you AVOID causing a harm
Prima Facie Principle
Accepted as correct until proved otherwise
-Nonmaleficence
Harmful actions require justification that either:
1. This principle is not, in fact, violated or
2. Other principles outweigh the harm being caused
How can pharmacists violate nonmaleficence?
Justified:
-Pain and potential complications of a vaccination - offset by beneficence and justice
-Distress felt by patient during a difficult conversation about treatment options
*Mitigate this harm
Unjustified:
-Causing a patient embarrassment by intentionally releasing sensitive health information –> no moral principle justifies this
*IF the harm is justified by another principle, there is no violation of nonmaleficence
Balancing benefits and harms
Trade off:
-All decisions in healthcare require the provider and patient to balance the anticipated good vs the harm
-When the benefit is greater than the harm we do not violate nonmaleficence
Clinical judgement:
-Reduce uncertainty to the extent possible by using clinical data, medical science, and reasoning to propose and revise a plan of care
-We offer a recommendation and the patient can take it or not
Quality of life:
-Refers to that degree of satisfaction that people experience and value about their lives as a whole and in its particular aspects
Observed Quality of life:
-Lives considered by observers to be of low quality are often considered satisfactory or at least tolerable by the one living that life
Patient perception of benefits and harms:
-If patients are able to express what they believe to be salient benefits and harms of a course of action, this should be incorporated into our analysis
Distributive justice
Concerned with fair distribution of the benefits and burdens in society
Procedural justice
Concerned with fair methods of making decisions and settling disputes
Corrective justice
Concerned with correcting wrongs and harms through compensation or retribution
Individual level of ethics
*Primary concern is balance of benefit and harm within and between individuals
-Consider probability, long and short term trade offs and extent of harms and benefits
Ex: Participation in experimental treatment
Organizational level
Organizations are social institutions with identity, purpose, history and character
*Primary concern is the net organizational benefit—enables the organization to maximizew its purpose now and into the future
EX: decision to downsize
Societal level
*Primary concern is the common good of society
Common good: that which constitutes the well-being of the community
- Balance the many conflicting common needs and goods (education, housing, defense, healthcare, etc)
EX: national health policy
How the levels of ethics relate
-Complexity and significance increase as consideration progresses from the individual to society
-Methods, concepts, principles, and conclusions, from one level may not apply or have the same relevance at another level
-The ethical character of the outer levels powerfully defines the limits on ethical behavior of the inner levels
-Deficits on the outerlevels cannot be adequately compensated by intervention on inner levels
Characteristics of procedural justice
- Oversight by a legitimate institution
- Transparent decision-making
- Reasoning according to information and principles that all can accept as relevant
- Procedures for appealing and revising individual decisions
- Meaningful public engagement
Allocation of resources
-Rationing
-Unavoidable because social goods draw funding from a common pool
-Some degree of rationing of healthcare is necessary for the overall wellbeing of society
EX: organs for transplantation, ICU beds
Who has the strongest claim on scarce medical resources
Held by individuals with:
-Medical condition where there is strong evidence that the intervention/medication will be beneficial
-A medical condition where there is strong evidence that harm would be caused if the intervention wasn’t given
-An interest in the intervention/medication
Individuals do not have a claim when the potential harms outweigh the benefits
Reciprocity principle
Society owes an obligation to those who take risks for the benefit of society
Who else might have a strong claim?
Healthcare workers may have a strong claim to certain resources because:
- They take on the risk of exposure when treating patients and society should reward this risk
- If they are healthy, they can continue to help others become healthy
Strategies of distributive justice-Utilitarian
To each person according to rules and actions that maximize social utility (welfare) –> Do the most good
Limitation: May result in unjust distribution of resources across individuals, despite the overall societal benefit
EX: maximizing total lives saved
QWOLLY
Measure that measures the amount of years of better quality of life someone will have because of an intervention
*Prioritizes younger people and is a disadvantage to those with chronic illness because they have a lower quality of life
Strategies of distributive justice-Egalitarian
To each person an equal measure of liberty and equal access to the goods in life that every rational person values
*Everyone has an equal chance
Limitation: ignores factors that are intuitevely important in health care such as patient need and likelihood of benefit
EX: Lottery
Strategies of distributive justice-Libertarian
Each person has a max of liberty and property which results from participation in fair free market exchanges
*Each person is entitled to what their skills can get them in a free market
Limitation: prioritizes individual rights over welfare of society, assumption of level playing field where skills/effort is the only differentiating factor
EX: First come first serve
Whats wrong with libertarian approach?
Biased towards individuals who:
-Have better access to health care facilities
-Are well integrated in the health system
-Have better knowledge about the shortage
*Does not distinguish based on medical benefit
Strategies of distributive justice-Prioritarian
Help those who are the worst off
Limitation: Greatest need can be defined in different ways which can discriminate against certain patient groups resulting in possible inefficient use of resources
EX: Prioritize those with the most to lose (youngest)
Combining strategies of distributive justice
Utilitarian strategy generally used as fist approach to determine priority of patients to be treated
-Consider who has the strongest claim
-May use a points system to rank liklihood of benefit
*If there is not enough supply to treat all patients within a priority level a egalitarian approach is preferred over libertarian
The rule of rescue
Powerful psychological impulse to attempt to save those facing death, no matter how expensive or how small the chance of benefit
*Leads to decisions that confound priority setting
Inter-related levels of Ethics: Distributive justice
-Distributive justice considers how benefits and burdens are distributed within and across the individual, organizational, and societal levels
-Each allocation strategy can be considered “fair” but can also result in a very different distribution of benefits and burdens across these levels
-Strive for a decision or allocation strategy that matches benefits and burdens within each level
Social justice
Justice in terms of the distribution of wealth, opportunities, and privileges within a society.
-Contained within distributive justice
-Procedural justice impacts social justice
But if we do procedural and distributive justice right then social justice follows
Veracity
Telling the truth
*Accurate, timely, objective, and comprehensive transmission of information and the way the professional fosters the patient’s understanding
Why is veracity necessary in Health Care?
-Respect for others
-Implicit promise to speak truthfully and not deceive listeners
-Essential to development and maintenance of trust between individuals and with the public
-Patients need the truth to make rational decisions
Guidelines for applying veracity in patient care
Tell the patients what they need to know to make an informed decision (what a reasonable person would want to know in the context of their own values and life circumstances)
There is almost never a justifiable reason to lie to a patient
-Withholding information because you are concerned that patients will make “bad” choices is rarely justifiable
Times when it is ok to not uphold veracity in healthcare
-Lying or withholding information to prevent imminent and serious harm
-Withholding irrelevant information
-Withholding information that violates the trust of another patient
-The patient requests information to be withheld (patients can waive right to be informed, patients can request that others be informed on their behalf)
Role of veracity in informed consent
Disclosure = always tell patients what they need to know
Understanding = How you disclose the information can frame the information in a misleading or manipulative way
-Instead of saying risks and benefits say potential benefits and harms
-Use absolute numbers instead of relative risk
Voluntariness = You can use persuasion to remind a patient of pot. benefits but this is tricky because it can turn to manipulation, which ultimately leads to coercion
Delivery = The way you tell the truth can be difficult but it should reinforce the patient’s ability to deliberate and choose
Framing information
Minor changes in language or framing can significantly alter judgments and decisions, including in health care settings
Such framing effects are thought to be driven by emotional or cognitive associations and expectations triggered by specific words and phrases
Sources of medical information for patients
-Social Media
-Mass media
-Friends/family/community
-Health care providers (verbal and written)
How is veracity violated?
The misinformation on social media/sources can cause lack of trust in health care
Ex: Body dieting scams, The one thing your doctor doesn’t want you to know
The pharmacist’s role in veracity
- Provide reliable, objective, understandable, non-promotional, accurate, up-to-date and appropriate written and spoken medicine-related information to the public, patients and healthcare practitioners
- Act as guidelines and interpreters to help address common misconceptions regarding health and medicine-related information
- Help identify reliable sources of medicine-related information for use by patients, caregivers, users of medicines, and other healthcare practitioners
Fidelity
Obligation to fulfill your commitments
-To follow the law
-To follow the rules and policies of your employer or organization
-To follow the rules and ethical code of your profession
Faithfulness
Loyalty
The covenantal relationship
- A gift, labor, or service between the covenant partners = Patients give us the “gift” of their health information and in return we give them our medical expertise
- A promise based upon this exchange = Our promise is to help individuals achieve optimum benefit from their medications
- The shaping of subsequent life for each partner = Patients help us grow as professionals and as persons, if we let them
The covenantal relationship is how pharmacists demonstrate the health care professional virtue of caring
*Requires significant relationship with patient
*We owe patients a special obligation above and beyond strangers
Ethics vs Law
Laws provide the boundaries
-What you must do (to avoid penalty)
-What you can or cannot do (w/o penalty)
Laws may not tell you what you should do among several options
Sometimes law may conflict with what you should do, ethically
Sometimes the law should be changed
Conflict among commitments
- Does a commitment exist?
- How do you know the commitment exists?
- Is there a hierarchy among these commitments
Limtis of codes of Ethics
-Not a direct reflection of moral philosophy
-Revised for changing practice standards and expectations
-Does not address all situations
-Too abstract for use in specific situations
Consequentialism
The rightness or wrongness of an act is judged solely on whether its consequences produce more benefits of advantages
-Utilitarianism
Limits of Consequentialism
-Maximal utilitarian outcomes could be achieved through immoral actions
-Too demanding, makes persons responsible for consequences they fail to prevent and what they directly cause
-Permits the interests of the majority to override the rights of minorities, can result in unjust distribution
Deontological (nonconsequentialist) theory
Actions must be in accordance with moral rules and with the intention of being moral (moral motive)
-Kantian ethics
Limits of Deontological theory
-Inadequate to handle the problem of conflicting obligations - obligated to do the impossible when rule is categorical
-Better suited for relationships among strangers than for relationships among friends/intimates
-No moral worth for actions based on symptathy, emotion
5 step Model - Step 1
- Respond to the “sense” or feeling that something is wrong
-Acknowledge that an ethical situation is occuring
-Intuition, heightened emotional sensitivity, avoidance, nagging, silence
-Signal to analyze this situation further
5 Step model - Step 2
- Gather informations/make an assessment
-“Good ethics begins with good facts”
a. Clinical (related to medical care)
b. Situational/contextual (values, perspectives, authority and relationships of those involved)
-Gather the facts that you can with the time you have available
5 Step Model - Step 3
Identify the ethical problem/consider a moral diagnosis
-Identify the values, rights, duties, or principles that are relevant and those that are in conflict with each other
5 Step Model - Step 4
Seek a resolution
-Propose multiple courses of action and examine the ethical justification of each
-Consider the likely consequences and the intention of each action
-Which actions can you be proud of and justify to others5
5 Step Model - Step 5
Work with others to determine a course of action
-A better decision can be reached if the people who are legitimately involved have the opportunity to openly discuss
-Decision implies the prioritization of your values
Balancing process
Prioritizing one principle over another
Balancing is concerned with the relative weights and strengths of different principles
-It’s a personal judgement
-Assign realtvie weights to the principles
Moral Disagreement
Conscientious and reasonable persons can and do disagree over moral priorities
Can emerge because of:
-Factual disagreements
-Disagreements resulting from insufficient information or evidence
-Disagreements about which principles are applicable or relevant
-Disagreements about the relative weights or rankings of the relevant principles
-Scope disagreements about who should be protected by a moral principle
Decisions family and patients must make an end of life
-Use of feeding tube
-Use of life support (ventilator, blood transfusion, kidney dialysis, artificial maintenance of BP and HR)
-Admission to nursing home or community-based residential facility
-Anatomical gifts (donating organs)
-Non oral nutrition or hydration
Advanced directive
Describes in writing the patients choices about treatments the patients wants or does not want, or about how health care decisions should be made if the patient becomes incapacitated and cannot express these wishes
Requirments:
-Must be at least 18
-Living will, power of attortney, legal documet drafted by an attortney
Living will vs power of attorney
Living will = informs the physician regarding preferences about life-sustaining measures when the patient is near death or in a persistent vegetative state
POA = Permits another person to make health care decisions for the patient when the patient is not capable of doing so
Substituted judgement
The goal is to choose as your loved one would have chosen, even if it is not what you would decide for yourself
Euthanasia
Deliberate intervention undertaken with the express intention of ending a life, to relieve intractable suffering
Voluntary = Conducted with consent of patient
Nonvoluntary = Conducted when consent of patient is unavailable
Involuntary = Conducted against the will of the patient
Provider action:
Passive = Withholding or withdrawing treatment necessary for contiuance of life
Active = Use of lethal substance or force to induce death
Medical aid in dying
Health care provider supplies information or materials but patient takes the last decisive step
-Form of voluntary, active euthanasia
Withholding vs withdrawing treatment
Withholding treatment = never starting treatment
*Patients have the right to forgo treatment they do not want
Withdrawing treatment = stopping treatment that has already started
*Patients have the right to discontinue treatment that has already started
Withholding and withdrawing treatment are considered morally equivalent, although they may feel different
*Withdrawing treatment is distinct from actively killing or causing death
Ethical implications to End of Life
Patients considering suicide without physician assistance are not screened for conditions that compromise autonomous decision making
Your intervention to prevent suicide is supported by beneficence
-Soft paternalism if patient is not autonomous
-Hard paternalism if patient is autonomous
The patients definition of benefits and harms may be different from yours
Principles affected:
-Autonomy
-Beneficence
-Nonmaleficence
-Fidelity
To be human is to be limited
Palliative sedation
Administering medication to keep patients in deep sedation or coma temporaily or death occurs naturally
Limitations: Decreased ability to interact with others, inability to change decision, inability to eat/drink
Provides comfort without shortening overall survival
Conscientious Objection
Traditionally health care professionals are required to abstain from moral judgments about their patients
C.O is refusal to participate which means a judgment formed on the basis of sincerely held moral values that participation in some particular action would be violating one’s own moral standards
Conscience clause
A pharmacy must dispense prescribed drugs and devices and shall deliver contraceptive drugs and devices unless its an OTC
Pharmacist implications: If the pharmacist objects morally to the drug another pharmacist who will dispense the drug must do it. But if the other pharmacist isn’t there you must do it
Patient: A patient might have awkward interactions with the pharmacist or the pharmacist might “punish” them by giving a limited consult
Employers
They cannot use religions as a basis for the terms, conditions, or privileges of employment
Employers are obliged to reasonably accommodate the religious needs of employees
If they violate the civil law the employee is due compensation
Potential conscientious objections
-vaccinations
-Physician assisted suicide
-Pre exposure prophylaxis of HIV
-Gender transitioning
-Erectile dysfunction
-Infertility treatment
-Treatment during pregnancy that can affect a fetus
Relationship of ethical principles to conscientious objection
Pros: Pharmacist moral values are kept validated, living life in accordance with their values
-Pharmacist exercises their autonomy
Cons: Patient’s autonomy is limited, and they might go somewhere else (might be illegal/dangerous)
Moral status
Any being has moral status if others have moral obligations to that being, that being has basic welfare interests, and the moral obligations owed to that being are based on that being’s interests
Human Properties Theory
All humans have full moral status and only humans have that status
-includes embryos as immature humans
-all humans “outrank” all non-humans
Cognitive theory
Individuals have moral status because they are able to reflect on their lives through their cognitive capacities and are self-determined by their beliefs in ways that incompetent humans and non-humans are not
Moral Agency theory
Moral status derives from the capacity to act as a moral agent, the ability to judge right and wrong
How it affects ethical decision making:
-How do we decide who gets moral status
-Does someone get Full/Partial/No moral status
-Is the result of this decision ethical and what implications will it have?
Sentience Theory
Sentience is consciousness in the form of feeling, especially the capacity to feel pain and pleasure and to suffer, as distinguished from consciousness as perception or thought. Having the capacity of sentience is a sufficient condition of moral status
Discrimination
The injust or prejudicial treatment of different categories of people or things, especially on the grounds of race, age, or sex
-What a person does
Bias–> What a person has
Harassment
Agressive pressure or inttimidation
-Verbal
-Emotional
-Sexual
Quid Pro Quo
-This for that
-Sexual bribery or coercion when a superior bases employment decisions on the rejection of or submission to sexual demands
Hostile Work Environment
Sexual harassment that creates an environment that violates a person’s civil rights by subjecting him or her to unwelcome sexual conduct that interferes with the person’s work
Retaliation
An adverse action take against an individual in response to, motivated by, or in connection with someone’s opposition of sex discrimination, sexual harassment or sexual violence
Adverse action
An action that a reasonable person would find materially adverse such that it would dissuade the person from making or supporting a charge of discrimination or harassment
Retaliation for reporting
Women in academic medicine see objecting to sexual harassment as a person and professional liability
-Women often experience direct retaliation for reporting sexual harassment
Responding to harassment as the target
-Take care of yourself
-Read the situation –> it may not always be safe to stand up for yourself alone, or there may be power dynamics that limit what actions you feel you can take
-Keep a detailed record of discriminatory or harassing actions, then share the record with someone in authority who can help correct it
Bystander intervention
Direct –> Step in and interrupt a harmful situation by pointing out the problem and engaging partipants in conversation about better alternatives
Distract –> If you aren’t comfortable calling out the problematic behavior, try interrupting a risky situation by distracting and redirecting the people involved
Delegate –> If you can’t do it alone, involve others
Responding to patient behaviors
-All health care professionals are empowered to speak up when someone is being harassed by a patient
-Those in a senior position must advocate for their trainees
Responsing with silence sends a powerful message
Ethical prinicples: Harassment
Autonomy
-Quid pro quo harassment = coercion
Fidelity
-Accountable to our law and code of ethics to avoid discriminatory practices, respect differences
Justice
-Intersectional discrimination and harassment
Nonmaleficence
-Feelings of fear, anger, shame, self-blame
-Physical health symptoms
-Alcohol abuse
-Mental health effects
-Educational + professional harm
Beneficence
-Speak up for others to show they are valued
Relationship of ethical principles to patient confidentiality
Autonomy –> Respect patients’ decisions about what is done with their info
Fidelity –> Health care provider’s commitment to patients, commitment to employer, and commitment to society/law
Confidentiality
Breach –> When we fail to protect information trusted to use or deliberately disclose this information without consent
Ex: Two pharmacists are discussing a patient care issue in an elevator and someone who knows the patient overhears this information
Privacy
Breach –> Accessing information which you have no authority to access, whether or not protections are in place
Ex:
A hacker accesses patient information from clinic’s health and billing records
Ethical exceptions to confidentiality
- Legal requirement based on the greater good of society
a. reportable infectious diseases
b. safety conditions of health care institutions
c. Prescriptions drug monitoring program
d. Suspected abused
e. “The protective privilege [of confidentiality] ends where the public peril begins” - Serious, credible threat of harm to the patient or specific individuals or groups
Beneficence > confidentiality
HIPPA
Health Insurance Portability and Accountability Act
-Federal law that safeguards PHI
*Indivudally identifiable health information
*Only applues to covered entities
-It is against the law to disclose a patient’s PHI outside of treatment, billing, or operational needs without patient’s consent
Who is not covered by HIPPA
Covered: health plans, health care providers that trasmit the data electronically
Not covered: NOT obligated to comply
-Employers that have health information about their employees
-Marketing companies
-Website operators
-Data brokers
-Life, disability, and long-term care insurers
-Many others
Belmont report
Respect for Subjects:
-Promote decisional autonomy of individuals
-Involve the least vulnerable population
Beneficence:
-Do not harm
-Minimize harms, maximize benefits
(To minimize harm the control group recieves a sham procedure, NOT a placebo given by intrathecal injection)
Justice:
-Selection of subjects appropriate the research
-Balance harms to individuals against benefits to society
Common rule
Founded in 1991
US Federal Regulations governing the review and conduct of research involving human subjects
Based on Belmont Report
Institutional review board (IRB)
Any institution that recieves federal funding to support human subjects research is required to have an IRB
-Primary function is to protect the rights and welfare of human subjects
-Federal regulations proscribe IRB composition and procedures
Citeria for IRB approval
- Risks to subjects minimized (Beneficence/Nonmaleficence)
- Risks reasonable in relation to benefits (Beneficence/Nonmaleficence)
- Subject selection equitable (justice)
- Informed consent obtained and documented (Autonomy)
- Adequate data monitoring performed (Beneficence/Nonmaleficence)
- Privacy and data confidentiality maintained (autonomy/fidelity)
- Vulnerable populations protected (autonomy/justice)
Right to health
-Health is a status, not an object, action, or rule
-Cannot owe “health” to a person
-There is no right to a specific health status
Right to health care
-Society can impact public health through a clean environment, workplace safety, education, etc.
-There can be a right to the facilities, goods, services, and conditions necessary for the realization of the highest attainable standard of health
Collective social protection argument
Similarities between health needs and other needs that government has traditionally protected; consistency suggests that critical health care assistance in response to threats to health should likewise be a collective responsibility
Criticism: Different perspectives on the role of government in society, so these governmental protections are neither obligatory nor essential
Reciprocity argument
Society has a right to expect a decent return on the investment made in health care professional education, funding for biomedical research, and funding for various parts of the medical system that pertain to health care paid for with tax dollars
Fair opportunity argument
Justice requires that we use societal health care resources to give persons a fair chance to use their capabilities, especially those worst off due to disease and injury
Universal Health Coverage
- Equity in access to health care services (everyone who needs services should get them, not only those who can pay for them)
- Promotive, preventive care - The quality of health services should be good enough to improve the health of those receiving services
- People should be protected against financial risk, ensuring that the cost of using services does not put people at risk of financial harm
How does the US private health care system result in inequity?
-Inequity arises from reliance on employers for financing health insurance
-When employed persons who are not covered become ill, taxpayers usually pick up the cost
-Low-income families spend a higher proportion of their income on insurance compared to high - income families
-Many individuals who do not qualify for group coverage pay significantly more for the same coverage than those who do qualify
How does the US health care system support a minimum level of health care for some populations
Medicare
-Federally funded and administered for eligible patients
*PART A IS THE MINIMUM LEVEL OF HEALTH CARE PROVIDED TO ALL ENROLLEES
Parts B, C, D are optional benefits for people who can afford them
Medicaid
-Funded jointly by state and federal government and administered by state for low-income patients and additional groups
-Each state determines own criteria for eligibility
*TREATMENT IS NOT SEPARATED INTO DIFFERENT PARTS - THE ENTIRE PROGRAM IS THE MINIMUM LEVEL OF HEALTH CARE
EMTALA = Ensures piblic access to emergency services regardless of ability to pay
*THE ONLY MINIMUM HEALTH CARE GUARANTEED TO ALL AMERICANS
Role of personal accountability?
Moral hazard: When a person bears less risk of the consequences, they may pursue more risky behavior
Requirements to enforce personal accountability in health
- Society must identify the risky health behaviors and use solid evidence to demonstrate the behaviors that cause disease or illness
- Individual’s decision to engage in the risky behavior is autonomous –> They know the risks of the behaviors before taking it
Conflict of interest
A set of conditions in which professional judgement concerning a primary interest tends to be unduly influenced by a secondary interest
*Risk of personal, secondary interests causing temptation or biases leading to a breach of role responsibilties
Primary vs secondary interest
Primary:
-Can vary by the discipline or practice setting (patient care, research, education, etc) —> Beneficence
Secondary:
-Everything that is not a primary interest
Earning profit, advacing professionally, advancing interest of friends and family, maintaining relationships, avoiding embarassment — may causes harm –> violation of nonmaleficence and/or violation of justice
*The presence of a conflict of interest is not unethical in and of itself, it is the action taken when the conflict is recognized and may be of concern
Direct PBM controls
Access to drugs is limited by policies or procedures
Ex: prior authorization, step therapy, excluding non-formulary drugs
Indirect PBM controls
Incentivize or motivate providers and patients to chooser lower cost drugs
EX: copayments, capitation, caps on drug benefits
Direct-to-consumer advertising
When companies promote their products to consumers through advertisements appearing in magazines and newspapers, on radio and television, or online
