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med ethics exam > Med Ethics Exam > Flashcards

Med Ethics Exam Flashcards

1
Q

What is ethics?

A

The discipline dealing with what is good and bad and with *moral duty and obligation

the principle of conduct governing a individiual or group

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2
Q

What are morals?

A

moral practices or teachings; modes of conduct

conduct or behavior of an indiv./group which reveals values or assumptions about good and evil

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3
Q

Ethics vs. Morals

A
  • Morals tells us what the right or good action is
  • Ethics tells us why and why another COA might be better
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4
Q

What are some sources of ethics?

A

Religion, Philosophy, Law, Experience

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5
Q

What are the two methods in biomedical ethics?

A
  • Normative: what ought to be
  • Descriptive: what is
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6
Q

Utilitarianism

A
  • Bentham and Mill
  • greatest good for the greatest number
  • we should do whatever will bring the most utility to all of humanity
  • appropriate if:
    • strong notion of fundamental human rights guarantees that it will not violate rights of minority
  • Strengths
    • general welfare of population
    • appeals to policy makers in a democracy
    • everyone’s happiness counts equally
  • Weaknesses
    • what about the minority?
    • right is just a means to get to the end: nothing is off limits if it will maximize a good end (kill 100 people to save 6 billion)
    • allows someone to judge the goodness of things without referring to right
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7
Q

Deontology

A
  • Kant
  • categorical imperative: set of absolute rules to guide all actions
    • universal law: act in a way that your action could become a universal law without contradiction
    • end in itself: each person is intrinsically valuable>cannot treat them as a means to an end (protects minority)
    • duties:
      • duties to self: don’t kill self
      • duties to others: dont kill others
  • ends in themselves>individuals
  • would you steal to feed your family? are they younger or grown?
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8
Q

Virtue ethics

A
  • Aristotle (known as his contribution to deontology>subtype)
  • goal is eudaimonia: good living, happiness, living well; develop qualities that are most productive for living in society
  • who am I? Reputation?
  • Strengths:
    • simple
    • what type of people we ought to be
  • Weaknesses:
    • culture dependent
    • difficult to apply to moral dilemma
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9
Q

Causistry

A
  • comparing one kind of case with another kind of case
  • used in legal sphere
  • philosophy looks down on it
  • required:
    • paradigm: principle to be understood and applied (lens)
      • Quinlan (1975): can remove ventilator because life support
    • analogy: case to which paradigm is applied
      • Cruzan (1990): food/hydration considered life support>can remove
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10
Q

Principlism

A
  • Beauchamp and Childress
  • canonical book in biomedical ethics
  • currently the predominate method of solving bioethical probs.
  • 4 clusters of moral principles:
    • autonomy: rational individuals should be permitted to be self determining
    • beneficence: do no harm
    • nonmaleficence: what is in the patients best interest
    • justice: what’s fair and due to PT; distributive justice
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11
Q

Autonomy:

A
  • rational individuals should be permitted to be self determining
  • what makes them rational?
    • liberty: independence from controlling influences
    • agency: capacity for intentional choice
  • Not absolute or unconditional:
    • cant harm others>public health>limit autonomy
    • minors
  • end to themselves>kant>deontology
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12
Q

Nonmaleficence

A
  • Do no harm
  • ought to act in ways that do not cause needless harm, risk, or injury to others
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13
Q

Beneficence

A
  • What is in the PTs best interest?
  • act in ways that promote the welfare of others>this can be limited
    • resources: humans, mechanical, technical, etc.
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14
Q

Justice

A
  • seeks to give each person what they are due; what is fair
  • under the auspice of principlism: distributive justice
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15
Q

Ethics of care

A
  • emphasizes bond between all parties (PT, provider, family)
  • balance benefits and harms
  • considers:
    • family life
    • financial (cost effectiveness and allocation) societal norms
    • culture
    • religion
    • imbalances of power (between provider and PT)
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16
Q

Bioethics: what does it encompass?

A
  • all ethical issues pertaining to biological and medical sciences
  • Clinical ethics: involves judgments in a clinical setting about what is the right thing to do in a given situation
    • ethics of care…
    • ethics vs law
      • ethics: moral philosophy guiding human conduct, self/society administered
      • law: rules governing society; government administered
  • Research ethics:
    • Tuskegee syphilis experiment
    • Nuremberg trials
  • Medical organizational ethics: ethical stances of specific org. or institution (e.g. hospital or military command)
  • Public health ethics: what we, as a society, do collective to assure conditions in which people can be healthy
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17
Q

Tuskegee syphilis experiment (research ethics):

A

started in 1932

studied syphilis in black males

PCN became DOC in 1943 but it was not offered to participants

only ended after public outcry in 1972

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18
Q

Nuremberg trials let to the ______ (research ethics):

A
  • Nuremberg Code: initial guidelines for human experimentation
    • voluntary, well informed, understanding consent of human subject
    • must be free to immediately quit at any point
    • risks should be in proportion to the expected, humanitarian benefits
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19
Q

Ethical obligations to bioethics:

A
  • regardless of the subfield of bioethics, obligations remain:
    • preventive ethics: “ground rules”; will prevent future probs
      • privacy
      • communication
      • decision making
      • informed consent
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20
Q

Professional ethics:

A
  • Professionalism demands placing the interest of the patients above those of the physician (stance of American Board of Internal Medicine)
  • maintaining the professional integrity of ones self and profession>focus is on the clinician>what kind of person should I be to fulfill my professional obligations
  • characteristics of a profession:
    • advanced TNG
    • well defined role
    • CE
    • control of admission to the profession
  • Hippocratic oath: what the provider should do, not what they should not do
    • futility…
    • professional refusal>conscientious objection
      • limits in knowledge/ability
      • religions convictions
      • financial reasons
      • fear
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21
Q

Informed consent

A
  • process whereby clinicians and patients interact to select an appropriate course of care>shared decision making
  • ethical requirement:
    • autonomy>self determination
    • enhances the PTs well being
  • legal requirement
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22
Q

Shared decision making

A

clinician brings medical knowledge

patient brings personal values, preferences, what risks vs. benefits are acceptable

back and forth process

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23
Q

1972, Quinlan case led to widespread use of ______.

A

Consent forms; due to legal cases

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24
Q

Elements of informed consent

A
  • Threshold elements:
    • capacity: ability to make a decision
    • voluntariness: free of coercion or manipulation
  • Information elements:
    • disclosure (e.g. nature of treatment/therapy, risks, prob. of success., prognosis, etc.)
      • professional standard: what would other providers tell PTs
      • reasonable person standard: what would other PTs want to know
      • subjective standard: what does PT want or need to know
    • recommendation: provider recommendation
    • understanding: can the PT communicate their understanding; watch the medical jargon
  • Consent elements:
    • decision: PT weighs alternatives; they can change their mind at any time
    • authorization:
      • PT must do more than express agreement or comply with proposal
      • two options: informed consent or informed refusal

Issues with informed consent>the patient: some don’t want to make decision, cannot anticipate how they’ll react to future conditions, their decisions may contradict their best interest

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25
Q

Threshold elements (informed consent):

A
  • Threshold elements:
    • capacity: ability to make a decision
    • voluntariness: free of coercion or manipulation
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26
Q

Information elements (informed consent)

A
  • Information elements:
    • disclosure (e.g. nature of treatment/therapy, risks, prob. of success., prognosis, etc.)
      • professional standard: what would other providers tell PTs
      • reasonable person standard: what would other PTs want to know
      • subjective standard: what does PT want or need to know
    • recommendation: provider recommendation
    • understanding: can the PT communicate their understanding
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27
Q

Consent elements

A
  • Consent elements:
    • decision: PT weighs alternatives; they can change their mind at any time (also applies to advanced directives)
    • authorization:
      • PT must do mare than express agreement or comply with proposal
      • two options: informed consent or informed refusal
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28
Q

Exceptions to informed consent

A

Emergency: life threatening; cannot consent

Incapacity: unable to consent (BH)

Patient waives right to know

Therapeutic privilege: withholding information from the PT that would potentially harm the PT; AMA says this is ethically unacceptable; aka therapeutic “non disclosure”

National/state gov’t waivers: generally applies to research ethics

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29
Q

What are some cross cultural issues with informed consent?

A
  1. Older patients may prefer less info
  2. Some cultures feel family must be included or even solely asserts authority (life support and end of life decisions)
  3. Ask the PTs what they would prefer in a given scenario
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30
Q

Informed consent and minors as decision makers:

A
  • dependent on age and ability of child
  • consent

vs.

  • assent (willingness to undergo treatment, etc. even though they are not technically capable of giving consent)
    • not legally effective alone
    • supplements consent
    • whether or not assent is required depends on maturity of child and seriousness and consequences
  • Should include one of the following (all maturity dependent):
    • awareness of condition, treatment, etc.
    • what to expect
    • clinical assessment of minors understanding> what are influencing factors? is there any coercion?
    • solicit their willingness to accept the care
31
Q

Privacy

A

Positive right: right to control access to and distribution (PI, property, personal behaviors)

Negative right: protection from interference and right to be left alone (secluded spaces, keeping door closed)

32
Q

Confidentiality

A
  • limits on the dissemination of information disclosed by a person within the doctor-patient relationship (confidentiality benefits this relationship)
    • used for medical benefit only
    • keep concealed from others
    • trust that the clinician will not disclose (without permission)
    • benefits the PT and prevents stigmatization and discrimination
33
Q

HIPAA

A

Health Insurance Portability and Accountability Act: 1996 law>2003 implemented and enforced

codified confidentiality into law (from a moral obligation)

34
Q

Exceptions to confidentiality

A
  • Need to provide treatment (needs of PT)
  • Protecting 3rd parties (infectious disease, public health, BH, police, etc)
    • Duty to warn: Tarasoff
  • Protecting the PT or others (will the PT hurt themselves?)
    • child, elder, intimate partner violence
35
Q

Tarasoff vs. Regents of UofC

A
  • California Supreme Court ruled there was a duty to warn
  • Tarasoff was killed by her ex BF; BF told UC counselor> counselor told supervisor> Tarasoff family sued UC
  • Mandated Disclosure:
    • victim must be identifiable
    • threat must be imminent ( or “serious” in some states)
    • capacity and history of/for violence
36
Q

Why do you want truth telling and disclosure when communicating with PTs?

A

Integrity: allows better practice by clinician

Autonomy: allows better outcome for PT

It is key to preventive ethics

37
Q

Communicating with PTs:

A
  • 3 styles of informing PTs (1993 study of oncologists)
    • what they want to know
    • what they need to know
    • translating into terms PT can “handle”
  • Tell the truth and disclosure
    • lying, deception, misrepresentation, and nondisclosure
    • what about therapeutic privilege?
    • what are the implications on the profession (publics trust)
    • medical error
38
Q

Dax Cowart Case

A
  • 1973 massive burns
  • right to refuse treatment? he wanted to just die? role of surrogate (his mother)?
39
Q

Which two principles are in conflict when determining decision making capacity?

A

Respect for the PT’s autonomy

Beneficence: acting in the best interest of the PT

40
Q

Competence vs. Capacity

A
  • Competence
    • ability of a person to take care of themselves
    • legal term (determined by a court)
    • dichotomous: have it or don’t
  • Capacity
    • ability of a person to make a given decision
    • clinical term (determined for a set of decisions)
    • sliding scale of abilities
    • must address the following:
      • individual abilities of the PT
      • requirement of the task at hand
      • consequences likely to flow from the decision
    • Does this PT have capacity?…for what decision
41
Q

Functional ability standard

A
  • ability to understand information
  • ability to communicate caregivers
  • ability to reason about alternatives in accordance with their own goals and values
42
Q

Determining capacity slide (picture)

A

Degree of capacity needed changes with the gravity of decision

Capacity fluctuates over time (treatment, medical condition, time, pain, etc.)

43
Q

Adolescents and minors and capacity

A
  • Assumed capacity
    • emancipated: military, courts, etc.
    • mature minors
    • statutory adult: STDs, birth control, pregnancy (certain states)
44
Q

Decision making for the incapacitated

A
  • Advance directives (most preferred):
    • designates surrogate and interventions
    • can be written or oral
      • written (preferred)
        • durable power of attorney: appoints a proxy
        • living wills: instructions on treatments, when to withhold/withdraw
    • promotes thought and discussion before incapacity
  • Substituted judgment
    • absence of advance directives
    • surrogate makes best judgment of what the PT would have done in the situation (uses their knowledge of PT and their values) however there are some issues (emotions, conflicts of interest, decision inconsistent with PT values)
  • Best interest (least preferred):
    • reasonable treatment standard (rules of futility)
45
Q

Surrogate:

A

anyone who makes decisions for a PT lacking decision making capacity

46
Q

Proxy

A

a surrogate appointed by a PT

strongest ethical and legal claim to make decisions for incapacitated PT

47
Q

Refusal of treatment/care:

A
  • Restrictions
    • compelled treatment of pregnant women (controversial)
    • communicable diseases (depends on circumstances)
  • Religious/cultural convictions:
    • see a compromise in treatment>Jehovah witness (blood products)
    • ensure the refusal is informed, voluntary, and steadfast
  • Specific cases:
    • Jehovah witness: blood transfusions
    • incapacity for other reasons: grief, guilt>seek psych consult
    • adolescents: lack life experience>see assent
    • children/infants: parents generally can’t refuse Tx if life saving
    • pregnancy: may be permissible to override mother if baby will die also
    • surrogate refusals
  • Refusal of providers:
    • conscientious objection
      • make issue clear to PT early and ensure views are ethically valid, not due to power imbalance
      • various medical settings that see this issue:
        • reproductive health: abortion, contraception
        • end of life care: PAD/PAS (if legal), withdrawal, palliative sedation
    • rationing and futility
48
Q

Brain death:

A

permanent loss of all brain functions of the entire brain (cortex and brainstem)

  • Clinical criteria (must be met):
    • unresponsiveness
    • absence of reflexes
    • apnea
  • 1968 JAMA article describing brain death
  • 1981 Uniform Determination of Death Act
49
Q

Practical suggestions on brain death (picture)

A
50
Q

Conditions other than death:

A
  • Terms
    • Conscious awareness:
      • higher cortical function
      • responses to external stimuli can be purposeful or reflexive
      • purposeful, meaningful response to motor, auditory, visual, or emotional stimuli
      • reflexive eye opening, roving eye movement, chewing, yawning, crying
    • Wakefulness (arousal):
      • subcortical and brainstem function
      • eye opening and the presence of a sleep cycle
      • do not alone imply consciousness
  • Coma:
    • alive but complete loss of consciousness and wakefulness/awareness
    • no sleep-wake cycles
    • no response to pain except reflex movements
  • Vegetative state (VS) or Unresponsive Wakefulness State (UWS)
    • no awareness
    • no communication but may cry, smile, utter noises reflexively
    • may be wakeful>sleep-wake cycles
    • Persistent=>1month
    • Permanent=
      • >3months after non trauma TBI such as anoxia
      • >12months after trauma TBI
  • Minimally conscious state
    • does not meet diagnostic criteria for UWS
    • awareness may fluctuate but is reproducible
    • motor or emotional response, verbalization, purposeful gesture
  • Locked-in syndrome:
    • fully conscious but paralyzed
    • can communicate purposefully through blinking and vertical eye movements
    • intact sleep-wake cycles
    • auditory and visual function, ability to experience emotion
51
Q

Coma

A
  • Coma:
    • alive but complete loss of consciousness both wakefulness and awareness
    • no sleep-wake cycles
    • no response to pain except reflex movements
52
Q

Vegetative state (VS) or Unresponsive wakefulness state (UWS)

A
  • Vegetative state (VS) or Unresponsive Wakefulness State (UWS)
    • no awareness
    • no communication but may cry, smile, utter noises reflexively
    • may be wakeful>sleep-wake cycles
    • Persistent=>1month
    • Permanent=
      • >3months after non trauma TBI such as anoxia
      • >12months after trauma TBI
53
Q

Minimally conscious state:

A
  • Minimally conscious state
    • does not meet diagnostic criteria for UWS
    • awareness may fluctuate but is reproducible
    • motor or emotional response, verbalization, purposeful gesture
54
Q

Locked-in Syndrome:

A
  • Locked-in syndrome:
    • fully conscious but paralyzed
    • can communicate purposefully through blinking and vertical eye movements
    • intact sleep-wake cycles
    • auditory and visual function, ability to experience emotion
55
Q

Palliative vs. Hospice Care

A
56
Q

Active voluntary euthanasia:

A

clinician administers drugs to intentionally hasten death; voluntary in the sense that the PT requests it

57
Q

Terminal sedation:

A
  • clinician administers drugs to relieve pain, which may unintentionally hasten death
  • while foregoing artificial nutrition or hydration
  • put them into coma
58
Q

Physician assisted death (PAD)/ Physician assisted suicide (PAS):

A

clinician prescribes lethal drugs; PT takes them sua sponte

59
Q

PAD and active euthanasia are ______ the same as pain relief. Palliative care can be aggressive.

A

NOT

60
Q

Doctrine of double effect:

A
  • It is permissible to perform an act to produce a good outcome when it will also produce an undesirable outcome
  • Example:
    • provider administers very high dose morphine to control pain of terminally ill PT with DNR
    • PT stops breathing and dies
  • these 4 conditions must be satisfied:
    • intent of intervention is good (e.g. relief of pain/suffering)
    • death of intervention is possible but not intended
    • risk of death is proportionate to magnitude of benefit
    • death is not a necessary means to the desired effect
61
Q

PAD/PAS: Arguments FOR and AGAINST

A
  • For:
    • respect for PT autonomy
    • die with perception of dignity
    • decide time and manner of death
    • compassion for the suffering
  • Against:
    • sanctity of life
    • suffering can be relieved
    • requests for PAD/PAS are not always autonomous
    • who will advocate for survival if PAD/PAS is an option
    • fear of abuse
    • the providers profession>to save a life, do no harm, help others
62
Q

Futility

A
  • nothing is futile until it is related to a goal (clinical or personal)
    • issues:
      • goals and values are subjective
      • uncertainty of prognosis>disagreement in goals of care>often a proxy for underlying issues (bad commo, misunderstandings, religious beliefs)
      • data pertains to population not an individual
  • Narrow (physiologic): when a treatment is ineffective in producing a desired physiologic effect; administering CPR in presence of cardiac rupture
  • Broad (qualitative): intervention has a lack of benefit even if treatment is physiologically effective in a given case; fails to prevent total dependence on intensive care or lead to an acceptable quality of life
63
Q

Withholding vs. withdrawing

A
  • example: not intubating (withhold) vs. extubating (withdrawal)
  • no ethical distinction between the two (courts have consistently agreed)
  • most providers prefer withholding rather than withdrawal
  • withdrawal is more difficult (especially emotionally)
    • withdrawing care may be seen as provider interrupting Tx>they are cause of death (especially when death occurs rather quickly)
64
Q

Karen Quinlan Case

A
  • 1976 Severe brain damage from anoxia
  • PVS/UWS
    • ventilator, nutrition, and hydration
  • Life support could be removed from incapacitated PTs with evidence of their wishes
  • Effects:
    • PTs, families and physicians don’t need to routinely involve court
    • motivated development of hospital ethics committees
    • widespread use of consent forms>due to litigation
65
Q

Nancy Cruzan Case

A
  • 1990 brain damage after car accident
  • analogy to Quinlan case
  • PVS/UWS:
    • no ventilator but had nutrition and hydration
  • medical nutrition and hydration was a form of medical life support just like a ventilator
  • Effects:
    • widespread use of Advance Directives
    • Patient Self Determination Act 1991: hospitals must discuss self determination with PTs
66
Q

Rationing

A
  • healthcare: potentially beneficial intervention withheld from a PT due to resource constraints
  • bedside: the individual clinician makes the rationing decision for the individual PT
    • when is this occurring:
      • individual clinician is withholding, withdraw, not recommending something that is in PTs best interest, even if clinicians best clinical judgement
      • act is primarily to promote financial interests of a party other than PT (facility, clinician)
      • the clinician has control over the use of the rationed service/treatment/etc.
    • For: its inevitable, necessary to control costs, avoids red tape, clinician is best placed to make the rationing decision
    • Against: damages PT-provider relationship, risk of bias/injustice, the rationed resources may not actually be put to better use, clinician not “qualified” to make the moral decision
  • rationing happens at all levels
    • self rationing: costs? self treatment>mexico?
    • insurance: whats covered; in network care
    • absolute scarcity (think COVID>N95, vaccines, vents)
67
Q

Bedside rationing:

A

the individual clinician makes the rationing decision for the individual PT

  • when is this occurring:
    • individual clinician is withholding, withdraw, not recommending something that is in PTs best interest, even if clinicians best clinical judgement
    • act is primarily to promote financial interests of a party other than PT (facility, clinician)
    • the clinician has control over the use of the rationed service/treatment/etc.
  • For: its inevitable, necessary to control costs, avoids red tape, clinician is best placed to make the rationing decision
  • Against: damages PT-provider relationship, risk of bias/injustice, the rationed resources may not actually be put to better use, clinician not “qualified” to make the moral decision
68
Q

Possible rules for rationing:

A
  • Treating people equally:
    • lottery: hard to game the system; how much time is gained (4months or 40 years)
    • 1st come 1st served: can favor the wealthy; used in ICU beds and some organ allocation decisions
  • Favoring worst off:
    • sickest first: helps the suffering but may be only after they have deteriorated; used in ED and some organ allocation decisions
    • age based: benefits the young but>infants over toddlers? need other principles
  • Maximizing total benefits: used in disaster and military triage
    • maximizing lives save: saves more lives but>save a single 20yo PT or three 70yo PTs
    • prognosis: maximized life years but> add 5yrs to one life or 3 years to two lives
  • Social usefulness
    • value to society: future oriented; very vulnerable to abuse (politicians, health care workers, etc.?)
    • reciprocity: past oriented; may direct resources away from needs>vulnerable to abuse (past presidents?
69
Q

PCN and the military (WW2)

A
  • Flemming discovered but could not produce in large quantities>until drug companies were able to mass produce BUT>could not meet both civilian and military demand
  • Military took control (freeze order): nearly all PCN in the US went to military (15% went to civilians)
  • Principles for military allocation:
    • prognosis: proven efficacy of drug against that disease
    • instrumental value (value to society rule): get soldiers back into the fight
    • Example: Soldiers with gonorrhea (prognosis and instrumental value) received priority over wounded soldiers with unknown infections (no prognosis)
70
Q

Geneva convention:

A
  • Dunant: proposed a relief agency for humanitarian aid (Red Cross); won 1st Nobel Peace Prize
  • Standards of international law for humanitarian treatment in war
    • 4 treaties
    • 3 protocols
  • renegotiated after WW2
71
Q

What are the categories of detainees (4 + 1)?

A
  • EPW: one who is engaged in combat under orders of their gov’t
    • armed forces
    • must be under a command
    • distinctive emblem
    • obey laws of war
  • civilian internee: interned during armed conflict or belligerent occupation for security reasons or because they committed an offence (insurgent, criminals)
  • retained persons: EPWs who are medical personnel, chaplains, staff of Red Cross
    • protection from attack
    • medical and chaplains grouped together
  • other detainees: person in custody who has not been classified into the other categories; treated as an EPW until different legal status and accordant treatment is established
  • enemy combatant: not entitled to protections of Geneva convention by virtue of their own actions (e.g. terrorists)
    • still entitled to be treated humanely, subject to military necessity, consistent with GC; afforded adequate food, H2O, shelter, clothing, medical Tx and exercise of religion
72
Q

Rights of detainees (medical):

A

entitled to the same standard of care as US/Coalition SMs at all times

73
Q

Duality

A

dual nature of military medical (i.e. military AND medical) personnel

“mixed agency”

med ethics exam (1 decks)

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