Philosophy 2 Flashcards
supports autonomy (ADC) (autonomy is the abcs)
Determining the patient’s ability to understand the issues, consider the consequences of different options, and communicate these thoughts to professionals is necessary
personhood (babies to comatose are persons)
newborns, cognitive impairment, comatose, children
Competence (in legal terms) (your dad)
Competence is a legal presumption that a person who has reached the age of majority has the requisite cognition and judgment to negotiate legal tasks, such as entering into a contract, making a will, or standing for trial.
decisional capacity (in medicine)
clinical context it is customary to refer to the patient’s decisional capacity, a clinical determination of the ability to make decisions about treatment or health care
Elements of Decisional Capacity (DPT BRD) decision to dip bird - this is basically informed consent
Decisional capacity refers to the patient’s ability to perform a set of cognitive tasks, including • • • • • understanding and processing information about diagnosis, prognosis, and treatment options; weighing the relative benefits, burdens, and risks of the therapeutic options; applying a set of values to the analysis; arriving at a decision that is consistent over time;
Capacity can be seen as an index of a person’s…
ability to exercise autonomy by making decisions that reflect personal preferences, values, and judgments at a given time.
Having capacity enables but does not obligate patients to…
to act independently. Despite our good intentions, we cannot force people who are unwilling to exercise their capacity for self- determination to do so.
delegated autonomy - assisted autonomy
These patients often entrust to others the authority to make decisions on their behalf
Capacity is not global, but…
decision- specific, referring to the ability to make particular decisions. ie - can decide what to have for lunch, but not specifics about surgery
Just as capacity is not global in its application to all decisions, it is not always…
constant. Elderly patients and sundowning.
The fact is, we only question the capacity of people who
not agree with us.
mini mental status exam (MMSE) - pros and cons
good for “orientation of the subject to person, place, and time, attention span, immediate recall, short- term and long- term memory, ability to perform simple calculations, and language skills” (Lo 2000, pp. 84– 85), it is less helpful in assessing an individual’s ability to grasp situations, weigh alternatives, and appreciate consequences— the skills required for capable decision making
Three standards are customarily invoked in attempting to make decisions as the patient would have made them (p (prior) is)
prior explicit articulation, substituted judgement - inferring, best interest
most problematic decision making standard (hardest for the substitute)
substituted judgement most problematic because, as commonly formulated, it requires the intellectually convoluted task of imagining what the now-incapacitated patient would choose if she were magically capable and in possession of all the relevant clinical facts.
how to use decision making standard (decisions must be authentic bc life is cohesive) AND what is it called
Apply Authenticity, which expresses the value of having one’s life be a coherent narrative, and surrogate decisions guided by this value seek to maintain the coherence of the patient’s life through the decisions that are made on her behalf, rather than to honor her hypothetical choices
advanced directives (disease is advancing) use by whom?
used for the formerly capacitated, ie dementia
2 types of advanced directives (instructions for the appointment)
instruction directives, also known as living wills, and appointment directives, also known as health care proxies or powers of attorney for health care.
hybrid advance directive, Five Wishes (5 hybrids decide my treatment, comfort, treat me, and loved ones)
provides the opportunity to communicate decisions about (1) the person I want to make care decisions for me when I can’t; (2) the kind of medical treatment I want or don’t want; (3) how comfortable I want to be; (4) how I want people to treat me; and (5) what I want my loved ones to know.
Without the patient’s explicit instructions in an advance directive, health care decisions made by surrogates have traditionally been based on the remaining two decision- (BS - is this judgement in the best interest?)
making standards— either substituted judgment (when the patient’s wishes can be inferred) or the best interest standard
EDMM - steps (FEPACCD) EDMM is fee packed
1) gather the facts
2) determine the ethical issues
3) state the principles which have a Bearing on the Case
4) List the Alternatives
5) Compare the Alternatives with the Principles
6) Consider the Consequences
7) Make a Decision
8) glossary
EDMM - ethical issues compete
“Ethical issues are stated in terms of legitimate competing interests or goods. These competing interests are
what actually create an ethical dilemma. The issues should be presented in an X versus Y format in order to
reflect the competing interest in a particular dilemma”
EDMM - state the principles
In bullet point fashion, list the ethical principles involved in the case. Such principles include things like:
professional codes of conduct, constitutional principles, legal principles, commonly accepted cultural
principles, natural law principles, or religious principles. The principles should be listed in order of their
ethical weight in the given case, e.g. P1, P2, P3, P4
EDMM - Consider the Consequences
“Both positive and negative consequences should be considered. They should be informally weighted since
some positive consequences are more beneficial than others, and some negative consequences are more
detrimental than others” (Rae, p. 106). You might list the alternatives with their consequences in the order of
informal weight, e.g. A2→ C2 weightier than A3→C3
EDMM - make a decision
“Deliberation cannot continue indefinitely. At some point, you must make a decision. Realize, too, that
ethical dilemmas often have no easy and painless solutions. Frequently, the decision that is made is one that
involves the least number of problems of negative consequences, not one that is devoid of them” (
principles of autonomy (RI DC) autonomy is redic (think about signing paper at doc office)
1) Informed Consent
2) Disclosure of Medical Information
3) Confidentiality
4) Right to Refuse Treatment
Four Main principles in medical ethics (the big ones - AJNB)
1) Autonomy (self-law/self-determination)
2) Justice (fairness/make-right; “doing and
pursuing the good”)
3) Nonmaleficence (do no harm/not
harming)
4) Beneficence (benefitng)
2 components of informed consent (doctor do job and patient understood)
1) doctor’s disclosure of medical information to the patient
2) competent patient
informed consent - doctor’s disclosure (DPAR BR) what you didn’t get for your mom - (disclosure is a dapper bro)
diagnosis, prognosis, available and
alternative treatments, and the risks,
benefits, and consequences of having or
refusing treatment.
informed consent - competent patient (was I competent)
A patient who understands the nature of his or her condition and the consequences of accepting or refusing an intervention for it.
If a patient thinks or believes that the
burdens of treatment will outweigh the benefits of treatment, then the patients autonomy must be respected.
If the level of risks to the patient for refusing treatment is high, then a greater level of competence is required by the patient
Competence vs. Risk vs.
Invasiveness of the Procedure
Some would argue that only a minimal degree of competence would be necessary for the patient’s doctor to be obligated to respect and not override the patient’s decision
2 ways surrogates act (surrogate in your shoes or theirs)
1) They make decisions about treatment as the patient would have made them if they were
competent.
2) They can decide on a course of action that they believe to be in the patient’s best interest.
informative model (information is basic)
The physician is obligated to provide all the
available medical facts. On the basis of
personal values, the patient then determines
which treatments they will accept or refuse.
interpretive model
In addition to the medical facts, the physician
also provides the patient with information
about the nature of their condition and the
risks and benefits of different interventions.
deliberative model (deliberately tell me what to do)
The physician is engaged in not only
presenting medical information to the
patient, but also in recommending treatment
in line with the patient’s health-related
values and preferences. (Non-coercive)
disclosure of medical information - This obligation is grounded in both..
deontological and consequentialist reasons
arguments to support confidentiality (Kant and Mill)
1) It is deontological (there is a duty) and
involves respect for the patient’s autonomy
and privacy. It is an extension of the
patient’s right to privacy.
2) It is consequentalist (bad outcome), e.g., if
physicians violate confidentiality by
divulging information about their patients to
third parties, then patients might lose trust
research/experimentation
Practices aimed at the advancement of scientific knowledge
therapy
Practices aimed at maintaining or restoring wellness of subject
therapeutic research
: Research which “offers the prospect of direct medical benefit” to the research participant
Utilitarian justification for research
Social benefits of advanced knowledge applied to therapeutic practice; controlled research methods enhance efficacy of therapies, reducing overall suffering over time, thus justifying pains endured by research participants.
justification for research (pay the research forward)
Duty
Duty to participate in research professed via appeals to fairness:
“paying back”
or
“paying forward”; just distribution of burdens/
benefits of medical advancement
Protection model v. access model: Protection model
Safeguard participant from undue risks, faulty experimental
design, uninformed/under-informed consent.
access model
Ensure participant has access to experimental trials that might
provide therapeutic benefit; ensure representative access to such trials, particularly to traditionally underrepresented groups.
Informed consent requirement - voluntary
1. Nuremberg Code (1946) and Declaration of Helsinki (1964): Two of the more than thirty statements of human-participant research ethics promulgated since World War II. 2. Informed consent is the central issue
Voluntary informed consent as a central issue
Duties of trust, loyalty, veracity in practioner-patient interactions. 1. Sometimes viewed as a safeguard against act-utilitarian impulse to use bodies/pains/sufferings of the few to benefit the many.
Voluntary informed consent as a central issue - cont
2. Thus, respect for persons entails informed-consent requirement: i) Each has a right to decide for herself, whether to consent; ii) Consent is autonomous if and only if it is fully informed. 3. Proxy consent for incompetent participants: Helsinki code, Articles 24-26.
two principles and 3 more
- Voluntary Informed Consent
- Ratio of Benefits
Later - Distinction between therapeutic
research (benefit patient) and
nontherapeutic (generate scientific
knowledge; not to benefit patient) - Institutional Mechanisms to ensure
ethical principles (Inst. Review Boards). - Provision for Proxy consent by family
member
fernald state school (no ferns grow)
low does of raditation
willowbrooke (willow will never get it)
hepatitis
san quentin
testosterone
statesville (don’t have it in our state)
malaria
holmsburg (hopefully not in our home)
dioxin - carcenogen
guatalmala
radiation
marshall islands
radiation
ethical dilemmas - randomized trial
- Patient may or may not receive
potentially-preferable treatment; thus,
conflicting obligations of Researcher qua
Physician (ensure patient benefit)
Vs. - Researcher qua Scientist (ensure viability
of experimental control group).
ethical dilemma - con’t
Others argue against the assumption of ethical equipoise (balance of interest) between MD as researcher and MD as care-giver; different roles have different ethical obligations; model of “researcher-as- caregiver” yields an overly paternalistic relationship between researcher and participant.
equipoise (equipoise is not biased)
A researcher is in equipoise when he or she
does not know whether one treatment is
more effective than another.
A research community is in equipoise when
there is genuine disagreement within the
community about the comparative merits
of the experimental and control arms of the
trial.
design of clinical trials - the phases
1) Phase I: Test the toxicity.
2) Phase II: Test the dosing.
3) Phase III: Test for effectiveness and side-effects.
4) Phase IV: Once FDA approved, collect more information and continue to test for side-effects.
Phase I and II are….(AND main moral obligation)
nontherapeutic
- Main moral obligation:
i) Protect subjects from harm.
Phase III and IV may be (AND main moral obligation) (is nara risky?)
therapeutic
2. Main moral obligation:
i) Ensure that there is an appropriate risk-
benefit analysis.
• Ideally there is a randomized controlled
clinical trial (double-blind).
3 ethical requirements to protect human participants (informed risk and distribution)
- Voluntary Informed Consent
- Appropriate Risk-Benefit Ratio
- Fair Distribution of Risks between different
groups
singer is a…
utilitarianist
cohen
animals cannot have rights because they are not moral
for children, there should never be…
more than a minimal risk
Pellegrino and Thomasma
argue that the patient autonomy model does not give
sufficient attention to the impact of disease
on the patient’s capacity for autonomy.
