Bringing Ethics into Focus Part 2: Professional Responsibility in Contex t

1. Bringing Ethics into FocusPart 2: Professional Responsibility in Context

2. AOA Code of Ethics To keep the visual welfare of the patient uppermost at all times; To promote in every possible way, in collaboration with this Association, better care of the visual needs of mankind; To enhance continuously their educational and technical proficiency to the end that their patients shall receive the benefits of all improvements in visual care; To see that no person shall lack for visual care, regardless of his financial status; To advise the patient whenever consultation with an optometric colleague or reference for other professional care seems advisable; To hold in professional confidence all information concerning a patient and to use such data only for the benefit of the patient; To conduct themselves as exemplary citizens; To maintain their offices and their practices in keeping with professional standards; To promote and maintain cordial and unselfish relationships with members of their own profession and of other professions for the exchange of information to the advantage of mankind.

3. Core Values of the AOA Code • A survey of the AOA’s code, typical of a mixed form, reveals a set of core values animating the code. These values include: • Patient Welfare • Eye Health/Vision • Professionalism • Collegiality

4. Operative Principles • Beneficence: actions or practices are right insofar as they produce good consequences. • Expressed negatively as Nonmaleficence: Do No Harm). • Autonomy: actions or practices are right insofar as they involve respecting the autonomous choices of individuals. • Justice: The principle that actions or practices are right insofar as they treat people in similar situations equally.

5. Beneficence and Paternalism • Mr. Lawson, a longtime patient of Dr. McMasters, has lived with Type II diabetes for more than a decade. Each year, during his eye exam, Mr. Lawson refuses dilation, part of the recommended standard of care for patients with diabetes. This year, Dr. McMasters observed signs of diabetic retinopathy during his standard examination. Though McMasters explained the possible implications of this observation to Mr. Lawson, the patient still steadfastly refused dilation. Dr. McMasters considers it his duty to follow the recommended care standards, and is considering refusing to prescribe vision correction for Mr. Lawson unless he consents to the dilation and examination.

6. Beneficence as a Moral Perspective • Beneficence has an important historical role in medical ethics as the core of the Hippocratic Oath. • The focus of the principle of Beneficence is on the consequences of the actions of the practitioner for the health and welfare of the patient. • The weight in the decision-making process is thus placed on the judgment of the practitioner.

7. Problems with Beneficence • The principle of Beneficence, while relatively non-controversial, is not as straightforward as it first appears. • There are important questions that need to be resolved before a practitioner can be confident that they are acting beneficently. • Subjective vs. Objective Estimates of Benefits • Medical vs. Other Personal Benefits • Conflicting Goals within the Medical Sphere

8. Beneficence and Paternalism • Paternalism: action taken to benefit a person against her will. • Strong: taking such an action even though the person is mentally competent. • Weak: taking such an action when a person is known or suspected to be incompetent. • Hippocratic ethics are often taken to justify both forms of paternalism. This is one of the reasons many contemporary medical ethicists are moving away from the Hippocratic perspective toward perspectives the emphasize respect, autonomy, truth-telling, and fidelity.

9. Autonomy and Informed Consent • Dr. Joan Paulsen had a problem. Her good friend Marcia had brought in her elderly mother for an eye exam during which Dr. Paulsen found advanced diabetic retinopathy in the periphery of both eyes. Typically, she would immediately report these findings to the patient, prepared to discuss the diagnosis and treatment options, but Marcia had told her that her mother’s emotional and mental states were very fragile. In light of this Marcia had requested that any negative information about her mother’s ocular health be withheld from her, and instead reported to Marcia. In her conversation with Marcia’s mother, Joan had not noticed any sign of fragility. Now she wondered how to proceed.

10. Autonomy as a Moral Perspective • Autonomy is a moral perspective that frequently conflicts with beneficence, and thus with the Hippocratic perspective. • The beneficence perspective gives a great deal of prominence to the consequences of actions. Autonomy, on the other hand, places the emphasis on the claims that a patient has on a practitioner. • These claims can be articulated as rights the patient has relative to the practitioner or as the duties the practitioner has to the patient.

11. The Conflict: Informed Consent • “Informed Consent” refers to obligations a practitioner has to provide her patient with all relevant information about her health and treatment options. • This obligation allows the patient to make appropriate decisions about their care. • The Beneficence perspective can provide some justification of informed consent, but only to the extent that the consent benefits the patient. • The Autonomy perspective, on the other hand, requires that all meaningful information be disclosed to the patient, even when it is believed that the disclosure may be harmful.

12. Standards for Disclosure • Fully informing a patient is frequently, if not always, impossible. The general obligation is to provide adequate information. • How can a practitioner determine when they’ve met their obligation? • The Professional Standard: what would similarly situated colleagues do? • The Reasonable Person Standard: what information would a reasonable person want? • The Subjective Standard: what information fits the life plans and interests of the individual?

13. Justice and Resource Allocation • Faced with declining insurance reimbursements and increasing practice costs, Dr. Ball fears that she may be forced to discontinue her participation in the statewide insurance program for the economically disadvantaged and uninsurable. Though one of her original motivations to become an optometrist was her conviction that providing quality care to underserved populations was the right thing to do, the economic implications of this choice seemed increasingly dire. What was more important, maintaining her principled commitment to the less fortunate, or pursuing her own fortune?

14. Justice as a Moral Perspective • Justice is another moral perspective that seems to conflict with implications of the principle of beneficence. Most obviously, beneficence seems to lack a notion of moral community. • The autonomy perspective seems to fare little better. • The perspective of justice corrects this inattention to the broader social implications of health care by raising the question of the duties medical professionals have to third parties.

15. The Problem of Scarcity • Scarcity of medical resources is an obvious concern of the justice perspective in medical ethics. One form of scarcity is that of access to care. • Despite the amazing amount of money spent each day on health care in this country (~3.5 billion dollars/day), significant numbers of our citizens lack even basic insurance coverage. In 2000, 14% of the U.S. population was completely without coverage. • At the same time, practitioners are increasingly pinched by the insurance industry (public and private), and by rising costs, exacerbating access scarcity.

16. Justice in Allocation • The justice perspective requires practitioners to balance their obligations to themselves and their patients against their obligations to those who lack the means of access to appropriate care. • Clearly, there are limits to this balancing act. practitioners may lack the means to accurately calculate the balanced benefits. There are also problems posed by the conflicts between the obligations of justice and those that flow from their patients. • In response, some people have argued that practitioners should be exempt from considerations of justice, but that seems too extreme.

17. Balancing Values and Principles • Despite the conflicts between the various perspectives we’ve considered, each of them has their place in an individual practitioner’s attempts to embody the values outlined in the AOA code. • An important part of being a responsible optometric professional is reflecting on the different implications these principles have for the values you should embody. • Ultimately, it is the individual practitioner’s responsibility to reflectively negotiate the conflicts between principles and across values.