K. Waugh Zucker, Associate Professor

1. Bioethics K. Waugh Zucker, Associate Professor Army - Baylor University Graduate Program in Health & Business Administration karin.zucker@amedd.army.mil

2. Ethics -The branch of philosophy dealing with values relating to human conduct with respect to the rightness or wrongness of actions and the goodness or badness of the motives and ends of such actions.

3. Bioethics - That branch of ethics which addresses moral conflicts in medicine; that branch of ethics which addresses moral problems of the life sciences (medicine and biology) and of the environmental and social sciences.

4. Why consider bioethics ? • Healthcare providers are often introduced to the subject in their professional schools; they expect ethical concerns to be addressed • Joint Commission on the Accreditation of Healthcare Organizations • DoD / Army Executive Skills Programs

5. Healthcare providers -- • May have a good grounding; or not • Probably have some familiarity with the principles (autonomy, beneficence, nonmaleficence, and justice) • May well not know, or remember, a decision - making method

6. Joint Commission-- • Standards on patients’ rights • Goal is to help improve outcomes by respecting each patient’s rights • Standards on organization(al) ethics • Goal is to protect, honor, and respect patients’ desires while providing quality care

7. Patients' Rights • Patients involved in all aspects of care • Informed consent • Patients (and families) informed about outcomes • Families participate in care decisions • Patients involved in resolving dilemmas • Advance directives • Choices about resuscitative services • Human subject research

8. Organization(al) Ethics • Protecting, honoring, and carrying out patients’ desires while providing quality care • Processes for -- • Privacy • Confidentiality • Security • Protective Services • Staff competence • Staffing levels • Education

9. DoD Executive Skills Program (Ethics in the Healthcare Environment) • Ethical decision - making • Personal and professional ethics • Bioethics (bedside ethics) • Organizational ethics

10. Major Approaches to Medical Ethical Decision - Making • Principlism • Casuistry • Narrative Ethics • Virtue Ethics • Feminist Ethics In medical ethics Principlism rules.

11. The Principles • Autonomy - or - Respect for Persons • Beneficence • Nonmaleficence • Rule of Double Effect • Justice

12. Army – Baylor 7 - Step Method 1. Frame the question. 2. Set out the medical situation. 3. Note contextual situation: 4. Revisit / reframe the question. 5. Apply principles / identify conflict(s). 6. Identify and weigh alternatives. 7. Decide. • familial • social • legal • economic • religious • ethical

13. 7 - Step Method Modified for Organizational Decision - Making 1.Frame the question. 2. Set out the organizational situation. 3. Note the contextual factors. 4. Revisit / reframe the question. 5. Ask and answer the 12 questions. 6. Identify and weigh alternatives. 7. Decide.

14. 12 Questions for Examining Business Decisions 1. Have you defined the problem accurately ? 2. How would the other side define it ? 3. How did this situation occur ? 4. To whom / what do you give your loyalty ? 5. What is your intention ? 6. How does your intent compare with probable results ? 7. Whom could your decision injure ? 8. Can you discuss the problem with the affected parties ? (continued)

15. 12 Questions(continued) 9. Are you confident that your position will be valid over the long haul ? 10. Does your decision pass the "grandmother" test ? 11. What is the symbolic potential of your decision ? 12. Under what conditions would you allow exceptions ? Adapted from L. L. Nash, "Ethics Without the Surgeon" in The Business of Ethics and Business, 1986, Harvard Business Review

16. Where is bioethics likely to come up ? • Education • IRB (Institutional Review Board) • Ethics Committees

17. IRB • Purposes are to consider / determine-- • Scientific merit • Compliance with the rules • Ethics (w/re to patients and providers) • Allocation of funds

18. History -- Why Do We Have Ethics Committees ? • Tuskegee • Willowbrook Hepatitis Study • Jewish Chronic Disease Hospital Cancer Study • Milgram’s Obedience Study • Radiation Experiments • And, on and on -- Gelsinger / genetics • -- Kennedy Krieger / lead

19. History -- Some Responses • Nürnburg Code • Declaration of Helsinki • 10 U.S.C. § 980 • The God Committee • President’s Commission (Belmont Report) • The Common Rule • The Joint Commission • Ethics Committees

20. JCAHO does not mandate an ethics committee. However, in most facilities the mechanism for addressing ethical concerns or problems, at least in clinical matters, is an ethics committee.

21. Purposes and Organization • Historically, the primary focus has been on direct patient care issues. • Primary functions have included: education, policy review, and consultation. • We are still discussing what to do with organizational ethics concerns.

22. Organization - Membership • Generally, membership has been multi-disciplinary: • Physicians • Nurses • Social workers / discharge planners • Administrators • Lawyers • Chaplains • Community representatives

23. Clinical + Organizational = • So, should existing ethics committees also be tasked with the organizational ethics function ? • Already in place - who better ? • Already recognized as source of advice and information • Membership already experienced with ethics work

24. Problems with "Super" Ethics Committees • Not all members are knowledgeable about or interested in all subjects • Size may be unwieldy • Organizational problems may be too widely discussed • Too many meetings • Too much work

25. Alternatives to "The Super Ethics Committee" • Use an ethics consultant • Have two committees • Divide one committee into subcommittees • Fit people to needs and interests • Meet jointly for education • Have some overlapping membership • Assume management can deal with organizational ethics problems

26. Who is the client ? • Staff (a physician, nurse, social worker, etc.) • The patient • A member of the patient’s family • The patient’s family as a whole

27. Method -- How do they do it ? • Committee process • As committees of the whole • In consultation teams • In subcommittees

28. What do they do ? • Help the "client" work through a decision - making process • Identify ethical courses of action

29. With what method ? • Beauchamp and Childress’ • Jonsen, Seigler and Winslade’s • Gross – Schaffer’s • Army – Baylor 7-Step

30. Areas of Discussion - Patient Care • Determinations of decision - making ability • End - of - life matters • Advance directives • Actions by surrogates • Palliative care • Organ harvesting and donation • Determinations of futility

31. Areas of Discussion - Patient Care (continued) • Abortion • Nurturing defective neonates • Sterilization • Surrogate motherhood • Self - directed care • Complementary or alternative medicine

32. Frequent Underlying Issues • Communication problems • Provider is personally uncomfortable with patient’s / surrogate’s choice • Provider notices something not right with patient - surrogate relationship

33. Areas of Discussion - Organizational • Staffing levels • Resource allocation • Marketing • Non - institutional providers • And, recent hot topics: • Providers’ objections to providing care • Organ donation after cardiac death

34. Legal Issues • Advance directives • Conflicts between • Original missing • Executed in another state • Determinations of incompetence • Determinations of surrogacy • Care over religious objections

35. Legal Issues (continued) • Organ or tissue donation by minors • Consent by mature minors • Suspected abuse • Transfers over objection • Confessions of error

36. Sustaining the Committee’s Life • Brown bag luncheons • Discussions (journal club format) • Facilitated Discussions (hot topics) • Facilitated Discussions (rip & read) • Films (film excerpts) • Speakers

37. Questions ?