Ethics – difficult issues

1. Ethics – difficult issues

2. Ethics in Surgery–Selected Topics • I. Surgical Ethics—Basic principles or ethical theories • II. Informed Consent • A. Physician-Patient Communication • B. Confidentiality • III. End-of-Life Issues • A. Advance Directives and End-of-Life Care • B. Do-Not-Resuscitate (DNR) Orders • C. Futility • D. Palliative Care • E. Physician-Assisted Suicide • F. Euthanasia • IV. Research in Surgery • A. Randomized Clinical Trials • B. Informed Consent for Research • C. Scientific Integrity • D. Innovative Surgery • V. Ethics in Surgical Education • VI. Resource Allocation • A. Ethics and Organ Transplantation • B. Rationing of Care • C. Third-Party Issues • VII. Medical Genetics • A. Research Issues • B. Clinical Issues

3. Examples of important clinical ethics • Confidentiality • Consent • End of life issues • Distribution of healthcare resource (resource allocation) • http://www.ethox.org.uk/

4. Issues Related to Surgical Ethics • Family conflict regarding patient care – examples • Professional issues – pharmaceuticals and doctor gifts • Allocation of scarce resources – inability to pay • Lack of attending involvement – insurance fraud • Informed consent • Truth-telling • Questionable “over treatment” vs. “under treatment” of patients • Educational Issues – 80 Hour Work Week vs. Education – ACGME Perspectives

5. The Four Principles ** • Respect for autonomy • respecting the decision-making capacities of autonomous persons; enabling individuals to make reasoned informed choices. • Beneficence • this considers the balancing of benefits of treatment against the risks and costs; the healthcare professional should act in a way that benefits the patient • Non maleficence • avoiding the causation of harm; the healthcare professional should not harm the patient. All treatment involves some harm, even if minimal, but the harm should not be disproportionate to the benefits of treatment. • Justice • distributing benefits, risks and costs fairly; the notion that patients in similar positions should be treated in a similar manner. Beauchamp and Childress, Principles Biomedical Ethics, OUP, 5th edition 2001

6. The Jonsen Framework • Indications for medical intervention • establish a diagnosis, what are the options for treatment, what are the prognoses for each of the options. • Preferences of patient • is the patient competent- if so what does he / she want? If not competent then what is in the patient's best interest? • Quality of life • will the proposed treatment improve the patient's quality of life? • Contextual features • do religious, cultural, legal factors have an impact on the decision? Jonsen, Siegler and Winslade; Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine 3rd edition McGraw-Hill 1992

7. End of life issues • Highly emotionally charged for healthcare professionals and public • May arise conflicts and ethical dilemmas • Need careful ethical and legal approaches to resolve issues • Clinicians should take into account certain ethical theories and principles

8. Sanctity of life doctrine • All human life has worth and therefore it is wrong to take steps to end a person’s life, directly or indirectly, no matter what the quality of that life. • In keeping with traditional codes of medical ethics and general perception of what doctors should do – to save and preserve life. • Challenges to this doctrine • Should life be preserved at all cost? • Quality of life issue (how to consider, how to define and who to define)

9. Distribution of healthcare resource (resource allocation) • More of policy issues • Involves the administrators more • For front-line staff, you are see your “time management” at your work as resource allocation • Cataracts vs. liver transplantation

10. Acts / Omissions distinction • This distinction argues that there is a difference between actively killing someone or refraining from an action that may save or preserve that person’s life. • In medical context: • A doctor should not give his patient a lethal dose of poison to end his/her life • Withholding treatment would be permissible if the patient’s quality of life was so poor, and the burden of treatment so great that it would not be in the patient’s best interests to continue treatment.

11. Doctrine of double effect • There is a moral distinction between acting with the intention to bring about a person’s death and performing an act where death is a foreseen but unintended consequence. • Usually referred example – giving large doses of pain killers to terminally ill patient • Intention was to relieve pain and the foreseen but unintended consequence is that the patient would pass away on respiratory suppression

12. Respect for autonomy • This principle acknowledges the right of a patient to have control over his or her own life, including decisions about how his/her life should end or to refuse life saving treatments. • Problems: • If a patient asks for assisted suicide • If a patient requests treatment that the clinician does not think it is of the patient’s best interest or the treatment is simply futile • In these situations, the principle of respect for autonomy comes into conflict with other ethical consideration, like non-maleficence or justice.

13. A duty to act in the patient’s best interest (Beneficence) • Very fundamental principle in healthcare • Dilemma: • What course of action will be in the patient’s best interest? • For example, in the end of life issue, it is difficult to see how death can be a benefit or in patient’s interests.

14. A duty not to harm(Nonmaleficence) • An obligation not to inflict harm intentionally – again a fundamental tenet as a doctor. • Dilemma: • Many treatments may have very harmful side effects • In end of life decisions, questions are how much harm is the treatment causing and whether death itself is always a harm.

15. Withholding treatment vs. withdrawing treatment • Although emotionally it may be easier to withhold treatment than to withdraw that which has been started, there are no legal, or necessary morally relevant, differences between the two actions. • Both actions are considered as “omissions to act” • Withholding and withdrawing life-prolonging treatment: Good practice in decision-making, GMC (August 2002) • Where it has been decided that a treatment is not in the best interests of the patient, there is no ethical or legal obligation to provide it and therefore no need to make a distinction between not starting the treatment and withdrawing it.”

16. How to revise • please think about the followings: • what kind of patient would have that conditions • how would they present clinically • would they have particular physical signs • how can we confirm the diagnosis • how can we stage the pathology • what are the treatment options available • what are the benefits and risks for certain treatment • how are the surgical procedures being done • what is the prognosis like

17. 《金剛經》有言﹕「一切有為法，如夢幻泡影，如露亦如電，應作如是觀。」《金剛經》有言﹕「一切有為法，如夢幻泡影，如露亦如電，應作如是觀。」 平常心