Ethics and Professionalism in Health Care - Contemporary Topics and Issues

2. The Culture of Health Care Ethics and Professionalism Lecture c This material (Comp 2 Unit 8) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. This material was updated in 2016 by Bellevue College under Award Number 90WT0002. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.

3. Ethics and Professionalism Learning Objectives • Discuss foundational concepts in medical ethics and professionalism (Lecture a). • Examine the relationships among ethical ideals, professionalism, and legal duties (Lectures a, b). • Apply the general principles of ethics and professionalism to specific topics (Lectures c, d). • Examine ethical issues in health informatics (Lecture d).

4. Contemporary Topicsin Medical Ethics • Informed consent • End-of-life issues • Conflicts of interest • Health care disparities • Conscientious objection

5. Informed Consent Patients must • Be capable of making medical decisions • Be provided with all relevant information • Understand the information given • Communicate a decision • Make voluntary decisions

6. Relevant Information • Nature of the treatment • What is the purpose? • What will be done? • Availability of reasonable alternatives • Risks and benefits of proposed treatment

7. Examples of Exceptions to Informed Consent Requirement • Patient lacks mental capacity • Adult with severe developmental disability • Adult has severe dementia • Children usually lack legal capacity • Implied or presumed consent in an emergency • Patient is unconscious OR lacks capacity AND • No surrogate decision-maker is available

8. End-of-Life Issues • Definition of death can be unclear • Can a person be “alive” if his/her heart has stopped beating? • Can a person be “dead” if he/she is still breathing? • Other prominent end-of-life issues • Medical futility • Advance directives

9. Medical Futility • Treatment would not improve the patient’s condition • Decision considers the unique situation of an individual patient • Should be consistent with general professional standards • Relationship to health care “rationing” • Advocates say there is no cost/benefit analysis • Question is benefit of treatment for individual

10. Arguments about Futility 8.7 Table: Pros and cons of medical futility (CC BY-NC-SA, 2012).

11. Advance Directives • Living will • “Do not resuscitate” • Wishes regarding artificial food or drink • Durable power of attorney for health care • Designates someone to make decisions • Can be combined with instructions in living will

12. Arguments aboutAdvance Directives 8.8 Table: Pros and cons of advance directives (CC BY-NC-SA, 2012).

13. Conflict of Interest “A conflict of interest is a set of circumstances that creates a risk that professional judgment or actions regarding a primary interest will be unduly influenced by a secondary interest.” —Institute of Medicine (2009)

14. Primary and Secondary Interests in Medical Practice 8.9 Table: Primary and secondary interests in medical practice (CC BY-NC-SA, 2012).

15. Physician Compensation • Payment for each service • Can motivate physicians to inappropriately increase the number of services they provide • Can motivate selection of services that have a high profit margin • Flat fee per patient • Can motivate undertreatment

16. Health Care Disparities • Differences in access to health care • Differences in quality of health care • Differences in overall health • Most frequent comparisons are by • Socioeconomic status • Race • Presence or absence of disability

17. Causes of Health Differences • Natural biological variation • Voluntary participation in potentially health-damaging activities, such as certain sports • Exposure to unhealthy, stressful living and working conditions • Inadequate access to essential health services and other basic services

18. Systematic Discrimination • Three features, when combined, turn a mere difference in health into a social inequity in health: • The difference is systematic • The difference is socially produced and therefore modifiable • The difference is unfair

19. Conscientious Objection • A health care professional’s moral or religious objection to a certain medical intervention • Health care professionals have refused to provide medical interventions, for example: • Abortions • Sterilization procedures, such as vasectomy • Pain medications for terminally ill patients • Emergency contraception

20. Conscience, Ethics, and Law • Laws protect patients’ rights to access to medical interventions • Laws protect medical professionals’ rights to refuse to provide certain medical interventions • Laws vary from state to state

21. Ethics and Professionalism Summary – Lecture c • Informed consent is based in the duty to respect patient autonomy • Caring for terminally ill patients involves thorny ethical questions about the definition of death, medical futility, and the use of advance directives • Conflicts of interest can pose temptations • Health inequities require society-wide solutions • Conscientious objection represents a clash between professionals’ rights and patients’ rights

22. Ethics and Professionalism References – Lecture c References Braveman, P. (2014). What are health disparities and health equity? We need to be clear. Public Health Reports, 129. Committee on Bioethics, American Academy of Pediatrics. (2009). Policy statement: Physician refusal to provide information or treatment on the basis of claims of conscience. Pediatrics, 124(6),1689–1693. De Bord, J. (2014). Ethics in medicine: Informed consent. University of Washington School of Medicine.Retrieved from http://depts.washington.edu/bioethx/topics/consent.html del Carmen, M. G., & Joffe, S. (2005) Informed consent for medical treatment and research: A review. Oncologist,10(8), 636–641. Institute of Medicine.(2009). Conflict of interest in medical research, education, and practice.Retrieved fromhttp://www.ncbi.nlm.nih.gov/books/NBK22942 Jecker, N. S. (2014). Ethics in medicine: Medical futility. University of Washington School of Medicine. Retrieved from https://depts.washington.edu/bioethx/topics/futil.html Kong, W. M. (2015). What is good medical ethics? A clinician’s perspective. Journal of Medical Ethics, 41(1), 79–82. Retrieved from http://jme.bmj.com/content/41/1/79.full Marmot, M., Allen, J., Bell, R., Bloomer, E., & Goldblatt, P. (2012). WHO European review of social determinants of health and the health divide. Lancet, 380(9846), 1011–1029.

23. Ethics and Professionalism References – Lecture c Continued Oakley, J. (2015). Good medical ethics, from the inside out—and back again. Journal of Medical Ethics, 41(1), 48–51. Pope TM.(2010). Legal briefing: Conscience clauses and conscientious refusal. Journal of Clinical Ethics, 21(2), 163–176. Rich, BA. (2015). Your morality, my mortality: Conscientious objection and the standard of care. Cambridge Quarterly of Healthcare Ethics, 24(2), 214–220.  Schneiderman, L. J., Jecker, N. S., & Jonsen, A. R. (1990). Medical futility: Its meaning and ethical implications. Annals of Internal Medicine, 112, 949–954. Tillyard, A. R. (2007). Ethics review: “Living wills” and intensive care—An overview of the American experience. Critical Care, 11(4), 219. University of Minnesota Center for Bioethics. (2005).End of life care: An ethical overview.Retrieved from http://www.ahc.umn.edu/img/assets/26104/End_of_Life.pdf Wade, J., Donovan, J., Paramasivan, S., Lane, A., Neal, D., & Hamdy, F. (2013). Evaluating best practice in informed consent discussions: A new method of evaluating information provision and patient understanding during trial recruitment consultations. Trials, 14(Suppl 1), O70. Whitehead, M. (1990). The concepts and principles of equity and health. World Health Organization Regional Office for Europe. Retrieved from http://publicaciones.ops.org.ar/publicaciones/piezas%20comunicacionales/cursoDDS/cursoeng/Textos%20Completos/the%20concepts%20and%20principles%20of%20equity%20and%20health.pdf

24. Ethics and Professionalism References – Lecture c Continued 2 Whitehead, M., & Dahlgren, G. (2006). Levelling up (part 1): A discussion paper on concepts and principles for tackling social inequities in health. World Health Organization Regional Office for Europe.Retrieved from: http://www.who.int/social_determinants/resources/leveling_up_part1.pdf Tables, Charts, Figures 8.7 Table: Pros and Cons of medical futility (CC BY-NC-SA, 2012). 8.8 Table: Pros and Cons of advance directives (CC BY-NC-SA, 2012). 8.9 Table: Primary and secondary interests in medical practice (CC BY-NC-SA, 2012).

25. The Culture of Health CareEthics and ProfessionalismLecture c This material was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. This material was updated in 2016 by Bellevue College under Award Number 90WT0002.