Clinical Ethical Issues: Principles, Range of Cases, History Lessons

1. Clinical Ethical Issues:Principles, Range of Cases, History Lessons Robert L. Perkel, M.D. Chair, Thomas Jefferson University Ethics Committee The 2nd Annual Healthcare Leadership Network of the Delaware Valley Spring Institute, May 2, 2014

2. Objectives • To understand the principles that guide every ethics case discussion and dissection. • To use case examples that describe clinical ethical issues at the beginning, in the prime, and at the end of life. • To underscore the ultimate importance of professionalism with lessons from history

3. Bioethical Principles • Autonomy • Beneficence • Nonmaleficence • Justice • Truth telling • Informed Consent • Confidentiality • Futility

4. Practical Considerations • Particular clinical facts of “this case” • Attitudes and beliefs • “Culture” of the patient & physician • Societal factors • Demographics (aging) • Finances (fixed %GDP) • Insurance (traditional v. prospective $$)

5. Ethics Case Discussion:What the HEC does • Important “players” represented • Case presentation: facts; data; questions • Discussion: listen carefully; weigh different opinions; “try on” opposing viewpoints • Arrive at option(s) • Support with underlying principles • Communicate to all “the players” • Don’t tell people what to do

6. Range of Cases: HEC • Ethics at the Beginning of Life • Ethics in the Prime of Life • Ethics at the End of Life • Ethics of Professionalism

7. Ethics at the Beginning of Life • Reproduction • Human genome project • Cloning • Abortion • The NICU “technology imperative” • “I can, therefore I do” • “Use it or lose it” • Learning how and when to say “No!” Autonomy vs. Paternalism; Justice; Informed Consent

8. Ethics in the Prime of Life • Dialysis; plasmapharesis • BMT for certain malignancies • HIV/AIDs Autonomy vs. Social Justice Autonomy vs. Beneficence Competing Autonomies (“Duty to Warn”)

9. Bioethical Issues in HIV/AIDS • Individual vs. Society • patient autonomy vs. social justice • Individual vs. Individual • competing autonomies: patient vs. provider • End of Life/Medical Futility • beneficence; nonmaleficence • Allocation of Resources • social justice

10. Ethics at the End of Life:Refusing Life Sustaining Treatmentvs. Requesting Assistance in Dying • 37 yo F Multiple Myeloma • Failed Alkeran/Prednisone, VAD • “I’m tired … fed up … ready to die” • “No CPR, no antibiotics, let me die” • “Keep me comfortable” • When the time comes, (“help me die”)

11. The Principle of Double Effect • Long history, primarily but not exclusively in Roman Catholic tradition • Supports claims that an act having a harmful effect such as death does not always fall under moral prohibitions such as the rule against killing • There is a morally relevant difference between the intended effects of a person’s action and the nonintended though forseen effects of the action

12. 4 Conditions That Must Be Satisfied to Justify Double Effect • The action itself must not be intrinsically wrong • The agent must intend only the good effect and not the bad effect • The bad effect must not be a means to the end of bringing about the good effect • The good result must outweigh the evil permitted

13. Helping Patients Die with Dignity:A Continuum of Life/Death Issues • Withholding life support • Withdrawing life support • Physician assisted suicide • Active euthanasia • Gov’t & politics: lessons from history

14. Let History Judge • The Tuskegee Syphilis Experiment • “The Nazi Doctors”

17. Objectives • To understand the principles that guide every ethics case discussion and dissection. • To use case examples that describe clinical ethical issues at the beginning, in the prime, and at the end of life. • To underscore the ultimate importance of professionalism with lessons from history.