An Ethics Lens: How will emerging technologies impact clinical and administrative decisions?

1. An Ethics Lens: How will emerging technologies impact clinical and administrative decisions? Kate Michi Ettinger, JD NHS Fife February 10, 2011

2. Acknowledgement Disclosures • No financial conflicts of interest Disclaimers • Trained in law, but nothing presented is intended as legal advice.

3. Introductions

4. Goals Explore together: • How will emerging technologies impact delivery of clinical care? • How do we approach clinical and administrative decisions that arise from these changes in care delivery? • How do we negotiate values conflicts?

5. What is health care ethics consultation?

6. Expectations Make room for confusionas the context

7. Clinical Ethics Guides how clinicians use their professional power and governs the imbalance in power Clinician/Team - Pt Relationship

8. Health Care Ethics • Navigate Uncertainty • Negotiate Values Conflicts

9. Health Care Ethics • What to do when discretion in decision making • Why we choose to take a course of action

10. Clinical Ethics • Clinical Ethics Principles & Analysis • What does patient want? • Respect for patient autonomy • What will promote this patient's well-being? • Beneficence • What can we do to avoid harming this patient? • Non-maleficence • Justice Farber-post L, Blustein J, Dubler N. Handbook for Health Care Ethics Committees, Johns Hopkins University Press, 2007

11. Health Care Ethics

12. Invitation develop a future consciousness to inform the present

13. VIABILITY Three Horizons radically different operating environment new paradigm fits and takes off increasing disruption to status quo innovation shifts allegiance from old to new paradigm HORIZON 1 Innovation settles to new equilibrium Initially innovation keeps things going Radically new ideas with better fit to new environment emerge at the periphery HORIZON 2 new context retains useful old ways HORIZON 3 NOW TIME

14. Scenario for the Future A telemedicine project to deliver broader access to primary care for rural areas. The telemedicine project has hired Victoria from the local community to operate the clinic. She has received training as a nursing assistant and has a web-cam laptop & monitor based at a rural clinic. Victoria takes vital signs and the physician has an interview with patients via the television screen. One day, Tom, a 25 year old man comes into the clinic with severe chest pain. Via the laptop, an urban physician, Dr. White, diagnoses Tom with a tension pneumothorax. The nursing assistant is not licensed to provide the intervention needed for this young man’s life threatening condition. Should Victoria perform the intervention?

15. Clinical Ethics Consult • Nursing Assistant’s Dilemma • What does patient want? • Respect for patient autonomy • What will promote this patient's well-being? • Beneficence • What can we do to avoid harming this patient? • Non-maleficence

16. Clinical Ethics Consult • Physician’s Dilemma • What does patient want? • Respect for patient autonomy • What will promote this patient's well-being? • Beneficence • What can we do to avoid harming this patient? • Non-maleficence

17. Health Care Ethics Lens • Narrative • Ethical • Clinical • Legal Moral Theories • Utilitarian • Kantian • Libertarian • Communitarian • Ethics of Care Farber-post L, Blustein J, Dubler N. Handbook for Health Care Ethics Committees, Johns Hopkins University Press, 2007. See Also. Beauchamp & Childress, Principles of Biomedical Ethics, 5th Ed. Oxford University Press, 2001.

18. Trends Overview Decision Making Style Ethics Consult For Patients LDC Approach 1976 Living Will legal/ Directive/ transaction Authoritarian 1993/4 Advance Directive transaction/ Facilitative communication 2008 Advance Care facilitated Mediation Planning communication POLST Draft Recommendation, Core Competencies for Ethics Consultation, ASB&H, 1998. ABA Commission on Law & Aging, February 2008. “Beyond Schiavo,” J Clinical Ethics, Winter 2007.

19. Lateral Decision Making Purple hat Ethical justification Adapted from Edward DeBono’s 6 Hats Method

20. Lateral Decision Making Adapted from Edward DeBono’s 6 Hats Method

21. So, what about justice?

22. Clinical Ethics • Clinical Ethics Principles & Analysis • What does patient want? • Respect for patient autonomy: • What will promote this patient's well-being? • Beneficence • What can we do to avoid harming this patient? • Non-maleficence • Justice

23. Justice Principle • “Treating similarly situated patients similarly” • Whose view of Justice? • Pt • MD • Hospital • NH • Payer

24. Justice Principle • “Treating similarly situated patients similarly” • Whose view of Justice? • Pt, MD, Hospital, NH, Payer • Who is “treating”? • Physician/Clinical Team • Organization (Hospital, Nursing Home) • Payer/Insurer

25. Justice Principle • “Treating similarly situated patients similarly” • Whose view of Justice? • Pt, MD, Hospital, NH, Payer • Who is “treating”? • Physician/Team, Organization, Payer • What is included in defining “similarly situated”? • Disease condition v. current status • Social determinants of health factors

26. Justice Principle • “Treating similarly situated patients similarly” • Whose view of Justice? • Pt, MD, Hospital, NH, Payer • Who is “treating”? • Physician/Team, Organization, Payer • What is included in defining “similarly situated”? • Disease condition v. current status; personal factors • How does one assess “treating similarly”? • Based upon clinical diagnosis or outcome • Access may inform whether pts are treated similarly

27. Operationalizing Justice • Key Considerations • Systematic approach • Consistent, Fair • Principled distribution of burdens/benefits • Transparency • Explicit consideration of competing interests • Well-reasoned justification for decisions • Participatory processes • Inclusive of relevant, diverse stakeholders • Transparent

28. Historical Care Paradigm Hospital as Silent Partner in Care Delivery

29. Hospital as Active Player in the Care Paradigm Organization to Patients Relationship

30. Hospital as Active Player in the Care Paradigm Organization to Providers Relationship Hospital is actor on care team impacting Clinician-Patient Relationship

31. Hospital as Active Player in the Care Paradigm Organization to Patients Relationship Organization to Providers Relationship Clinical Team - Pt Relationship

32. Institutional Approach Montefiore Organizational Ethics Principles • Principle of Protecting Professional Integrity Health care organizations have a moral obligation to protect the integrity of clinical decision making and the physician-patient relationship, irrespective of the means by which the organization and their physicians are compensated or share risk. Blustein J, Dubler N, Farber-post L, Ethics for Health Care Organizations, New York, United Hospital Fund Press, 2002

33. Institutional Approach Montefiore Organizational Ethics Principles • Principle of Ethics Audit Health care organizations have a moral obligation to conduct an “ethics impact audit” of all decisions affecting the allocation of health care services to particular patient populations, including the opportunity costs of those decisions. These decisions should be defensible as a reasonable way of meeting stewardship obligations, and the reasons for these decisions should be publicly accessible to the appropriate parties. Blustein J, Dubler N, Farber-post L, Ethics for Health Care Organizations, New York, United Hospital Fund Press, 2002

34. Organizational Issues • Issues addressed: • Allocating critical care resources • Justice and access to unreimbursed therapies • Guidelines for transferring patients between services • Decision making protocol for the patient alone • Confidentiality and privacy in the Era of IT • Physician autonomy and the uninvited consultant • Disclosure of medical errors & adverse events • Determination of cardiac death • Medical futility

35. A Flavor of Integrated Ethics

36. Decisions & Actions Systems & Processes Environment & Culture System Approach • VA: Integrated Ethics Program • Ethics Consultation CASES approach • Preventative Ethics ISSUES approach • Ethical Leadership Leadership Compass Veteran’s Administration, National Center for Ethics in Health Care

37. How will emerging technologies impact the delivery of care?

38. Scenario for the Future In 2025, you are a clinician administrator of the NHS and your team has to make the following decision on neonatology incubators: • For $1M, you can purchase an incubator that will support a premie baby from week 20 on with a 50% chance of survival • For $100K, you can purchase an incubator that will support a premie baby from week 25 on with a 60% chance of survival Your current units were purchased in 2011, for $ each and they support premie baby from week 23 on with a 50% chance of survival. In the past 3 years, your hospital has had # delivered at week 20-23 and # delivered at week 23-25. Status of current machines (6). In the last year, three machines broke at different times and required repair limiting your institution’s neonatal care resources. One just broke and can no longer be fixed. You have a budget of $1M, what will you do?

39. Clinical Ethics • Clinical Ethics Principles & Analysis • What does patient want? • Respect for patient autonomy: • What will promote this patient's well-being? • Beneficence • What can we do to avoid harming this patient? • Non-maleficence • Justice

40. Organizational Ethics • Principle of Protecting Professional Integrity • Principle of Ethics Audit Blustein J, Dubler N, Farber-post L, Ethics for Health Care Organizations, New York, United Hospital Fund Press, 2002

41. Public Health Ethics • Effective • Proportional • Necessary • Least Infringing • Public Justification Childress J, Faden R, Gaare R, et al. Public Health Ethics: Mapping the Terrain. 30 Journal of Law, Medicine & Ethics, 171-172 (2002)

42. Thank you! Kate Ettinger kate@muralinstitute.com

43. Recommended Resources Clinical & Organizational Ethics • Farber-post L, Blustein J, Dubler N. Handbook for Health Care Ethics Committees. Johns Hopkins Press, 2007 • Blustein J, Dubler N, Farber-post L. Ethics for Health Care Organizations. New York, United Hospital Fund Press, 2002 • Beauchamp & Childress, Principles of Biomedical Ethics, 5th Ed. Oxford University Press, 2001. Integrated Ethics • Veteran’s Administration, National Center for Ethics in Health Care, Integrated Ethics Program: www.ethics.va.gov Decision Making Process • DeBono E. Six Thinking Hats, Back Bay Books, 1999. • Dubler N and Liebman C. Bioethics Mediation. Vanderbilt Press, 2011.