Managing Ethical Situations & Decisions

1. Managing Ethical Situations & Decisions February 15, 2013 Mr. Rob Sibbald Ms. Marleen Van Laethem Clinical Ethicist Clinical Ethicist London Health Sciences Centre St Joseph’s Health Care London

2. Agenda 0800 - 0820 - intro to ethics/decision making, clinical and organizational (Marleen) 0820 - 0900 - consent / capacity / frameworks (Rob) 0900 - 0930 - Catholic ethics, research ethics (Marleen) 0930 - 0945 - recent cases (Rob)

3. How to manage ethical situations?

4. How to manage ethical situations? Discern when issues have ethical implications Access supports and resources Know the minimum standard (legal as well as hospital policies) Identify the appropriate decision-maker(s) Reflect on values & alternative perspectives Strive to be more than simply within limits; strive to conduct ourselves ethically

5. What is ethics? (1/2) Ethics is concerned with principles and values, issues of right and wrong, and what we owe each other as persons A branch of philosophy concerned with the “right” and “virtuous” behavior Moral Theories Rational Thought/Deliberation Deciding which particular need, action, value, or belief should have precedence over another

6. What is ethics? (2/2) When ethical issues are clear, Black & White, laws or guidelines are written E.g. get informed consent before diagnostics and treatments Mostly shades of grey

7. Reflective Practice A challenge due to: fiscal restraints, scarce resources, “doing more with less”

8. Some ethical dilemmas – 1 A patient, recently diagnosed as HIV+, requests that his wife not be informed of his HIV status. Should his wish be respected? Or Should his wife be told?

9. Consider… • To whom is your duty? Husband? Wife? • Competing claims / priorities • His autonomous decision-making over his Personal Health Information (PHI) • Her potential harm of infection • Laws (protecting PHI, preventing spread of disease)

10. One Approach Limitation: no specific priority of principles Ethical Principles • Respect for autonomy • Beneficence – doing good • Non-maleficence – do no harm • Justice - fairness

11. Some ethical dilemmas – 2 An elderly patient has carcinoma of the prostate. Should he be told of his diagnosis against his son’s instructions?

12. Common signs of an ethical issue • The “ick” factor • the “six o’clock news” test • Uncertainty, disagreement or conflict about what ought to be done • Dignity or fairness is at stake

13. Resources Royal College of Physicians and Surgeons of Canada Ethics Tutorials http://rcpsc.medical.org/test/research/learning_materials/ethics/tutorials/index.php CMA Code of Ethics http://policybase.cma.ca/dbtw-wpd/PolicyPDF/PD04-06.pdf

14. Cma code of ethics

15. CMA Code of Ethics Fundamental Responsibilities Responsibilities to the Patient Responsibilities to Society Responsibilities to the Profession Responsibilities to Oneself

16. 10 Fundamental Responsibilities 1. Consider first the well-being of the patient. 2. Practise the profession of medicine in a manner that treats the patient with dignity and as a person worthy of respect.

17. 30 Responsibilities to the Patient • General Responsibilities • Initiating and Dissolving a Patient-Physician Relationship • Communication, Decision Making and Consent • Privacy and Confidentiality • Research

18. General Responsibilities 12. Inform your patient when your personal values would influence the recommendation or practice of any medical procedure that the patient needs or wants. 14. Take all reasonable steps to prevent harm to patients; should harm occur, disclose it to the patient.

19. Communication, Decision Making and Consent 21. Provide your patients with the information they need to make informed decisions about their medical care, and answer their questions to the best of your ability. 22. Make every reasonable effort to communicate with your patients in such a way that information exchanged is understood.

20. Respect patient’s wishes 24. Respect the right of a competent patient to accept or reject any medical care recommended. 26. Respect your patient's reasonable request for a second opinion from a physician of the patient's choice. 27. Ascertain wherever possible and recognize your patient's wishes about the initiation, continuation or cessation of life-sustaining treatment.

21. Patients without capacity 28. Respect the intentions of an incompetent patient as they were expressed (e.g., through a valid advance directive or proxy designation) before the patient became incompetent. 29. When the intentions of an incompetent patient are unknown and when no formal mechanism for making treatment decisions is in place, render such treatment as you believe to be in accordance with the patient's values or, if these are unknown, the patient's best interests.

22. Decision-making at various levels 1 patient (± family) + at least 1 member of the health care team = Clinical Ethics Affects multiple patients, potentially multiple stakeholders = Organizational Ethics

23. Organizational Ethics

24. Different from Clinical Ethics? Clinical Ethics The moral agent is the individual who is making the decision • e.g. Patient, Substitute Decision Maker, Health Care Provider • If there is conflict, it is typically: • between patient and health care team, or • between family members, or • between health care team members. • Organizational Ethics • The organization is the moral agent. • Mission/Vision/Values are akin to the physician/nurse code of ethics.

25. Conflict in Organizational Ethics Conflict is more likely than in clinical ethics • Because there are many more stakeholders: • LHIN, public, community partners, all professions, University, etc. • Process becomes even more important • Because agreement on substantive values is unlikely. • Most organizational ethics issues are managed through procedural values – ensuring there is a fair process by which to manage ethical dilemmas.

26. Values • Organizational Ethics Values • Rationality • Transparency • Accountability • Specific wording in the Catholic context • Stewardship of resources • Social Justice (Engagement on behalf of the less powerful, the marginalized and the dispossessed)

27. Top Organizational Ethics Issues • Resource Allocation • Resources are, by definition, scarce • (We don’t always acknowledge this basic fact.) • Applies to human capital as well as financial • Mission / Culture • How do we define ourselves? • How do we live in such a way as to honour our identity / values? • How do we bridge the gap between who we are and who we want to be?

28. More Organizational Ethics Issues • End of Life Care • How to support physicians and other staff? • How to appropriately educate and assist patients / SDM to make difficult end of life decisions? • Fundraising • Governance • HR related issues • Uninsured patients • Business development

29. Standards for Business Conduct Gifts/favours (what is nominal?) No payment from a supplier if you are in a position to make decisions about their service at the hospital Hiring family members Conflicts of interest Use of hospital resources

30. How to manage ethical situations? Discern when issues have ethical implications Access supports and resources Know the minimum standard (legal as well as hospital policies) Identify the decision-maker(s) Reflect on values & alternative perspectives Strive to be more than simply within limits; strive to conduct ourselves ethically