Ethics Exam 2

Veracity, Autonomy, Fidelity/Confidentiality, HIPAA, Avoidance of Killing, Formularies/Drug Distribution Systems

Veracity

Veracity

• legal principle that states that a health professional should be honest and give full disclosure to the patient, abstain from misrepresentation or deceit, and report known lapses of standards of care to the proper agencies

• habitual observance of truth in speech or statement; truthfulness

When is it okay to lie?

Hippocratic Oath allows a lie to a patient if it spares the patient agony. Why?

It judges the immoral act of lying against the beneficial consequences of the lie

• Lying as whole is immoral, but ‘beneficial consequences’ to lying makes it moral via Hippocratic Oath

When is it okay to lie?

APhA has conflict → Second Principle

Looks at consequences (‘case-by-case’ evaluation)

When is it okay to lie?

APhA has conflict → Third Principle

Ignores consequences, looks to principles; respect patients ability to make their own decision based off information pharmacist gives (‘alternative rules’ analysis)

Situations that challenge veracity

• Condition of doubt

  • Are all patient facts known?

  • Is drug information fact or opinion?

• Lying in order to benefit the patient

  • Use of placebos

  • Protect the welfare of others

• When complete disclosure is unwanted

  • Patient doesn’t want to be told

  • Family doesn’t want patient to be told

Autonomy

• The doctrine that the individual human will, is, or ought to be governed only by its own principles and laws

• The capacity of a rational individual to make an informed, un-coerced decision

What is the central premise of ‘informed consent’ and ‘shared decision making’?

Autonomy

Age of majority

Age at which one can make informed decisions for themselves

• 18 years old

• 14 or 16 years old in some jurisdictions (mainly females)

Internal constraint issues

• Conscious vs. Unconscious

• When capacity is in question

  • Emergency - consent is assumed

  • Non-emergency - who is surrogate?

• Competency

  • Court determination

  • Court will appoint surrogate (i.e. power of attorney)

External constraints

In a “total” institution (i.e. prisons, boarding schools, military)

Irresistibly attractive offers

• Imprisoned - improved conditions, release/early parole

• Terminal illness - longer life, cure

Does/can another ethical principle conflict and override the patient’s autonomy?

Beneficence, preserving life (i.e. avoidance of killing)

Fidelity

• Faithfulness to a person, cause, or belief, demonstrated by continuing loyalty and support

• Strict observance of promises, duties, etc

• Adherence to truth; accuracy in reporting detail

In provider-patient relationship, what is the covenant or contract between the two, consisting of mutual promises?

Fidelity

What does promise-keeping demonstrate?

Loyalty

Types of possible promises that may be in conflict when determining when it is okay to break a promise

• Promises to patient

• Promises to self

• Promises to family

• Promises to other providers

• Promises to profession

Implicit

Not written down / Not spoken

Explicit

Spoken / Written

When might it be okay to break a promise?

Possibly when the promise was given to a colleague/patient who is:

• Incompetent

• Impaired

• Planning violence

• Dishonest/Engaged in criminal activity

• Dead

In what situations can the promise of confidentiality possibly be broken?

• When it benefits the patient

• When it benefits others

  • Terminal infectious diseases

  • Patient is planning violence on another

• When the patient dies

What does HIPAA stand for?

Health Insurance Portability and Accountability Act

Provisions of HIPAA 1996

• Protects the privacy of patient information

• Provides for the electronic and physical security of patient health information

• Requires the “minimum necessary” use and disclosure of private health information

• Specifies patients’ rights regarding the approval of access and use of their health information

Updated HIPAA → HITECH Act 2009 Provisions

• Notification requirements when a privacy breach occurs

• Fine and penalty increases for privacy violations by covered entities and business associates

• Patients’ right to request copies of their electronic health care record in electronic format

• Holding business associates civilly and criminally liable directly for privacy and security violations

HIPAA training helps one understand…

• Who has to follow HIPAA?

• When does one have to do so?

• How does HIPAA affect you?

• Why is HIPAA important?

• Where can you get more information regarding HIPAA?

Who has to follow HIPAA?

Any “covered entity” or “business associate”, other than the involved patient, who controls or comes in contact with a patient’s protected health information

What is protected health information (PHI)?

Information related to a patient’s past, present or future physical and/or mental health or condition; includes at least one of the 18 personal identifiers in association with health information

Most common PHI identifiers

• Name

• Postal Address

• Telephone Number

• Social Security Number

• etc.

Notice of privacy practices

A statement given to each patient describing how the practice will use and disclose health information and outlining the patient’s rights under HIPAA

Acknowledgement

Written documentation that the notice was provided to a patient, and either signed by the patient, their personal representative, or completed by a staff member explaining why the patient did not sign it

Authorization is required for any PHI uses and disclosures other than

• Treatment

• Payment

• Health care operations

• Legal mandates

For what reason can you use PHI?

Only to do your job!

How does HIPAA apply to you?

• Assure that every patient or representative, at the first contact with the organization, receives the organization’s notice of privacy practices and acknowledges receipt of it

• Use and disclose only the minimum PHI necessary for treatment, payment or other allowed health care operations

• Patient must provide an authorization before his/her PHI may be used (i.e. Psychotherapy notes, Research)

• Responsibility for the security of all PHI - Do not share/give anyone any passwords; Log-off computers when finished and secure any paper records containing PHI; Destroy, shred or put in designated areas all paper that could contain PHI

“Killing”

• An act of causing death, especially deliberately

• Cause to die; put to death, usually intentionally or knowingly

• To deprive of live

“Avoidance”

The act of keeping away from or preventing from happening

Is killing always immoral?

Some believe killing of any kind is never morally justified —

Nonviolence is supreme

Can a killing ever be justified?

• Self-defense (defense of life)

• Police actions (defense of others’ lives)

• War (defense of country)

• Protection of property

• State executions

• Euthanasia (mercy killing) - assisted vs suicide

What used to happen if you attempted suicide?

Imprisonment, because you attempted to destroy “government property” (your body)

Distinctions in killing

Motive

merciful or not

Distinctions in killing

Actor in killing

Self (suicide), Other (homicide)

Distinctions in killing

Consent to killing

• Voluntary (one’s free will)

• Involuntary (against victim’s wishes)

• Non-voluntary (without approval or disapproval)

Distinctions in killing

Types of euthanasia

• Homicide on request (provider kills on patient’s request)

• Assisted suicide (supply information/materials)

Consequentialists

Beneficence and nonmaleficence (do good and avoid harm)

Rigorists (Nonconsequentialists)

Pure application of a principle (e.g., justice, autonomy, veracity, fidelity)

Rule-utilitarians (Rule-consequentialists)

Application of the ethical principle that produces the best consequences

Formulary

• A listing of drugs intended to include a large enough range of meds and sufficient info about them to enable health practitioners to prescribe treatment

• A list of preferred pharmaceuticals to be used by a managed care plan’s network physicians, chosen based on drugs’ efficacy, safety, and cost-effectiveness

What ethical principles might apply?

Ethical principles possibly applicable to formulary decisions:

• Justice - Distribution of scarce “insurance” resources, as well as drug resources

• Beneficence and nonmaleficence - Do what’s best and avoid harm

• Veracity - Always provide the best for the patient

• Fidelity - Promise to give the best to the patient

• Autonomy - Allow the patient to decide

• Avoid killing - Abortifacients, Euthanasia

Problems with Formulary Systems

• Increasing complexity of drugs challenges abilities of P&T Committees. How or why?

• Many stakeholders are questioning the validity of the use of formulary systems. Why?

• Which is more important: drug cost or drug benefits?

• Beneficiaries of insurance plans want what was prescribed - not what the insurance plan (i.e. PBMs) wants them to have.

• Who is making the health care decisions: Insurance companies (PBMs) or health care personnel?