HAN 335 Ethics Midterm

Doherty's six-step process (list all 6)

1) Gather relevant information 2) Identify the type of ethical problem 3) Use ethical theories/approaches to analyze 4) Explore practical alternatives 5) Complete the action 6) Evaluate the process and outcome

Six-step process: Step 1

Gather relevant information - get the story/facts straight; separate clinical, legal and ethical content

Six-step process: Step 2

Identify the type of ethical problem - moral distress, ethical dilemma, and/or locus of authority

Six-step process: Step 3

Use ethical theories or approaches to analyze the problem (narrative, utilitarian, deontology, virtue, principles)

Six-step process: Step 4

Explore the practical alternatives - what you CAN do once you know what you SHOULD do; openness and creativity; include a least-restrictive option

Six-step process: Step 5

Complete the action - requires resolve and moral courage; without action it's just a 'philosophic exercise'

Six-step process: Step 6

Evaluate the process and outcome - reflect on what went well, what was hard, what you'd do differently

Is 'report the problem' one of the six steps?

No

Goal of the six-step process / professional ethics

To arrive at a caring response; primary loyalty is to the patient

Four parts of ethical reasoning (Week 1)

Recognize, Analyze, Seek resolution, Act

Autonomy

Patient's right to decide for themselves (self-determination); requires liberty (freedom from controlling influences) and agency (capacity for intentional action)

Two conditions of autonomy

Liberty (freedom from controlling influences) and agency (capacity for intentional action)

Beneficence

Act in the patient's best interest - prevent harm, remove harm, bring about good; ACTIVE. 'I am in a position to benefit someone'

Nonmaleficence

Do no harm (primum non nocere); refrain from abuse; somewhat PASSIVE. 'I am in a position to harm someone'

Fidelity

Faithfulness to promises/commitments - to the patient, self, colleagues, institution and profession

Veracity

Telling the truth about diagnosis, prognosis and treatment options

Therapeutic privilege

Uncommon exception to veracity: withholding the truth when it would harm the patient more

Justice (distributive)

Fair, proper distribution of benefits and burdens; fair, equitable treatment for all patients

Confidentiality

Keeping harmful, shameful or embarrassing information within proper bounds; an ethical DUTY self-imposed by the profession; the basis of trust

Paternalism ('when applicable')

'I am in a position to decide for someone else'

Absolutism

There is one right answer for an ethical outcome

Relativism

Other people's views count

Do ethical principles give you the right answer?

No - they guide decisions and help balance duties to patients, families, colleagues and society

Ethical dilemma

Two or more courses of action, and no one outcome feels completely 'right'

Moral distress

Challenge to maintaining your integrity or the profession's integrity - 'something is blocking me from taking ethical action'

Locus of authority problem

Uncertainty about who should be the primary decision-maker ('who decides?')

Clear authority, but the WRONG person has it =

Moral distress (textbook)

Amrou Croteau case - main problem type

Moral distress (also a possible dilemma and a locus of authority/moral agency issue)

Baby Fae - main problem type

Locus of authority (can parents volunteer a child for an experimental procedure?)

Baby M - main problem type

Ethical dilemma (which family gets custody)

Barney Clark - main problem type

Ethical dilemma (too old for a human heart vs. an unproven artificial heart)

Deontology

Duty-driven; the MEANS count; acting rightly = acting according to duties and rights (Kant)

Utilitarianism / teleology

Outcome/goal-driven; the ENDS count; best balance of benefits over burdens - 'greatest good for the greatest number' (Bentham, Mill)

Immanuel Kant

Deontologist; veracity is absolute (lying is always wrong); autonomy = self-legislation

Jeremy Bentham & John Stuart Mill

Utilitarians who opposed Kant

Mill's view of autonomy

A person's actions can be restricted only when they threaten to harm someone else

Virtue ethics

Focuses on moral character (who you are) - compassion, courage, honesty, respectfulness; framework from Aristotle

Aristotle

Provided the basic framework of virtue ethics

Narrative approach

Keeps the relevant details of the patient's story at the center of deliberation

Rule utilitarian

Hybrid of deontological and utilitarian approaches

Deontology example

Refusing to lie about a diagnosis because truth-telling is a duty, even if it causes distress

Utilitarian example

Giving scarce ventilators to patients most likely to survive to save the most lives

Ethics (definition)

The systematic reflection on and analysis of morality

Morality includes

Values, duty and character

Three levels of morality

Personal (your own compass), group (profession, religion, workplace), societal (community standards)

Moral integrity

The sense of integrity you feel when you act in line with your personal values

'Moral thing to do' vs 'ethical thing to do'

Moral = follow traditions/customs/laws; ethical = you reflected on it and used moral judgment

Law vs ethics

Law: government-defined, minimum standard, 'must', coercive. Ethics: individual/community, ideal, 'should', noncoercive

Caring response

Ethical goal of every professional-patient relationship; patient is the primary focus of loyalty

Paternalism

Deciding FOR the patient instead of WITH them 'for their own good' (incl. withholding info); limits autonomy

Strong (hard/extended) paternalism

Overrides the decision of a COMPETENT patient

Weak (soft/limited) paternalism

Overrides the decision of a DOUBTFULLY competent patient

Physician picks a treatment without consulting a competent patient

Strong paternalism

Public health mandates (e.g., mandatory isolation, seat belt laws)

Examples of paternalism; overriding a competent adult = strong paternalism

Is paternalism the same as a health care proxy?

No - a proxy carries out the PATIENT'S own wishes

Quiet paternalism (pitfall)

Avoid it - always do a capacity check and choose the least-restrictive option

Informed consent

A PROCESS, not just a signature - patient gets clear information and freely agrees; verbal or written

Five key parts of informed consent

Information, Understanding, Voluntariness, Capacity, Consent

Elements of informed consent

Explain the condition, explain the procedure with risks/benefits, alternatives (incl. no treatment), time for questions, right to withdraw without penalty

Implied consent

Actions or situation show agreement (rolling up a sleeve), OR an emergency: patient unconscious/incapable, no surrogate, immediate danger

Expressed consent

Clearly stated agreement - verbal, written, or non-verbal but unmistakable (nodding); usually simple, common procedures

Involuntary consent

Not true consent - court-ordered or legally imposed; e.g., mentally ill, behavioral crisis, I/DD, psychiatric commitment

Oxygen for a patient who is losing consciousness

Implied consent (emergency)

Can a patient withdraw consent after signing?

Yes - at any time, without penalty

Capacity

MEDICAL/clinical concept - ability to weigh medical info to make decisions; can fluctuate

Competence

LEGAL term - everyone is presumed competent until a court rules otherwise

Criteria for decision-making capacity

Communicate a choice, understand the info, appreciate the situation/consequences, reason about options

HIPAA year

1996 (privacy rule took effect April 2003)

Who enforces HIPAA?

DHHS Office for Civil Rights (OCR)

HIPAA covered entities

Health plans, health care clearinghouses, and providers who transmit health info electronically

PHI

Individually identifiable health information held or transmitted by a covered entity, in any form (electronic, paper, oral)

How many identifiers must be removed to de-identify PHI?

18

Two REQUIRED disclosures under HIPAA

To the patient when they request access/accounting, and to DHHS during an investigation

PHI may be shared without authorization for

Treatment, payment and healthcare operations (plus public interest activities, facility directories, limited data sets)

Student education records are covered by

FERPA (1974), not HIPAA

Confidentiality vs privacy

Confidentiality = ethical obligation of the profession; privacy = legal right of the patient

When can confidentiality be broken?

Patient threatens self or others (third parties), or required by law: communicable disease, occupational disease, wounds of violence, suspected abuse, loss of consciousness

'Need to know' test

Does this person need the info to provide the most caring response?

HITECH Act

2009; promoted EHRs and strengthened HIPAA privacy/security and breach notification

Breach affecting 500+ people

Notify OCR within 60 days and prominent media

Aetna HIPAA case

'HIV medication' visible through envelope windows; paid $1,000,000

Notice of Privacy Practices

Must be available on request and posted prominently

Patient Self-Determination Act (PSDA)

Federal law (1990, after Cruzan): patients must be asked on admission whether they have an advance directive

Advance directives (2 types)

Living will and durable power of attorney for healthcare (health care proxy)

Luis Kutner

Coined the 'living will' (1969)

Health care proxy

Legal document appointing a trusted adult (18+, two witnesses) to decide only when you can't; must follow your wishes, or your best interest if wishes are unknown

Moral repugnance / conscience clause

Allows a provider to refuse to take part in procedures they find morally objectionable (came from Roe v. Wade); burden of proof is on the clinician

State interests (4)

Save a life, prevent suicide, protect innocent third parties, protect the integrity of the professions

Right to a safe environment

Clean and safe environment free of unnecessary restraints (Patient Bill of Rights)

Who protects belongings kept by the patient?

The patient (Patient Responsibilities #9)

Professional code of ethics

Official statement of a profession's duties; sets the bar ABOVE the legal floor; published by national associations (ANA, AMA, APTA, AOTA…)

Whistle-blowing

Reporting an impaired, unethical or incompetent colleague to leadership or government agencies; prosocial; requires moral courage

Professional responsibility (Niebuhr)

Accountability + Responsiveness

Does following unethical orders excuse you?

No - you are accountable for your own actions ('the buck stops here')

Ethics committees

Multidisciplinary (nurses, physicians, chaplains, social workers, lawyers); grew after Quinlan (1976)

Nancy Cruzan

Missouri, 1983-1990; persistent vegetative state after a car crash; parents wanted the feeding tube removed; led to the PSDA

Cruzan - Missouri Supreme Court standard

'Clear and convincing evidence' of the incompetent patient's wishes

Cruzan - US Supreme Court (1990)

Competent people can refuse life-prolonging treatment, incl. nutrition/hydration; states may require clear and convincing evidence for incompetent patients

Elisabeth Kübler-Ross

'On Death and Dying'; 5 stages of grief

Kübler-Ross 5 stages of grief

Denial, Anger, Bargaining, Depression, Acceptance