L7 - Clinical Neuroethics

Give an example of challenging clinical scenarios

• patient with dementia at risk of choking still wants to continue eating favourite solid food

• patient being certified for involuntary psychiatric treatment (legal process where individuals with severe mental disorders are getting treatment without their consent) refuses to take antibiotics for a urinary tract infection

• patient insisting on getting MRI scans for a minor back pain → demanding inappropriate care

What is defined as Clinical (Neuro)Ethics? (conceptualized on 3 levels)

• Metaethics / Logic of ethics

  • is it right/wrong and WHY do we think that

• Normative ethics / Moral theories

  • what makes a good life based on : deontology (rules), consequentialism (outcome), virtue (personal values)

• Applied ethics → making a choice

  • what is the right thing to do, which values should be prioritized

What are the principles of biomedical ethics? (4) + some limitations

• Autonomy

• Beneficence → best interest

• Maleficence → do no harm

• Justice

FLAWS: cultural differences & conflict between principles

Discuss the other applied approaches to health care ethics (3)

• Relational ethics = how you interact with patient based on context

  • looking at relationships between people

  • bottom up approach: address the contextual relationships & emotional knowledge before applying the universal principles

• Narrative ethics = how you understand patient through history & story

  • build an understanding of patient’s history and life context

• Rights based = how you treat patient as a human (universal rules)

  • basic human rights

What is the modern understanding of autonomy? (how has the definition changed?)

• relationships and social environments can contribute to a sense of self without imposing specific beliefs

• BEFORE: moral if you’re obedient

• NOW: make decisions without external influences

What are the criteria for assessing capacity? (4) + discuss the pros & cons of this approach

• Understanding the information

• Reasoning about the information

• Communicating a choice

• Appreciating the implications for one’s own life

PROS: prevent any misinformation, protect autonomy, assess patient’s decision making ability so focus on the process rather than just the outcome of the choice

CONS: subjectivity based on personal background, choice made may be contradictory so it shows lack of capacity, patient can reason the information but not necessarily applying it

Why is there the capacity challenge? => challenges with capacity assessments

• different assessment tools

• time consuming

• variety in training and experience in capacity assessment

Discuss the important things to consider on capacity/capability (3) + misconceptions on incapability (3)

• Capacity is => task specific (capable for some and incapable for others)

• Capacity can => fluctuate (timing)

• Capacity should be => attempted (making efforts) to include patients in decision making

Incapable is NOT

• refusing care

• living at risk

• immutable traits

Define encumbered capacity

decrease in decision making ability (capacity) due to a reversible reason such as

• mental health condition

• emotional state

• undue influence/coercion/pressure

• lack of information

Define the principle of precedent autonomy + what is advance directives

• ability to respect an individual’s preferences for future decisions in case they no longer have the capacity to do so in the future

  • e.g. allows for capable past self to make decisions for incapable future self

• Advance directives: legal document providing directions for care provider on decision making (EX: accept/refuse a drug)

What does it mean to be living at risk? + when is it ethically necessary to intervene?

Living at risk = engaging in behaviour that may result in negative consequences for the person or others in physical, emotional, or psychological ways

Things to consider when assessing the nature of possible harm & process of intervention :

• severity of the risk → how to reduce to tolerable level?

• patient / sub decision maker ok with the intervention?

• harmful to others VS self (patient) possible?

• team makes decision for patient VS assess patient’s capacity

• document and monitor the resulting intervention

Explain the GUIDE framework

Framework for an ethical decision making

• Gather info & learn → background

• Understand & prioritize values → patient’s values

• Identify & weigh options → options

• Decide, implement & communicate → decision

• Evaluate & revisit decision → evaluation

Discuss the procedural VS substantive considerations + some examples of each

Procedural = process

• we make decisions collaboratively & work together (with patient and their close ones)

  • shared decision making / review panel (assess ethics) / triage protocol (allocate resources depending on case of patient)

Substantive = outcome

• we pursue end goals & values to weigh

  • avoid restraint / provide enough pain control / respect capable refusal