HTH 423: Final Exam Review

ethics (moral philosophy)

study of morality using the tools and methods of philosophy

Normative ethics

search for, and justification of, moral standards, or norms, understanding what is right or wrong for a culture

Metaethics

study of the meaning and justification of basic moral beliefs (large scale, across populations and cultures)

Applied ethics

use of moral norms and concepts to resolve practical moral issues

Bioethics

applied ethics focused on health care, medical research, and medical technology

moral norms

normative dominance, universality, impartiality, reasonableness

normative dominance

one norm is more important (present) than another norm

universality

norm applicable in numerous places around the world, has not happened

impartiality

going into a situation without bias or judgement towards it

reasonableness

an idea should make sense, use logic to apply it, and outcome should be appropriate

Absolute principle

applies without exceptions (ex. santa claus)

Prima facie principle

applies in all cases unless an exception is warranted (ex. Abortion with exceptions based on situational factors, stealing is wrong unless it's to save a life)

Autonomy

the ability to choose for yourself

Nonmaleficence

do no harm, inaction, deliberately performing an action tht harms or injures a patient (ex. Using chemicals that are expensive but do not cause birth defects instead of using cheap chemicals that cause birth defects)

Beneficence

do good, action, weakness of requiring you to make the good choice, (ex. Cancer --> perform operation --> get rid of cancer)

Utility

do more benefit / good than harm, it should have a benefit

Justice

idea of fairness

Ethical relativism

view that moral standards are not objective but are relative to what individuals or cultures believe

Subjective relativism

view that right actions are those sanctioned by a person
-actions are sanctioned by the subject

Cultural relativism

view that right actions are those sanctioned by one's culture

Obligations and values

- Moral obligations concern our duty, our actions
- Moral values concern things we judge to be morally good, bad, praiseworthy, or blameworthy (character or motives)
- Actions are morally right or wrong

Moral objectivism

view that there are moral norms or principles that are valid or true for everyone

argument

at least one statement (premise) providing support for another statement (conclusion)

Deductive argument

argument intended to give logically conclusive support to its conclusion

Inductive argument

argument intended to give probable support to its conclusion, not designed to support their conclusions decisively

Moral argument

one whose conclusion is a moral statement
- Has at lease one moral premise
- Has at least one nonmoral premise

Morality

beliefs regarding morally right and wrong actions and morally good and bad persons or character

Paternalism

overriding of a person's actions or decision-making for her own good
Ex. Physician tries to spare feeling of a competent, terminally ill patient by telling her that she will eventually get better, even though she insists on being told the truth

Dunning-Kruger effect

phenomenon of being ignorant of how ignorant we are, the dumber you are the more confident you are that you're not actually dumb

confirmation bias

resisting conflicting evidence but also seeking out and using only confirming evidence

Motivated reasoning

reasoning for the purpose of supporting a predetermined conclusion, not to uncover the truth

Availability error

rely on evidence not because its trustworthy but because it is memorable or striking, psychologically available

Distributive justice

looks at the balance of burdens vs. benefits

Procedural justice

equal application of the laws, regulations, policies, etc.

Moral theory

explains why an action is right or wrong, explains why a person's character is good or bad, yet to be proven
- What is it about an action that makes it right?
- Moral theories alone are not the ultimate authority in moral deliberations
-Moral deliberations involve both the general and the particular - theory, principles, and considered judgements

Theories of obligation (action)

moral theories concentrating on right and wrong actions

Virtue based theories

moral theories focused on good and bad persons or character

Consequentialist moral theories

insist that the rightness of actions depends solely on their consequences, results, or outcomes

Ex. Stealing is wrong because it causes more harm (consequence) than good
Ex. Torture of one person to save a million lives is ethical (the consequence of saving more lives outweighs the torture of one life)

Deontological (nonconsequentialist) theories

the rightness of actions is determined not solely by their consequences but partly or entirely by their intrinsic nature
- The action itself is either unethical or ethical

Ex. Stealing is inherently wrong regardless of its consequences, good or bad
Ex. Torture is wrong regardless of whether lives are saved

Utilitarianism

right actions are those that result in the most beneficial balance of good over bad consequences for everyone involved
- The greatest good, everyone considered
-Similar to consequentialism

Act-utilitarianism

the rightness of actions depends solely on the relative good produced by individual actions, based on the outcome not intention
Act is good or bad depending on the outcome

Ex. A person with a bomb is standing on a bridge with other people, is it ethical to push the person with a bomb off the bridge?

It would be ethical because it is saving more people

Rule-utilitarianism

avoids judging rightness by specific acts and focuses instead on rules governing categories of acts
-A right action is one that conforms to a rule that, if followed consistently, would create for everyone involved the most beneficial balance of good over bad
-Following rules make an act right or wrong

Ex. If a person is on the operating table, is it ethical to kill the person and use the organs to save others?
Rule: Doctors can't kill one person to save another
It would be unethical because of the rule

Kant's categorical imperative

all of our moral duties are expressed in the form of categorical imperatives
-Similar to deontological (nonconsequentialist) theories

Principlism

theory that right actions are not necessarily those sanctioned by single-rule theories such as utilitarianism, but rather by reference to multiple moral principles that must be weighed and balanced against each other
-Not only one theory should applied, but multiple values and principles weighed against each other

Divine command theory

morality depends fundamentally on religion, the moral law is constituted by the will of God
-Right actions are those commanded by God, and wrong actions are those forbidden by God

Natural law theory (St. Thomas Acquanes)

right actions are those that conform to moral standards discerned in nature through human reason
-if it is in nature, it must be good

Tests of morally permissibility

1. The action itself must be morally permissible
2. Causing a bad effect must not be used to obtain a good effect (the end does not justify the means)
3. Whatever the outcome of an action, the intention must be to cause only a good effect (the bad effect can be foreseen but never intended)
4. The bad effect of an action must not be greater in importance than the good effect

AIM High

action, intent, mean, whether or not the balance is higher

Doctrine (principle) of double effect

affirms that performing a bad action to bring about a good effect is never morally acceptable but that performing a good action may sometimes be acceptable even if it produces a bad effect
-Always wrong to intentionally perform a bad action to produce a good effect, but doing a good action that results in a bad effect may be permissible if the bad effect is not intended although foreseen

Contractarianism (Rawl's)

moral or political theories based on the idea of a social contract, or agreement, among individuals for mutual advantage
- What is in the agreement is ethical
Ex. Bdsm contracts

Principles contractarianism

-Each person is to have an equal right to the most extensive total system of equal basic liberties compatible with a similar system of liberty for all
-Social and economic inequalities are to be arranged so that they are both
A . To the greatest benefit of the least advantaged and …
B. Attached to offices and positions open to all under conditions of fair equality of opportunity

Demands of the first principle must be satisfied before satisfying the second, and the requirements of part b must be met before those of part a

Virtue ethics (nicomanchian ethics)

focuses on the development of virtuous character, character the key to the moral life for it is from virtuous character that moral conduct and values naturally arise
-What is ethical or unethical is determined by if the person meets the virtues

Ex. Kindness, if you walk past a homeless person and do not give food, you are violating kindness and the action is unethical

Ethics of care

heart of the moral life is feeling for and caring for those with whom you have a special intimate connection with, distinctive moral perspective that arose of feminist concerns and grew to challenge core elements of most other moral theories
-Showing care and concern for another person, looking at how you treat people

Ex. If your grandmother is moving houses and you refuse to help, you care for that person but you are not showing care or love for that person and is unethical

Feminist ethics

approach to morality aimed at rethinking or revamping traditional ethics to eliminate aspects that devalue or ignore the moral experience of women
- Generally downplays the role of moral principles and traditional ethical concepts
- Moral reflection must take into account the social realities (social practices, relationships, institutions, power arrangements)
- Viewpoint from a woman's perspective

Feminist ethics assumptions

1. Women's moral concerns are not as important as men's
2. Women are morally inferior to men (less mature or rational)
3. The moral issues that arise from domestic or private life (the area traditionally relegated exclusively to women) are inconsequential, and
4. The concepts or virtues traditionally associated with women in Western cultures (community, nature, interconnectedness, caring, feeling, sharing, among others) are not central to morality

Casuistry

method of moral reasoning that emphasizes cases and analogy rather than universal principles and theories, moral judgements are supposed to be deduced
- Reasonable moral judgements are arrived not by applying theories, rights, and rules, but by paying careful attention to specific cases and circumstances
- Judgments about new cases are made by analogy with similar or paradigm cases

Criterion I

consistency with our considered moral judgements
- are the facts with one case similar with the facts in another case

Criterion II

consistency with the facts of the moral life

Criterion III

resourcefulness in moral problem-solving

Autonomy

person's rational capacity for self-governance or self-determination, ability of a person to make decisions for themselves

Weak paternalism

paternalism directed at persons who cannot act autonomously or whose autonomy is greatly diminished (may be psychotic, intellectually disabled, extremely depressed, those with cognitive difficulties, or acutely addicted)

Ex. Children cannot understand the complexities of vaccines

Strong paternalism

overriding of a person's actions or choices, even though he is substantially autonomous

Ex. When a teenager is taken to get a vaccine by their parents or if the teenager wants the vaccine but the parents will not allow

Refusing treatment

the courts have established the principle that a competent patient has a right to reject recommended treatments, even life-saving ones

problems associated with refusing treatment

- The patients are "mature minors," does not exist in VA, courts can determine the person is able to make their own decision
Ex. My sisters keeper
- Parents reject medical treatment for their minor children
Ex. Parents refusing cancer treatment

Physician autonomy

freedom of doctors to determine the conditions they work in and the care they give to patients

Medical futility

alleged pointlessness or ineffectiveness of administering particular treatments
- Physicians may claim that a treatment is futile and therefore should not be used or continued
- Patients or their surrogates may reject the label of futility and insist that everything be done that can be done
- Physicians appeal to this principle: physicians are not obligated to provide treatments that are inconsistent with reasonable standards of medical practice

Ex. Life support will not bring someone back who is brain dead

Advanced directive

legal document that allows you to express your values and desires related to end-of-life care
- Medical technology is moving quicker than ethics: we have not always been able to sustain life through technology, our morals have not developed around theses new scenarios
- Even though we may be able sustain life, there are other medical burdens that need to be taken into account

DNR

directive telling the medical staff to forgo CPR on a patient if his heart or breathing stops

Moral conflicts in nursing

nurses must come to terms with many of the same moral questions and principles that weigh so heavily on physicians, first line of care and the people patients trust and look to
- beneficence versus patient autonomy
- patient-provider confidentiality
- truth-telling
- refusal of treatment
- informed consent
- futile treatment

Main argument in favor of truth-telling

we must always respect the principle of autonomy (rational capacity for self-determination), full disclosure respects their autonomy, without truth-telling a person cannot be autonomous
- Autonomous persons must be allowed to freely exercise the capacity to decide how to live their own lives and what can and cannot be done to their own bodies
- Deception is failing to respect their autonomy

Deception

not intentionally providing false information (lying) but deliberately misleading patients by withholding crucial facts and avoiding definite statements

Confidentiality

obligation or pledge of physicians, nurses, and others to keep secret the personal health information of patients unless they consent to disclosure

- Concerns patients imparting information to health professionals who promise, implicitly or explicitly, not to disclose that information to others

Right to privacy

authority of persons to control who may possess and use information about themselves

Ex. Getting undressed: closing the door while changing gives you privacy (controlling who comes in and out of the room, who has the information, privacy), once the doctor comes in the room they don't tell people outside what they see (once the person has the information they don't share it, confidentiality)

Truth-telling and cultural diversity

- The truth is an essential tool that allows the patient to maintain a sense of personal agency and control, telling the truth is empowering (used in the US)
- The truth is traumatic and demoralizing, sapping the patient of hope and the will to live, truth-telling is an act of cruelty (shown in the article about the Massai)

Arguments for confidentiality

- Without respect for confidentiality, physicians would have a difficult time fulfilling their duty of beneficence
- Without respect for confidentiality, trust between physician and patient would break down
- Disclosure of confidential medical information could harm patients
- Persons have a right to privacy

Conflict in confidentiality

absolute (applying in all cases) vs. prima facie (allowing exceptions when other duties obtain)
- If the person is going to harm themselves, another person, or the public at large, prima facie applies (you do not have to tell everyone, just someone)

The duty to warn

many believe that exceptions to confidentiality are justified when confidentiality must be weighed against other duties, such as the duty to prevent serious harm to the patient or others

Tarasoff v. Regents of the University of California (1976)

court held that duties of patient-psychotherapist confidentiality can be overridden when "a patient poses a serious danger of violence to others"
- conflict between a duty of confidentiality and a duty to warn

Principles-approach

to ethics applies principles to ethical situations (beneficence, justice, etc.)

Anthropological approach

use local societal norms and cultural perspectives
-Places emphasis on the dilemmas resulting from cultural pluralism, thus because we are different there are ethical issues

Ethno-medical

approach to medical ethics, which would encompass a broad range of areas, including complex relationships that exist between healers and patients, among groups of healers, and between healers and the larger society

Collective autonomy

concept that decisions and consent are made by the group

Informed consent

action of an autonomous, informed person agreeing to submit to medical treatment or experimentation

Thought to be an ethical ideal in which physicians are obligated to tell patients about possible medical interventions and to respect their choices regarding them

Legal requirement, compelling health care providers to disclose information about interventions to patients and obtaining their permission before proceeding

Conditions of informed consent

1. The patient is competent to decide
2. The patient gets an adequate disclosure of information
3. The patient understands the information
4. The patient decides about the treatment voluntarily
5. The patient consents to the treatment

Competence

ability to render decisions about medical interventions

Individuals who are incompetent cannot give their informed consent, in which case the burden of decision-making falls to a surrogate (often a court-appointed guardian or a proxy selected through the patient's advanced directive)

mandated disclosure

1. The nature of the procedure (whether it is a test or treatment, whether it is invasive, and how long it will take to perform)
2. The risks of the procedure (what kind of risks are involved, their seriousness, their probability of occurring, and when they might happen)
3. The alternatives to the proposed procedure, including the option of no treatment (includes information on the options' nature, risks, and benefits)
4. The expected benefits of the proposed treatment, including their extent and their likelihood of being achieved

Decision-making capacity

involves determining whether or not a patient or subject is psychologically or legally capable of adequate decision-making

- Relates to the specific medical decision at hand and does not imply a global ability to make any or all decisions about health care or other matters
- Lacking decision-making capability may result in decisions contrary to one's best interests
- If decision-making capacity is intact, the physician generally should respect the patient's choices

Waiver

patient's voluntary and deliberate giving up of the right to informed consent, exercise in autonomous choice (the choice to not to choose or decide)

Therapeutic privilege

withholding of relevant information from a patient when the physician believes disclosure would likely do harm

Some patients are so distraught, depressed, or weak that disclosure could make their condition worse

Schloendorff v. Society of New York Hospital (1914)

"every human being of adult years and sound mind has a right to determine what shall be done with his own body," but there was no suggestion that any consent had to be informed

Salgo v. Leland Stanford Junior University Board of Trustees (1957)

physician's disclosure of information firmly tied to the patient's consent

"a physician violates his duty to his patient and subjects himself to liability if he withholds any facts which are necessary to form the basis of an intelligent consent by the patient to the proposed treatment"

"have the duty to disclose any facts which are necessary to form the basis of an intelligent consent by the patient to proposed treatment"

Natason v. Kline (1960) and Mitchell v. Robinson (1960)

these decisions further specified the information to be conveyed to patients, insisting that the risks involved in medical procedure should be disclosed

Cobbs v. Grant (1972)

California Supreme Court held that disclosure must consist of "all information relevant to a meaningful decisional process"

Canterbury v. Spence (1972)

U.S. Court of Appeals ruled that the adequacy of disclosure by a physician should not be judged by what the medical profession thinks is appropriate but by what information the patient finds relevant to his or her

can break HIPAA when

-threats of violent
-abuse of minors
-duty to warn (differs by state)
-sexual misconduct
-communicable diseases
-weapon related injuries

threats of violence

mental health service provider has a duty to take precautions to protect third parties from violent behavior or other serious harm if the provider reasonably believes the client has the intent and ability to carry out that threat immediately or imminently; if there is any evidence of physical or sexual abuse against a child the health care provider must report it

Actions that can be take by a provider

-Seeks involuntary admission of the client
-Makes reasonable attempts to warn the potential victims or the parent or guardian of the potential victim
-Make reasonable efforts to notify a law-enforcement official
-Takes steps reasonably available to the provider to prevent the client from using physical violence
-Provides therapy or counseling to the client or patient in the session in which the threat has been communicated until the client no longer has the intent or ability to carry out the threat
-In the case of a registered peer recovery specialist, or a qualified mental health professional, reports immediately to a licensed mental health service provider to take one or more of the actions set forth in this subsection

abuse of minors

confidentiality can be broken and there is a requirement that certain injuries to children be reported by physicians, nurses, teachers, etc. by any person licensed to practice medicine or any of the healing arts, sexual misconduct

Penalty for failure to report- "shall be fined not more than $500 for the first failure and for any subsequent failures not less than $1,000"

In cases evidencing acts of rape, sodomy, or object sexual penetration a person who knowingly fails to report shall be guilty of a Class 1 misdemeanor

JMU mandated reporting

all university employees (except confidential resources defined above) are responsible employees (student employees are covered by this definition)

all responsible employees must disclose any reports of sexual misconduct, including reports that they receive within the course of their employment to a Title IX officer

Designated reporters

must report an offense to the university’s Title IX coordinator under any circumstances. These include high-level and supervisory employees, including the president, vice presidents, deans and athletic directors. Resident advisers and campus police officers also fall into this category