Biomedical Ethics MPAS 5005 Review PDF

Lincoln M. McGinnis, M.D. Biomedical Ethics MPAS 5005 Class of 2026 Introduction to Medical Ethics – Review PRESBYTERIAN COLLEGE CONFIDENTIAL Ethics = Moral Philoso...

Lincoln M. McGinnis, M.D. Biomedical Ethics MPAS 5005 Class of 2026 Introduction to Medical Ethics – Review PRESBYTERIAN COLLEGE CONFIDENTIAL Ethics = Moral Philosophy Branch of philosophy that deals with moral considerations. Systemizes, defends, and recommends concepts of right and wrong behavior. Deals with systems of moral rules or principles. Value judgements about behavior or character. right versus wrong goodness or badness Concerned with what is good for individuals and society. Ethics and Conscience are different. – Ethics involve a series of systematic beliefs guided by society. – Conscience refers to thoughts about one’s personal beliefs and actions  Greek word ethos which can mean custom, habit, character or disposition. Ethics considers the following: how to live a good life our rights and responsibilities, individually and collectively the language of right and wrong moral decisions - what is good and bad? – Our concepts of ethics have been derived from religions, philosophies and cultures. They infuse debates on topics like abortion, human rights and professional conduct. Broad Categories of Ethics and Medicine / Biology ETHICS Applied Normative Metaethics Ethics Ethics Bioethics Moral philosophy of Biological Science Medical Professional Research Clinical Ethics Ethics Ethics Normative Ethics: Virtue-Based Ethics Individual values determine ethical issues, – emphasizes the moral character, or virtues of the individual. – Virtues drive conduct, for example, wisdom, courage, temperance, and justice (the cardinal virtues). Principlism is an example of Virtue-based ethics – Principlism is a commonly used in healthcare (Tom Beauchamp and James Childress). – key ethical principles (autonomy, beneficence, non-maleficence, and justice) – most ethical approaches blend these virtues or principles with practical, legal, and regulatory considerations and elements of ethical theories which are compatible with most societal, individual or religious belief systems.  Principlism is One approach to health care ethics was actually developed as a result of its originators’ belief that, especially, utilitarian and deontological ethical theories were inadequate to deal effectively with the issues that had arisen in medical ethics in particular. Tom Beauchamp and James Childress introduced their “four principle approach” to health care ethics, sometimes referred to as “principlism,” in the final quarter of the 20th century. Central to their approach are the following four ethical principles: 1) respect for autonomy, 2) nonmaleficence, 3) beneficence, and 4) justice. These four ethical principles, in conjunction with what are identified as moral rules and moral virtues, together with moral rights and emotions, provide a framework for what they call the “common morality.” This common morality is put forward as the array of moral norms, which are acknowledged by all people who take seriously the importance of morality, regardless of cultural distinctions and throughout human history and so are said to be universal. However, given the abstract nature of these ethical principles, it is necessary to instantiate them with sufficient content so as to be able to be practically applicable to particular cases of moral decision-making. Statement of Values of the PA Profession PAs hold as their primary responsibility the health, safety, welfare, and dignity of all human beings. PAs uphold the tenets of patient – autonomy, – beneficence, – nonmaleficence, and – justice. Normative Ethics: Consequential Approach Right or wrong decisions are determined by the outcome. This balances good over bad consequences. “The end justifies the means.” Consequentialist ethics holds the view that the correct moral response is related to the outcome, or consequence, of the act. Consequentialist theories are sometimes called teleological theories, from the Greek word telos, or end, since the end result of the action is the sole determining factor of its morality. Autonomy: Definition Autonomy, strictly speaking, means self-rule. Patients have the right to make autonomous decisions and choices, and PAs should respect these decisions and choices. – Patient has freedom of thought, intention and action when making decisions regarding health care procedures – For a patient to make a fully informed decision, she/he must understand all risks and benefits of the procedure and the likelihood of success. Beneficence: Definition Beneficence means that PAs should act in the patient’s best interest. In certain cases, respecting the patient’s autonomy and acting in their best interests may be difficult to balance. – Beneficence means that all medical practitioners have a moral duty to promote the course of action that they believe is in the best interests of the patient. Nonmaleficence: Definition Nonmaleficence means to do no harm, to impose no unnecessary or unacceptable burden upon the patient. – Non-maleficence states that a medical practitioner has a duty to do no harm or allow harm to be caused to a patient through neglect. Any consideration of beneficence is likely, therefore, to involve an examination of non-maleficence. – Beneficence vs Nonmaleficence Do good vs. Do no harm. Rules of beneficence state positive requirements of action, and rarely provide moral reasons that support legal punishment when agents fail to abide by the rules of beneficence. Justice: Definition Justice means that patients in similar circumstances should receive similar care. Justice also applies to norms for the fair distribution of resources, risks, and costs. – Justice – in the context of medical ethics – is the principle that when weighing up if something is ethical or not, we have to think about whether it’s compatible with the law, the patient’s rights, and if it’s fair and balanced. The distribution of scarce health resources, and the decision of who gets what treatment “fairness and equality” The burdens and benefits of new or experimental treatments must be distributed equally among all groups in society Fair distribution of scarce resources Competing needs Rights and obligations Potential conflicts with established legislation Clinical Ethics seeks to balance Ethical Ideals Approaches to Resolving Clinical Ethical Dilemmas Many approaches, but common threads: – Defining the dilemma, medical facts, stakeholders and their concerns, beliefs, contextual legalities. – Defining ethical issues and guidelines including legal. – Seeking a consensus on best way to proceed. 1. Three step model 2. Clarification approach [Integrative Model] 3. Four Box Model 4. Clinical Consultative approach Three-Step Ethical Decision-Making Model Three-Step Ethical Decision-Making Model. 1. Is it legal? Typically, if it is not legal it is not ethical or practical. 2. Is it balanced? If it seems extreme to you, it is most likely not balanced. 3. How does it make me feel? This is an essential factor in decision making; how you feel (e.g., feeling guilty) is most likely a product of your beliefs and values. Decision making by the clinician involves intentional reflection. Knowing your own values facilitates a logical and practical conclusion and appropriate choice. Practice and experience enhance decision-making skills. The Three-Step Ethical Decision-Making Model is adopted from Kenneth Blanchard and Norman Vincent Peale, The Power of Ethical Management.  Integrative Model: Resolving Ethical Dilemmas Clarifying or defining the problem and ethical conflicts. Outlining the medical facts and issues. Defining the stakeholder’s values and preferences: Patient and their family Caregivers Seeking Consensus Lo, Bernard. Resolving Ethical Dilemmas : A Guide for Clinicians, Wolters Kluwer Health, 2013. ProQuest Ebook Central, The Four Box Model: Four Principles of Bioethics The Four Box Model: Four Principles of Bioethics 1. Medical Indications (Beneficence and Nonmaleficence) – Medical issues; benefits and risks of treatment 2. Preferences of Patients (Autonomy): – informed consent & decisions 3. Quality of Life (Beneficence and Nonmaleficence and Autonomy) – Cure, palliate, or support at end of life 4. Contextual Features (Justice) – Legalities, patient stakeholders, clinicians Jonsen AR, Siegler M, Winslade WJ. eds. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, 8e. McGraw-Hill; Accessed September 27, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=1521&sectionid=88929324 The Four Box Model: Box 1, Medical Indications Beneficence and Nonmaleficence 1. What is the patient’s medical problem? 2. Acute? Chronic? Critical? Reversible? Emergent? Terminal? 3. What are the goals of treatment? 4. In what circumstances are medical treatments not indicated? 5. What are the probabilities of success of various treatments? 6. What are the risks of treatment? 7. How can this patient best be benefited by medical care, and how can harm be avoided? Jonsen AR, Siegler M, Winslade WJ. eds. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, 8e. McGraw-Hill; Accessed September 27, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=1521&sectionid=88929324 The Four Box Model: Box 2, Preferences of Patients Respect for Autonomy 1. Is the patient unwilling or unable to cooperate with medical treatment? If so, why? 2. Has the patient been informed of benefits and risks of diagnostic and treatment recommendations? Have they understood this information and communicated consent? 3. Is the patient mentally capable (decision making capacity) and legally competent? 4. If mentally capable/competent, what are the patient’s preferences? 5. If incapacitated, has the patient expressed prior preferences? 6. Who is the appropriate surrogate to make decisions for an incapacitated patient? 7. What standards should govern the surrogate’s decisions? Jonsen AR, Siegler M, Winslade WJ. eds. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, 8e. McGraw-Hill; Accessed September 27, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=1521&sectionid=88929324 The Four Box Model: Box 3, Quality of Life Beneficence and Nonmaleficence and Respect for Autonomy 1. What are the prospects, with or without treatment, for a return to an acceptable quality of life? 2. What criteria should evaluate the quality of life of a patient who cannot make or express such a judgment? 3. Are there biases that might prejudice the provider’s evaluation of the patient’s quality of life? 4. What ethical issues arise concerning improving or enhancing a patient’s quality of life? 5. Do quality of life assessment raise any questions that might contribute to a change of treatment plan, such as forgoing life-sustaining treatment? 6. Plans to provide pain relief / comfort after a decision has been made to forgo life-sustaining interventions? 7. Is medically assisted dying ethically or legally permissible? Jonsen AR, Siegler M, Winslade WJ. eds. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, 8e. McGraw-Hill; Accessed September 27, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=1521&sectionid=88929324 The Four Box Model: Box 4, Contextual Features Justice 1. Do decisions about treatment and diagnosis raise issues of fairness? 2. Are there conflicts of interest in the clinical treatment of patients? [financial, personal, professional] 3. Are there parties other than clinicians and patient, who have a legitimate interest in clinical decisions? What are the limits imposed on patient confidentiality by the legitimate interests of third parties? 4. Are there problems of allocation of resources that affect clinical decisions? 5. Are there religious factors that might influence clinical decisions? 6. What are the legal issues that might affect clinical decisions? 7. Are there considerations of clinical research and medical education that affect clinical decisions? 8. Are there considerations of public heath and safety that influence clinical decisions? Jonsen AR, Siegler M, Winslade WJ. eds. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, 8e. McGraw-Hill; Accessed September 27, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=1521&sectionid=88929324  Do decisions about treatment and diagnosis raise issues of fairness? 2. Are there professional, interprofessional, personal, interpersonal or business interests that might create conflicts of interest in the clinical treatment of patients? 3. Are there parties other than clinicians and patient, such as family members, who have a legitimate interest in clinical decisions? 4. What are the limits imposed on patient confidentiality by the legitimate interests of third parties? 5. Are there financial factors that create conflicts of interest in clinical decisions? 6. Are there problems of allocation of resources that affect clinical decisions? 7. Are there religious factors that might influence clinical decisions? 8. What are the legal issues that might affect clinical decisions? 9. Are there considerations of clinical research and medical education that affect clinical decisions? 10. Are there considerations of public heath and safety that influence clinical decisions? Does institutional affiliation create conflicts of interest that might influence clinical decisions? CASES Approach to Clinical Ethics Summary: Clinical Ethics Approaches Common Elements: – Review the medical data and decisions to be made. – Define the stakeholder's viewpoints and interests; Patient Family and Surrogate decision maker Clinicians – Outline the ethical considerations and conflicts. – Seek a consensus solution within legal and ethical boundaries. Summary: Beliefs, Values, and Ethics = Moral Philosophy Normative Ethics and Different Approaches 1. Virtue based ethics and Principlism 2. Consequentialism 3. Deontology or Duty based Statement of Values of the PA Profession Ethical Dilemmas and Biomedical Issues Approaching Clinical Ethical Issues Transference Transference occurs when a patient retains feelings or attitudes associated with childhood which may surface during treatment and be transferred onto the healthcare provider. Counter-transference occurs when the provider experiences feelings for the patient that are out of the norm, such as anger. The primary responsibility for honoring the provider-patient relationship boundaries is in the hands of the healthcare provider. The PA and Patient: PA Role and Responsibilities PAs are professionally and ethically committed to providing nondiscriminatory care to all patients. While PAs are not expected to ignore their own personal values, scientific or ethical standards, or the law, they should not allow their personal beliefs to restrict patient access to care. A PA has an ethical duty to offer each patient the full range of information on relevant options for their health care. If personal moral, religious, or ethical beliefs prevent a PA from offering the full range of treatments available or care the patient desires, the PA has an ethical duty to refer a patient to another qualified provider. That referral should not restrict a patient’s access to care. PAs are obligated to care for patients in emergency situations and to responsibly transfer patients if they cannot care for them. Mandatory Reporting Healthcare professionals must be on the lookout for signs of neglect or abuse. Mandatory reporting laws require healthcare professionals to report suspected cases of abuse. Types of abuse that must be reported are – child abuse (physical, sexual, emotional mistreatment or neglect of a child) and – elder abuse (intentional harm, neglect, exploitation, and abandonment of persons 60 years and older). Which ethical principles may be in conflict? Non-malficence and Autonomy Minors: Overview Legally, minors are considered anyone younger than 18 years of age, the age of “autonomy”. Generally, medical procedures for minors require parental or guardian consent as a surrogate decision maker with responsibility to do what is best for the minor. If a minor has no parent, courts can appoint a guardian ad litem as the legal guardian for all decision-making processes, including health care. Parents can be guardian ad litem for disabled children after their age of majority, or for their elderly parents no longer considered competent. Minors: SC law SECTION 15-1-320. to minors in State laws mean persons under age of 18 years 18, 19, and 20-year-olds became adults in February 1975 “(a) All references to minors in the law of this State shall after February 6, 1975, be deemed to mean persons under the age of eighteen years except in laws relating to the sale of alcoholic beverages; …” 1976 South Carolina Code of Laws Minors: Mature Minor Doctrine The mature minor doctrine provides greater autonomy to minors older than 16 years of age who understand and consent to relatively simple medical procedures. If parents and minors disagree on medical action, the legal system can intervene. Minors: Age of Majority South Carolina The age of majority or when a person becomes a legal adult is 18 years old in South Carolina. Age for Marriage: A person who is at least 16 years old can marry in South Carolina with parental permission. Minors’ Consent to Medical Treatment – A married minor or his or her spouse can consent to health procedures (such as diagnostic, therapeutic, or post-mortem). – Additionally, a minor parent can consent to procedures for his or her minor child. – Finally, a 16 or 17 year old can consent to health services for himself or herself. Another person, such as his or her parent, will only be consulted when a procedure is essential to the health or life of the child according to the doctor and a consulting physician, if available. 1976 South Carolina Code of Laws Minors: Mature Minor Doctrine The mature minor doctrine provides greater autonomy to minors older than 16 years of age who understand and consent to relatively simple medical procedures. If parents and minors disagree on medical action, the legal system can intervene. Elderly Patients: Decision making capacity Elderly competence refers to an individual’s ability to make decisions to live independently. This is a legal definition, not synonymous with decision making capacity. The decision to withdraw or withhold medical treatment requires time to understand the options during the decision-making process. The healthcare professional must serve the patient’s best interests and not make decisions for the patient. HIV/AIDS Patients and Discrimination Fear of contracting HIV has created a stigma than can lead to discrimination. Laws protecting people with HIV/AIDS include: 1. The Americans with Disabilities Act (ADA); the Supreme Court ruled that HIV meets the definition of disability. 2. The Health Insurance Portability and Accountability Act (HIPAA); this helps prevent discrimination against HIV/AIDS patients by keeping their medical condition confidential. The PA and Patient: PA Role and Responsibilities PAs are professionally and ethically committed to providing nondiscriminatory care to all patients. While PAs are not expected to ignore their own personal values, scientific or ethical standards, or the law, they should not allow their personal beliefs to restrict patient access to care. A PA has an ethical duty to offer each patient the full range of information on relevant options for their health care. If personal moral, religious, or ethical beliefs prevent a PA from offering the full range of treatments available or care the patient desires, the PA has an ethical duty to refer a patient to another qualified provider. That referral should not restrict a patient’s access to care. PAs are obligated to care for patients in emergency situations and to responsibly transfer patients if they cannot care for them. SECTION 15-1-310. Liability for emergency care rendered at scene of accident. Any person, who in good faith gratuitously renders emergency care at the scene of an accident or emergency to the victim thereof, shall not be liable for any civil damages for any personal injury as a result of any act or omission by such person in rendering the emergency care or as a result of any act or failure to act to provide or arrange for further medical treatment or care for the injured person, except acts or omissions amounting to gross negligence or willful or wanton misconduct. 1976 South Carolina Code of Laws The PA and Patient: Initiation and Discontinuation of Care A PA and supervising physician may discontinue their professional relationship with an established patient as long as proper procedures are followed. The PA and physician should provide the patient with: – adequate notice, – offer to transfer records, and – arrange for continuity of care if the patient has an ongoing medical condition. Discontinuation of the professional relationship should be undertaken only after a serious attempt has been made to clarify and understand the expectations and concerns of all involved parties. – Also 30 day rule, have to give emergency care for 30 days If the patient decides to terminate the relationship, they are entitled to access appropriate information contained within their medical record. Can a Physician “Fire” a Patient? A provider has a right to release a patient. In June 1996, the American Medical Association (AMA) issued Opinion 8.115 – Termination of the Physician-Patient Relationship. Notice must be given to the patient or patient’s representative sufficiently in advance to permit a replacement. Patients may be dismissed by a provider due to – noncompliance (not following the provider’s advice), – insurance plan participation, – failure to keep appointments, and – nonpayment for services. Valid reasons to end a doctor-patient relationship include: insufficient skills to provide adequate treatment to the patient insufficient supplies or resources to provide adequate treatment ethical or legal conflicts arise during the treatment process the patient violates the physician’s policies the patient has numerous cancelled or missed appointments Noncompliance with the physician’s recommendations, and the patient demonstrates inappropriate behavior, such as making sexual advances or engaging in verbal abuse. Not every situation where a doctor stops treating a patient leads to an actionable claim for medical malpractice. Most don’t, in fact. fact-specific issue, and a doctor’s potential legal liability can vary from state to state. Having said that, there are certain common elements among patient abandonment cases: First, the doctor-patient relationship must be established. This means that the physician must have agreed to treat the patient, and treatment must be underway. Second, the abandonment must take place when the patient is still in need of medical attention -- this is known as a “critical stage” of the treatment process. Third, the abandonment must have taken place so abruptly that the patient did not have enough time or resources to find a sui table replacement physician to take over treatment. Finally, the patient must suffer an injury as a direct result of the patient abandonment. Copyright © 2019 MH Sub I, LLC dba Nolo ® What is Patient Abandonment? Patient abandonment is a form of medical malpractice that occurs when a physician terminates the doctor-patient relationship without reasonable notice or a reasonable excuse, and fails to provide the patient with an opportunity to find a qualified replacement care provider. Elements of Patient Abandonment: – First, the doctor-patient relationship must be established. This means that the physician must have agreed to treat the patient, and treatment must be underway. – Second, the abandonment must take place when the patient is still in need of medical attention -- this is known as a “critical stage” of the treatment process. – Third, the abandonment must have taken place so abruptly that the patient did not have enough time or resources to find a suitable replacement physician to take over treatment. – Finally, the patient must suffer an injury as a direct result of the patient abandonment. Copyright © 2019 MH Sub I, LLC dba Nolo ® SC BOARD OF MEDICAL EXAMINERS POLICY RELATIVE TO TERMINATION OF PHYSICIAN-PATIENT RELATIONSHIPS 1. The patient or the patient’s legal representative (relative, responsible friend) should be notified in writing, sent by certified mail, to the patient’s or his or her legal representative’s last known address. 2. The physician must at minimum offer to refer the patient to another qualified physician or appropriate medical professional. 3. The physician must provide emergency care to the patient for up to thirty (30) days. 4. The physician must comply with the S.C. Physician’s Patient Records Act (§44- 115-10, et seq.) and the “Closing a Medical Practice” guidance document, if applicable. This document is available on the Board’s website (http://www.llr.state.sc.us/POL/Medical/index.asp?file=MDDOPolicies.HTM) The PA and Patient: Informed Consent-1 Informed Consent PAs have a duty to protect and foster an individual patient’s free and informed choices. The doctrine of informed consent means that a PA provides adequate information that is comprehendible to a competent patient or patient surrogate. At a minimum, this should include the nature of the medical condition, the objectives of the proposed treatment, treatment options, possible outcomes, and the risks involved. – WHAT--Nature of procedure / treatment – WHY—objectives or benefits – ALTERNATIVE treatments – RISKS—risks of treatment and/or alternatives – ASSESMENT of understanding Guidelines for Ethical Conduct for the PA Profession; https://www.aapa.org/wp-content/uploads/2017/02/16-EthicalConduct.pdf The PA and Patient: Informed Consent-3 When the person giving consent is a patient’s surrogate, a family member, or other legally authorized representative, the PA should take reasonable care to assure that the decisions made are consistent with the patient’s best interests and personal preferences, if known. If the PA believes the surrogate’s choices do not reflect the patient’s wishes or best interests, the PA should work to resolve the conflict. This may require the use of additional resources, such as an ethics committee. Guidelines for Ethical Conduct for the PA Profession; https://www.aapa.org/wp-content/uploads/2017/02/16-EthicalConduct.pdf Capacity vs Competency Competency is a global assessment and a legal determination made by a judge in court. Capacity, on the other hand, is a functional assessment regarding a particular decision. Capacity is not static, and it can be performed by any clinician familiar with the patient. – communicating a choice, – understanding, – appreciation, and rationalization and – Reasoning In cases in which a second opinion is warranted, psychiatry, geriatrics, or ethics consults could be utilized. Decisional Capacity Group time – – By tables – Go to How Do I Determine if My Patient has Decision- Making Capacity? - The Hospitalist (the-hospitalist.org) – Read thru the case, and the discussion on decisional capacity – Answer the following questions: What are the four key components for assessing capacity? What are the clinical tools for assessing capacity, and what are the strengths/weaknesses with each one? The PA and Patient: Confidentiality (1) PAs should maintain confidentiality. By maintaining confidentiality, PAs respect patient privacy and help to prevent discrimination based on medical conditions. If patients are confident that their privacy is protected, they are more likely to seek medical care and more likely to discuss their problems candidly. In cases of adolescent patients, family support is important but should be balanced with the patient’s need for confidentiality and the PA’s obligation to respect their emerging autonomy. Adolescents may not be of age to make independent decisions about their health, but providers should respect that they soon will be. To the extent they can, PAs should allow these emerging adults to participate as fully as possible in decisions about their care. It is important that PAs be familiar with and understand the laws and regulations in their jurisdictions that relate to the confidentiality rights of adolescent patients. (See the section on Informed Consent.) Guidelines for Ethical Conduct for the PA Profession; https://www.aapa.org/wp-content/uploads/2017/02/16-EthicalConduct.pdf The PA and Patient: Disclosure A PA should disclose to his or her supervising physician information about errors made in the course of caring for a patient. The supervising physician and PA should disclose the error to the patient if such information is significant to the patient’s interests and well being. Errors do not always constitute improper, negligent, or unethical behavior, but failure to disclose them may. Guidelines for Ethical Conduct for the PA Profession; https://www.aapa.org/wp-content/uploads/2017/02/16-EthicalConduct.pdf Disclosure: Components Components of disclosure that matter most to patients: – Disclosure of all harmful errors – An explanation as to why the error occurred – How the error's effects will be minimized – Steps the physician (and organization) will take to prevent recurrences Process – Consult expertise: senior clinicians, risk managers, corporate compliance, etc. – The supervising physician and PA should disclose the error to the patient if such information is significant to the patient’s interests and well being. The PA and Patient: Care of Family Members and Co-workers Treating oneself, co-workers, close friends, family members, or students whom the PA supervises or teaches may be unethical or create conflicts of interest. – For example, it might be ethically acceptable to treat one’s own child for a case of otitis media but it probably is not acceptable to treat one’s spouse for depression. – PAs should be aware that their judgment might be less than objective in cases involving friends, family members, students, and colleagues and that providing “curbside” care might sway the individual from establishing an ongoing relationship with a provider. If it becomes necessary to treat a family member or close associate, a formal patient-provider relationship should be established, and the PA should consider transferring the patient’s care to another provider as soon as it is practical. – If a close associate requests care, the PA may wish to assist by helping them find an appropriate provider. There may be exceptions to this guideline, for example, when a PA runs an employee health center or works in occupational medicine. Even in those situations, the PA should be sure they do not provide informal treatment, but provide appropriate medical care in a formally established patient-provider relationship. Guidelines for Ethical Conduct for the PA Profession; https://www.aapa.org/wp-content/uploads/2017/02/16-EthicalConduct.pdf SC LLR-Board of Medical Examiners: Prescribing for family members POLICY: Approved by the Board: February 7-10, 1999 Board meeting While the Board recognizes that in certain instances a physician may need to prescribe medications for family members, the Board recognizes that such treatment may provide less than optimal care for a family member. Treatment of the immediate family members should be reserved for minor illnesses, temporary or emergency situations. Appropriate consultations should be obtained for the management of major or extended periods of illness. State law requires the presence of a valid physician/patient relationship before any controlled substance can be prescribed. This relationship should include knowledge of the medical condition and an assessment of the benefit-risk ratio of the use of such substance. A practitioner cannot usually acquire a valid physician/patient relationship with himself or herself nor with a member of his or her immediate family for the purpose of prescribing controlled substances, due to the loss of objectivity in making the proper medical decisions. The Board feels that prescribing controlled substances for family members is outside the scope of good medical practice in South Carolina except for a bona fide emergency situation where the health and safety of an individual may be at great detriment. A practitioner may prescribe limited amounts of controlled substances until such time as another objective practitioner can be contacted. Guiding Principle… “Care must be taken that the nonreligious physician [clinician] does not underestimate the importance of the patent’s belief system. Care must be taken that the religious physician who believes differently than the patient, does not impose his or her beliefs onto the patient at this vulnerable time. In both cases, the principle of respect for the patient should transcend the ideology of the physician. Our first concern is to listen to the patient.” Spirituality and Medicine Thomas R. McCormick, D.Min. (April 2014) How can you open the door for a spiritual discussion? Know – You have an obligation to do so. Observe - Are there any religious artifacts, books, jewelry in on the patient or in the room? Listen – Is the patient talking overtly about their faith or saying words such as ”blessing?” Be Sensitive – This is NOT about you and NOT your mission field to change people. You need to be open to all world views. You may not agree, but you must be respectful of all religions and thoughts of spirituality. Ask – Ask for the patient’s input on their spiritual needs The PA and Patient: Reproductive Decision Making Patients have a right to access the full range of reproductive health care services, including fertility treatments, contraception, sterilization, and abortion. PAs have an ethical obligation to provide balanced and unbiased clinical information about reproductive health care. When the PA's personal values conflict with providing full disclosure or providing certain services such as sterilization or abortion, the PA need not become involved in that aspect of the patient's care. By referring the patient to a qualified provider who is willing to discuss and facilitate all treatment options, the PA fulfills their ethical obligation to ensure the patient’s access to all legal options. Guidelines for Ethical Conduct for the PA Profession; https://www.aapa.org/wp-content/uploads/2017/02/16-EthicalConduct.pdf Elderly Patients: Advance Directives-1 Legal or informal documents outlining the health and welfare wishes of a patient if the patient is unable to communicate or is no longer competent. An advance directive allows you to communicate your healthcare preferences if and when you can no longer make your own decisions. Legal – Durable Power of Attorney for Healthcare Decisions appointment of an agent to make healthcare decisions for you when you are unable to make these decisions for yourself – Healthcare Treatment Directive or Living Will a description of the kind of medical treatment you want when you are facing serious illness Durable Power of Attorney for Healthcare Decisions I, ________________________________________, SS#______________________ (optional, last 4 digits), appoint the person named in this document to be my agent to make my healthcare decisions. This document is a Durable Power of Attorney for Healthcare Decisions. My agent’s power shall not end if I become incapacitated or if there is uncertainty that I am dead. This document revokes any prior Durable Power of Attorney for Healthcare Decisions. My agent may not appoint anyone else to make decisions for me. My agent and caregivers are protected from any claims based on following this Durable Power of Attorney for Healthcare. My agent shall not be responsible for any costs associated with my care. I give my agent full power to make all decisions for me about my healthcare, including the power to direct the withholding or withdrawal of life-prolonging treatment, including artificially supplied nutrition and hydration/tube feeding. Durable POA for Healthcare Decisions: My agent is authorized to Consent, refuse, or withdraw consent to any care, procedure, treatment, or service to diagnose, treat, or maintain a physical or mental condition, including artificial nutrition and hydration; Permit, refuse, or withdraw permission to participate in federally regulated research related to my condition or disorder Make all necessary arrangements for any hospital, psychiatric treatment facility, hospice, nursing home, or other healthcare organization; and, employ or discharge healthcare personnel (any person who is authorized or permitted by the laws of the state to provide healthcare services) as he or she shall deem necessary for my physical, mental, or emotional well -being; Request, receive, review, and authorize sending any information regarding my physical or mental health, or my personal affairs, including medical and hospital records; and execute any releases that may be required to obtain such information; Move me into or out of any State or institution; Take legal action, if needed; Make decisions about autopsy, tissue and organ donation, and the disposition of my body in conformity with state law; and Become my guardian if one is needed. In exercising this power, I expect my agent to be guided by my directions as we discussed them prior to this appointment and/or to be guided by my Healthcare Directive (see reverse side). Healthcare Treatment Directive or Living Will I always expect to be given care and treatment for pain or discomfort even if such care may affect how I sleep, eat, or breathe. I would consent to, and want my agent to consider my participation in federally regulated research related to my disorder or condition. I want my doctor to try treatments/interventions on a time-limited basis when the goal is to restore my health or help me experience a life in a way consistent with my values and wishes. I want such treatments/interventions withdrawn when they cannot achieve this goal or become too burdensome to me. I want my dying to be as natural as possible. Therefore, I direct that no treatment (including food or water by tube) be given just to keep my body functioning when I have a condition that will cause me to die soon, or a condition so bad (including substantial brain damage or brain disease) that I have no reasonable hope of achieving a quality of life that is acceptable to me. An acceptable quality of life to me is one that includes the following capacities and values. (Describe here the things that are most important to you when you are making decisions to choose or refuse life-sustaining treatments.) _______________________________________________________________________________________________ _______________________________________________________________________________________________. Examples: recognize family or friends make decisions communicate feed myself take care of myself be responsive to my environment  Guidelines for Ethical Conduct for the PA Profession The PA and Individual Professionalism Conflict of Interest PAs should place service to patients before personal material gain and should avoid undue influence on their clinical judgment. Trust can be undermined by even the appearance of improper influence. Examples of excessive or undue influence on clinical judgment can take several forms. These may include financial incentives, pharmaceutical or other industry gifts, and business arrangements involving referrals. PAs should disclose any actual or potential conflict of interest to their patients. Acceptance of gifts, trips, hospitality, or other items is discouraged. Before accepting a gift or financial arrangement, PAs might consider the guidelines of the American College of Physicians, “What would the public or my patients think of this arrangement?” Professional Identity PAs should not misrepresent directly or indirectly, their skills, training, professional credentials, or identity. PAs should uphold the dignity of the PA profession and accept its ethical values. Competency PAs should commit themselves to providing competent medical care and extend to each patient the full measure of their professional ability as dedicated, empathetic health care providers. Providing competent care includes seeking consultation with other providers and referring patients when a patient’s condition exceeds the PA’s education and experience, or when it is in the best interest of the patient. PAs should also strive to maintain and increase the quality of their health care knowledge, cultural sensitivity, and cultural competence through individual study and continuing education. Garnet book: Student policies governing all students at PC Presbyterian College Honor Code “On my honor, I will abstain from all deceit. I will neither give nor receive unacknowledged aid in my academic work nor will I permit such action by any member of this community. I will respect the persons and property of the community, and will not condone the discourteous or dishonest treatment of these by my peers. In my every act, I will seek to maintain a high standard of honesty and truthfulness for myself and for the College.” Types of Academic Dishonesty Duplication Fabrication Fraud Plagiarism Bribery Cheating Misrepresentation Conspiracy Collusion Duplicate Submission Academic Dishonesty in PA school Examples – Cheating on a test / OSCE – Group text about a test / OSCE – Collating / sharing information about test questions (ex – key words) – Plagiarism on papers, including self-plagiarism The PA and Individual Professionalism: Conflict of Interest Conflict of Interest PAs should place service to patients before personal material gain and should avoid undue influence on their clinical judgment. Trust can be undermined by even the appearance of improper influence. Examples of excessive or undue influence on clinical judgment can take several forms. These may include financial incentives, pharmaceutical or other industry gifts, and business arrangements involving referrals. PAs should disclose any actual or potential conflict of interest to their patients. Acceptance of gifts, trips, hospitality, or other items is discouraged. Before accepting a gift or financial arrangement, PAs might consider the guidelines of the American College of Physicians, “What would the public or my patients think of this arrangement?” People versus GlaxoSmithKline (GSK) led to the strengthening of the FDA restrictions on drug promotions and stiffened penalties on companies who withheld research information or offered kickbacks to providers. Guidelines for Ethical Conduct for the PA Profession; https://www.aapa.org/wp-content/uploads/2017/02/16-EthicalConduct.pdf Conscience objection Some decisions are made because of deeply held values. Both patients and healthcare providers. Strong reasons and legal protection to honor objection. Professional standards re: conscientious objection – Patients have the right to be referred to practitioners who do not object to procedures medically indicated – In emergency situations, providers must provide the medically indicated care, regardless of their own personal beliefs  Conscience Clauses, Health Care Providers, and Parents Conscientious objection in health care is the refusal to perform a legal role or responsibility because of moral or other personal beliefs. Most states have “conscience clauses” that describe the right of physicians and other health care providers to refuse to provide services such as abortions. Most of these conscience clauses, as well as similar federal statues and professional guidelines, were enacted after the passage of Roe v. Wade in 1973 to permit physicians to opt out of performing or participating in legalized abortions. Nancy Berlinger, “Conscience Clauses, Health Care Providers, and Parents,” in From Birth to Death and Bench to Clinic: The Hastings Center Bioethics Briefing Book for Journalists, Policymakers, and Campaigns, ed. Mary Crowley (Garrison, NY: The Hastings Center, 2008), 35-40.  Conscience Clauses, Health Care Providers, and Parents Conscientious objection in health care cannot be framed solely as an issue of individual rights or beliefs because it always affects someone else’s health or access to care. – Health care providers with moral objections to providing specific services have an obligation to minimize disruption in delivery of care and burdens on other providers. – Allowing parents to opt out of vaccinating their children is ethically troubling because it can leave entire communities vulnerable to preventable diseases Most states also permit parents to refuse to immunize their children because of religious beliefs; 20 states permit such a refusal based on personal beliefs. Nancy Berlinger, “Conscience Clauses, Health Care Providers, and Parents,” in From Birth to Death and Bench to Clinic: The Hastings Center Bioethics Briefing Book for Journalists, Policymakers, and Campaigns, ed. Mary Crowley (Garrison, NY: The Hastings Center, 2008), 35-40. Guidelines for Ethical Conduct for the PA Profession The PA and Other Professionals Illegal and Unethical Conduct PAs should not participate in or conceal any activity that will bring discredit or dishonor to the PA profession. They should report illegal or unethical conduct by healthcare professionals to the appropriate authorities. Impairment PAs have an ethical responsibility to protect patients and the public by recognizing their own impairment and identifying and assisting impaired colleagues. “Impaired” means being unable to practice medicine with reasonable skill and safety because of physical or mental illness, loss of motor skills, or excessive use or abuse of drugs and alcohol. PAs should be able to recognize impairment in any member of the healthcare team and should seek assistance from appropriate resources to encourage these individuals to obtain treatment. The PA and Other Professionals: Resolution of Conflict Resolution of Conflict Between Providers While a PA’s first responsibility is the best interest of the patient, it is inevitable that providers will sometimes disagree when working as members of a healthcare team. When conflicts arise between providers in regard to patient care, it is important that patient autonomy and the patient’s trusted relationship with each member of the healthcare team are preserved. If providers disagree on the course of action, it is their responsibility to discuss the options openly and honestly with each other, and collaboratively with the patient. It is unethical for a PA to circumvent the other members of the healthcare team or attempt to disparage or discredit other members of the team with the patient. In the event a PA has legitimate concerns about a provider’s competency or intent, those concerns should be reported to the proper authorities. PAs should be aware of and take advantage of available employer resources to mitigate and resolve conflicts between providers. The PA and Other Professionals: Illegal and Unethical Conduct PAs should not participate in or conceal any activity that will bring discredit or dishonor to the PA profession. They should report illegal or unethical conduct by health care professionals to the appropriate authorities. State Medical Licensing Board Appropriate first contact for advice and direction. Appropriate for reporting concerns about conduct. The PA and the Health Care System: PAs and Research PAs and Research The most important ethical principle in research is honesty. This includes assuring subjects’ informed consent, following treatment protocols, and accurately reporting findings. Fraud and dishonesty in research must be reported to maintain the integrity of the available data in research. PAs are encouraged to work within the oversight of institutional review boards and institutional animal care and use committees as a means to ensure that ethical standards are maintained. PAs involved in research must be aware of potential conflicts of interest. Any conflict of interest must be disclosed. The patient’s welfare takes precedence over the proposed research project. PAs are encouraged to undergo research ethics education that includes periodic refresher courses to be maintained throughout the course of their research activity. PAs must be educated on the protection of vulnerable research populations. Sources of funding for the research must be included in the published reports. The security of personal health data must be maintained to protect patient privacy. Plagiarism is unethical. Incorporating the words of others, either verbatim or by paraphrasing, without appropriate attribution is unethical and may have legal consequences. When submitting a document for publication, any previous publication of any portion of the document must be fully disclosed Passage of the National Research Act in 1974 regulates approval of all studies involving human subjects. Guidelines for Ethical Conduct for the PA Profession; https://www.aapa.org/wp-content/uploads/2017/02/16-EthicalConduct.pdf Regulations - overview (1) 1974--Privacy Act (Public Law 93579—Gerald Ford) 1985--COBRA--Consolidated Omnibus Budget Reconciliation Act – Mandated 18 months health insurance for employees that leave – Businesses >20 employees 1986 – The Health Care Quality Improvement Act (Ronald Reagan) – Congress passes the Health Care Quality Improvement Act of 1986 (HCQIA). This legislation is intended to protect peer review bodies from private money damage liability and to prevent incompetent practitioners from moving state to state without disclosure or discovery of previous damaging or incompetent performance. – led to the National Practitioner Data Bank's (NPDB) establishment. Regulations – overview (3) 1986 - EMTALA – federal law that requires hospital emergency departments to: medically screen every patient who seeks emergency care and to stabilize or transfer those with medical emergencies, regardless of health insurance status or ability to pay — this law has been an unfunded mandate since it was enacted in 1986. Regulations – overview (4) 1996 – HIPAA ( Health Insurance Portability and Accountability Act—1996 Clinton) – Health Insurance Portability and Accountability Act – Portability: no lapse in changing jobs. Preexisting conditions—continuous coverage for conditions (no lapse). – Accountability: PHI = protected health information Personal data obtained as part of providing healthcare – ID data – Lab data – Hospital records – Pharmacy records – Outpatient records – Mental health records HIPAA Exceptions – Financial documents – CIA information – Educational records including vaccinations – Employment records HIPAA: Exceptions and Exclusions The Privacy Rule, implemented in 2003, is a portion of HIPAA that refers to personal data, known as protected health information (PHI). PHI comes in three primary forms: written, electronic, and oral. Exceptions to HIPAA include suspected abuse. There are many items that HIPAA does not cover: – financial documents, – educational records, – employment records. However, a company that is self-insured for medical coverage of employees, the handling of insurance claims and other health-related information is covered by HIPAA. Exceptions to Confidentiality in Healthcare Child Abuse. In 18 states any person who suspects child abuse is required to report it. Elder Abuse refers to harmful treatment of an elderly person, with reporting being mandated in 16 states. Mental Health Patients Who Might Pose a Threat are a vulnerable population. Matters of the Greater Good. Alerting the public to a potential danger can help to ensure safety. Malpractice: Legal Requirements 4 elements must be met: – Existence of a legal duty on the part of the provider to provide care or treatment to the patient – Breach of this duty by failure to adhere to the standards of the profession – Causal relationship between breach of duty and injury to the patient – Existence of damages that flow from the injury such that the legal system can provide redress QUESTIONS?