Health Ethics 1: Introduction to Ethical Approaches and Decision Making Framework (PDF)

Health Ethics 1: Introduction to Ethical Approaches and Decision Making Framework Public Health and Healthcare Ethics MEDF 1021 Term 1 2024-25 Yin Ting Cheung, Ph.D. Associate Professor School of Pharmacy Email: [email protected] 1 Outline...

Health Ethics 1: Introduction to Ethical Approaches and Decision Making Framework Public Health and Healthcare Ethics MEDF 1021 Term 1 2024-25 Yin Ting Cheung, Ph.D. Associate Professor School of Pharmacy Email: [email protected] 1 Outline Background and Definitions Scenarios (poll) 4 Guiding Principles of Medical Ethics Autonomy Nonmaleficence Beneficence Justice Take-home Message 2 Learning Objectives Understand the basic bio-ethical approaches, including theories and principles Appreciate the uniqueness of different ethical viewpoints Learn about the principle of respecting patients’ autonomy 3 Health Ethics What is Ethics? Moral principles that govern a person’s behavior or the conducting of an activity https://cheezburger.com/8189870080/ethics-exam Photo: Sam Tsang By Sjschen (Sjschen) - Own work, CC BY 2.5, 4 https://commons.wikimedia.org/w/index.php?curid=1951252 Why Health Ethics? A set of moral principles that guide us in making medical care decision Ethical issues are embedded in every clinical encounter People may have different: Beliefs Attitudes Feelings Opinions Patient may have different goals than healthcare professionals which may create conflict on the “correct” action 5  Go to URL: http://ureply/mobi Session number: 16955 Ethical Dilemma 1 When should abortion be legal? A. At any time the woman decides B. Before 6 weeks of age of fetus C. Before 12 weeks of age of fetus D. Only under specific situations (Sexual harassment) E. Never should be legal https://www.nytimes.com/interactive/2024/us/abortion-laws-roe-v-wade.html 6 Ethical Dilemma 2 When should medical euthanasia be permitted? A. Anytime a patient decides B. When certain criteria are met (Age > 65, terminal disease, etc.) C. Never, it goes against the Hippocratic oath "First do no harm" 7 Ethical Dilemma 3 A patient with poor prognosis when patient/family doesn’t have the funds to pay for critical care. How much should be spent by the public hospital (i.e. tax payers’ money) prolonging this patient’s life as per the family’s wishes? A. 250,000 HKD (~1 months ICU stay) B. 500,000 HKD C. 1,000,000 HKD D. 5,000,000 HKD E. Cost should not be a consideration as every life matters https://www.scmp.com/news/china/science/article/3099491/chinese -coronavirus-patient-recovers-after-more-100-days 8 Outline Background and Definitions Scenarios (poll) 4 Guiding Principles of Medical Ethics Autonomy Nonmaleficence Beneficence Justice Take-home Message 9 Four Principles that Guides Healthcare Professionals Respect for autonomy: patient’s Nonmaleficence: decision making avoiding the causation of capacity harm Justice: Beneficence: fairness irrespective of age, provide benefit race, sex, personality 10 Outline Background and Definitions Scenarios (poll) 4 Guiding Principles of Medical Ethics Autonomy Nonmaleficence Beneficence Justice Take-home Message 11 Case 1 A 35 year-old male with congenital Moyamoya disease recently had a severe intracranial bleed. Subsequently, he suffered a stroke and is comatose. He is in the ICU requiring intensive life support. MRI imaging reveals possible extensive paralysis. The medical team has evaluated his case, his chance of recovery is very slim, and he will be handicapped even if he wakes up. Moreover, the likelihood of another hemorrhage is still present and high 12 Case 1 You are part of a multidisciplinary medical team discussing the continuity of care for this patient with the family. Patient’s girlfriend (of 2.5yrs) tells you that the patient once mentioned to her that he does not want to be resuscitated if he suffered from a traumatic brain injury. Patient’s parents feel that they do not want to give up and want to continue the life-sustaining machines. They also believe the patient would choose to survive. 13 Case 1: Sorting Facts Prognosis = very poor. If he ever wakes up = handicapped Is it in his best interest to keep him alive with machine? Who will take care of him after he leaves the hospital? Is it fair to keep this patient in the ICU when there are many other patients who may need the service even more? Legally, who can make a life and death decision for the patient? Ethically, is it right for doctor to withdraw care? Whose’ advice should be listen to? 14 Respect for Autonomy Respect for persons affirms that each and every person has moral value and dignity in his or her own right. Health care professional’s judgments about how to benefit patients should NOT ignore or override the preferences of those patients. Respect patient’s capacity to make decision Respect patient’s right 15  Advance Directive A statement, usually in writing, that allows a mentally competent individual to decide what kinds of health care he/she wants to have in the future when he/she is no longer competent Provide family members and health care professional a clear indication of the patient’s wishes 16 Advance Directive Concept of advance directives Based on the principle that every individual should have the right to make an informed determination of his own healthcare decisions People may express clearly their wishes to their families and healthcare professionals. Different from euthanasia Read: https://www.info.gov.hk/gia/general/200907/08/P200907080162.htm 17 Who Can Make An Advance Directive? Any adult who has the necessary mental capacity to make his/her own healthcare decisions. Usually, it requires 2 witnesses, one of whom must be a medical practitioner Witnesses without interest in the estate of the person 18  Standards of Competence Mentally incompetent (examples) Congenital intellectual disability Abilities to Brain injury Comprehend and process information Dementia or psychiatric condition Reason about the consequences of one’s Substance abuse actions In medical contexts, a person is “Before a doctor signs as witness on an HA AD considered as competent if s/he can form, he/she should be satisfied that the patient Understand a therapeutic or research is mentally capable of understanding the nature and effect of making an AD and is properly procedure informed6. AD does not require formal Deliberate regarding its major risks and assessment of the patient’s mental capacity by benefits psychiatrists unless circumstances suggest it.” – Clause 13 (CEC-GE-1) Make a decision in light of this deliberation 19 How Does an Advance Directive Operate? Recommend the person specify the decision under any of the 3 conditions: Terminally ill In a state of irreversible coma or In a persistent vegetative state Other end-stage irreversible life-limiting conditions Usually about NOT receiving any life-sustaining treatment or any other treatment specified for basic care. Legally binding in common law 20 https://www.ha.org.hk/visitor/ha_visitor_index.asp?Content_ID=233583&Lang=ENG 21 Benefits of Advance Directive Protect the patient against what s/he regards as harmful outcomes Reduce stress for families who fear making the wrong decision It helps healthcare professionals to make difficult choices (eg. whether life-sustaining treatment should be withheld or continued) 22 Drawbacks Lack of explicit instructions Coma with virtually no chance of recovery versus coma with small chance of recovery versus terminal illness versus… many situations… An individual’s preference may change… they would need to revoke their advance directives Can be done orally. However, written, signed and witnessed revocation is a better method as it minimizes uncertainty and dispute Prior decision may not be in the best medical interest in current situation Some may be fearful that an advanced directive interferes with adequate care 23 http://acpe.cuhk.edu.hk/ 24 Case 2 54 year-old teacher is diagnosed with ischemic heart disease. Doctor planned to prescribe the antiplatelet drug (blood thinner) “aspirin”. Aspirin potential benefit in reduction of myocardial infarction outweighs potential harm due to increased bleeding By Sauligno - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=5854994 At the pharmacy, the patient expressed concerns and felt uncomfortable with the thought of taking a “blood thinner”. 25 Case 2 Her late husband had died following complications of a heart valve replacement surgery. Anticoagulants are used to prevent valve thromboembolic events (blood clots) in patients with prosthetic heart valves. Husband was prescribed “warfarin” (blood thinner) Diet restrictions Repeated visits to the hospital for blood draws Died from intracranial bleeding You, as a healthcare provider, know it is unlikely for her to encounter such complication with aspirin, and you explained to her the situation. By Gonegonegone at English Wikipedia - Own work by the original uploader, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=38353653 26 Case 2 The patient still does not want to take aspirin. She is in the right state of mind with decision making capacity. What would you do? A. Continue to persuade B. Accept patient’s decision 1. What if professionally, you think this is a “bad” decision? Should you still listen to the patient? 2. Should patients be allowed to make “bad” decision? 3. How should “bad” decisions be responded to in clinical encounter? 27 Patient’s Rights – HK Medical Association Right of information Reasonable and balanced understanding of the sickness, prognosis, treatment Operation Charges for medical services and treatment Drugs use, dosage, common side effects Right of refusal Right of confidentiality Right to medical reports Right to launch a complain 28 What is a “Bad” Decision? “Bad” decision: the one that did not lead to optimal health outcomes of the patient. Facts Perceptions “Bad” decision is a very subjective matter! Clinical Patient’s Autonomy and outcome values 29 “Bad” vs. Uninformed Decision Unlike bad decisions, decisions that are not fully informed do not involve making value judgments. If patient does not understand all the relevant information, the decision is not a fully autonomous one. Does the patient understand the difference between her husband’s vs. her own situation? 30 Informed Consent Widely accepted that no medical interventions can be performed on competent adult without their informed and voluntary consent. Agreement with the HCP’s recommendations after considering the risk associated with the plan of care. In a broader view of informed consent Explain different medical / treatment options Work with the patient to come to a mutual decision. 31 Reasons for Informed Consent Respect patient’s autonomy Each person may have different values on Intensity of medical care Levels of risk Information to Discuss with Patients Enhance patient’s well-being Nature of Test/Treatment/Procedure Judge based on patient’s values and goals Patient’s Role in Treatment Fulfill legal requirements Benefits vs Risks & Consequences Promote the patient’s best interest Alternative options Clarify misconceptions Braddock CH 3rd, Edwards KA, Hasenberg NM, et al. Informed decision making in outpatient practice: time to get back to basics. JAMA. 1999;282(24):2313–20. 32 Informed Consent Patients may not understand medical information Example: A patient with Stage 2 breast cancer declined standard treatment (chemotherapy and radiation) and decided to seek help from a TCM practitioner. If you are a HCP of the oncology team, how would you advise the patient? If you are the TCM practitioner, how would you advise the patient? Information on treatment or consent 1. Purpose of treatment 5. Cost of treatment 2. Nature of treatment 6. Role of patients 3. Benefits of treatment 7. Role of HCP 4. Complications of treatment 8. Alternative treatments (if33any)  Communication Skills Have an open communication with patient and actively discuss options Understand the patient’s own perspectives and concerns → Address the issues relating to the decision making (e.g. worry about burdening family, etc.) Discuss with other colleagues or social workers 34 Outline Background and Definitions Scenarios (poll) 4 Guiding Principles of Medical Ethics Autonomy Nonmaleficence Beneficence Justice Take-home Message 35 Case 3 Mr Green is a 57 year old gentleman with aggressive prostate cancer who is taken care of by the nursing team in the oncology department On the last admission Mr Green was told that he may only have 4–6 weeks to live Mr Green pulled one of the author's colleagues aside and confided to the nurse that he planned to kill himself and that is was a secret that the nurse was not to tell anyone. To tell or not to tell? https://doi.org/10.1016/j.ijnss.2015.01.013 36 Sorting Facts Patient is on palliative care If the nurse chooses to keep secret as patient required, this behavior will respect patient's own decision Autonomy and confidentiality But… Beneficence? If the nursing staff chose to tell other health care team members about it, the health care team would be involved in avoiding the suicide Nonmaleficence But… Beneficence? Autonomy? Patient’s perspective of “harm” versus nurse’s perspective of “harm” 37 Nonmaleficence & Beneficence Nonmaleficence Beneficence Do no harm to patients Do good for patients 38 Nonmaleficence & Beneficence If there is a conflict: (More stringent) Nonmaleficence Beneficence (Less stringent) 39  Benefit-Risk Ratio This ratio needs to be assessed by the health care professionals. Procedures Associated Risk Potential Benefits Surgical procedure Wound, injury Symptom relief/resolution Medication Adverse effects Quality of life Life expectancy Invasive diagnostic Complication, Prevention of future complications procedure infections Slow down disease progression When recommending treatment to patient, we need to take this into consideration and allow patient to evaluate in light of his/her own value. 40 Outline Background and Definitions Scenarios (poll) 4 Guiding Principles of Medical Ethics Autonomy Nonmaleficence Beneficence Justice Take-home Message 41 Justice Treating every person with fairness and equity and distributing benefits and burdens of health care as fairly as possible in society How would you distribute limited kidneys to the many patients who need them? Age? Projected organ survival? Ability to pay? Medical benefit as seen by patient? Comorbidities? Compliance? Indication? 42 Organ Allocation Heart Transplant Must be < 60-65 years old Urgency, waiting time, body size, etc… Current Hong Kong Wait list (June 30th 2018) Organ Patients Waiting Approx. Transplants Done Annually Kidney 2214 60-100 Heart 49 5-17 Liver 74 60-85 Cornea 287 200-337 43 Source: Hospital Authority Genetic Testing Does genetic testing need to be offered equally and universally, or does the laboratory have the right to impose restrictions on the availability of the tests they offer? Prenatal test for early onset, life-threatening diseases (e.g. inborn metabolic disorders) Prenatal test for late onset, debilitating diseases (e.g. Huntington disease) Prenatal test for diseases that can’t be predicted with any certainty (e.g. diabetes, heart diseases) Prenatal test for early sex identification Prenatal test for desirable traits (e.g. intellectual ability, height) https://www.who.int/genomics/publications/en/ethical_issuesin_medgenetics%20report.pdf 44 Genetic Testing “Equitable distribution of genetics services, including prenatal diagnosis, is owed first to those with the greatest medical need, regardless of ability to pay, or any other considerations” “Prenatal diagnosis solely for relief of maternal anxiety, in the absence of medical indications, should have lower priority in allocation of resources than prenatal diagnosis with medical indications” – WHO Human Genetics Program 45 Outline Background and Definitions Scenarios (poll) 4 Guiding Principles of Medical Ethics Autonomy Nonmaleficence Beneficence Justice Take-home Message 46 Conclusions 1. Patient’s welfare and best interests must be main concern 2. Medical team must ensure patient/family is informed 3. Unethical to refuse to care for a patient solely because of medical risk, or perceived risk, to the clinician 6. Welfare of patient is more important than fiscal considerations 7. Be an advocate for health of the public 8. Remember all citizens are equal under the law and should be treated so 47 Conclusion To prepare yourself on resolving ethical dilemma Identify ethical issues Understand areas of ethical consensus and controversy Reading about ethical issues, thinking about them, and discussing them with colleagues can help resolve ethical dilemmas Gather more information about the medical situation and the patient’s values and preferences Plan for open communication & patient education shared-decision making 48 References Beauchamp TL, Childress JF. Principles of Biomedical Ethics. New York, NY: Oxford University Press; 2009. Childress, JF. Priorities in Biomedical Ethics. Philadelphia: The Westminister Press; 1981. Chin, Berlinger, Dunn, Ho, and Gusmano, eds. Making Difficult Decisions with Patients and Families: A Singapore Casebook (NUS, January 2014). Available at http://www.bioethicscasebook.sg/ Jonsen AR, Siegler M, Winslade WJ. Jonsen A.R., Siegler M, Winslade W.J. Chapter 1. Medical Indications. In: Jonsen AR, Siegler M, Winslade WJ. Jonsen A.R., Siegler M, Winslade W.J. eds. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, 7e. New York, NY: McGraw-Hill; 2010. http://accesspharmacy.mhmedical.com/content.aspx?bookid=364&Sectionid=39900119. Accessed September 08, 2014 Lo B. Resolving Ethical Dilemmas: A Guide for Clinicians. 4th ed. Philadelphia: Lippincott, Wolters Kluwer; 2009. Mappes TA, Zembaty JS. Biomedical Ethics and Ethical Theory. Biomedical Ethics. 3rd ed. New York: McGraw- Hill; 1991:1-44. Wai A, Wong D, Joynt G, Cheung R. Medical Law and Ethics in Hong Kong. 1st Ed. Hong Kong Sweet & Maxwell. 2016. 49 Health Ethics 1: Introduction to Ethical Approaches and Decision Making Framework Public Health and Healthcare Ethics MEDF 1021 Term 1 2024-25 Yin Ting Cheung, Ph.D. Assistant Professor School of Pharmacy Email: [email protected] 50