Ethical Case Analysis 2023 PDF

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn ETHICAL CASE ANALYSIS Prof David Smith Learning Objectives Students should have an awareness of the importance of Ethical Reasoning Student...

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn ETHICAL CASE ANALYSIS Prof David Smith Learning Objectives Students should have an awareness of the importance of Ethical Reasoning Students should have an understanding of the Four Principles Approach to Ethical Reasoning Students should have an understanding of the Four Question Approach to Ethical Reasoning Students should have the ability to apply these approaches to the case studies  ETHICAL REASONING SKILLS Ethical dilemmas in healthcare can be resolved by drawing on ethical reasoning skills, particularly those of ethical analysis and argument. Ethical analysis requires one to clarify clinically relevant and applicable concepts and use them with consistent meaning. Ethical argument requires one to use clearly formulated ideas in suggesting reasons that support a conclusion that should guide clinical judgement, decision-making and behaviour. Laurence B McCullough and James W Jones in ‘The art of medicine’. The Lancet Vol. 374, September 26, 2009: 1058-1059.  Whose ethics? The Four BMA Principles method METHOD S OF ETHICAL Four REASONI Principle Quadrant NG of Double s method Effect Using Conceptu case al studies analysis The Four Principles  PRINCIPLISM* THE FOUR PRINCIPLES METHOD SPECIFICATION: adding content to your analysis of a case from this specific case. Respect for autonomy Judgement Beneficence & Nonmaleficence Decision Justice BALANCING: finding reasons about which moral norms should prevail. *Beauchamp T & Childress J, Principles of Biomedical Ethics (1979; 7th edition 2013) The BMA eclectic method BMA 1. Recognise the situation as one that raises an ECLECTIC ethical issue. 2. Break the dilemma down to its component parts. METHOD* 3. Seek additional information, including the patient’s viewpoint. 4. Identify any relevant legal or professional guidance. YES Is the issue resolved? NO 5. Subject the dilemma to critical analysis. YES Is the issue resolved? NO 6. Be able to justify your If there is an unresolvable decision with conflict or the law is unclear, sound arguments. *BMA, (2012) Medical Ethics Today. 3rd edition. BMJ Books. pp 13-19 it may be necessary to seek THE FOUR QUESTION APPROACH THE FOUR QUESTION APPROACH Goran Hermeren “Human stem-cell research in gastroenterology: Experimental treatment, tourism and biobanking” Best Practice & Research Clinical Gastroenterology 28 (2014) 257-268 The idea is to begin with three questions: – What do we know? – What do we want? – What are we able to do? THE FOUR QUESTION APPROACH Variations may have to be considered, depending on who ‘we’ are in each particular case. Then we can move on to the fourth question: – What ought to be done?  The Four Quadrants method  FOUR QUADRANTS METHOD* MEDICAL PATIENT INDICATIO PREFEREN NS CES CONTEXT QUALITY UAL OF LIFE FEATURES *Jonsen AR, Siegler M, Winslade WJ, Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 8th edition. McGraw-Hill 2015 FOUR QUADRANTS METHOD Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, 7th ed. New York: McGraw-Hill, 2010. Medical Indications Principles of Beneficence and Nonmaleficence 1. What is the patient’s medical problem? Is the problem acute? chronic? critical? reversible? emergent? terminal? 2. What are the goals of treatment? 3. In what circumstances are medical treatments not indicated? FOUR QUADRANTS METHOD Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, 7th ed. New York: McGraw-Hill, 2010. 4. What are the probabilities of success of various treatment options? 5. In sum, how can this patient be benefited by medical and nursing care, and how can harm be avoided? FOUR QUADRANTS METHOD Patient Preferences Principles of Respect for Autonomy 1. Has the patient been informed of benefits and risks, understood this information, and given consent? 2. Is the patient mentally capable and legally competent, and is there evidence of incapacity? 3. If mentally capable, what preferences about treatment is the patient stating? FOUR QUADRANTS METHOD 4. If incapacitated, has the patient expressed prior preferences? 5. Who is the appropriate surrogate to make decisions for the incapacitated patient? 6. Is the patient unwilling or unable to cooperate with medical treatment? If so, why? FOUR QUADRANTS METHOD Quality of Life Principles of Beneficence and Nonmaleficence and Respect for Autonomy 1. What are the prospects, with or without treatment, for a return to normal life, and what physical, mental, and social deficits might the patient experience even if treatment succeeds? 2. On what grounds can anyone judge that some quality of life would be undesirable for a patient who cannot make or express such a judgment? FOUR QUADRANTS METHOD 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 assessments raise any questions regarding changes in treatment plans, such as forgoing life-sustaining treatment? FOUR QUADRANTS METHOD 6. What are plans and rationale to forgo life-sustaining treatment? 7. What is the legal and ethical status of suicide? FOUR QUADRANTS METHOD Contextual Features Principles of Justice and Fairness 1. Are there professional, interprofessional, or business interests that might create conflicts of interest in the clinical treatment of patients? 2. Are there parties other than clinicians and patients, such as family members, who have an interest in clinical decisions? FOUR QUADRANTS METHOD 3. What are the limits imposed on patient confidentiality by the legitimate interests of third parties? 4. Are there financial factors that create conflicts of interest in clinical decisions? 5. Are there problems of allocation of scarce health resources that might affect clinical decisions? FOUR QUADRANTS METHOD 6. Are there religious issues that might influence clinical decisions? 7. What are the legal issues that might affect clinical decisions? 8. Are there considerations of clinical research and education that might affect clinical decisions? 9. Are there issues of public health and safety that affect clinical decisions? 10. Are there conflicts of interest within institutions and organizations (e.g., hospitals) that may affect clinical decisions and patient welfare?  SUMMARY OF FOUR QUADRANT METHOD MEDICAL INDICATIONS: diagnosis, prognosis, treatment options, treatment goals, risks and benefits PATIENT PREFERENCES: capacity for decision-making, full information for informed consent, what options are preferred? QUALITY OF LIFE: prospects for a return to normal life? Who makes quality-of-life decisions? Plans and rationale for forgoing life sustaining treatment? CONTEXTUAL FEATURES: conflicts of interest? Whose decides? confidentiality, resource allocation, financial issues, public health and safety? research issues?  ”We have used this ‘The Four-Quadrant Approach to Ethical framework at the Issues in Burn Care’, University of Chad M. Teven, MD and Lawrence J. Gottlieb, MD Chicago Burn and AMA J Complex Wound Ethics. 2018;20(6):595- Center and have 601. https://journalofethics.ama found it to be -assn.org/sites/journalofet effective in hics.ama-assn.org/files/20 18-06/vwpt1-1806.pdf navigating ethical issues that arise." CASE STUDIES Case No. 1: Edward Bilton Edward Bilton is a 31 year old computer analyst. He has recently married his long-term girlfriend and they are expecting their first child. Both of them work fulltime and lead a very active life pursuing outdoor activities that include windsurfing, mountaineering and cross-country skiing. Edward’s parents are in their early 60’s. His mother was a solicitor, and his father is a retired school teacher. Three weeks ago, Edward was involved in a road traffic accident on his way to work. He was on a motorbike. He has sustained severe head injuries and his right leg has had to be amputated. He is still in ICU. He is not brainstem dead. There has been one unsuccessful attempt to get him off the ventilator. Although he is brain injured, Edward is expected to regain consciousness but with severe neurological impairment. Continued… Case No. 1: Edward Bilton Edward and his wife both discussed how they would like to be treated in different medical scenarios. Edward made it clear that in the event of an accident he does not wish to be artificially kept alive should he be fully dependent and disabled. After one week, his wife raises the views that Edward had expressed. The ICU team wants to keep Edward on the ventilator. His mother feels he should be kept alive. However, the wife feels strongly that he should be allowed to die. What are the ethical issues in this case? Case No. 2: THE NOTE You are called to a case of ‘patient unwell’. Upon arrival you find a young female, aged around 30, lying on her bed, the phone beside her and a piece of paper on her chest. She is semi-conscious and, when she sees you, she says, ‘Good, you’re here. I don’t want to be saved. Here are my directions,’ and passes you the paper from her chest. On the table beside the bed is an empty bottle of ethylene glycol (otherwise known as antifreeze). Her letter says the following: “To whom it may concern, if you attend to me because I have overdosed or made an attempt on my life, I do NOT want any life-saving treatment to be given. I would appreciate medicine to relieve my discomfort. I understand that refusing life-saving treatment may result in my death. I refuse life-saving treatment knowing this. If I survive the initial attempt but have resultant kidney failure, I do NOT consent to dialysis being commenced. I only called the ambulance so that they could take me to hospital and make me comfortable. I would also prefer to die in hospital and not at home alone. Thank you for respecting my wishes.” What are the ethical issues in this case? Case No. 3: Growth Attenuation- The Ashley Treatment Ashley, now nine years old, was born with static encephalopathy, severe brain impairment. She could not walk, talk, keep her head up, or roll over or sit up by herself. She was fed with a tube. Her parents called her “Pillow Angel”, because she stayed right where they placed her, usually on a pillow. They feared their angel would become too big on day to care for. Doctors treating her decided to inhibit further growth through high doses of estrogen over several years as well as a hysterectomy and the removal of her breast buds to avoid the possibility of pregnancy, and to decrease the likelihood of sexual abuse. The treatment is expected to keep Ashley’s height at about 4 feet 5 and her weight at about 75 pounds for the rest of her life. Without the treatment, doctors’ estimate, she would have grown into a woman of average height and weight, about 5 feet 6 and 125 pounds. Case No. 3: Growth Attenuation- The Ashley Treatment Questions: Should parents be permitted to choose the “Ashley Treatment”? Explain why you agree or disagree with those who say that growth attenuation is playing God. Case No. 4: Young bride requests secret access to contraception EF, aged 16, was married six months ago to a man aged 27 she knew only very little, by an arrangement made between her parents and his family. Her husband has brought her to Dr. GH, a family physician, for a routine health examination. Dr. GH finds EF quite petite, malnourished and with an underdeveloped pelvis. EF informs Dr. GH that she wants to delay childbearing until she is aged 20, although her husband and his family are anxious that she should bear a child as soon as possible. She asks Dr. GH for a contraceptive method. Questions: What is Dr GH’s primary ethical responsibility in this case? What social and medical conditions should Dr GH discuss with EF during the consultation? Should Dr GH inform EF’s husband about EF’s request without her approval? Case No. 5: Confidentiality & Disclosure A 45-year-old man had a relationship with a 35-year-old woman. Due to some bouts of jealously on the part of the man (possibly of morbid dimensions), the woman decided to put an end to the relationship. Following this, the man visited a psychiatrist, who he had been seeing for some time, informed him that he was carrying a gun and that his next visit would be to his ex-girlfriend whom he had the intention of killing. He added that this information was confidential from patient to doctor and that any breach in confidentiality would not remain unnoticed. The psychiatrist decided that a breach of confidentiality was necessary in this case and informed the lady and the police. When asked by the police, the man denied that he had bad intentions. A heated discussion among professionals followed. QUESTION: Was the breach of confidentiality justified in this case? Case No. 6: ETHICAL - PRIORITY SETTING ON AN ICU The Regional Hospital is a major trauma centre with a large emergency department and intensive care unit (ICU). During the outbreak of COVID 19, the ICU is filled to capacity with patients suffering from life-threatening medical conditions, including severe respiratory problems. The emergency department calls the ICU seeking to admit Mr. M, who was brought to the emergency room with a severe but potentially reversible brain injury after a bicycling accident. One alternative is to move one of the current ICU patients to a medical unit in order to make room for Mr. M. However, the ICU staff reports that all of their patients need ventilator support, and there are no other ventilated beds available in the hospital. Case No. 6: ETHICAL - PRIORITY SETTING ON AN ICU Another alternative is to send Mr. M to another unit in the hospital. However, given Mr. M's injuries, it is clear that this would overtax the clinical capabilities of the health care staff, who are not trained in critical care and who are already struggling to care for other patients. The final alternative is to transfer Mr. M to another health care facility. However, the COVID 19 pandemic has overwhelmed all hospitals in the region, and there are no available ICU beds anywhere else. You now hear that an ICU patient has passed away. There is now a bed available in the ICU for Mr. M. Case No. 6: ETHICAL - PRIORITY SETTING ON AN ICU Just as his transfer is about to be made, an ICU nurse named Ms. A is admitted with severe difficulty breathing. It is determined that she has been infected with COVID 19, which she may have contracted while caring for patients in the hospital's ICU. She needs immediate ventilation support, which is only available in the ICU bed designated for, but not yet occupied by, Mr. M. It also comes to light that Mr. M has aging parents at home who rely on him for help with activities of daily living. Ms. A is a mother of three children and a longstanding employee of the hospital and is well respected by her peers at the hospital. Case No. 6: ETHICAL - PRIORITY SETTING ON AN ICU Questions What are the most important considerations in this scenario? Which ones are the most relevant? Are there any considerations that you find significant in this last piece of information? Do these personal details about the two patients’ lives affect your perspective on this case? Who should be given the ICU bed: Mr. M or Ms. A? Who should make these kinds of decisions? How should these kinds of decisions be made? Case No. 7: LEGAL CASE STUDY You are working in the emergency department and a young man is admitted with breathing difficulties. He is subsequently diagnosed with COVID-19. He makes a full recovery but now wants his medical record relating to the admission and diagnosis of COVID-19 deleted under GDPR. What are the ethical and legal issues? How should you proceed? Case No. 7: LEGAL CASE STUDY An elderly patient is in hospital being treated for a physical injury he sustained. While in hospital he is tested and diagnosed with COVID- 19. He is having difficulty complying with infection control. He is uncooperative with staying in his room and has been agitated and physically aggressive towards staff. He is coughing openly when out on the hospital corridors and cannot follow instructions on hand hygiene. Those treating him feel he lacks capacity to understand the significance of his diagnosis, how contagious the virus is and the risk it poses to others. The family is supportive of the hospital’s assessment. What are the ethical and legal issues? RECOMMENDED READING Primary sources: Beauchamp T L & Childress, J F (2013) Principles of Biomedical Ethics. 7th edition. Oxford University Press. R. Gillon, ‘Ethics needs principles – four can encompass the rest – and respect for autonomy should be “first among equals”’. J Med Ethics 2003; 29: 307 – 312. David Misselbrook, ‘A basic model for medical ethics – the four principles plus scope’. G Hermerén, ‘Human stem-cell research in gastroenterology: Experimental treatment, tourism and biobanking’. Best Practice & Research Clinical Gastroenterology 28 (2014) 257–268. http://dx.doi.org/10.1016/j.bpg.2014.02.002