Ethical Issues in Healthcare - University of Notre Dame Australia PDF

3/18/24 Law and ethics 1 WELCOME Darren Conlon, Sydney Campus E u n i c e Ta n , F r e ma n t l e a n d B r o o me C a mp u s e s School of Nursi ng and Mi dwi fery 2 ACKNOWLEDGEMENT OF COUNTRY The University of Notre Dame Australia is proud to acknowledge the traditional owners and custodians of th...

3/18/24 Law and ethics 1 WELCOME Darren Conlon, Sydney Campus E u n i c e Ta n , F r e ma n t l e a n d B r o o me C a mp u s e s School of Nursi ng and Mi dwi fery 2 ACKNOWLEDGEMENT OF COUNTRY The University of Notre Dame Australia is proud to acknowledge the traditional owners and custodians of this land upon which our University sits. The University acknowledges that the Fremantle Campus is located on Wadjuk Country, the Broome Campus on Yawuru Country and the Sydney Campus on Cadigal Country. 3 1 3/18/24 Objectives By the end of this lecture, you will be familiar with: q Conscience and Conscientious Objection q Advance Care Directives and Not for Resuscitation Orders q Palliative Care and Euthanasia q The Principle of Double Effect & Therapeutic Privilege q Procedures for the ethical handling of human tissue and remains 4 Copyright statement 5 Therapeutic privilege and conscientious objection 6 2 3/18/24 Therapeutic privilege Therapeutic privilege q Exists to protect a patient 7 Therapeutic privilege Therapeutic privilege q The withholding of information from a patient q Should only be used by a doctor when in a patient’s best interests q Was commonly used in the past q Patient feedback indicated that despite diagnosis or prognosis, the patient preference was that they be told the truth 8 Therapeutic privilege Therapeutic privilege and the biomedical principles q Autonomy q Self determination. q Free to self make own decisions without interference or control from others q Self determination requires a true appreciation of circumstances q Practitioners should not withhold the truth or lie to a patient 9 3 3/18/24 Therapeutic privilege Therapeutic privilege and the biomedical principles q Beneficence q The practitioner must act to do good or remove harm from a patient q Non-maleficence q The practitioner must refrain from taking action that could cause harm to a patient q Justice q A patient should receive that which they need or deserve as a person 10 Therapeutic privilege However q In some limited situations an exception can arise q A doctor may choose to not disclose information to a patient that is believed to be detrimental to the patient’s best interests q But practitioners should note, information should not be withheld except in very limited circumstance 11 Therapeutic privilege Exclusions to disclosure of information q The doctor judges on reasonable grounds that the patient’s physical or mental health might be seriously harmed by the information; or q The patient expressly directs the doctor to make the decisions and does not want to hear the information as offered. 12 4 3/18/24 Therapeutic privilege Despite therapeutic privilege q The doctor should still give basic information about the illness and the proposed intervention. q To widen the application of therapeutic privilege beyond the two given circumstances runs counter to the general duty to inform 13 Therapeutic privilege Withholding truth q To avoid harm to the patient or others q Or with the prior consent of the patient q Is also know as benevolent deception 14 Therapeutic privilege Paternalism q One problem with using therapeutic privilege is the risk of paternalism q Interference with, or limitation of, a person’s right to autonomy 15 5 3/18/24 Conscientious objection Conscientious objection q Exists to protect a practitioner 16 Conscientious objection Nurses q “Nurses have a right to refuse to participate in procedures which would violate their reasoned moral conscience (i.e. conscientious objection). In doing so, they must take all reasonable steps to ensure that quality of care and patient safety is not compromised”. 17 Conscientious objection Right to raise conscientious objection q Respect for properly formed conscience is fundamental to the concept of tolerance in a society q A repressive society grants only limited room for conscientious differences in belief. q A tolerant society finds a mean between repression & licentiousness (‘anything goes’). 18 6 3/18/24 Conscientious objection Practitioners should take note that q Conscientious judgments can sometimes be wrong – conscience is not infallible q This may happen as a result of faulty reasoning, ignorance of facts or rules, emotional imbalance, etc. 19 Conscientious objection Respect for conscience q Conscientious persons can disagree: need for humility & tolerance q However, forcing a person to violate their own conscience is objectionable 20 Conscientious objection Responsibilities of the conscientious objector q Ensure that the objection is a moral objection - not simply that you don’t want to do the work. q Let the nurse in charge of the ward know that you are refusing to participate and on what grounds (good reasons). q Ensure that someone else will perform the task for you. q Document your objection and refusal. 21 7 3/18/24 Conscientious objection The patient q Consequently, conscientious objection also protects a patient because they receive the care they need and where possible, by a nurse who is able to undertake care without any objections 22 Ethical issues at beginning of life 23 Beginning of life issues Ethical conflicts & dilemmas are often associated with q Attitudes and beliefs about when life begins q Beliefs about rights to life; and determining what happens in and to one’s own body q Consequences of beginning of life decision-making q Differing opinions regarding use of technology at beginning of life 24 8 3/18/24 Beginning of life issues 3 different views on the status of an embryo: q The embryo is the kind of being that it is wrong to kill (John Finnis). q The embryo is not the kind of thing that it is wrong to kill (Michael Tooley). q What matters are the strength of the ‘rights’ of the persons involved (Judith Thomson). (So is the foetus a person?) 25 Beginning of life issues Definition of termination of pregnancy q Direct & deliberate termination of the life of a foetus/embryo before or after implantation However q An intervention prior to birth which may indirectly cause a baby’s death is NOT properly understood as an act of deliberate termination: e.g. inducing delivery before full term because baby’s condition is deteriorating or because mother will die otherwise q The induction is not intended to end the life of the baby (Principle of double effect) 26 Beginning of life issues Debate on termination q The right to life (pro-life) versus the right of a woman to choose (prochoice) q Question of harm (implies competing views of consequences) q Other considerations (e.g. some believe there is a responsibility to terminate a pregnancy in case of abnormal pre-natal findings; others – for example the Catholic Church - believe we ought to do no such thing.) q Inconsistent attitudes toward an unborn child – compare grief at miscarriage with pragmatic approaches to termination 27 9 3/18/24 Beginning of life issues Some debates around IVF q Separation of biological parenthood & responsibility for offspring q Status of the embryo - can a human being be treated as property? q Questionable success rate - do burdens outweigh benefits? q Cost of technology, and thus who should pay? - Should IVF be freely available in the public health system? q IVF for persons unable to have children - for same-sex couples, postmenopausal couples, single women? 28 Beginning of life issues Ethical debate on gamete donation q Confidentiality of donor (may encourage higher donation rates) versus q Person born of this technology is entitled to knowledge of his or her biological parents (including family history, medical history etc.) 29 Beginning of life issues Ethical debate on sex selection q Does it threaten our social & moral ideal of unconditional love? q Is there a danger of population imbalance? q Is there a danger of devaluing one sex (e.g. boys may be favoured over girls) q Is being a girl (or a boy) a pathology? 30 10 3/18/24 Beginning of life issues Ethical debates on gene testing q Commercialisation of human genetic material q Consent to genetic testing & psychological implications for subject & family q Worry over scientists ‘playing God’ 31 Beginning of life issues Stem cell research from foetal cells q Destruction of human embryo q Treating human life as a commodity q Disagreement about when life begins q Obtaining informed consent from donors q Ownership of biological materials from cells q Altering human genetics 32 Beginning of life issues The issue of saviour siblings q Permissibility of creating a child for the sake of saving the life of another child (e.g. using the child as a bone marrow donor) Versus q Kant: we ought not to treat other people only as a means to our ends: we are all ends in ourselves. 33 11 3/18/24 Beginning of life issues Cloning q Violates the right to a unique genetic identity – questions of human dignity, integrity 34 Ethical issues at end of life 35 End of life issues End of life issues often arise around palliative care q Palliative care may incorporate: q Comprehensive, interdisciplinary, and total care focusing primarily on comfort and support of patients and families who face illness of a chronic nature or who are not responsive to curative treatment q Delivery of coordinated and continuous services in home, hospice, hospitals, skilled nursing facilities, and bereavement care 36 12 3/18/24 End of life issues Faulty arguments q ‘If an outcome is foreseeable, it must be intended’. q ‘There is no difference between killing & letting die’. 37 End of life issues Faulty arguments, the extremes q Every effort must be made to preserve a patient’s life – ‘we must do everything within we can’. to q The ‘right to choose the timing & other circumstances of one’s own death’ is obvious. 38 End of life issues Principle of sanctity of human life q Human life is sacred irrespective of arbitrary factors (race, age, social status, wealth, etc.) q However, it does not follow that human beings must be kept alive at all times, or under all circumstances, and at any cost q Humans are mortal, and knowing when to act in recognition of that fact is a fundamental aspect of end-of-life decision-making 39 13 3/18/24 Principle of double effect Principle of double effect: Case study example q The administration of opioid pain relief to a compromised patient with a terminal illness 40 Principle of double effect Condition 1 of the principle of double effect q The act in itself must not be morally wrong (and will usually be a last resort). q Pain relief in itself is good q Relieving pain is not morally wrong 41 Principle of double effect Condition 2 of the principle of double effect q The agent must not intend the bad effect (as an end to be sought). q The pain relief is administered in order to ease the patient’s suffering q It is not intended to end the patient’s life, even though death can be foreseen q The act must bring about as much good as the risk of evil 42 14 3/18/24 Principle of double effect Condition 3 of the principle of double efffect q The evil effect must not be a means to achieving the good effect. q The patient’s death cannot be the means of achieving the relief of pain 43 Principle of double effect Condition 4 of the principle of double effect q The bad effect must not outweigh the good effect. q The agent must have a justifiable and sufficient reason for acting, rather than refraining from acting q The dying patient’s level of pain provides a reason for administering pain relief and hence acting beneficently 44 Principle of double effect Susan Anderson Fohr (1998) q “It is important to emphasize that there is no debate among specialists in palliative care and pain control on this issue. There is a broad consensus that when used appropriately, respiratory depression from opioid analgesics is a rarely occurring side effect. The belief that palliative care hastens death is counter to the experience of physicians with the most experience in this area.” 45 15 3/18/24 Principle of double effect Susan Anderson Fohr (1998) q “The mistaken belief that pain relief will have the side effect of hastening death may have the unfortunate effect of leading physicians, patients, and the patients' families to undertreat pain because they are apprehensive about causing this alleged side effect. “ 46 Euthanasia Euthanasia q “Eu” = Good q “Thanatos” = Death 47 Euthanasia Some descriptions q Voluntary euthanasia: the 'ending the life of a competent, informed patient at their request'. q Passive euthanasia: 'not initiating or no longer continuing lifesustaining treatment that results in death as a direct consequence of the underlying disease'. q Physician assisted suicide (PAS): applied by the AMA to 'where the assistance of the medical practitioner is intentionally directed at enabling an individual to end his or her own life'. 48 16 3/18/24 Euthanasia Some arguments against euthanasia q Violates principle of sanctity of life q Slippery slope argument q Undermines personal and professional integrity of doctors and nurses involved q Undermines trust in healthcare professionals q Undermines the law 49 Euthanasia Passive euthanasia q Terms like ‘passive euthanasia’/‘indirect euthanasia’ are misunderstandings of the term euthanasia. 50 Euthanasia Preserving life q We should preserve life except when doing so would take the patient beyond what is ordinarily possible or bearable. q So, it is morally legitimate to withdraw & withhold medical treatment when: q the treatment at issue is therapeutically futile. q the treatment at issue is overly-burdensome to the patient. q Should a patient die following the withdrawal of futile treatment, that death is due to the incurable disease and not to the withdrawal of treatment. 51 17 3/18/24 Euthanasia and ’double effect’ Euthanasia and the principle of double effect q Euthanasia refers to the intentional termination of life to relieve suffering. q In the unlikely event that a properly prescribed & properly administered dose of morphine acts to hasten a patient’s death, it does not follow that euthanasia has been performed unless the patient’s death was intended. q This is so even if the patient’s death is considered a possible (albeit unintended) outcome of administering morphine. 52 Euthanasia and ’double effect’ Euthanasia and the principle of double effect q Euthanasia refers to the intentional termination of life to relieve suffering. q In the unlikely event that a properly prescribed & properly administered dose of morphine acts to hasten a patient’s death, it does not follow that euthanasia has been performed unless the patient’s death was intended. q This is so even if the patient’s death is considered a possible (albeit unintended) outcome of administering morphine. 53 Directions at end of life 54 18 3/18/24 Directions at end of life Directions at end of life q Ethical/legal arguments for starting or stopping treatments are based on relative benefit or burden for patient. q Withholding or removing treatments where burden or harm is determined to outweigh benefit is allowing a person to die as a result of the natural progression of the illness/disease process. q While dying is a medical occurrence, it is also a spiritual process that impacts upon the individual, family, community, and health professionals involved. 55 Directions at end of life Advance Care Directive q “An advance care directive (ACD), is sometimes called a ‘living will’, q It is a document that describes one’s future preferences for medical treatment in anticipation of a time when one is unable to express those preferences because of illness or injury q An ACD must be adhered to provided that it is made voluntarily by a capable adult; was made without undue influence; and it is clear and unambiguous in applying to the circumstances at hand q Any person with decision-making capacity is able to make their own decisions, including decisions related to life saving treatment. All adults are presumed to have capacity unless there’s evidence to suggest otherwise 56 Directions at end of life Respect for autonomy q Encourage people to talk about what is to happen if they lose capacity q Gives the person a sense of control (retains autonomy) q Can provide flexibility in decision-making, which can transfer from the ACD to a relative at some given trigger point q Allows others to make decisions in keeping with the person’s wishes 57 19 3/18/24 Directions at end of life Not for Resuscitation/Do not resuscitate (NFR/DNR) orders q “Planning care for patients who are approaching end of life will generally include a shift in the focus of care away from aggressive medical intervention and towards a palliative approach” q “Decisions to withhold CPR and other resuscitation measures seek to avoid unwanted, excessively burdensome or insufficiently beneficial interventions for patients at the end of life” q Which option is of most benefit and does least harm to the patient? 58 Directions at end of life A resuscitation plan should be discussed q If the patient’s recovery is uncertain q If the treating clinician asks him or herself, ‘Would I be surprised if this patient were to die in 6-12 months?’ (so-called ‘surprise question’) and the answer is ‘No’ q If a patient clinically deteriorates requiring activation of a Rapid Response System, or is anticipated to do so q If the patient’s condition is considered high risk 59 Directions at end of life NFR Orders q Are written directions placed in the patient’s medical record indicating that cardiopulmonary resuscitation (CPR) is to be avoided q Require open communication about clinical condition and prognosis, efficacy and desirability of CPR; and potential harm and suffering that CPR may cause 60 20 3/18/24 Directions at end of life NFR orders q Provide rationale to withhold treatment where treatment has become overly burdensome q A decision of a person with capacity q A decision of another who is empowered to make decisions on behalf of the person q Where the AMO judges that attempts to resuscitate will bring no benefit and may even cause harm 61 Directions at end of life NFR orders q Senior doctor should attempt to establish whether, in the event of an arrest, the patient wishes to be resuscitated q If possible, must communicate clearly with patient nature of CPR, likely effects of CPR in their case, and consequences of refusing CPR q If patient wishes to be resuscitated, then such measures should, ordinarily, be undertaken q Incompetent patient: M.O. considers patient’s reasonable directives (ACD) and what the family or significant others know of patient’s wishes. 62 Directions at end of life NFR orders require q Immediate charting to indicate the reason order was written q Who gave consent? q Who was involved in the discussion;? q Was the patient competent to give consent or who was authorised to do so (proxy or guardian) q Time frame for the NFR order to remain active 63 21 3/18/24 Directions at end of life NFR orders q apply only to resuscitation – other treatment and comfort measures may be provided q Nurses must q Provide good supportive and comfort care q Facilitate communication about NFR order with patients, families, and physicians q Document requests by patients or surrogate for NFR and bring to attention of health care team 64 Directions at end of life NH&MRC Guidelines For Organ and Tissue Procurement q Respect human dignity q Respect the wishes of the deceased q Give precedence to the needs of the potential donor & the family over the interests of organ procurement itself q As far as possible, protect recipients from harm q Recognise the needs of all those directly involved, including the donor, recipient, families, carers, friends & health professionals 65 Questions Please bring any questions you have about this lecture to your weekly tutorial 66 22 3/18/24 References Fohr, S. A. (1998). The double effect of pain medication: Separating myth from reality. Journal of Palliative Medicine, 1(4), 315-328. doi:10.1089/jpm.1998.1.315 International Council of Nurses. (2012). ICN code of ethics for nurses. Retrieved from http://www.icn.ch/who-we-are/code-of-ethics-fornurses/ Staunton, P.J., & Chiarella, M. (2020). Law for nurses and midwives (9th ed.). Elsevier. Sulmasy, D. P. (2008). Within you / without you: Biotechnology, ontology, and ethics. Journal of General Internal Medicine, 23(S1), 69-72. doi:10.1007/s11606-007-0326-x 67 68 23