YR1 Lecture 1H - Ethics Doctors and Medical Students 2023.pdf

Ethics Doctors and Medical Students 2023 Annemarie Hennessy COPYRIGHT COMMONWEALTH OF AUSTRALIA Copyright Regulations 1969 WARNING This material has been reproduced and communicated to you by or on behalf of University of Western Sydney pursuant to Part VB of the Copyright Act 1968 (the Act). The ma...

Ethics Doctors and Medical Students 2023 Annemarie Hennessy COPYRIGHT COMMONWEALTH OF AUSTRALIA Copyright Regulations 1969 WARNING This material has been reproduced and communicated to you by or on behalf of University of Western Sydney pursuant to Part VB of the Copyright Act 1968 (the Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of this material by you may be the subject of copyright protection under the Act. Do not remove this notice. Ian Wilson 2007 …. say that ethics is rational is a nonsense - ethics is the ability to reflect on moral issues which are context and culturally specific and are thus subjective and require a great deal of interpretation. 2 Learning Objectives Understanding of the principles of an ethical framework to address ethical dilemmas (e.g. principle or care based approach to ethics) Identify and evaluate the ethical accountability of actions, intentions and outcomes Look at potential contentious issues or unethical requests that might be made to a medical student http://www.bioethics.net/2020/03/the-professional-obligations-ofmedical-students-in-covid-19-responses/ Send to the chat line: Identify three major issues as you see them relevant to being a medical student in a COVID 19-world? 7 Are Medical Students considered to be “young Doctors”? Medical student Student of Medicine compared to Student of Law/articled clerks/paralegals t n e d Stu rs o doct Pupil 8 Do medical students reputations matter? To themselves To the patients To the community at large To their colleagues 10 Key concepts today Your relationship with each other, with your peers and with the university Your concepts of patient privacy Social Media / Digital Medical Records http://mobile.news.com.au/finance/work/instagram-for-doctors-figure-1-medical-image-sharing-appraises-concerns-about-patient-privacy/story-e6frfm9r-1227085877092 11 The role of undergraduate medical students training in respect for patient confidentiality BMC Medical Education volume 21, Article number: 273 (2021) 245 valid replies 67.8 % of participants were women, with an average age of 24.05 ± 3.49 years. 90.6 % were aware that confidentiality affected the data in CHs, 43.3 % possessed non-anonymized photocopies of patient clinical reports outside the healthcare context, 49.8 % of the students were always adequately identified. 59.2 % accessed patient CHs on some occasions by using passwords belonging to healthcare professionals 77.2 % of them did not have the patients’ express consent 71.9 % accessed a CH that was not anonymised. 13 In the news... Case Western Reserve University can revoke medical degree because student lacked "professionalism," court rules Cleveland NEWS Jan 2015 (Federal Appeals Court) 14 During his five years of medical training, CWRU's Committee on Students had disciplined Al-Dabagh for trying to cover three late attendances; for rude behaviour at a 2012 dance; for trying to skirt a cab fare by jumping out of the moving car; for complaints from a patient's family; and for giving patient case summaries where he might not have personally examined the patient. "While Case should receive great discretion in judging academic standards, the determination of 'professionalism' goes well beyond academic or patient related matters," 15 Learning Objectives Identify basic ethical principles Develop a framework for ethical thinking Look at potential contentious issues or unethical requests that might be made to a medical student Identify professionalism Academic Professionism Patients Ethics 16 Obvious WRONGS Not so obvious WRONGS A pattern of behaviour : The RIGHT WAY 17 In the Case western example: What is fraud? Why does plagiarism matter? 18 The CLASSICS: Autonomy Non-malfeasance Beneficence Justice 19 Confidentiality Privacy protection Non-Malfeasance Do No Harm Trust Firm belief in the reliability, truth or ability of someone Altruism For the benefit of others above self Autonomy The patients right to accept or refuse treatment Beneficence Act in the best interest of the patient 20 Another framework.. Peking Union Medical College’s (PUMC) framework for medical professionalism 21 A student friend of yours is in hospital, you are on the wards and you see their medical record in the team list on the eMR. You are tempted to check out their history so that you can go and comfort them and offer assistance. Which of the principles does this breach? A B C D E F Confidentiality Non-Malfeasance Trust Altruism Autonomy Beneficence 22 A student friend of yours is in hospital, you are on the wards and you see their medical record in the eMR. You are tempted to check out their history so that you can go and comfort them and offer assistance. Which of the principles does this breach? A B C D E F Confidentiality Non-Malfeasance Trust Altruism Autonomy Beneficence 23 A student friend of yours has instragrammed an entry telling the story of a patient that your friend has mentioned from their tutorial. Which of the following principles is breached and how? A B C D E Confidentiality Respect Trust Justice Non-Malfeasance 24 What is acceptable in conversation.. 25 Social Media in a medical life ETHICAL REPUTATIONAL 26 WSU: SOM Social Networking Policy With regard to patients Don’t do it With regard to tutors Don’t do it With regard to each other Limit to social conversation 27 Context Rights and Wrongs Criminality Legal Ethical Professional 28 Some facts for you to think about.. Your tutors see you as medical peers A case reference here is rarely indicated on the slides and rarely on line. An open conversation (Lecture) with the experienced staff may be different to what is on line or recorded How privileged is this information from your point of view? 29 Why do you think the patients are so willing to share so many secrets with you? How do you think their behaviour differs when there are students in the room? 30 Population Health Scientific basis of Medicine Personal and Professional Development Clinical practice Your Portfolio 31 Quote from PPD previous student.. particularly because it makes me think of situations where I've been taking histories with other students unsupervised before, and when the eventual "so what do you think is wrong with me?" question comes along I've heard some very serious diagnosis's listed which of course causes the patient to panic, simply because this is based off textbook learning and our experiences are only limited. 32 A care-based approach A friend from school rings up and says the neighbour’s son who was at school with you all is under the care of your tutor in hospital – can you find out what is going on? What do you do? 33 Your group with your tutor arrives on the ward to see a patient – it is your recent high school teacher whom you didn’t like What do you do? 34 If the ethical issues are not considered… loss of public trust, low hospital staff morale, confusion about roles and responsibilities, stigmatization of vulnerable communities, and misinformation "where guidance is incomplete, consequences uncertain, and information constantly changing, where hour-by-hour decisions involve life and death, fairness is more important, rather than less" 35 Fairness in the time of covid-19 Fairness to whom : the community Your peers and other health care workers Your tutors To the vulnerable Your family “..care for ourselves and each other, meant better care for the patients…” What might be ethical issues for you in year one ? Fairness Student access to a patient on the ward Student safety and patient safety (contacts vs PPE) Staff business and planning Patient’s getting sicker Patient ability to consent to be seen/ refusing to be seen 37 Whose interests come first and why? Patient Student University/ universities Hospital Health system Community Family 38 A patient tells you (knowing that you are a student) quietly during an interview that they were diagnosed with Hepatitis C last year but they do not want you to tell their doctor. What do you do? 39 The CLASSICS: Autonomy Non-malfeasance Beneficence Justice 40 Ethical processes : Pandemic influenza preparedness. Adapted from Daniels, N. Accountability for reasonableness. BMJ 2000, 321:1300–1301 Accountability Inclusiveness Openness & Transparency Reasonableness Responsiveness 41 Accountability There should be mechanisms in place to ensure that ethical decisionmaking is sustained throughout the crisis You need to be strongly accountable for your actions; they will be scrutinized very closely 42 Inclusiveness Decisions should be made explicitly with stakeholder views in mind and there should be opportunities for stakeholders to be engaged in the decision-making process. Racisim, sexism and homophobic comments and leanings have no place in an inclusive medical life 43 Openness & Transparency Decisions should be publicly defensible. This means that the process by which decisions were made must be open to scrutiny and the basis upon which decisions are made should be publicly accessible to affected stakeholders. For example, there should be a communication plan developed in advance to ensure that information can be effectively disseminated to affected stakeholders and that stakeholders know where to go for needed information 44 Reasonableness Decisions should be based on reasons (i.e., evidence, principles, values) that stakeholders can agree are relevant to meeting health needs in a pandemic influenza crisis and they should be made by people who are credible and accountable. For example, decisionmakers should provide a rationale for prioritising particular groups for anti-viral medication and for limiting access to elective surgeries and other services. 45 Responsiveness There should be opportunities to revisit and revise decisions as new information emerges throughout the crisis as well as mechanisms to address disputes and complaints. For example, if elective surgeries are cancelled or postponed, there should a formal mechanism for stakeholders to voice any concerns they may have with the decision. 46 47 Ethical values to guide decision-making Duty to Provide Care Equity Individual Liberty Privacy Proportionality Protection of the Public from Harm Reciprocity Solidarity Stewardship Trust 48 Duty to Provide Care The duty to provide care and to respond to suffering is inherent to all health care professionals' codes of ethics. In an influenza pandemic, demands on health care providers and the institutions in which they work will overwhelm resources. Health care providers will have to weigh demands from their professional role with other competing obligations to their own health, to family and friends. Health care workers will face significant challenges related to resource allocation, scope of practice, professional liability, and workplace conditions. Decision makers should: Work collaboratively with stakeholders and professional colleges in advance of an influenza pandemic to establish practice guidelines Work collaboratively to develop fair and accountable processes to resolve disputes Provide supports to ease this moral burden of those with the duty to care Develop means through which institutions will handle appeals or complaints, especially with regards to work exemptions, or the vaccination/prophylaxis of staff Health care workers who are at increased risk because they are caring for patients with influenza must weigh familial obligations, and obligations to self with their professional duty to care. In addition, they may also have to comply with vaccination or antiviral regimens for prophylaxis which may conflict with their individual liberty. 49 What expectation of Duty of Care have you encountered already? 50 Equity The principle of equity holds that, all things being equal, all patients have an equal claim to receive needed health care. During influenza pandemic, however, tough decisions will need to be made about which health services to maintain and which to defer because of extraordinary circumstances. Measures taken to contain the spread of a deadly disease will inevitably cause considerable collateral damage. In an influenza pandemic, this will extend beyond the cessation of elective surgeries and may limit the provision of emergent or necessary services. Decision-makers must strive to: Preserve as much equity as possible between the interests of patients [afflicted with the influenza] and those who need urgent treatment for other diseases Ensure procedural fairness in decision-making In allocating scarce resources, the value of equity could guide in developing fair criteria for allocation while consideration is given also to compensation for those who will not meet inclusion criteria yet are entitled to receive care. https://bmcmedethics.biomedcentral.com/articles/10.1186/1472-6939-7-12/tables/2 51 What equity issues have you encountered already? Student selection Patient access 52 Individual liberty is a value enshrined in health care practice under the principle of respect for autonomy. Under usual circumstances, health care providers balance respect for individual autonomy with a duty to protect individual patients from harm. In a public health crisis, however, restrictions to individual liberty may be necessary to protect the public from serious harm. Patients, staff, and members of the public may all be affected by such restrictions. Restrictions to individual liberty should: Be proportional to the risk of public harm Be necessary and relevant to protecting the public good Employ the least restrictive means necessary to achieve public health goals Be applied without discrimination Social distancing strategies that employ visitor restrictions in hospitals must be necessary for the protection of the public and must be proportionate to the threat being allayed. 53 Anything that makes reference to a patient or their condition in a sexual way: is viewed by the profession to be highly unethical and is illegal, because It runs the risk of/ makes an assumption about you taking advantage of someone else’s misery for your own gain Anything that disrespects staff or colleagues ….. 54 Can you think of an example of individual liberty? Patients right to refuse to see students 55 Privacy Individuals have a right to privacy in health care. In a public health crisis, it may be necessary to override this right to protect the public from serious harm. A proportionate response to the need for private information requires that it be released only if there are no less intrusive means to protect public health. Decision makers should: Disclose only private information that is relevant to achieve legitimate and necessary public health goals Release private information only if there are no less intrusive means to protect public health Determine whether the good that is intended is significant enough to justify the potential harm that can come from suspending privacy rights, (e.g. the harm from stigmatization of individuals or particular communities) Provide public education to correct misconceptions about disease transmission and to offset misattribution of blame to particular communities The need to conduct contact tracing of possibly infected people might require that particular groups or even individuals are identified publicly. The need to do so must be weighed against the potential harm of exposing communities and individuals to stigmatization. 56 Can you think of an example of where you have encountered issues around privacy? Peers and staff right to privacy over their health information 57 Proportionality Proportionality requires that restrictions to individual liberty and measures taken to protect the public from harm should not exceed what is necessary to address the actual level of risk to, or critical need of, the community. Decision makers should: Use least restrictive or coercive measures in limiting or restricting liberties or entitlements Use more coercive measures only in circumstances where less restrictive measures have failed to achieve appropriate public health ends. The decision to close an emergency room must consider if the potential harm in keeping the emergency room open is significant enough to warrant its closure. 58 Can you think of an example of proportionality? Lock up the HIV positive sex worker? 59 Protection of the Public from Harm A foundational principle of public health ethics is the obligation to protect the public from serious harm. This principle requires that citizens comply with imposed restrictions in order to ensure public wellbeing or safety. To protect the public from harm, hospitals may be required to restrict public access to service areas (e.g. restricted visiting hours), to limit availability of some services (e.g. elective surgeries), or to impose infectious control practices (e.g. masks or quarantine). When making decisions designed to protect the public from harm, decision makers should: Weigh the medical and moral imperative for compliance Ensure stakeholders are made aware of the medical and moral reasons for public health measures Ensure stakeholders are aware of the benefits of compliance & the consequences of non-compliance Establish mechanisms to review these decisions as the public health situation changes and to address stakeholders concerns or complaints When making the decision to quarantine individuals, protection of the public from harm must be weighed against individual liberty. Note that while the ethical value of individual liberty is often in tension with the protection of the public from harm, it is also in individuals' interests to minimize harm to others. 60 Reciprocity 9 1 D I COV Reciprocity requires that society supports those who face a disproportionate burden in protecting the public good and takes steps to minimise their impact as far as possible. In an influenza pandemic, measures to protect the public good are likely to impose a disproportionate burden on health care workers, patients, and their families. Health care workers may face expanded duties, increased workplace risks, physical and emotional stress, isolation from peers and family, and in some cases, infection leading to hospitalization or even death. Similarly, quarantined individuals or families of ill patients may experience significant social, economic, and emotional burdens. Decision-makers and institutions are responsible for: Easing the burdens of health care workers, patients, and patient's families in their hospitals and in coordination with other health care organizations Ensuring the safety of their workers, especially when redeploying staff in areas beyond the usual scope of practice The provision of antiviral medication and/or vaccination to hospital staff for prophylaxis is one way hospitals can ensure the safety of their workers who may be exposed to greater than usual risks in discharging their duty to care. 61 Solidarity SARS heightened the global awareness of the interdependence of health systems and the need for solidarity across systemic and institutional boundaries in stemming a serious contagious disease. An influenza pandemic will not only require global solidarity, it will require a vision of solidarity within and between health care institutions. Solidarity requires: Good, open and honest communication Open collaboration, in a spirit of common purpose, within and between health care institutions Sharing public health information Coordinating health care delivery, transfer of patients, and deployment of human and material resources Territoriality between hospital departments and between health care institutions needs to be overcome with good communication and sense of common purpose in order to provide equitable care across jurisdictions 62 Stewardship In our society, both institutions and individuals will be entrusted with governance over scarce resources, such as vaccines, antivirals, ventilators, hospital beds and even health care workers. During a pandemic influenza outbreak, difficult decisions about how to allocate material and human resources will have to be made, and there will be collateral damage as a result of these allocation decisions. Those entrusted with governance roles should be guided by the notion of stewardship. Inherent in stewardship are the notions of trust, ethical behaviour, and good decision-making. Decision makers have a responsibility to: Avoid and/or reduce collateral damage that may result from resource allocation decisions Maximize benefits when allocating resources Protect and develop resources where possible Consider good outcomes (i.e. benefits to the public good) and equity (i.e., fair distribution of benefits & burdens) A hospital's decision to stock-pile antiviral medication must consider whether this is an effective way 63 Trust is an essential component in the relationships between clinician and patient, between staff and the organization, between the public and health care providers, and between organizations within a health system. In a public health crisis, stakeholders may perceive public health measures as a betrayal of trust (e.g. when access to needed care is denied) or as abandonment at a time of greatest need. Decision-makers will be confronted with the challenge of maintaining stakeholders' trust while at the same time stemming an influenza pandemic through various control measures. It takes time to build trust. Decision-makers should: Take steps to build trust with stakeholders before the crisis hits not while it is in full swing Ensure decision making processes are ethical and transparent to those affected stakeholders Early engagement with stakeholders may go some distance to justify stakeholder confidence in decisionmakers' trustworthiness. In part, the value of trust is respected and promoted by following the ethical processes outlined above. 64 Principles in Medicine Autonomy Beneficence - benefits Non-malfeasance - harm Justice 65 Dignity Truthfulness and Honesty Trust Therapeutic relationship 66 Autonomy Disclosure Truth – telling Informed consent Competence Paternalism confidentiality Decision-making 67 Professionalism A body of skills and knowledge Commitment to high standards of service Varying degree of self-regulation and autonomy Moral and ethical standards of behaviour 68 Unprofessionalism Powerful Controlling work Promotes self-interest Constricts public service Constricts Modern notions of free trade zealousness 69 Anything that makes reference to a patient or their condition in a sexual way: is viewed by the profession to be highly unethical and is illegal, because It runs the risk of/ makes an assumption about you taking advantage of someone else’s misery for your own gain Anything that disrespects staff or colleagues ….. 70 Likelihood of malpractice charge or litigation Reflects on behaviour as a medical student Engaging in illegal activity Participation and responsibility 71 Calman’s “key values” High standards of ethics Continuing professional development Concern with health as well as illness Patient and public focused Concern with clinical standards, outcomes, effectiveness and audit Ability to define outcomes Interest in change and improvement, research and development Ability to communicate 72 Within the context of medicine Values are held Ethical sensitivity Moral obligations Law and ethics Autonomy Confidentiality Consent Harm 73 Patient Preferences The Principle of Respect for Autonomy Is the patient mentally capable and legally competent? Is there evidence of incapacity? If competent, what is the patient stating about preferences for treatment? Has the patient been informed of benefits and risks, understood this information, and given consent? If incapacitated, who is the appropriate surrogate? Is the surrogate using appropriate standards for decision making Has the patient expressed prior preferences, eg. Advanced Directives? Is the patient unwilling or unable to cooperate with medical treatment? If so why/ In sum, is the patient’s right to choose being respected to the extent possible in ethics and law? 74 Learning Objectives Identify basic ethical principles Develop a framework for ethical thinking Look at potential contentious issues or unethical requests that might be made to a medical student Identify professionalism 75 HETI (for consultation) 77