Medical Ethics

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Medical Ethics

• Unit 19
• HIV Care and ART
• A Course for Healthcare Providers

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Learning Objectives

• Explain the importance and utility of medical
  ethics
• Describe the methodology of ethical deliberation
• Analyze practical issues in the clinical setting
  from an ethics perspective

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Skepticism and Medical EthicsTrainer Role Play
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Basic Rights and Ethical Duties

• Human Rights
• Access to health care
• Right to non-discrimination
• Right to privacy and confidentiality
• Right to environment that is not harmful to
  health or well being

Human Dignity
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Medical Ethics Definition

• The practice of medicine is rooted in a covenant
  of trust among patients, healthcare
  professionals, and society.
• The ethics of medicine must seek to balance the
  healthcare professionals responsibility to each
  patient and the professional, collective
  obligation to all who need medical care.
• The Council of Medical Specialty Societies, 2000
• http//www.nyu.edu/gsas/dept/philo/faculty/ruddick
  /papers/medethics.html

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Utility of Medical Ethics

• Medical ethics principles provide a framework for
  discussing ethical issues and for medical
  decision making
• The principles provide consistent guidance where
  there are substantive considerations on both
  sides of an issue

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Ethical vs. Legal Obligations

• Medical ethics and the law are not the same, but
  often help define each other
• Breach of ethical obligation may not necessarily
  mean breach of law
• Breach of ethical obligation may be used to prove
  medical malpractice or medical negligence

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Healthcare Professional Role

• Paternalistic model
• Emphasizes health and well-being (beneficence)
  over respect for autonomy and patient choice
• Patient is selectively given information
• Evolution of newer decision-making models
• Independent choice vs. enhanced autonomy
• Paternalistic vs. informative vs. interpretive
  vs. deliberative

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Interconnectedness of Rights, Trust, and
Obligation
Public Trust
Patient Rights
Health Care Worker Obligations
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Benetars Levels of Ethics in HIV/AIDS

• Micro Level
• Individual doctor-patient relationship
• Meso Level
• Civic and public health ethics, including
  equitable access to health care
• Macro level
• Ethics of interdependance and international
  relationships

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Micro Level Ethical Principles

• I. Respect for Autonomy (or Person)
• Respect the decisions of autonomous persons and
  protect persons who lack decision-making capacity
  (e.g., confused pts, mentally ill).
• Recognize the capacity of mentally and legally
  competent patients
• To think and make decisions independently
• To act on the basis of their decisions
• To communicate their wishes to health workers
• Uphold patient confidentiality

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Ethical Principles (2)

• II. Non-Maleficence (Not inflicting harm)
• Health professionals should not inflict harm on
  patients (Premum non nocere)
• III. Beneficence
• Act in the best interests of patients or research
  participants.
• Contribute to patient welfare help patients
  further health interests

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Ethical Principles (3)

• Sometimes there is ethical tension between
  beneficence (attaining a beneficial outcome) vs.
  non-maleficence (not inflicting harm)
• It is important to weigh the chance of success
  against risks of treatment

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Ethical Principles (4)

• IV. Justice
• Requires that people be treated fairly. (It is
  often understood to require that benefits and
  burdens be distributed fairly within society.)
• Treat all patients equally no unfair
  discrimination
• Distributive justice

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Informed Consent

• Definition A patients willing acceptance of a
  medical intervention after adequate disclosure
  from their MD of the nature of the intervention,
  risks, benefits and alternative treatment options
• What constitutes informed consent?
• Disclosure information to allow reasonable
  person to make a decision
• Understanding comprehension of the information
  given
• Voluntary no coercion or incentive to accept or
  deny a treatment
• Agreement verbal or written (preferred) to
  discussed intervention

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Confidentiality

• Patient confidentiality must be upheld
• Breaching patient confidentiality may be merited
  only
• When ordered by court of law a court case
• Where statutory requirement public health laws
  
• Where required in health professionals defense
  malpractice suit
• Where necessary for appropriate patient
  care-speaking to another provider in the medical
  care system

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Honesty

• The percentage of patients who would like to be
  told their diagnosis if it is a
  
• Metastatic cancer Terminal Prognosis
• European Americans 87 69
• African Americans 88 63
• Mexican Americans 65 48
• Korean Americans 47 35
• Ethiopians (can you guess?)?? ??
• Source Blackhall LJ, et al. (1995) JAMA 274
  820-5.
• The more traditional the culture the less truth
  telling regarding patient condition

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Framework for Medical Ethics Development in
Ethiopia
Capacity
OUTCOMES
Ethics Committees
Awareness
Standards

• platforms for ethical action
• intensive public debate
• informed public opinion
• (inter)national normative frameworks
• morally sensitized professionals and health
  professionals
• assisted policy-making

Academics/ Teaching/ Research
Declara- tions
Legislation/ Guidelines
Publications
Ethics Teaching
Seminar/ Workshops/ Trainings
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Case Studies
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Case Study Lake

• Lake, your 36-year-old patient, has just tested
  positive for HIV. He asks that you not inform his
  wife of the results and claims he is not ready to
  tell her yet.

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Case Study Lielit

• Lielit, a 22 year-old woman, is admitted to the
  hospital with a headache, stiff neck and
  photophobia but an intact mental status. Lab
  tests reveal cryptococcal meningitis, an
  infection commonly associated with HIV infection.
  When given the diagnosis, she adamantly refuses
  to be tested for HIV.

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Case Study Berhan

• Berhan, a 35 year-old man with AIDS, admits that
  he is often unable to take his medicines
  regularly because of his alcohol and chat
  addictions. His lab profile is consistent with
  immunological treatment failure.

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Case Study Mihret

• Mihret, a 27 year-old healthy looking mother,
  brings her 3 year-old son to a clinic with
  chronic diarrhea, weight loss, and failure to
  thrive. She reports that an older child died
  several years ago, at age 2. She is advised to
  have her son tested for HIV, but she adamantly
  refuses because of her fear of knowing her own
  HIV status and that of her husband.

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Case Study Mikael

• You are have been caring for a 12 year-old
  HIV-infected boy who has been clinically stable
  until recently. He now meets criteria for ARV
  treatment but you are very concerned because his
  mother has refused to allow disclosure of his
  HIV-status to him. He has been asking questions
  about why he keeps getting sick.

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HIV should be a Notifiable Disease
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Medical Ethics
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Key Points

• The most commonly accepted principles of medical
  ethics include
• Respect for Patient Autonomy
• Beneficence and Nonmaleficence
• Justice
• Other principles include informed consent,
  confidentiality and honesty
• Medical ethical discussions need to take into
  account the cultural situation in which they
  occur.