General Internal Medicine Tuesday Conference

1
General Internal Medicine Tuesday Conference

• Ethical Dilemmas
• 4/24/07
• Barbara Cleary, MD

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Overview

• Introduction
• Ideal ethical observer
• Human ethical observer
• Ethical dilemma
• Codes, Principles, Rules, Virtues

3
Overview

• Process for ethics
• Beauchamp and Childress
• Jonsen, Siegler and Winslade
• Glover - system at UCHSC
• Cases
• 51, terminal dementia, suicidal
• 82, end-stage dementia, stage 4 decub, FC/FT
  directive

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Overview

• 26, severe TBI, family - do everything
• Conclusion
• References

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Introduction

• Ideal ethical observer Roderick Firth
• Omniscient
• Omni percipient
• Disinterested
• Dispassionate
• Consistent

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Introduction

• Human ethical observer
• Cultural values
• Religious values
• Professional values
• Emotions
• Life experience

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Introduction

• Ethical dilemma
• Related to differing values
• Conflicting moral imperatives
• Morally suspect requests

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Codes, Principles, Rules, Virtues

• AMA Code of Conduct
• 4 Principles
• Respect for Autonomy
• Nonmaleficence
• Beneficence
• Justice

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Codes, Principles, Rules, Virtues

• Rules
• Fidelity
• Truthtelling
• Confidentiality
• Privacy

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Codes, Principles, Rules, Virtues

• Virtues
• Compassion
• Integrity
• Discernment
• Trustworthiness
• Conscientiousness

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Process for Ethics

• Consistency
• Fairness
• Ensure facts are known
• Understand ethical dilemma
• Based on multiple theories of ethics

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Process for Ethics

• Beauchamp and Childress 4 Principles
• Medical Facts
• Value data from interested parties
• Prioritize the 4 principles
• Downside
• Lack of practical detail
• No room for emotion

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Process for Ethics

• Jonsen, Siegler and Winslade 4 Topics Method
• Medical indications
• Patient preferences
• Quality of life
• Contextual Features

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Process for Ethics

• Jacqueline Glover UCHSC system
• What is the ethical question?
• Initial gut check
• What are the facts?
• What values are at stake?
• What are the options?
• What should I do?
• What justifies the choice?

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Case 1

• 51 y/o woman with Huntingtons Disease
• Husband died unexpectedly
• S/p suicide attempt at NH
• Currently starving herself to death
• Son is DPOA, Feed her through grief process

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Case 2

• 82 y/o male, end-stage dementia
• Stage 4 sacral decubitus ulcer
• Pain
• NH contextual features
• Family comfort measures, but
• FC/FT directive from 2 months prior

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Case 3

• 26 y/o male with severe TBI
• Bilat ACA, thalamic and basal ganglia CVAs
• L MCA and L PCA CVAs
• Brainstem ok
• Empyema
• NS and Neurology, no hope of meaningful recovery
• Family do everything

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Conclusion

• On being an ethical observer
• Principles, rules, etc
• Process for ethics
• Cases
• In Summary..

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Conclusion
As to diseases, make a habit of two things to
help or at least do no harm
Hippocratic writings
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References

• Beauchamp TL, Childress JF. Principles of
  Biomedical Ethics, (5th ed.). New York Oxford
  University Press 2001.
• Jonsen AR, Siegler M, Winslade WJ. Clinical
  Ethics A Practical Approach to Ethical Decisions
  in Clinical Medicine (5th ed.). New York
  McGraw-Hill Co Inc 2002.
• Doka KJ, Jennings B, Corr CA. Living with Grief
  Ethical Dilemmas at the End of Life. Washington
  DC Hospice Foundation of America 2005.
• Glover JJ. Ethical Decision-Making Guidelines and
  Tools in Ethical Challenges in the Management of
  Health Information by Laurinda Beebe Harman, 2nd
  ed., Jones and Bartlett, 2006.
• Campbell AV. The Virtues (and Vices) of the Four
  Principles. J Med Ethics 200329292-296

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References

• Hurst SA, Hull SC, DuVal G, Danis M. How
  physicians face ethical difficulties a
  qualitative analysis. J med Ethics 2005317-14.
• Sommerville A. Juggling law, ethics, and
  intuition practical answers to awkward
  questions. J Med Ethics 200329281-286
• Gillon R. Ethics needs principles four can
  encompass the rest and respect for autonomy
  should be first among equals. J Med Ethics
  200329307-312