Ethics in Radiation Sciences: Improving our Ethical Fitness

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Ethics in Radiation Sciences Improving our
Ethical Fitness

• Rosanna Macri, Ethicist
• Member, Joint Centre for Bioethics, University of
  Toronto
• Adjunct Lecturer, University of Toronto,
  Department of
• Radiation Oncology

May 28 30, 2015, Montréal, Québec
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Disclosure Statement No Conflict of Interest
I do not have an affiliation, financial or
otherwise, with a pharmaceutical company, medical
device or communications organization. I have no
conflicts of interest to disclose ( i.e. no
industry funding received or other commercial
relationships). I have no financial relationship
or advisory role with pharmaceutical or
device-making companies, or CME provider.
May 28 30, 2015, Montréal, Québec
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Objectives

• Review the history of ethics in Radiation
  Sciences
• Explore a few common ethical issues in Radiation
  Sciences
• Resource Allocation VIP Treatment
• Consent Capacity SDM
• Privacy Confidentiality
• Review ethics skills Strategies to improve
  ethical fitness
• Introduce a tool to help work through ethics
  issues

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Did you know

• Human radiation experiments (1944-1974)
• Almost 4000 experiments sponsored by US gov.
• The ringworm affair
• Children treated for scalp ringworm
• Pregnant women and babies
• Pregnant women and babies were given radioactive
  iodine to better understand its uptake by the
  thyroid gland
• Vitamin drinks - 829 pregnant mothers in
  Tennessee contained radioactive iron to
  determining how fast the radioisotope crossed
  into the placenta
• Mentally disabled children
• Fed oatmeal containing radioactive calcium and
  other radioisotopes, in order to track "how
  nutrients were digested
• Told they were joining a science club

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Ethics Issues Can Cause Moral Distress

• Have you ever encountered a situation in which
  you felt you had no choice but to do something
  that
• You believed was morally wrong?
• Or violated your professional integrity?
• Or was contrary to your code of ethics?

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How did you feel?
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Common Ethics Issues

• Resource Allocation VIP Treatment
• Consent Capacity SDM
• Privacy Confidentiality

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Resource Allocation
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(No Transcript)
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VIP Treatment
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CAMRT Code of Ethics

• Fairness, accountability and integrity
• Prioritize the use of resources according to need
• Utilize and distribute resources over which they
  have control in a fair and responsible manner
• Advocate for working environments that support
  safe, competent and ethical practice
• Contribute to interdisciplinary collaboration
• Participate in collaborative problem solving

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Consent, Capacity SDM
Mr. T is an 85 year old man. He has recently been
admitted to a palliative care unit. Due to Mr.
Ts diagnosis of metastatic prostate cancer, two
months ago he was given a prognosis of 3-6
months. Over the past couple of months Mr. T has
been taking pain medication however upon
admittance to the palliative care unit the family
has asked for the pain medication to be
discontinued for religious reasons and also
because they feel that the meds may be hastening
Mr. Ts death. The doctor has ordered an x-ray
for a suspected hip fracture. Mr. T is now in the
x-ray suite on a stretcher. He continues to groan
and ask for pain medication. You are unable to
transfer him.
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Consent and Capacity Quick Review

• Consent Informed decision-making involves has 3
  components
• Disclosure the provision of all relevant
  information and the comprehension of this
  information by the patient
• Capacity- the patients ability to understand
  information and appreciate potential consequences
  of their decision
• Voluntariness- the patients right to come to a
  decision freely (without force, coercion or
  manipulation)

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Quick Review Continued

• Bad decisions ? incapacity
• Capacity is decision specific
• No such thing as global incapacity
• Capacity is PRESUMED for ALL patient until proven
  otherwise
• Observe your environment
• Capacity is time specific (i.e. Capacity may
  fluctuate)
• Include the right players
• Mind all barriers in communication

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The Players in the CC Game

• Who delivers the information?
• the member of the health care team offering the
  treatment
• Thats YOU
• Who decides?
• The patient if capable
• The substitute decision maker (HCCA)
• How should that decision be made?
• Prior expressed capable wishes
• Best interests

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CAMRT Code of Ethics

• Patient respect and dignity
• Assist patients and families to make informed
  decisions regarding care
• Facilitate the patients free and informed
  choices
• Provide the patient with an accurate description
  of all procedures and associated risks in a
  truthful and comprehensible manner
• Answer patient questions fully and honestly
  within the limits of their knowledge and
  authority/ responsibility
• Participate in the formal consent process by
  ensuring patient willingness to participate in
  the procedure
• Respect the patients right to refuse or withdraw
  from treatment

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Privacy Confidentiality

• Whatsoever I shall see or hear in the course of
  my professionif it be what should not be
  published abroad, I will never divulge, holding
  such things to be holy secrets.
• (Hippocratic Oath)

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Definition

• Privacy persons right to control access to
  their personal information
• Confidentiality the duty of every health care
  practitioner to respect and maintain this patient
  privacy
• Privacy itself is the foundation of a persons
  dignity and autonomy
• Confidentiality is a basic tenet of the
  therapeutic relationship
• Ethics Theory Virtue Theory

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Former Toronto Mayor
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CAMRT Code of Ethics

• Patient respect and dignity
• Take steps to ensure the physical privacy of the
  patient
• Maintain the confidentiality of information
  provided by or about the patient, as well as
  anything contained in the patients record,
  except as part of standard therapeutic
  information sharing within the health care team,
  or where required by law

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What is Bioethics?

• Bioethics involves critical
• reflection on moral/ethical
• issues arising in the areas of
• health care and research
• toward
• deciding what we should do
• What decisions are morally right or acceptable
• explaining why we should do it
• Justifying our decision in moral terms
• describing how we should do it
• The method or manner of our response
• 
  (Dr. Barb Secker)

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Guides to Our Practice

• Our Principles
• Organizational Values
• Professional codes of Practice
• The Law

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Strategies to Work Through Ethical Issues

• Ethics education (i.e. issues techniques)
• Ethically fitness
• Can lead to prevention
• Ethics debriefing
• Ethics consultations

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Ethics Education Ethical Fitness

• Rushworth Kidder president and founder of the
  Institute for Global Ethics in the USA
• Similar to physical fitness
• we are not born with it, rather, it is
• reached by giving a little effort each
• day, and it needs to be maintained
• Must be mentally engaged thinking,
• reasoning, grappling with difficult
• situations or their potential, as well as a
  commitment to
• finding better ways to reach good outcomes
• Take time for ethical reflection in practice

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Ethics Education Ethics Skills
Frank Wagner, Toronto Central CCAC

• Sensitivity attunement to know when an issue is
  an ethical issue
• Critical reflection
• Practical reasoning
• Problem solving

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Ethics Skills
1. Sensitivity Attunement
We need to be aware and be sensitive to
recognizing when an issue is an ethical issue.
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What is an Ethical Issue?
Could
Should
Any situation where we Encounter conflicting
values, beliefs goals, or difficult
alternatives Have conflicting obligations or
responsibilities Are concerned that rights are
being violated or persons not being respected
Are concerned with fairness justice Are
unsure about what we should do or why we should
do it
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Ethics Skills

1. Critical Reflection

Give careful consideration
To question assumptions, both our own and others
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Ethics Skills

1. Critical Reflection Continued..

• Why is critical reflection important?
• Initial reactions are often knee-jerk emotional
  responses.
• Initial reactions do not take other perspectives
  into account.
• We naturally jump to conclusions.

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Ethics Skills

1. Critical Reflection Continued..

• Levels of a Moral Response
• The expressive level (unanalyzed expressions or
  feeling that, by themselves, dont provide
  reasons or justification)
• The pre-reflective level (appeal to law,
  religious tenets, social values, codes of ethics,
  etc. accepted uncritically)
• The reflective level (reasoned ethical
  argument/defense using ethical principles,
  values, rules, virtues, etc., i.e., justification
  provided)
• (Thomas J and Waluchow W, 1998)

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Ethics Skills

• Practical reasoning
• the ability to reach a well-supported answer to a
  well-defined question (Stanford Encyclopedia of
  Philosophy)
• Problem solving
• the ability to apply practical reasoning and
  critical reflection to the problem at hand.

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The Role of an Ethics Debriefing

• Definition
• Group-based reflective practice exercise
• The role of the ethicist
• Facilitation create the space and rules
• Focus on individuals needs not team needs
• Listen, stabilize, inform, normalize and recover
• Reflect on ethical issues discuss where values
  clash introduce ethics language where
  appropriate
• Provide follow-up as agreed by the group

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The Role of Ethics Consultation

• Definition
• A process by which a trained ethicist responds to
  a request for assistance around an ethically
  challenging situation
• Purpose
• To identify and promote reflection on ethical
  issues, principles/values, and relevant policies
  and law
• To promote fair decision-making

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The Case of Mrs. V

• Ms. V is an 88-year-old Russian woman who lives
  alone with her elderly dog. She does not speak
  English well.
• Ms. V was recently diagnosed with advanced lung
  cancer.
• Her son has asked the doctor not to tell his
  mother that she has cancer. He states that she
  has never wanted to know that type of health care
  information and that the knowledge of the
  diagnosis would cause more harm than good.
• You are asked to provide treatment.
• In broken English you believe the patient is
  asking what type of treatment she is receiving
  and why.

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The IDEA Tool for Ethical Decision-Making

• Step-by-step tool
• Considers facts, emotions, ethical principles,
  alternatives consequences, outcome evaluation
  
• Forum for open non-threatening discussion

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STEP 1 IDENTIFY THE KEY QUESTION FACTS

• Clinical indications
• Clients current health status history,
  diagnosis, prognosis?
• Type of problem acute, chronic, critical,
  emergent, reversible?
• Goals of treatment/ intervention?
• Probabilities of success?
• Plans in case of therapeutic failure?
• Benefit of treatment/ intervention to client?
• Harm to be avoided?
•  

• Relevant Facts
• Describe the relevant facts of the case/issue.
• What are the main problems or areas of
  concern/tension?
• Who are the individuals involved, and who else
  needs to be involved?
• What statutes, regulations, policies, standards,
  etc. are relevant?

• Contextual features
• Family issues influencing decisions re.
  treatment/ intervention?
• Any relevant religious or cultural factors
• Any health practitioner issues influencing
  decisions, e.g., judgments about quality of life?
• Any organizational issues influencing decisions,
  e.g., financial/economic factors, teaching or
  research?
• Any legal implications of decisions regarding
  treatment/ intervention?
• Any limits on confidentiality?
• Any conflict of interest on the part of the
  providers or the organization?

• Client preferences
• Client's assessment of quality of life with and
  without treatment/ intervention?
• Clients preferences re. treatment/ intervention?
• Clients decision voluntary and informed?
• Substitute decision-maker if client not capable
  of making decision?
• SDM understands role?
• Client expressed prior wishes (oral, (written, or
  other means)?
• Client willing or ability to cooperate? If not,
  why not?
• Clients right to choose respected to extent
  possible in ethics and law?
•  

Jonsen, Albert, Siegler, Mark and Winslade,
William. Clinical Ethics A Practical Approach to
Ethical Decisions in Clinical Medicine, 5th ed.
McGraw-Hill Medical 2002.
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STEP 2 DETERMINE THE ETHICAL PRINCIPLES IN
CONFLICT
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STEP 3 EXPLORE OPTIONS
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STEP 4 ACT ON YOUR DECISION AND EVALUATE
1. Develop an action plan (Note the actual plan
should be documented in the chart) Given all the
information that you have, choose the best option
available. Develop an action plan. Present
your suggested alternative and action plan to the
client and those involved in such a way that it
allows them to accept the plan. Re-examine the
alternatives if other factors come to light, if
the situation changes, or if an agreement cannot
be reached. Determine when to evaluate the
plan. Document and communicate the plan
2. Evaluate the plan What was the outcome of
the plan? Are changes necessary? Document the
evaluation.
3. Self-evaluate your decision How do you feel
about the decision and the outcome? What would
you do differently next time? What would you do
the same? What have you learned about yourself?
What have you learned about this
decision-making process?
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Questions/Comments