Ethics Final

Front 1

Know the difference between privacy and confidentiality.

Back 1

Privacy - a basic human right; a positive right (the person has the right to control access/distribution of info, property and knowledge of personal behaviors); there is a "zone of privacy" that is invaded only with permission; a negative right ("noninterferance"; protects against interference, calls on other to leave patient alone
Confidentiality - keeping secret intimate knowledge that a patient has entrusted to a physician; an obligation to use knowledge only for patient's medical benefit; patient's consent must be gained before sharing any info; the foundation for this duty is based on the ethical virtue of trust

Front 2

Know the difference between a positive and a negative right.

Back 2

Privacy is explained as a positive and a negative right
Positive - the person has teh right to control access to and/or distribution of personal info, property and knowledge of personal behaviors; a zone of privacy that they get to set; can be invaded only by their permission
Negative - protects against interferance and calls on others to leave the patient alone; this right is protected by providing patients/families with secluded spaces for their own medical discussions; ex. knocking on a door before entering; keeping a patients door closed at their request

Front 3

Know Tsarasoff v. Regents of the University of California and clinicians' duty to warn.

Back 3

- a college student to killed his former girlfriend
- he had threatened to do it in a psychotherapy session with his college mental health counselor
- counselor followed standards: gave info to supervisor, tried to have patient place in temp. psych custody
- ruling: therapist had a duty to warn the identified third party
- A duty to respect privacy and confidentiality, except when specific threat is made towards a specific person
- introduced the idea of the duty to warn for the first time - also applies in issues of people with HIV who knowingly have unprotected sexual relations

Front 4

•Know the types of flawed disclosures and why they are flawed

Back 4

•Just the facts – a very complete/scientific rendition of the truth, where the medical jargon keeps the patient from knowing the truth. True statemements can be deceptive if not authentically communicated
•There’s always hope – overly optimistic falsification of the best abailable clinical judgement. Need to acknowledge fallibility and probability; dodging the truth with “miracles always happen”
•You can’t tell a patient everything – “the facts are infinite”; true, but your responsibility is to tell what is meaningful, important and useful to them
•Omission – remaining silent when speech is ethically appropriate = a form of deception
•Evasion – in trying to tell hard news in a less blunt/hard way, it can become avoidance/self-deception; alternative is gentle, considerate and open

Front 5

•Know the communication elements necessary for an “ideal clinician-patient relationship”

Back 5

•Choice, competence, compassion, continuity, lack of conflict of interest, and communication
•A good relationship is one of the most valuable therapeutic tools

Front 6

• Know when it is ethically appropriate and inappropriate to disclose or not to disclose information to a patient

Back 6

oTell patients what they want to know
oTell patients what they need to know
oTranslate info into terms that the patients can take
oDisclosure is determined by the patient – what do they want to know, how much is too much
oPatient has right to: diagnosis, alternative treatments, prognosis, in ways that they can understand
oWhen not to tell: therapeutic privaledge/benevolent deception – only with documentation and a second opinion that disclosure would cause substantial harm to the patient’s physical or mental well-being.

Front 7

Know what distinguishes ethics and morality.

Back 7

– Clinical ethics = ethics of clinical practice and with ethical problems that arise in the care of patients (i.e., ethics at the bedside)
• Clinical ethics concerns problems and practices in the care of patients in a variety of health care settings: hospitals, nursing homes, rehabilitation, home care, and hospice.
• Buildfs on ethical obligation
– Ethics = Greek word ethos = character
– Morality = Latin word mores = character, custom, or habit
– We now understand morality to mean customary morality (widely shared beliefs about the moral life and norms of right and wrong conduct that prevail in our culture)
– Ethics has many meanings. Philosophers use ethics to mean systematic ethics (a perspective from which to evaluate and live the moral life).
A practical way to distinguish between morality and ethics is to regard morality as normative or prescriptive
What ought I to do in this and similar situations?

Ethics is systematic and to be regarded as justificatory, interpretative, and analytical
Why should I do X? What reasons would justify such action and why?

Front 8

Know the four basic ethical obligations that pertain to each case after establishment of the clinician-patient relationship

Back 8

 4 ethical principles are relevant sources of general ethical guidance:
1. Beneficence, which creates an obligation to benefit patients and other persons and to further their welfare and interests
2. Respect for patients’ autonomy, which obligates clinicians to protect and defend the informed choices of capable patients
3. Nonmaleficence, which asserts an obligation to prevent harm, or, if risks of harm must be taken, to minimize them
4. Justice, which is relevant to fairness of access to health care and to issues of rationing at the bedside
 After the clinician-patient relationship is established, the following obligations are morally binding:
1. respecting the patient’s privacy and maintaining a process that protects confidentiality
2. communicating honestly about all aspects of the patient’s diagnosis, treatment, and prognosis
3. determining whether the patient is capable of sharing in decision-making
4. conducting an ethically valid process of informed consent throughout the relationship

Front 9

Know the eight ethically relevant considerations and virtues for caring for patients

Back 9

 Eight considerations that bridge between ethical principles, an ethics of caring, and the clinical situation:
1. the balance between benefits and harms
2. disclosure, informed consent, and shared decision-making
3. the norms of family life
4. the responsibilities of physicians and nurses in the context of relationships with patients
5. professional integrity
6. societal norms of cost-effectiveness and allocation
7. cultural and religious variations
8. considerations of power

Front 10

Know what professional integrity is

Back 10

Integrity = the integration of beliefs about values and purposes, by which lives are conducted; integration of mind and body including emotions
This principle plays an important role in determining whether treatment or care requested by patients or surrogates is ethically appropriate.
 Although patients are free to refuse treatment, they are not entitled to receive whatever treatment they demand.
– Clinicians have no responsibility to offer or provide treatments that are medically inappropriate.

Front 11

Know the basic tenets of the nursing code of ethics

Back 11

- The nurse, in all professionall relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributres or the nature or health problems
- The nurse’s primary commitment is to the patient – whether an individual, family, group or community
- The nurse promores, advocates for, and strives to protect the health, safety and rights of the patient
- The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks
- The nurse owes the same duties to self as to other, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professiona growth
- The nurse participates in estabslishing, maingaining and improving healthcare environments and conditions of employment
- The nurse participates in the advancement of the profession
- The nurse collaborates with other health professionals and the public in promoting widespread efforts to meet health needs
- The profession of nursing is responsible for maintaining the integrity of the profession

Front 12

Know how law and ethics are similar yet different

Back 12

 Clinical ethics and health law evolve together in a dynamic and interactive relationship.
– Because of the diversity of moral traditions in our society, among other reasons, citizens look to the law to articulate both settled and developing norms of conduct in healthcare.
– Clinicians need to know about this society's legal institutions and their own institution's legal process in order to practice wisely.
 Notwithstanding the importance of the relationship between law and clinical ethics, a very poor, even antagonistic, understanding of this relationship exists in many clinical settings.
 The threat of lawsuits and the costs of defending against them have sadly bent this relationship out of shape.
– The anger that many good clinicians feel about being sued and their defensive posture can pose many roadblocks to a simpler and less costly process of resolving ethical problems in the clinical setting.
– Ironically, if such ethical problems remain unsolved, they can flare into legal problems.
 Fear of the law and lawyers makes some clinicians ask about legal liability before asking about what is ethically sound.
 Furthermore, ignorance about what the law requires or permits may lead clinicians to make ethically inappropriate decisions.

Front 13

Know the difference between capacity and competence

Back 13

Incompetance = legal term used when a person has been judged by a court to be unable to take care of himself or to manage his property; completely negates a person’s legal rights
Incapacity – individual limitations (mental or physical) don’t globally restrict their cognitive abilities or life activities; usually refers to specific deficits; ex. financial affairs
Capacity = the ability to make a decision

Front 14

Know the concepts put forth in the literature to determine capacity and how to properly determine if a patient has capacity

Back 14

Determine: abilities of patient, requirement of task at hand, consequences of action
Categories of Criteria for capacity: ability to communicate choices, understand info, appreciate situation and consequences, rationally manipulate info
Also: Informability: Cognitive and affective capability (relate it to themselves, reason, rank alternatives); resolution and resignation (pick one and resign yourself to the choice); Recount your decision-making ability (how did you make the decision)
Depends on situation: easy: awareness and assent; less certain: understand risks and benefits; danterous and risky: highest standards of understanding and judgement

Front 15

Know the types of surrogate decision-making standards for incapacitated patients

Back 15

Advance directives first (living wills or durable power of attourney)
Surrogate order: designated proxies; family members (guardian/committee; spouse, adult child, parent, brother/sister, other relative), institutional committees, the courts
Decision based on 2 standards: Substituted judgement standard (what they would’ve wanted) and best interest standard
Surrogate questionable b/c of : inconvenience, financial, emotions, guild, relition, disinterest

Front 16

Know what a valid informed consent involves

Back 16

Threshold elements (preconditions): Capacity (to understand and decide), Voluntariness (in deciding)
Informational elements: Disclosure (of material information); Recommendation (of a plan); Understanding (of disclosure and recommendation by the patient)
Consent elements: Decision (in favor of a plan); Authorization (of chosen plan)

Front 17

Know what role the nurse has in the informed consent process

Back 17

Determine patients problem in cooperation with patient; determine how problem can be treated; determine resks and benefits of therepies; communicate this to patient
Also, be an advocate, etc

Front 18

Know the difference between informed consent and assent

Back 18

Assent is used to distinguish a kids agreement from a legally valid consent given by an adult
Assent includes: patient aware of condition; told what to expect, clinical assessment of patients understanding of the situation influencing how he will respond, solicit expression of willingness to accept proposed care

Front 19

Know the “senses” of futility

Back 19

Futile – a particular treatment simply doesn’t work
Quantitative futility – likelihood of success of treatment is extremally remote
Qualitative futility – where the care provicers assessment of futility is different from the patient’s

Front 20

Know when it is appropriate for clinicians to refuse to treat a patient

Back 20

To benefit patients
To be true to their own moral views
To meet the interest of larger numbers of other patients or the interests of the greater society

Front 21

Know the various definitions of death

Back 21

Whole body definition – absence of heartbeat and/or pulse; last breath
Whole brain definition – coma (demonstrated by total unreceptivity and unresponsivity to stimuli); absence of spontancous breathing (given normal CO2 range); absence of reflexes (given absence of neurologic meds); flat or isoelectric electroencephalogram

Front 22

Know how clinicians should properly deliver bad news

Back 22

Privacy, complete introductions, address patient, sit down, face to face, open ended questions, not interrupting, be comfortable with silence
Buckman’s six step method:
- Good start (good environment, everyone is there, , making introductions/physical contact with patient
- Find out how much the patient knows
- Find out how much the patient wants to know
- Share infor according to patient’s needs/desires; make a mutually-agreed upon plan for the future
- Respond to patient’s feelings – identify and acknowledge
- Planning and follow through – plan of care

Front 23

Know what distinguishes euthanasia and clinician-assisted suicide

Back 23

Euthanasia – intentional taking of another life to promote a “good” or merciful death
PAS (physician assisted suicide) = patient takes life, clinician helps

Front 24

Know the ethical guidelines for deciding to forgo life-sustaining treatments when the patient is incapacitated

Back 24

- Respect advance directives
- Use benefit/burden standard as major guideline: Treatment benefits( 2 types – health and quality of life benefits); Treatment burdens (2 types – treatment reduces quality of life or provides no measurable health benefits and entails increased pain/suffering)
- Disclose poor prognosis or futility: don’t offer futile treatments Use 6 steps for writing of DNR order (benefit/burden assessment of CPR; if negative, consult with other healthcare workers; if no objectives explain the DNR to patient/surrogates; if no objections, write order in patient’s chart, along with reasons; reevaluate every 7 days)
- During disputes with surrogates, treat patient until resolution, unless treatment harms the patient

Front 25

Know what the Baby Doe regulations were

Back 25

Required maximal treatment of handicapped infants in all cases except when treatment was futile b/c the infant was irreversibly and imminently dying
Baby doe squads started to check the hospitals – laws eventually changed
Modified: all must receive nutrion, hydration and meds no matter what; all must be given medically indicated treatment; exceptions: chronically/irriversitly comatose; if treatment would just prolong tying; if treatment would be futile and the treatment would be inhumane in those conditions

Front 26

Know the standards for making medical decisions when dealing with neonates, infants, and children

Back 26

- Medical indications – as long as they aren’t dying
- Quality of life: - minimal quality is freedom from intractable pain/suffering, capacity to experience/enjoy life; expectation of continued life
- Technical medical criteria
- Nonmaleficence/best interest (principle violated; if they are inable to survive infancy, to live w/o severe pain, to participate minimally in human experience)
- Evaluate best interest based on severity, achievability of treatment, important medical goals, presence of neurologic impairments; extent of suffering, other medical problems, life expectancy, benefit/burden balance for treatments

Front 27

Know about the types of assisted reproductive technologies and what ethical issues they pose

Back 27

o Methods:
 Artificial insemination – husband or sperm donor
 In vitro fertilization
 Oocyte donation – fertilized in vitro
 Surrogacy
 Intracytoplasmic sperm injection – direct injection of 1 sperm into egg
 Reproductive cloning – not used in practice

Hint 27

o Ethical issues:
 Use of reproductive technologies
• Initially accepted
o Does the intense desire to have children provide sufficient ethical justification to warrant their use?
• Whether it is “unnatural” and therefore wrong
• Whether it will change what we mean by family and parenthood
• Whether it commodifies procreation and children
• Special ethical questions that arise:
o Requiring evidence of safety/effectiveness of new treatments
o Need to improve informed consent procedures
o Multifetal pregnancies
 Fetal “reduction”
o Financial arrangements
 If IVF fails, money returned to patients – increases general cost greatly
• Encourages physicians to implant more fetuses
 Employing pre-implantation genetic diagnosis
• Enables parents to select certain traits or avoid a certain genetic illness

Front 28

Know the names and key points of each of the big three ethical theories

Back 28

Virtue Theory
 Virtues can be applied to:
– Human beings
– Objects
 Three goals:
– Develop and defend conception of the ideal person
– Develop and defend list of virtues necessary for being a person of a specific type
– Defend a view of how persons can possess these virtues
– Examples from the history of philosophy:
– Aristotle – four cardinal virtues: courage, justice, temperance, and wisdom
– St. Aquinas and St. Augustine – faith, hope, and charity
Deontology
 Deon = Greek word for “duty”
 Deontology regards the fundamental ethical task as one of doing the right thing (or avoiding the wrong thing)
 Commonly guide action with a set of moral principles or rules. Two types:
– Rules may refer to particular circumstances: Actions of type T are never (always) to be performed in circumstance C
– Rules may be absolute (prohibiting actions in all circumstances): Actions of type T’ are never to be performed
 Essential tasks of deontology:
– Formulate and defend a set of moral rules
– Develop and defend some method of determining what to do when rules conflict
– Two general types of deontology:
– Rule deontology: requires agents to perform actions that can be specified by a rule or general action guide
– Act deontology: requires particular actions that elude specifications by a rule in their particularity
Consequentiality
 Judgments of the value of consequences of actions are most important
 One should act so that one will bring about the most one designates as valuable
 Three goals:
– Specify and defend some thing or list of things that are good in themselves
– Provide technique to measure and compare quantities of these intrinsic goods
– Defend policy for those cases where one cannot determine which of a number of alternative actions will maximize the good
– Two types:
– Act consequentialism: perform the action that in a particular situation is most likely to maximize good consequences
– Rule consequentialism: follow those rules the observance of which will maximize good consequences
– Instrumental versus intrinsic:
– Instrumental things are good only so far as they play a role in bringing about intrinsically good things
– Intrinsically good things – their goodness is independent because it is constituted by the kind of thing the good thing is

Front 29

Know why it is important not to divorce ethical reasoning from clinical reasoning

Back 29

- if decisions are just clinical, then the healthworker can be blind to abuse of the healer’s power
- response just to the law/being sued itn’t enough either
- also a problem if you assume that the medical knowledge gives you the right to be the one who makes ethical decisions
- often, people distance ethical reasoning from their practice, and just base decisions on the norms

Front 30

Know what palliative care involves

Back 30

- Effective control of pain and other symptoms
- Care of patient and family as a unity
- Interdisciplinary team approach
- Continuity of care
- Follow up w/family members after patient’s death
- Goal – to achieve the best quality of life through:
o Relief of suffering
o Control of symptoms
o Restoration of functional capacity
o Remaining sensitive to personal, cultural and religions things

Front 31

Know the various forms of advance directives and under what circumstances they apply (or don’t)

Back 31

• When an incapacitated patient who is terminally ill or in a state of PVS has a living will and/or has appointed a surrogate with a durable power of attorney for health care (DPAHC), clinicians and family have moral and legal duties to honor such directives and to share authority with the patient’s proxy in decisions to forgo life-sustaining treatment.
• However, statements that persons make in living wills about their preferences in the event that they are in a terminal stage of illness are not helpful when they are not yet in that stage.
• Advanced directives do not trump a benefits/burden assessment.
• Moreover, advance directives can function more broadly in helping to determining a substituted judgment.