Medical Ethics:

Front 1

What are the types of Codes?

Back 1

1. Hippocratic
- Those following the oath's wording
- Those including the hippocratic principles.

Front 2

What are the types of codes?

Back 2

Hippocratic Oaths
- Include Hippocratic Wording, and follow the principles.

Non-Hippocratic Oaths
- Written by health care proffesionals and come from outside of the health care proffesions (i.e. Islamic Code).

Front 3

Hippocratic Oath

Back 3

- Grandaddy of Western Medical Ethics.

- Comes from large collection of hippocratic writings that come from a hippocratic "schools" (probobly written by his followers)

- The school existed on the island of Cos (around 4 BC).

- Belived to be pythogorean in charachter (they were religious phylosophical, scientific group.. they practice medicine).

Front 4

Hippocratic Oath Characteristics:

Back 4

Oath of Initiation:
- Beging by swearing by gods/goddesses (usually take it out in re-writings)
- Pledge of Loyalty to One's Teacher (Responsibility of the med school student to be loyal to the teacher)
- Concern about Seceret Knowledge
-- ideas that it is dangerous that this knowledge is transfered to non-educated.
[Different from current idea: we must teach out patient]

Division of Medicine into three parts:
- Dietetics (what you eat)
- Pharmacology
- Surgery

Front 5

The Hippocratic Oath states that the doctor should obstain from:

Back 5

- Surgery
- Giving deadly drugs
- Abortion
(*contreversial?)

Front 6

What is the "core" principle of the hippocratic oath as stated in lecture?

Back 6

"That the regiment I will prescribe will be for the good of my patients according to my ability and my judgment"

Front 7

What are the different hippocratic wording...?

Back 7

- The first one.. christian tradition (10th century A.D.)
- The Florence Nightengale Pledge (Parphrase of hippocratic oath written for nurses 1983).
- The Solem Oath of Physician of Russia (1992, Post Soviet Russian Physician, adopted the hippocratic ethic)
- Declaration of Geneva (1948, 1983 --> rewrite some of the Nazi ideology, again hippocratic )
- State of New York of Saracus (used to swear by the original oath).
- SGU (has an oath, paraphrase of hippocratic oath).

Front 8

What are some oaths which are based on Hippocratic Principles?

*NOT hippocratic in words but principles are hippocratic*

Back 8

- Percival's Code (1803) -> work for the benefit of the patient...

- American Medical Association (1847) - Code of ethics to convery to the public that they are not here for their own self interest
[based on Percival's Oath]
- British Medical Association (early 20th century) - copied from the American Medical Association...

Front 9

What are some NON-Hippocratic Oeaths?

** Outside of Health Professions: Secular Codes **

Back 9

- The Nuremberg Code (1946)
- The Oath of the Soviet Physician (1971)
- The American Hospital Association Patient's Bill of Rights (1973)
- Council of Europe Convention on Human Rights and Biomedicine (1997)
- The U.S. Consumers Bill of Rights (1997)
- **Liberal Political Phylosophy**
(Founding Fathers..--> different foundating for an ethic in medicine)

Front 10

1. Patient Rights first appeared in?

2. What were some of the non-hippocratic codes that appeared in the 70s and 80s.?

Back 10

1. 1980 (big change) before this, there was no patient rights (was always benefits twoards patient). Was done by the AMA - rewrite in 2001.

------------>2<---------------
2. The chilean medical association

3. The American Nurses association code for nurses (1985)

4. The Federal Council of medicine of brazil

5. The New Zeland Medial Association

Front 11

The Neuronberg code has something that the hippocratic oath does not, what is it?

Back 11

- Consent of the subject. (Willingness of the subject is essential)

Front 12

The Oath of the Soviet Physician?

Back 12

- Says you must practice medicine for the country, and based on soviet/marxist morality.

Front 13

UNSECO?

Back 13

Universal Declaratio on Bioethics and Human Rights....

Front 14

What are some non-hippocratic codes which are based on religious groups?

Back 14

1. The Caraka Samhita
2. The Oath of Asaph (Jewish)
3. Te Seventeen Rules of Enjuin, Japan.
4. Ten Maxims for Physicians and Ten maxims for Patients, China (17th Century CE).
5. The Islamic Code of Medical Ethics
6. The Ethical and Religous Directives for Catholic Health Facilities.

Front 15

Which Ethics are Consequenstialist / Duty - Based, and apply to Individual and Social?

Back 15

Consequentialist Principles (Individual) - Hippocratic Oath

Consequentialist (Social) - AMA Code

Duty-Based (Individual) - AMA Patient's Bill of Rights

Duty-Based (Social) - AMA Code 1980

Front 16

What are some charachtaristics of non-hippocratic oaths?

Back 16

- Often from groups outside health professions
- Concern with social as well as patient welfare
- Concern with duties and rights as well as benefits and harms.

Front 17

1. What is Moral Status?
2. What is moral standing?

Back 17

1.The Moral Standing: Moral Status of the Brain Dead, Fetuses and Non-Human Animals.

2.The term used to describe the moral status of various beings.

Front 18

Moral Standing: Define Full vs. Limited Standing

Back 18

Living Human beings often said to have "Full Standing"

"Limited Standing" sometimes attributed to:
- Human Corpses
- Egg and Sperm Cell
- Perhaps Fetuses
- Non-Human animals

Front 19

The Cardiac - Oriented View is:

Back 19

An individual dies when there is irreversible cessation of circulatory and respiratory function.

Irreversible Stoppage:
- Cf. Temporary Cardiac Arrest w/out death
- Open heart surgery with heart-lung machine

"Oriented"
- Not just the heart
- Barney Clarke (artificial heart patient)
"Clinical Death"
- A meaningless or confusing term.

Front 20

The Whlole - Brain view is:

Back 20

An individual dies when there is irreversible cessation of all functions of the entire brain (including the brain stem)

This is the current law with limited exceptions:
- Japan
- New Jersry
- New York

Front 21

The higher - brain view:

Back 21

An individual dis when there is an irreversible loss of 'higher' brain function.

Consciousness usually considered critical.

Not currently law and jurisdiction.

Front 22

Abortion: What are the three views?

Back 22

- Acceptable until capacit for higher-brain function exists
- Acceptable until capacity for any brain function exists
- Acceptale until capacity for cardiac function exists

Front 23

In Abortion, define potential and capacity?

Back 23

Capacity - actual ability to carry out function.

Potential - Genetic program to develop the capacity to carry out the critical function.

Front 24

Non-Human Animals:

Back 24

Western thought traditionally has seen a sharp division beteween human and other animals.

Eastern thought has seen connection as closer
- Hindu doctrine of ahimsa (avoidance of suffering)

Recent Western increase in concern
- Speciesism = the belief that membership in a species per se is relevant to moral standing.

Front 25

What is a principle?

Back 25

A principle = A general characteristic of actions that makes them morally right.

Front 26

What are the four problems in assessing benefit and harm?

Back 26

A. Objective vs. Subjective Judgments

B. Medical vs. Other Benefits

C. Conflicting Medical Goals

D. Relating Benefits to Harms

Front 27

What is Beneficence ? What is nonmaleficence? What is Utility?

Back 27

Beneficence - Doing Good.
Nonmaleficence - Not Doing Harm.

Utility = Beneficence and nonmaleficence together.

Front 28

Describe if Hippocratice Principle, Modern Medicine or Postmodern Medicine are objective or subjective..

Back 28

(1) Hippocratic Principle: Clinician subjective judgment of facts and therapy

(2) Modern Medicine: Strives for objective judgment of facts, belives medical science can tell which therapy is best.

(3) Postmodern or Contemporary view: Factual judgments should be s objectie as posible. Therapeutic Choices are inevitably value judgments. Patient's values should take precedence.

Front 29

Medical vs. Other Benefits.

Back 29

Is physicians goal to maximize patient's health or to maximize patient's total welfare?

-> If health is the goal, patient may want to trade health off for other goods

--> If total welfare is goal, the physician's skills are inadequete.

Front 30

What are some conflicting medical goals?

Back 30

1. Save life.
2. Cure Disease
3. Relieve Suffering
4. Promote Health

Front 31

What is the hippocratic formula?

What is Primum non nocere?

Back 31

a. Arithmetic Combining (add up)
b. Geometric Combining (Ratio)
--> Harm vs. Benefit <--

Primum non nocere - "First of all, do no harm"

Front 32

What are the four respect-for-persons principles?

Back 32

1. Fidelity (promise-keeping and confidentiality)
2. Autonomy (informed concent)
3. Veracity (truth telling and lying)
4. Avoidance of Killing (Euthanasia)

Front 33

Fidelity -

Back 33

You have a duty to keep a promise regardless of the consequence. You have the DUTY to keep that consequence.

On the other hand in hippocratic code, you CAN break the confidence / promise if it benefits the patient. [Benefits vs. Harm]

i.e. Dr. Brown and Birth Control Pill ... broke confidentil

Front 34

Codes NOT Permitting Paternalistic Disclosure [ NO BREACH OF CONFIDENTIALITY ] i.e. Exception to the Hippocratic Code.

Back 34

-The World Medical Association Code, 1948.

- The British Medical Association, 1971
Exceptions:
- The patient has to agree / give permission
- Formal Public Policy (i.e. must report gun shot wounds., epilepsy)

The American medical Association, 1980
- Exception
- Threat of serious bodily harm to others
- Applicable Statue or ordinance

* HIV has to be reported *

Move from paternalistic (individual) --> non paternalistic (i.e. social)

Front 35

Autonomy (Informed Consent)

Back 35

- Absent from Hippocratic Oath
- Absent from all ancient traditions
- Grounded in liberal political philosophy
- Some compatibility with early Christianity.
- Absent in most other religious traditions.

Front 36

Example of Autonomy:
Natanson v. Kline (1960)

Back 36

Patient: Irma Natanson (breast cancer)
Dr. John Kline (gave radiation)
Patient claims se was NOT informed of radiation risk
Dr. Kline claims "therapeutic privilege" --> i.e He thought it was for her benefit NOT to tell her

Justice Schroeder:
' Anglo-American law starts with the premise of a thoroughgoing self-determination. It follows that each man is considered to be master of his own body, and he may, if he be of sound min, expressly prohibit the performance of life-saving surgery, or other medical treatment"

Complication: "The physician's choice... should not be questioned if his motive was the patient's best therapeutic interests"

"So long as the disclosure is sufficient to assure an informed consent";

Front 37

Canterburry v. Spence (1972)

Back 37

Patient: Youth named Canterbury, back pain.
Physician: Dr. Spence, back operation
Patient fell from bed after surgery
Dr. Spence claims therapeutic privilege
--> Court rejects the claim<--

Front 38

1. The professional standard:
2. The reasonable person standard:
3. The subjective standard:

Back 38

1. What competent physician similar situated would disclose

2. What reasonable patient would want to know or find material to their decisions

3. What the specific patient would want to know.

Front 39

Consent: The emerging consensus

Back 39

Autonomy required the use of the reasonable person standard modified by what the clinician knows or should be expected to know about the patient's unique situation.

Front 40

Varacity (truth - telling and lying)

Back 40

Changed-> from 1961 where 88% tended to withhold the diagnosis to 1979 where 98% of the people tended to disclose cancer diagnosis.

Front 41

Views about truth telling: What did
(1) Meyer
(2) Fletcher
(3) Kant
(4) W.D. Ross
Think?

5. What does the AMA think, post 1980.

Back 41

(1) Opposes Disclosure
(2) Defends Disclosure
(1 & 2) Are still Hippocratic Code
(3) Defends Disclosure
(4) Favors Disclosure
- Hippocratic Utility (Not so clear)
- Veracity (clear cut, so he chooses disclosure)
Kant is duty-based medicine

(5) " A physician shall deal honestly with patients and colleagues." --> Favors Disclosure

Front 42

Active Killing vs. Letting Die
- What are arguments against distinction?

Back 42

-------> FOR Active Killing <----
- The consequence may be no worse or even better (Killing Actively or letting die)
- Autonomy should give competent people the right to kill themselves

---------> Against <---------
(1) Consequence of active killing may be worse
- Those not terminally ill may die
- Weakening of societal opposition to killing
- Netherlands Data
- 2318 Euthanasia Following Persistent, Voluntary request.
- 386 physician-assisted suicides
- 1030 life-terminating acts without persistent, voluntary requests.

(2) Patient autonomy requires clinician not to treat but does not require physician to actively kill.

(3) Active killing is simply inherently wrong.

Front 43

What is the difference between Stopping treatment and not starting treatment?

Back 43

- It feels different to clinicians
- It feels the same/or the difference is rejected by Theorists (Lawyers, Theologians, Philosophers) because in the end of the day the patient has the right to withdraw the treatment.

Front 44

What is the difference in Direct Killing and Indirect Killing?

Back 44

Direct Killing = Intentional, can be passive or active

Indirect Killing - Unintentional
Can be active (anesthesia, narcotic side effects) or passive (forgoing life-support)

[NB: some foreseen deaths may be unintended]

Front 45

What is the difference between ordinary and extraordinary treatment?

Back 45

Ordinary - Proportionally beneificial treatment (i.e. offers MORE benefit THEN harm)

Extraordinary - benefits DO NOT exceed burdens ( May cause More harm then benefit or may not offer more benefit then harm.. i.e. it may lead to another burden to a patient or it may not offer burden nor benefit)

Front 46

What is a formally competent patient?

What is a proxy directive?

Back 46

- Have expressed wishes about terminal care while competent
- Principles for Decisions:
- Moral: "Autonomy Extended"
- Legal: Substituted Judgment

* did not need to put it in writing* as long as he expressed wishes to someone before.

Proxy Directive: Who do you want to be your agent.. (i.e. two children) one of them can speak for you.

Front 47

What is a Never-Competent Patients? (W/Out Families)

Back 47

No one withstanding to speak for the patient.

Principles:
-Moral: Hippocratic Utility
-Legal: Best Interest

If no one is there to speak for the patient, then use your best judgment.

Front 48

In the Aggregate Net Medical Benefit as a function of stay Graph what are N, a , b , and N+5.

Back 48

a = Patient can withdraw from treatment and go home and save money
b= There is some treatment, but the benefit may not be all that great.
N = Number of days that it takes to reach a plateau of maximum benefit.
N+5 = When the net medical benefit begins to decline.

Front 49

What is the Principle of Social Utility?

Back 49

An action is justified insofar as it produces as much net good in aggregate as possible considering all who are affected. Does NET good for everyone.

Front 50

What is Quality Adjusted Life Year?

Back 50

It is the extra time of life adjusted for the quality of that life that you recive from an intervention.

Front 51

What are the 2 problems with principle of social utility?

Back 51

1. The quantification problem
2. The inequality problem (allocation of goods may not be distributed equaliy between race or gender due to the fact that the distribution of good is not normal)

Front 52

What is the principle of justice?

Back 52

An action is justified insofar as it strives for an "end-state pattern" of the distribution of the good. [This means that you ignore the fact that a treatment is better for a certain race or gender and treat based on a Normal Distribution.. even thought it may not maximize the total social good]

Front 53

How / or what methods can a doctor use to reconcile the conflicts among competing principle?

Back 53

1. Single-Principle Theory (use one principle to allocate your resources, no conflict)
2. Balancing Theories (Intuitivly balance your theories)
3. Ranking (lexically ordering, i.e. rank principles 1,2,3 .. and go with that.. Ross usually would go w/ Duty-Based Principles First)
4. Combining balancing and Ranking.

Front 54

In Social Ethics what are the two ways/problems clinitians have in allocating resources

Back 54

1. Let clinitians abandon their patients at the margin (i.e. abandon at expencive marginally theraputice intervention).

2. Give clinitians an exeption from the principle of social ethics.
- Permit them to remain loyal to their patients
- Make/Require someone else / some other party to take responsibility of social ethics by setting certain boundries.