Clinical Ethics & OncologyAndrea Chatburn, DO, MAMedical Director for Ethics, PHCFebruary 19, 2016

Learning Objectives

• Describe common reasons for ethics consultation in oncology

• Review the Providence model for ethics consultation

• Discuss a cases in which principles conflict

• Apply the Providence model for ethics consultation to the cases discussed

Nothing to disclose

Reminder regarding Cases

• Cases are based on actual clinical experiences.

• We will use the Providence Model for Ethical Decision-Making

• The cases presented may not include all the information you want

Moral Distress

Moral Uncertainty

Moral Dilemma

DISCOMFORT

Sources of Ethical Dilemmas

• Differing views on values• Differing Goals of Care• Ineffective communication• Inadequate psychosocial support• Scarce Resource Allocation• Institutional Policy or State Law

Providence Model for Ethics

Clinical Integrity Beneficence

AutonomyJustice &

Non-Maleficence

The Providence Model

Promote: •Honesty in representing right professional practices and delivery of health care•Dependability in delivering care that benefits patients medically•Fairness to patients in their contexts•Accountability to the legitimate interests of others in light of justice

Ethical Decision-Making Model

Clinical Integrity Beneficence

AutonomyJustice &

Nonmaleficence

Clinical IntegrityBeneficence

AutonomyJustice &

Nonmaleficence

Therapeutic relationship between patient and caregiver

Clinical Context

Acute Rescue, FixChronic Maintain, ManagePalliative Alleviate, Enhance QOLLife-Sustaining Prolongation of

biological lifeFutile Non-Beneficial

or harmful

Clinical Integrity Beneficence

AutonomyJustice &

Non-Maleficence

IV Antibiotics

Fever & Confusion Resolve

Infection

Moral Hazards

gjsentinel

Ethics Consults in Oncology• Cancer-directed therapies no longer

effective• Lack of Decision-Making capacity• Withholding / Withdrawing life support• Relational disagreements• Research-Treatment discrepancy

Case #1: Ms. Johnson

32 yo woman with biliary cancer and peritoneal mets & malignant obstruction

– Requests chemotherapy after no longer recommended

– Seeks 2nd opinion for experimental chemo– Demands CPR– In secret states she hates how chemo

makes her feel & thinks about stopping

Autonomy

Who is she as a person?

What does she think is a good outcome?

Beneficence

Which interventions can she depend on benefiting from?

What is her clinical context?

Beneficence

• Improve or maintain the quality of the person’s critical life activities

• Beneficence: “I will come to the benefit of my patient, or at least not to harm them”

Clinical Integrity

What is the honest practice of medicine for her?

What are our professional obligations to her?

Goals of Medicine

• Promotion of health & prevention of disease

• Relief of symptoms, pain, suffering • Cure of disease• Prevent untimely death• Improve or maintain functional status• Education and counseling• Avoid harming patientJonsen et al, Clinical Ethics, 8th ed.

Justice & Nonmaleficence

What are our justice obligations to others?

Are there conflicts of interest?

Are we managing patient safety/reducing harm?

Quality of Life

• The “quality” of one’s life is not a measure of performance or quality of function. It refers to the state of personal satisfaction derived from one’s ability to engage life, irrespective of the measure of performance or the quality of one’s function. It is a matter of being able to cope with and find satisfaction in life as one finds it.

Spectrum of Shared Decision Making

Diagnosis Death

Clinically Directed PaternalismPatient

Directed Autonomy

Adaptive Coping Maladaptive Coping

Models of Surrogate Decision-Making

Best Interests

Substituted Judgment

Substituted Interests

• What would serve the patient’s medical good?

• What decision echoes what the patient has already said?

• What would represent the patient’s values?

• What are the patient’s real interests in the case given his/her known values and the circumstances

• What is the best clinical pathway to promote those interests?

What about opiates at the End of Life?

Doctrine of Double Effect

Bad Effect

Good Effect

Cause & Effect

Cause & Effect

Action/Object

Doctrine of Double Effect

St. Augustine Thomas Aquinas Joseph Magnan (‘49)

•Act itself must be good or at least indifferent•Must intend the good effect •Good effect cannot be caused by bad effect•Proportionality

Bibliography• Kockler, N. Seeing Ethics Consultations for the First Time: Disclosure Models,

Analytic Design, and Ethical Decision-Making. ©2014 –Nicholas J. Kockler• http://www.usccb.org/beliefs-and-teachings/what-we-believe/catholic-social-

teaching/solidarity.cfm• Jonsen, Albert R., Mark Siegler, William J. Winslade. Clinical ethics: a practical

approach to ethical decisions in clinical medicine—7th ed. New York, McGraw-Hill. 1998.

• McIntyre, Alison. Doctrine of Double Effect. Stanford Encyclopedia of Philosophy.http://plato.stanford.edu/entries/double-effect/ Copyright 2014. Accessed 3_15_15.

• Stoljar, Natalie. Feminist Perspectives on Autonomy. Stanford Encyclopedia of Philosophy. http://plato.stanford.edu/entries/feminism-autonomy/ Copyright 2013. Accessed 3_15_15.

• Sulmasey, D. and L Snyder. Substituted Interests and Best Judgments. JAMA. 304; 17. 2010.