ETHICS & DECISION-MAKINGI. Definition of EthicsEthics The study of a system of decision-making based on moral PrincipalsMorality-traditions of belief about right/wrong human conduct. Values differences

ETHICS & DECISION-MAKING

Ethics brings structure & order to the decision-making process about our responsibilities for patient care and institutional management Larry McCullough, PhD.

ETHICS & DECISION-MAKING

Ethics should lead the LawMain discipline of Ethics is to follow the arguments where they lead us

ETHICS & DECISION-MAKING

Medicine is the science of uncertainty and the art of probability

-W.Osler, M.D.

ETHICS & DECISION-MAKINGFamilies, Doctors, Nurses,Health care team membersNo simple algorithms to followWe have fiduciary obligations to our patients

ETHICS & DECISION-MAKINGTools for Ethical AnalysisClarityConsistencyCoherenceClinical ApplicabilityClinical Adequacy

ETHICS & DECISION-MAKINGII.Principles Do good and Do no harm--Beneficence(Obligation as foundations of social morality)1. One should not inflict harm2. One should prevent harm3. One should remove harm4. One should promote good

ETHICS & DECISION-MAKINGPrinciplesJustice Persons should be treated equallyMany theories of justiceRespect for Autonomy to allow person to act for themselvesResponsibility for self and familyThis means that the person understands ConsentDisclosure of risk/benefits/complications

ETHICS & DECISION-MAKINGIII.Approaches to CareWait until certainty1. Treatment started on every infant thought to have a chance2. Collect all information before making decision Decision to err on side of maintaining life

ETHICS & DECISION-MAKING3. Aggressive approach in accordance with society that values individual(ism)4. Price to pay may have some patients with severe handicaps to salvage that one patient.

ETHICS & DECISION-MAKINGStatistical Approach1. Categorizes patients into groups which would benefit from care2. Goal is to avoid creating severely impaired infants even at cost of those who might have been normal

ETHICS & DECISION-MAKINGIndividualized Approach1. Initiate care on infants who have a chance2. Deciding as soon as possible if continuing is in best interest of infant.3. Decisions made before all information in 4. Problem What degree of certainty is necessary?

ETHICS & DECISION-MAKINGResponsibility AccountabilityProcess should be consistentOne needs to ethically justify ones decisions

ETHICS & DECISION-MAKINGThe technology is imperative -1. Availability of technology2. Does it mean we have to use it?

ETHICS & DECISION MAKINGTyranny of the Normal1. Only acceptable outcome is normal (subjective & varies from person to person)2. Worry about unrealistic expectations3. Need to understand family value systems

ETHICS & DECISION-MAKINGIV. Principal of Best Interests1. Patient can not speak for self.2. Parents have responsibility for decision-making.Who are we treating the patient or the family?

ETHICS & DECISION MAKINGCertainly want:1. Relief of suffering2. Preservation or restoration of function3. Quality of life (subjective)

ETHICS & DECISION-MAKINGOutcomeAnecdotal experiences both positive and negativeHow many times have we been wrong?

ETHICS & DECISION-MAKINGIV. Principal of Proportionality Treatment should lead to greater benefit than burden.One needs to agree on expectations1. Curing the patients2. Restoring patient to reasonable quality of life3. Minimizing pain & suffering

ETHICS & DECISION-MAKINGV. Who Decides?Decision-making Team1. Physicians2. Parents & Family3. Other members of healthcare team

ETHICS & DECISION-MAKINGToday there is increased respect for patient autonomy1. Role of parents in decision-making is increased2. We should not be afraid to think out-louda. This closes the gap between physician/parent.b. Demonstrate the trial & error nature of treatment.c. Parents need time to process information

ETHICS & DECISION-MAKINGRationing-using limited resources wiselyNeeds Ethical Impact StatementNeeds to meet rigorous standardsScientificMoralEconomic

ETHICS & DECISION-MAKINGSummary Very Important1. Honest decisions with patients and family early 2. Awareness of power of decisions made each hour3. Responsibility of thinking4. Justification of thought

ETHICS & DECISION-MAKINGSummary Very Important5. Respect for life6. An acceptable decision may mean no intervention7. Physician needs skill to help families explore their values8. Cannot leave family alone in decision-making process9. Decisions should be difficult

Tools for Ethical Analysis

ClarityConsistencyCoherenceClinical ApplicabilityClinical Adequacy