Introduction Definition of Ethics The birth of Bioethics Principles of ethical guidelines

Remarkable expansion of medicine’s technological capacities

Extend human life but affect the quality of patient’s lives

Major changes in health care delivery to control cost

Widespread social concern about moral and legal interests of individuals

Raise intricate moral issues which can be healed by specialists in ethics

Philosophy

Ethics Epistemology Logic Metaphysics

Descriptive Ethics Metaethics Normative ethics

Bioethics

Came as a response to the abuse of subjects

Beecher, Berber, and paperworthChronic disease hospitalTuskegee syphilis studyWillobrook hepatitis studyRadiation experimentsOral contraceptives trialsThalidomideHolmesburg prison experimentsAllen memorial/ CIA, prison experiments

(hallucinogenic drugs)

1932 determine the natural course of untreated,

latent syphilis in black males and the possibilities for mass treatment under the belief that antisyphilitic tx was unnecessary.

The town of Tuskegee was found to have the highest rate of syphilis

syphilitic black males between 26-60 yrs

no intention of providing any treatment

They were told they were ill and were promised free care

The subjects were not told they were participating in an experiment

400 syphilitic males, as well as 200 uninfected controls

the whole experiment was scheduled for at least 6/12

Most of the men were given either noneffective therapy or inadequate doses

The 1st published report 1936 When penicillin became widely available,

the men did not receive therapy in 1969, a committee decided that the

study should be continued Only in 1972 did the department of health,

education, and welfare halt the experiment

In 1972, an investigatory panel was established which issued a report the following year and found that the study had been “ethically unjustified” and argued that penicillin should have been provided to the men.

74 of the test subjects were still alive more than 100 had died directly from

advanced syphilitic lesions never addressed the question of how the

study was undertaken in the 1st place and why it continued for 40 years.

Nuremburg code Declaration of Helsinki U.S national commission/ Belmont report (1979) Civil codes Professional organizations

You are caring for a patient with cancer. She is refusing to undergo surgery or receive chemotherapy for the treatment of her condition. What would the right action be in this case?

A patient is being treated by you for a certain condition. He is from a different culture which uses alternative forms of treatment for this condition, treatment which you do not believe is effective, due mainly to lack of scientific evidence. Moreover, you believe that the alternative treatment might interfere with the standard treatment and cause the patient’s condition to worsen. Explain how you would handle this case?

You are a physician working in an intensive care unit with a capacity of five beds, four of which are occupied. You receive a call from the A&E where they have two patients needing ICU admission. The mother of one of those patients, whom you know, pleads with you to save her young son. The other patient, as you find out later is a foreigner with no relatives in the country. What would be the right action in this case?

Within 24 hrs, a ten month old boy was transferred from a small local hospital to a university hospital and then to its affiliated cancer center with the presumptive diagnosis of leukemia.

Because the diagnosis had not been confirmed by bone marrow examination, information on the type of prognosis was not available.

The information was explained to the parents who after a 2 hr deliberation told the physician they do not want the treatment and that they would place their faith in God.

Autonomy Beneficence Nonmaleficence Social Justice

Self-determination, independence, and freedom. physicians should take steps to promote more

patient autonomy, as by disclosing information and helping patients deliberate

With regard to health care, autonomy justifies the doctrine on informed consent

Informed, competent patients may refuse unwanted medical interventions. Such refusals respect patients bodily integrity, patients may not be subjected to invasive interventions without their consent.

In addition patients may choose among medically feasible alternatives. e.g. choosing whether to have an x-ray or choosing among several drugs for a condition do not implicate the patient's bodily integrity in a manner similar to surgery.

Competent, informed, patients have the right to make choices that conflict with the wishes of family members or the recommendations of their physician.

A person's autonomy is not absolute may be justifiably restricted for several

reasons:– person is incapable of making informed decisions.

Respecting autonomy < important than acting in the best interest of the patient.

– constrained by the needs of other individuals or society at large.

– not free to act in ways that violate the autonomy of other people, harm others, or impose unfair claims on society's resources.

Treating patients with respect entails several ethical obligations

Physicians must respect the medical decisions of persons who are autonomous.

act intentionally are informed are free from interference and control by others

respect for persons who are not autonomous because their decision making capacity is impaired

Patients may be incompetent because of :– Age– Illness– Medication

Physicians should still treat these patients as persons with individual characteristics, preferences, and values.

Decisions should respect their preferences and values as far as they are known.

In addition, all patients, whether autonomous or not should be treated with compassion and dignity. Thus respect for persons includes responding to the patient's suffering with caring, empathy, and attention.

respect related to other ethical guidelines such as avoiding misrepresentation, maintaining confidentiality, and keeping promises.

Breaches of those other guidelines show disrespect for patients and also compromises their self-determination.

Requires physicians to take positive actions for Requires physicians to take positive actions for the benefit of patients.the benefit of patients.

Because patients do not possess medical Because patients do not possess medical expertise and maybe vulnerable because of their expertise and maybe vulnerable because of their illness, they rely on physicians to provide sound illness, they rely on physicians to provide sound advice and to promote their well being.advice and to promote their well being.

Promotes patient best interest by:• Understanding patient perspective• Address misunderstandings and concern• Try to persuade patient• Negotiate a mutually acceptable plan of care• Ultimately let the patient decide

The physician cannot be required to violate fundamental personal values, standards of scientific or ethical practice, or the law.

If the physician is unable to carry out the patient’s wishes, the physician must withdraw and transfer care of the patient

DO NO HARM" forbids physicians:

From providing ineffective therapies From acting maliciously or selfishly provides limited guidance since many

interventions also entail serious risks and side effects.

Provide standard care If no benefit, at least do not harm or make

situation worse If benefit equals harm, do not intervene

The term in a general sense means fairness.The term in a general sense means fairness. It is important to act consistently in cases that It is important to act consistently in cases that

are similar in ethically relevant ways. Otherwise, are similar in ethically relevant ways. Otherwise, decisions would be arbitrary, biased, and unfair.decisions would be arbitrary, biased, and unfair.

In the health care setting, justice usually refers to In the health care setting, justice usually refers to the athe allocation of health care resources..

Allocation is usually unavoidable because Allocation is usually unavoidable because resources are limited and could be spent on other resources are limited and could be spent on other social goods, such as education or the social goods, such as education or the environment, instead of health careenvironment, instead of health care

Ideally allocation decisions are made by public policy and set by government officials

Physicians should participate in debates about allocation and help set policies.

In general however, rationing medical care at the bedside should be avoided because it may be:◦ inconsistent,◦ discriminatory◦ ineffective. ◦ At the bedside, physicians usually should act as

patient advocates within constraints set by society and sound practice.

In some case however, two Patients may compete for same limited resource such as physician time or a bed in intensive care. When this happens, physicians should ration their time and resources according to patient's medical needs and the probability and degree of benefit.

Respect for persons Avoid deception Maintain confidentiality Act in best interest of patient Allocate resources justly

Ethical generalizations cannot be mechanically applied but need to be used in particular cases with discretion and judgment.

Guidelines are derived from decisions made in specific cases as well as moral theories and shape decisions in similar cases in the future

However guidelines may be difficult to apply in new cases for several reasons

Case to case variations inherent Different priorities and goals for care Distinguishing cases in ethically

meaningful ways Shortcomings of existing guidelines

Guidelines are not absolute cases may have distinctive features To ensure fairness, physicians who make an

exception to a guideline should justify their decision

The justification should apply to all similar cases faced by other physicians

In many situations, following one ethical guideline would require the compromise of another guideline.

The practice of medicine would be much easier if there were a fixed hierarchy of ethical guidelines

The ability to make prudent decisions in some specific situations involves an understanding of how ethical guidelines are relevant in a variety of situations and to the particular case at hand.

Thank you