Introduction to Introduction to Medical EthicsMedical Ethics

Paul Dassow, MD, MSPHPaul Dassow, MD, MSPH

MD 815MD 815

November 15, 2006November 15, 2006

ObjectivesObjectives

1.1. Explain the difference between morality Explain the difference between morality and ethicsand ethics

2.2. Describe the Standard Medical Ethic in Describe the Standard Medical Ethic in place in today’s medical environmentplace in today’s medical environment

3.3. Apply this Ethic to a real world situationApply this Ethic to a real world situation

4.4. Understand the inherent difficulties with Understand the inherent difficulties with the current medical ethicthe current medical ethic

5.5. Know alternatives to the standard ethic Know alternatives to the standard ethic

The case of Terri SchiavoThe case of Terri Schiavo

The facts:The facts: Born Theresa Marie Schindler December Born Theresa Marie Schindler December

3, 19633, 1963 In 1983, Terri met Michael Schiavo at In 1983, Terri met Michael Schiavo at

Bucks County Community College and the Bucks County Community College and the two began dating. He was the first two began dating. He was the first romantic interest Terri had.romantic interest Terri had.

The couple was engaged within a few The couple was engaged within a few months and married a year later at Terri’s months and married a year later at Terri’s church in Southampton, Pa. She was 21. church in Southampton, Pa. She was 21.

The case of Terri SchiavoThe case of Terri Schiavo

The facts:The facts: In 1990, at the age of 26, Terri suffered a In 1990, at the age of 26, Terri suffered a

mysterious cardio-respiratory arrest for mysterious cardio-respiratory arrest for which no cause has ever been determined. which no cause has ever been determined. She was diagnosed with hypoxic She was diagnosed with hypoxic encephalopathy – neurological injury encephalopathy – neurological injury caused by lack of oxygen to the brain. Terri caused by lack of oxygen to the brain. Terri was placed on a ventilator, but was soon was placed on a ventilator, but was soon able to breathe on her own and maintain able to breathe on her own and maintain vital function. She remained in a severely vital function. She remained in a severely compromised neurological state and was compromised neurological state and was provided a PEG tube to ensure the safe provided a PEG tube to ensure the safe delivery of nourishment and hydration delivery of nourishment and hydration

Terri SchiavoTerri Schiavo

Video clips from the last year of Video clips from the last year of Terri’s life:Terri’s life:

The case of Terri SchiavoThe case of Terri Schiavo

The facts:The facts: On March 18, 2005, Terri Schiavo had On March 18, 2005, Terri Schiavo had

her feeding tube removed under the her feeding tube removed under the order of Circuit Court Judge, George W. order of Circuit Court Judge, George W. Greer of the Pinellas-Pasco’s Sixth Greer of the Pinellas-Pasco’s Sixth Judicial Court. On March 31, 2005, Terri Judicial Court. On March 31, 2005, Terri Schindler Schiavo died of marked Schindler Schiavo died of marked dehydration following more than 13 dehydration following more than 13 days without nutrition or hydration. Terri days without nutrition or hydration. Terri was 41. was 41.

What was the right thing What was the right thing to do here?to do here?

Morals and EthicsMorals and Ethics

Moral: Of or concerned with the Moral: Of or concerned with the judgment of the goodness or judgment of the goodness or badness of human action and badness of human action and charactercharacter

Ethic: A principle of right or good Ethic: A principle of right or good conduct or a body of such principles conduct or a body of such principles

1. 1. What was the morality What was the morality of the decision to pull of the decision to pull Terri’s feeding tube?Terri’s feeding tube?

2. How do we decide what 2. How do we decide what is the moral choice?is the moral choice?

The Standard Medical EthicThe Standard Medical Ethic

Rooted in the 1979 Belmont Report Rooted in the 1979 Belmont Report from the Committee on the use of from the Committee on the use of Human Subjects in researchHuman Subjects in research

Principles:Principles: AutonomyAutonomy BeneficenceBeneficence Non-malfeasanceNon-malfeasance JusticeJustice

AutonomyAutonomy

The principle that persons should be The principle that persons should be able to decide for themselves what able to decide for themselves what action, if any, should be taken in action, if any, should be taken in regards to their medical careregards to their medical care

Assumes appropriate informed consentAssumes appropriate informed consent Assumes capacityAssumes capacity Needs clarification when a patient Needs clarification when a patient

cannot speak (or think) for themselvescannot speak (or think) for themselves

BeneficenceBeneficence

The principle that physicians should The principle that physicians should always do what is in the best interest always do what is in the best interest of the patientof the patient

May vary from physician to physician May vary from physician to physician (Kevorkian)(Kevorkian)

Is this what the physician would want Is this what the physician would want done to them (the golden rule), or what done to them (the golden rule), or what they think the patient would want for they think the patient would want for themselves?themselves?

Non-malfeasanceNon-malfeasance

The principle that physicians should The principle that physicians should not harm patients nor treat with not harm patients nor treat with intent to harmintent to harm

Often decisions must be made regarding Often decisions must be made regarding which course of action will likely cause which course of action will likely cause the least harmthe least harm

Again, physician dependent Again, physician dependent

JusticeJustice

The principle that persons should be The principle that persons should be treated equally and fairly, without treated equally and fairly, without prejudice in regard to gender, race, prejudice in regard to gender, race, or personal creed.or personal creed.

Very difficult in our present systemVery difficult in our present system

So, back to TerriSo, back to Terri

AutonomyAutonomy

Did Terri want her feeding tube removed?Did Terri want her feeding tube removed? No living willNo living will Conflicting reports from husband and parents Conflicting reports from husband and parents

regarding “what Terri would have wanted.”regarding “what Terri would have wanted.” Since Terri deemed not to have the capacity Since Terri deemed not to have the capacity

to make decisions for herself, her next of kin to make decisions for herself, her next of kin (husband) is assigned the duty to make these (husband) is assigned the duty to make these decisions for her.decisions for her.

Terri’s next of kin said, “Yes.”Terri’s next of kin said, “Yes.”

CapacityCapacity

Involves the demonstration of 3 Involves the demonstration of 3 characteristics:characteristics:

Can understand the diagnosis and Can understand the diagnosis and prognosis for a given conditionprognosis for a given condition

Can understand the treatment optionsCan understand the treatment options Can understand the possible Can understand the possible

consequences involved in the various consequences involved in the various treatment optionstreatment options

BeneficenceBeneficence

What would be the right course of What would be the right course of action to benefit Terri?action to benefit Terri? Can death ever be considered a benefit Can death ever be considered a benefit

for a patient?for a patient? Consider the Hippocratic OathConsider the Hippocratic Oath

Would pulling Terri’s feeding tube benefit Would pulling Terri’s feeding tube benefit her?her?

If so, how?If so, how? Was artificially feeding Terri just Was artificially feeding Terri just

prolonging her suffering?prolonging her suffering?

Non-malfeasanceNon-malfeasance

Would pulling Terri’s feeding tube Would pulling Terri’s feeding tube cause her harm?cause her harm? Suffering from dehydration?Suffering from dehydration? Is death the ultimate harm?Is death the ultimate harm? Were other motives at play in this Were other motives at play in this

decisiondecision MoneyMoney Husband’s desire to “get on with life.”Husband’s desire to “get on with life.”

JusticeJustice

Is there precedent for this decision. Is there precedent for this decision. That is, are other similar patients That is, are other similar patients treated the same way?treated the same way? Neurologically impaired vs persistent Neurologically impaired vs persistent

vegetative state vs brain deadvegetative state vs brain dead Is there a national policy regarding how Is there a national policy regarding how

to treat these patients (only brain death)to treat these patients (only brain death)

What happens when What happens when principles conflict?principles conflict?

What happens when What happens when principles conflict?principles conflict?

In life and death decisions, typically In life and death decisions, typically Autonomy trumps othersAutonomy trumps others Exception: Assisted suicide in most Exception: Assisted suicide in most

states not legalstates not legal In Terri’s situation, the legal case In Terri’s situation, the legal case

surrounded whether she was in a surrounded whether she was in a persistent vegetative state or not.persistent vegetative state or not.

From this medical ethics framework, From this medical ethics framework, if autonomy trumps others, then if autonomy trumps others, then pulling the tube was the right pulling the tube was the right decisiondecision

A side note: Why did they A side note: Why did they pull the tube? Why not just pull the tube? Why not just

not feed her?not feed her?

So you’re the physician. Do So you’re the physician. Do you comply with the court you comply with the court

decision?decision?

The embattled physicianThe embattled physician

If you disagree with the court’s If you disagree with the court’s decision, most states would allow you decision, most states would allow you to “opt out” of performing the act.to “opt out” of performing the act. Examples: As a physician, you do not have Examples: As a physician, you do not have

to provide contraception or abortion to provide contraception or abortion servicesservices

However, some states do force behavior However, some states do force behavior deemed essential to the job (eg, deemed essential to the job (eg, pharmacists must dispense emergency pharmacists must dispense emergency contraception) contraception)