Medical Ethics 101 Balancing obligation outcomes and risk

Medical Ethics 101 Balancing obligation, outcomes, and risk in clinical decision-making Jill Ann Jarrell, MD, MPH Complex Care Program, Academic General Pediatrics Texas Children’s Hospital, Baylor College of Medicine

Disclosures § Dr. Jarrell has no relevant conflicts of interest to disclose

Patient-Provider Relationship

Patient-Healthcare Team Relationship

What is “Ethics”? “Ethics is a branch of philosophy; the formal, rational, systemic examination of the rightness and wrongness of human actions. ” 1

What is “Medical Ethics” Evaluating the rightness and wrongness of human actions in medicine Bioethics

Principles and Duties of Medical Ethics Principles Duties • Autonomy • Veracity • Justice • Confidentiality • Beneficence • Role Fidelity • Nonmaleficence • Respect for Societal Institutions

Ethical Principles Autonomy • Individual liberty, dignity, and capacity Justice • What is fair or deserved Beneficence • An obligation to do good Nonmaleficence • An obligation to not harm

Ethical Duties Veracity • Truth telling Privacy and Confidentiality Role Fidelity • Professional responsibility and autonomy Respect for Societal Institutions • Life, culture, family, religion

Hot Topics in Ethics • Surrogate or substitute decision-making • Advanced care planning • Principle of double effect • Informed consent • Futility

Decision-Making Capacity Able to understand medical treatment and make informed decisions.

Incapacitated Unable to understand the benefits, risks, alternatives to treatment.

Surrogate Decision-Maker Individual with authority to consent to medical treatment for an incapacitated patient.

Surrogate Decision-Makers • • • Spouse Adult child with POA or majority of adult children Parents Clearly identified individual Nearest living relative Patient’s clergy

Surrogacy in Minors Parents available • • Natural parents Adoptive parents Sole managing conservator Possessory conservator (non-invasive procedures during possession)

Surrogacy in Minors Parents not available • • Grandparent Adult sibling Adult aunt/uncle Educational institution with written authorization

Surrogacy in Minors Parents not available (cont’d) • • Adult with custody and written authorization Court with jurisdiction Adult with care of child subject to juvenile court Peace officer

Schizophrenic Child With Absent Family

History • 17 yo male with paranoid schizophrenia • Attempted suicide • Survived - multiple orthopedic and internal injuries

Conflict • Poorly compensated from a psychiatric perspective • Mother quit visiting/answering calls • Patient turned 18 during care

Who is in charge? Who is the decision-maker? • Patient • Mom • CPS/APS • Legal Guardian

Ethical challenges • Beneficence • Autonomy • Social Responsibility

Pregnant patient with terminal cancer

Pregnant Patient With Cancer • 30 yo woman • 24 weeks gestation • Stage IV breast cancer

Pregnant Patient With Cancer • Intractable pain • Progressive encephalopathy • Previously told her OB/GYN she wanted to “have this baby”

Pregnant Patient With Cancer • Patient’s condition declined • Patient’s mother asked for hospice care for her daughter

Pregnant Patient With Cancer Two patients?

Pregnant Patient With Cancer Who is the decision-maker? • Patient • Mother • Healthcare team

Pregnant Patient With Cancer Ethical Challenges? • Beneficence • Nonmaleficence • Social responsibility • Role Fidelity

To trach or not to trach…

History • • • 5 yo with Trisomy 21, repaired CHD, CP admitted for pneumonia PICU, intubated, difficult wean, trach was discussed with family Palliative care consulted on HD 55 to discuss “options”

Conflict • Palliative care recommended not to trach and for medical team to collectively advise palliation • ENT “just a technician” and uncomfortable • PCP and CCM wish to proceed with trach • Ethics committee consult requested

Ethical challenges • • • Benificence Non-maleficence Respect for family Autonomy (but how much? ) Role fidelity

Skills for Resolving Ethical Dilemmas 2 • Listening • Conflict resolution • Tolerance for ambiguity • Ability to apply ethical principles and carry out duties

Framework for Ethical Decisions 3 • Medical indications • Patient preferences • Quality of life • Contextual features

Take Home Messages • Continue to LEARN about your discipline and the ever-changing milieu in which it is practiced • COMMUNICATION and COLLABORATION between care team members and decision-makers is key to success

Questions?

References 1. 2. 3. Pellegrino, E. Toward a Reconstruction of Medical Morality. The American Journal of Bioethics 2006; 6 -65 -71 “Legal and Ethical Issues” Physician Board Review Course in Hospice and Palliative Medicine, MD Anderson Cancer Center, 10/12/2010. Jonson A, Seigler M, Winslade W. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 6 th ed, page 11.