Medical Ethics Basics

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Mohamed Shehata,MD Assistant Professor of Medicine Baylor College of Medicine Houston TX

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Medical Ethics Basics:

Medical Ethics Basics An American Board Certified Doctors for Egypt Presentation Mohamed Shehata, M.D Assistant professor of Medicine. Baylor College of Medicine Member of the American College of Physicians Member of the American Geriatrics Society

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The secret of the care of the patient is in caring for the patient. —Francis Weld Peabody ( 1 )

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Medicine, law, and social values are not static. Reexamining the ethical tenets of medicine and their application in new circumstances is a necessary exercise.

Learning objectives:

Learning objectives To Know: Professionalism Decision-Making and Informed Consent Withholding or Withdrawing Treatment Physician-Assisted Suicide and Euthanasia Confidentiality Conflicts of Interest Medical Error Reporting Sexual Contact between Physician and Patient The Impaired Physician and Colleague Responsibility

Professionalism:

Professionalism Medicine is not a trade to be learned, but a profession to be entered (1) . A profession is characterized by a specialized body of knowledge that its members must teach and expand, by a code of ethics and a duty of service that put patient care above self-interest, and by the privilege of self-regulation granted by society (2) . -Physicians must individually and collectively fulfill the duties of the profession. While outside influences on medicine and the patient–physician relationship are many, the ethical foundations of the profession must remain in sharp focus . 1.Peabody FW. The care of the patient. JAMA. 1927;88:877-82 2-ABIM Foundation; ACP-ASIM Foundation; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136:243-6. [PMID: 11827500]

Fundamental Principle:

Fundamental Principle Primacy of patient welfare Altruism is a central trust factor in the physician-patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle. Patient autonomy Patients’ decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care. Social justice Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.

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Competence Physicians must be committed to lifelong learning and to maintaining the medical knowledge and clinical and team skills necessary for the provision of quality care. Honesty with patients Obtain informed consent for treatment or research. Report and analyze medical errors in order to maintain trust, improve care, and provide appropriate compensation to injured parties. Patient confidentiality Privacy of information is essential to patient trust and even more pressing with electronic medical records.

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Appropriate patient relations Given the inherent vulnerability and dependency of patients, physicians should never exploit patients for any sexual advantage, personal financial gain, or other private purpose. Improve quality of care Work collaboratively with other professionals to reduce medical errors, increase patient safety, minimize overuse of health care resources, and optimize the outcomes of care. Improve access to care Work to eliminate barriers to access based on education, laws, finances, geography, and social discrimination. Equity requires the promotion of public health and preventive medicine, as well as public advocacy, without concern for the self-interest of the physician or the profession.

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Just distribution of resources Work with other physicians, hospitals, and payers to develop guidelines for cost-effective care. Providing unnecessary services not only exposes one’s patients to avoidable harm and expense but also diminishes the resources available for others. Scientific knowledge Uphold scientific standards, promote research, create new knowledge, and ensure its appropriate use.

Manage conflicts of interest:

Manage conflicts of interest Medical professionals and their organizations have many opportunities to compromise their professional responsibilities by pursuing private gain or personal advantage. Such compromises are especially threatening with for-profit industries, including medical equipment manufacturers, insurance companies, and pharmaceutical firms. Physicians have an obligation to recognize, disclose to the general public, and deal with conflicts of interest that arise.

Professional responsibilities:

Professional responsibilities Undergo self-assessment and external scrutiny of all aspects of one’s performance. Participate in the processes of self-regulation, including remediation and discipline of members who have failed to meet professional standards.

2-Decision making:

2-Decision making Competency vs Capacity

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Criterion Stringency Test Who Might Fail? Evidencing a choice Low Answer yes or no Comatose Capacity: Ability to understand in general sense Medium Mental status testing Dementia (advanced) Comprehension: Actual understanding of specific information provided Medium Can you repeat what I have just told you? Anxiety Low education Language barriers Cultural barriers Rational reasons for choice High Why are you choosing this? Psychosis; delirium Reasonable outcome expected High Does the decision make sense in terms of: • Disease prognosis • Patient's values Depression

Informed Consent:

Informed Consent the “three C’s” of informed consent—communication, comprehension, and no coercion. (1) disclosure of all relevant information, including the benefits, risks, and alternatives with respect to the treatment or research study; (2) adequate understanding of the information by the patient or subject. (3) voluntary decision-making by the patient or subject.

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How much information need to be disclosed It is the necessary reasonable amount information for the reasonable person.

Withholding or Withdrawing Treatment:

Withholding or Withdrawing Treatment Withholding or withdrawing therapy that is deemed futile or according to patient preference is justifiable from both an ethical and a legal perspective End of life issues to be discussed as early as possible.

Quantity vs quality :

Quantity vs quality Qualitative futility means that the treatment will not improve the patient’s already poor quality of life . Cardiopulmonary resuscitation is not appropriate for patients with terminal, irreversible disease or imminent death. However, do-not-resuscitate orders do not preclude provision of other life-prolonging measures or palliative care

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Advance directive. Medical Power of attorney. surrogate decision maker.

Physician-Assisted Suicide and Euthanasia:

Physician-Assisted Suicide and Euthanasia Patient autonomy VS. Ethics VS legal -knowingly prescribing a potentially lethal amount of medication to a patient for self-administration. Whether or not it is ever ethical for a physician to do this has been debated for years. The Hippocratic Oath does not support physician-assisted suicide. B oth the ACP and American Medical Association have issued statements opposing the practice. is currently illegal in all states except Oregon and Washington

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Active euthanasia, whereby a physician, with the patient’s consent, directly and intentionally administers a substance to cause death, is illegal in all states. Palliative care,PAIN MANAGEMENT,DEPRESSION EVALUATION, BARRIERS(physician related and patient related)

Confidentiality:

Confidentiality Privileged information, communication The Health Insurance Portability and Accountability Act (HIPAA) Legal issues STD,HIV,Drug abuse,Domestic violence,GSW . Minors vs Teens. Record keeping.

Conflicts of Interest:

Conflicts of Interest A conflict of interest exists when a physician’s professional duty to the patient conflicts (or gives the appearance that it conflicts) with another interest, such as personal financial gain, insurance or contractual obligation, or other arrangements or commitments. The physician’s main responsibility is to the patient—to make recommendations based on medical merit and to practice effective and efficient health care using available resources wisely.

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Gifts, trips, and subsidies offered by pharmaceutical and medical device industries may create conflicts of interest wherein the physician’s interest coincides more with the business than with the patient. CME Disclosure and avoidance

Medical Error Reporting:

Medical Error Reporting The Institute of Medicine defines a medical error as the failure of a planned action to be completed as intended (error of execution) or the use of a wrong plan to achieve an aim (error of planning). Barriers of reporting errors Reporting aim is to prevent further errors form happening.

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The Patient Safety and Quality Improvement Act established a federal system for voluntary reporting of medical errors (www.pso.ahrq.gov/index.html) and provides protection for health care providers who submit information intended to improve patient safety.

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The Institute of Medicine (IOM) reported in 2000 that nearly 100,000 patients die as a result of medical errors each year. A Brigham and Women’s Hospital self-audit from 2005 found 233 serious errors and 54 preventable adverse events during 1490 patient-days. The most common serious errors were medication-related (61%); 53% of performance-level failures were slips and lapses (rather than rule-based or knowledge-based errors). Two-thirds of adverse events do not cause direct harm to the patient, and many are “near-misses.” The IOM estimates that preventable errors cost approximately $20 billion in hospitals alone.

Root Cause analysis:

Root Cause analysis Were issues related to patient assessment a factor in this situation? Were issues related to staff training or staff competency a factor in this event? Was equipment involved in this event in any way? Was the work environment a factor in this event? Was the lack of information (or misinterpretation of information) a factor in this event? Was communication a factor in this event? Were appropriate rules/policies/procedures —or the lack thereof—a factor in this event? Was the failure of a barrier—designed to protect the patient, staff, equipment, or environment—a factor in this event? Were personnel or personal issues a factor in this event?

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Graber and colleagues studied factors that contributed to diagnostic error in 100 cases and found an average of 5.9 system-related or cognitive factors contributing to the diagnostic error in each case. This finding confirms the “Swiss cheese” model of error in a medical environment—that there must be a breakdown of several layers in a system to actually cause an injury .

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Swiss Cheese” model of error

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Build in multiple layers of protection between a patient and any potential harm. For example, an airline pilots’ checklist model has been used in intensive care units to ensure that important initiatives, such as sedation holidays, ventilator weaning, and infection prophylaxis, are addressed daily on morning rounds. A “time-out” policy to ensure proper matching of patient with procedure has quickly become a national norm. As an example, a surgical nurse may be the point person empowered to call “time out ” before an operation commences. Then, the patient and the team, including the anesthesiologist, the surgeons, and any technicians, confirm the correct patient name, the kind of planned surgery, and the correct surgical site.

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(EMR) systems, can be used to design “force functions” to decrease human error “Culture of Safety”

Quality Improvements plans:

Quality Improvements plans Plan/do/study/act

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Another quality management model used in health care is total quality management (TQM), typified by the Baldrige National Quality Program, which publishes evidence-based criteria by which an organization can judge its management (www.quality.nist.gov). The goal of TQM is to build quality processes into every level of the health care organization.

Sexual Contact between Physician and Patient:

Sexual Contact between Physician and Patient Unethical with a current patient even if the patient initiates or consents to the relationship Patient is dependent and vulnerable relationship between a physician and a former patient may also be unethical irrespective of the length of time elapsed since ending the professional relationship. Despite these prohibitions, it has been reported that 5% to 10% of psychiatrists have had sexual contact with a patient. Chaperon to be present at time of physical exam with respect of patient confidentiality.

The Impaired Physician and Colleague Responsibility:

The Impaired Physician and Colleague Responsibility The impaired physician is one who is no longer able to safely carry out his or her professional duties because of physical, psychological, or substance abuse problems Approximately 15% of physicians will be impaired at some point in their career

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Risks: male sex, underlying mood or personality disorders. E.R, Psychiatrists ,and solo practitioners. Older physicians

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Reporting Rehab programs

Strikes and Other Joint Actions by Physicians :

Strikes and Other Joint Actions by Physicians physician efforts to advocate for system change should not include participation in joint actions that adversely affect access to health care or that result in anticompetitive behavior. Ginsburg J; American College of Physicians-American Society of Internal Medicine. Physicians and joint negotiations. Ann Intern Med. 2001;134:787-92. [PMID: 11329239]

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Physicians should not engage in strikes, work stoppages, slowdowns, boycotts, or other organized actions that are designed, implicitly or explicitly, to limit or deny services to patients that would otherwise be available.

So, What Could/Should we do?:

So, What Could/Should we do? In general, physicians should individually and collectively find advocacy alternatives, such as lobbying lawmakers and working to educate the public, patient groups, and policymakers about their concerns. Protests and marches that constitute protected free speech and political activity can be a legitimate means to seek redress, provided that they do not involve joint decisions to engage in actions that may harm patients.

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