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RICHARD L. ELLIOTT, MD, PHD, FAPAD I R E C T O R , M ED I C A L ET H I C S A N D P R O F E SS I O N A L I S M

P R O F ESS O R , C O M M U N I T Y M E D I C I N EM ER C E R U N I V E R S I T Y S C H O O L O F M E D I C I N E

A D J U N C T P R O F E SS O RM E R C E R U N I V E R SI T Y SC H O O L O F L AW

Medical Ethics and Professionalism

Goals

What is medical ethics?Medical ethics and professionalism at MUSMExpectations for Community Medicine IWhat is an ethical dilemma?What are the principles of medical ethics?How to analyze an ethical problemIntroduction to informed consent and

confidentialityIntroduction to surrogate decisionmakingIntroduction to professionalism

What is Medical Ethics?

The application of moral principles and analysis to medical situations

Not bioethics

Overview of MUSM Medical Ethics and Professionalism

First Year Orientation White Coat ceremony Medical history, Delivering bad news, . . . Introduction to Medical Ethics and Professionalism Research opportunity as Summer Scholar Basics of Health Care Reform Ethics Interest Groups – Savannah and Macon

Medical Ethics and Professionalism Overview

Second Year Clinical research Pharmaceutical companies Physician impairment Student abuse BMP


Third Year Professionalism as a third year student Internal medicine – end-of-life, futility of care,

physician assisted suicide Pediatrics - child abuse, neonatal care Obstetrics and gynecology – reproductive

technologies, genetic screening Surgery – case analyses Psychiatry – competence, involuntary treatment,

boundary violations, duties to third parties Family medicine – elder abuse, domestic violence,

medical errors


Fourth Year Senior Case analysis Ethics in the Emergency Room Electives Capstone

Risk management Health care and resource allocation Special topics, e.g., social media, licensure

Medical Ethics and Professionalism – Year One

First week - two lectures Introduction to Medical Ethics and Professionalism

Principles of medical ethics Informed consent and surrogate decisionmaking Confidentiality Procedure for ethical case analysis

Principles and Codes of Medical Ethics and Professionalism Oath of Geneva

Second week Group discussion of two cases on medical ethics site

Advance directives Confidentiality

At the end of these two weeks, you should be able to:

Describe principles of ethics and professionalism

Identify an ethical dilemmaDescribe process of ethical case analysisState basis and principles of informed

consentState basis and exceptions to patient

confidentialityDescribe current challenges to the medical

profession

Resources and Examination

[email protected]. Greenberg

[email protected] Ethics site

Academics Degree Programs

Doctor of Medicine -> Medical Ethics -> First YearPowerpoints posted on Ethics site Exam on Powerpoint material

10-15 questions MDE format Not a fluff exam – look at details!

mailto:[email protected]

What is an Ethical Dilemma?

A conflict between ethical principles, i.e., “what is the right thing to do?” What is “medically” right vs. patient preference

Jehovah’s Witnesses and transfusions What is preferred by patient vs. proxy decision

maker Rights of minor vs. legal guardians

What is best for patient vs. what is best for society Commitment laws, notification of sexual partners of

patients with HIV

What do Mercer Students Consider Ethical Dilemmas?

2008 2009 Confidentiality 17 6 Decisionmakers 17 15 Right to refuse 4 8 Right to treatment 4 3 Futility of care 4 15 Medical error 2 3 AIDS/HIV 7 4 Pregnancy 6 8 Jehovah’s Witness 3 4 DNR/ventilator 4 Professionalism 12

What Would You Do?

Case 1: 36 year old man presents in respiratory distress, in the course of which he is found to be infected with HIV. He is firm that he does not want his wife to know.

Case 2: A 25 year old woman victim of a single car MVA enters a persistent vegetative state. After four years, her parents petition to have her feeding tube removed. The hospital insists on a court order, and the victim’s closest friend and parents testify that she would not have wanted to have a feeding tube.

Two Medical Dilemmas

Case 1 – HIV and confidentiality The patient has a right to keep his records confidential The wife has a right to be protected

Case 2 - PVS and feeding tube removal Patient has right to have wishes respected State has right to have its laws respected Hospital has a right to determine what interventions it

supports Physicians have a right to decide what treatments

they provide

How to Analyze an Ethics Case,(or how do I figure out what’s the right thing

to do?)

What are the medical issues? Risks, benefits, alternatives, prognoses

Who are the stakeholders? Patient, family, medical staff, hospital, state Cultural and religious concerns

What are the relevant laws, regulations, ethical codes?

Why is an ethical dilemma being created? Conflicts between decision makers, law and

ethicsWho are possible consultants?

Medical, family, ethicists, ethics committee, lawyers

Possible courses of actionProposed resolution

What are the Medical Issues?

Rule #1 We are doctors, not moral philosophers or lawyers Know your medicine! Most ethical problems have a clinical solution

Diagnosis, nature of treatment proposed, risks, benefits, prognosis with and without treatment, alternatives Evidence-based decisions

Remember this when you analyze cases next week!

Medical Issues

Case 1 – HIV and confidentiality What is course, prognosis, and treatment for HIV? What is likelihood wife is or will be infected? What is wife’s prognosis without treatment? What is likelihood wife will infect fetus, children?

Case 2 - PVS and feeding tube removal What is PVS? What are possible alternatives? What is prognosis with and without feeding tube?

Who are the stakeholders (potential decisionmakers)?

Patient Quality of life, autonomy, spiritual needs

Family Proxy decision makers, quality of life

Physician Risk management concerns

Medical profession Standards

Hospital Policies, accreditation, affiliations

State Resource allocation, legal regulation

StakeholdersCase 1 – HIV and confidentiality

Patient Wife Children Physician Medical profession State

Case 2 - PVS and feeding tube removal Patient Parents Medical profession State

What are the Relevant Laws?

Statutory vs. case lawOfficial Code of Georgia, Code of Federal

Regulations (Federal registry)Case law

Binding at appellate level in jurisdictionTwo famous (board material) ethics cases

Karen Ann Quinlan Nancy Cruzan

Legal Issues – HIV and Confidentiality

Case 1 – HIV and confidentiality HIPAA O.C.G.A and confidential nature of HIV information

§ 24-9-47. Disclosure of AIDS confidential information (b) Except as otherwise provided in this Code section: (1) No person or legal entity which receives AIDS confidential information pursuant to this Code section or which is responsible for recording, reporting, or maintaining AIDS confidential information shall: (A) Intentionally or knowingly disclose that information to another person or legal entity; or

Legal Issues – HIV and Confidentiality

But: (g) When the patient of a physician has been determined to

be infected with HIV and that patient's physician reasonably believes that the spouse or sexual partner or any child of the patient, spouse, or sexual partner is a person at risk of being infected with HIV by that patient, the physician may disclose to that spouse, sexual partner, or child that the patient has been determined to be infected with HIV, after first attempting to notify the patient that such disclosure is going to be made; And:

A physician having a patient who has been determined to be infected with HIV must disclose to the Division of Public Health (O.C.G.A. 31-12-2(b)) (A) The name and address of that patient; (B) That such patient has been determined to be infected with HIV; and (C) The name and address of any other person whom the disclosing physician or administrator reasonably believes to be a person at risk of being infected with HIV by that patient.

Legal Issues – Removal of Feeding Tube

Case 2 - PVS and feeding tube removal The patient did not have an advance directive

Power of attorney for health care Living Will

In the absence of an advance directive, the state may require by clear and convincing evidence a showing of what the patient would have chosen under the same or similar circumstances

Georgia Advance Directive for Health Care Combines Living Will and Durable Power of Attorney

for Health Care

Ethical dilemmas are conflicts between or among ethical principles

What are commonly accepted ethical principles in medicine?

Principles of Medical Ethics

Autonomy “Every human being of adult years and sound mind has a

right to determine what shall be done with his own body” Schloendorff, 1914

Right to PrivacyBeneficence

Act for the good of the patient Promote good Remove or prevent harm

Non-maleficence Primum non nocere First, do no harm

Social justice Access to heath care resources

What Are the Four Principles of Medical Ethics?

AutonomyBeneficenceNonmaleficenceSocial Justice

Why Does an Ethical Dilemma Exist?

Case 1 – HIV and confidentiality The patient has a right to keep his records confidential

Autonomy, Nonmaleficence HIPAA

The wife has a right to be protected Right to privacy (?)

Case 2 - PVS and feeding tube removal Patient has right to have wishes respected

Right to privacy, Autonomy State has right to have its laws respected Hospital has a right to determine what interventions it

supports Physicians have a right to decide what treatments

they provide

Possible Consultants

Case 1 – HIV and confidentiality Infectious disease

Clinical Policy on HIV and confidentiality

Division of Public Health Ethicist Health or malpractice insurance lawyer

Case 2 - PVS and feeding tube removal Medical

Establish prognosis, possible alternative interventions Others who knew patient’s wishes Ethics Committee Medical Director

Futility Policy? Mediator

Possible Courses of Action

Case 1 – HIV and confidentiality Do nothing Contact wife Contact Division of Public health Refer to another physician

Case 2 - PVS and feeding tube removal Do nothing Remove tube Contact hospital attorney to block family’s wishes

Proposed Resolution

Case 1 – HIV and confidentiality Attempt to meet with patient and wife to discuss test

results and implications, offer to test wife If patient refuses, contact DPH for partner notification

Case 2 - PVS and feeding tube removal Remove tube or refer to another physician/hospital

Two Ethically Problematic Situations

Informed consent Surrogate decisionmakers Right to die/wrongful life

Karen Ann Quinlan, Nancy Cruzan, Terry Schiavo Advance directives Rights of minors Treatment refusal

Jehovah’s Witnesses, dialysis, DaxConfidentiality

When to breach confidentiality Tarasoff

Ethical and Legal Bases of Informed Consent

What is the ethical basis for informed consent?

Autonomy underlies informed consentAssault and (intentional tort of) battery

Informed Consent

Three Elements of informed consent Voluntariness Information Competence (capacity)

Three Elements of Informed Consent

What three elements comprise informed consent?

Information How much?

Competence (capacity) How do we determine this?

Voluntariness What constitutes coercion?

Voluntariness

Freedom from undue influenceIncentives for research?Would decision of patient with HIV to disclose

information to wife be voluntary if alternative is partner notification through public health? Voluntary within constraints

Would decision of family to request withdrawal of feeding tube be voluntary if hospital threatened them with threat of massive health care costs?

Information – What must be disclosed??

No doctrine of informed consent in Georgia. Georgia requires disclosure “in general terms the treatment or course of treatment” but for surgical or diagnostic treatments standard is higher (O.C.G.A.31-9-6.1)

For surgical procedures, amniocentesis, contrast material “disclosure of the material risks generally recognized and accepted by reasonably prudent physicians which, if disclosed to a reasonably prudent person in the patient's position, could reasonably be expected to cause that person to decline the proposed treatment or procedure because of the risk of injury that could result”

Good practice to disclose diagnosis, nature of treatment, risks, benefits, alternatives, prognosis with and without treatment, and to invite questions

What should be disclosed?

Case 1 – HIV and confidentiality Meaning of test Risk of infecting wife Possible criminal consequences for failing to inform

her Woodrow Grady, Macon, sentenced to two years in 2009

HIV and fetus, children Treatment possibilities, alternatives, side effects,

prognosisCase 2 – PVS and removal of feeding tube

Prognosis with and without feeding tube Alternatives Costs – make it clear care does not depend on ability

to pay

Competence

§ 31-9-2.(c) For purposes of this Code section,

"inability of any adult to consent for himself" [shall mean the adult] "lacks sufficient understanding or capacity to make significant responsible decisions" regarding his medical treatment or the ability to communicate by any means such decisions.

Competence

Competence or capacity is specific to a particular decision Competence is a legal decision, but used synonymously

with capacityRange of competence:

Ability to communicate decision Not refusing Simple assent

Simple Understanding E.g., able to paraphrase

Appreciate complexities of decision Medical Interpersonal Spiritual

Level of competence needed related to risk/benefit

Competence

Case 1 – HIV and confidentiality Was patient competent to release or to deny release of

information? What if retarded? Depressed? Demented (HIV dementia)? Delirious?

Case 2 – PVS and PEG removal Were parents competent to request tube removal?

When the Patient is Incompetent

Karen Ann Quinlan1954-8521 yo, Valium and

ETOHPVS, ventilatorParents sued to

remove ventilator1976 New Jersey

Supreme Court decided on right to privacy

“Right to die”


Nancy Cruzan1983 MVAPVS, feeding tube1987 parents sued to

remove tubeCourt liberty interest

in being free from unwanted intrusions

Loosely “right to die”Patient Self-

Determination Act 1990

Patient Self-Determination Act

1990 after CruzanWritten notice upon admission to the health

care facility of decision-making rights The right to accept or refuse medical

treatment The right to make an advance health care

directive Facilities must ask whether the patient

has an advance health care directive Facilities must educate staff about

advance health care directives.


Guardian Probate court Guardian of person or estate or both

Advance directive Specifies what is to be done in the event patient is unable

to make a decision Durable Power of Attorney for Health Care

Who will make decision Living Will

Specifies particular decisions, e.g., ventilators Georgia Advance Directive for Health Care includes both

Power of Attorney and Living Will provisions (posted on ethics site, First Year)

Georgia Advance Directive for Health Care

GUIDANCE FOR HEALTH CARE AGENT When making health care decisions for me, my health care

agent should think about what action would be consistent with past conversations we have had, my treatment preferences as expressed in PART TWO (if I have filled out PART TWO), my religious and other beliefs and values, and how I have handled medical and other important issues in the past. If what I would decide is still unclear, then

My health care agent should make decisions for me that my health care agent believes are in my best interest, considering the benefits, burdens, and risks of my current circumstances and treatment options.

Substituted Judgment v Best Interests

Substituted judgment – for persons who have been competent to express a choice but who presently lack capacity Dementia Delirium Severe mental illness

Best interests standard – for persons never competent to have decided Children Mentally retarded/developmentally disabled


PART TWO will be effective if I am in any of the following conditions: A terminal condition, which means I have an incurable

or irreversible condition that will result in my death in a

relatively short period of time, and/or; A state of permanent unconsciousness, which means I

am in an incurable or irreversible condition in which I am

not aware of myself or my environment and I show no behavioral response to my environment.

To be determined by personal and second physician


Try to extend my life for as long as possible, using all medications, machines, or other medical procedures that in reasonable medical judgment could keep me alive. If I am unable to take nutrition or fluids by mouth, then I want to receive nutrition or fluids by tube or other medical means, OR;

Allow my natural death to occur. I do not want any medications, machines, or other medical procedures that in reasonable medical judgment could keep me alive but cannot cure me. I do not want to receive nutrition or fluids by tube or other medical means except as needed to provide pain medication, OR;


I do not want any medications, machines, or other medical procedures that in reasonable medical judgment could keep me alive but cannot cure me, except as follows:

[Initial each statement that you want to apply to option (C).] If I am unable to take nutrition by mouth, I want to receive nutrition by tube or

other medical means. If I am unable to take fluids by mouth, I want to receive fluids by tube or other

medical means. If I need assistance to breathe, I want to have a ventilator used. If my heart or pulse has stopped, I want to have cardiopulmonary resuscitation (CPR) used.

Default Surrogate Decisionmakers I

§ 31-9-2. Persons authorized to consent to surgical or medical treatment

(a) any one of the following persons is empowered to consent: (1) Any [competent] adult, for himself or herself, whether by living

will, advance directive for health care, or otherwise; (1.1) Any person authorized to give such consent for the adult under

an advance directive for health care or durable power of attorney for

health care (2) In the absence or unavailability of a living spouse, any parent,

whether an adult or a minor, for his or her minor child; (3) Any married person, whether an adult or a minor, for himself or

herself and for his or her spouse;

Default Surrogate Decisionmakers II

(4) Any person temporarily standing in loco parentis, whether formally

serving or not, for the minor under his or her care; and any guardian, for his or

her ward; (5) Any female, regardless of age or marital status, for herself when

given in connection with pregnancy, or the prevention thereof, or childbirth;

or (6) Others (A) Any adult child for his or her parents; (B) Any parent for his or her adult child; (C) Any adult for his or her brother or sister; or (D) Any grandparent for his or her grandchild. (E) Grandchild (F) Niece, nephew, aunt, or uncle Treatment which the patient would have wanted had the patient

understood the circumstances under which such treatment or procedures are provided.

Medical Consent in Minors

Under the age of 18 may consent to: Treatment for drug abuse HIV testing Prevention of pregnancy Treatment during pregnancy and childbirth Treatment for STD Abortion with parental notification

Informed Consent

Not just a piece of paperInformed consent is a means of engaging a

patient in important health care decisionsThere is therapeutic value to true informed

consent

Exceptions to Informed Consent

Emergency exceptions to informed consent Consent is implied in emergency when patient is lacks

capacity and surrogate unavailableTherapeutic privilegeWhat is Rule #1?Rule #1 - We are doctors, not lawyers

Confidentiality

What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself Hippocrates

Confidentiality

Confidentiality is the obligation on the physician not to reveal what has been learned during the course of treatment

Privilege is the right of a patient, established only by statute, whereby a patient may prevent his physician from testifying. Privilege is a legal right belonging only to the patient and not to the physician.

Health Insurance Portability and Accountability Act (HIPAA) 1996

Title II: Preventing Health Care Fraud and Abuse; Administrative Simplification; Medical Liability Reform Intent to restrict release of information to only that

necessary to achieve the purpose Patients are guaranteed access to their medical records

and may amend Not “psychotherapy” notes

What about disclosing information to a family member in an emergency? Consent not required if disclosure necessary for

treatment Notification of family may be necessary for treatment

Subpoena Duces Tecum

Immediate response: Reply, don’t comply

Check with patientGet legal advice if

neededRelease minimum

information necessary

Breaking Confidentiality

Reporting child abuse or neglectAbuse of seniorsAbuse of disabledResidents of long term care facilitiesReporting HIV to stateNotifying sexual partners of HIV“Tarasoff” warnings

“protective privilege ends where the public peril begins”

Optional Review of First Meeting

What is an ethical dilemma? Conflict between or among moral imperatives

Principles of medical ethics Autonomy, beneficence, non-maleficence, justice

Procedure for ethical case analysis Rule #1, stakeholders, relevant laws, potential

consultants, possible decisions, proposed resolution

Review

What are four commonly accepted ethical principles?

What is an ethical dilemma?Where can you find resources for medical

ethics at Mercer?What ethical principle is the basis for

informed consent?What does the Karen Ann Quinlan case

emphasize?What legislation resulted from the Nancy

Cruzan case?

The principle of autonomy in medical ethics concerns the patient’s Right to determine what shall be done to her own

bodyA capacity determination is

A judgment about the patient’s ability to make a particular decision about her medical care

When obtaining informed consent from a patient for a surgical procedure, the standard in Georgia for disclosure of risks includes material risks which are

Accepted by reasonably prudent physicians that would cause a reasonably prudent patient in similar circumstances to refuse the procedure

When a decision must be made about the medical care of an adult patient who has had, but who no longer has, decision-making capacity, the surrogate decision-maker should Use the “substituted judgment” standard to reach

a decision, i.e., what the patient would have decided if competent

Which three elements comprise valid, informed consent? Competence, relevant information, voluntary

Which of the following is recognized as the primary ethical foundation for informed consent?

a. Principle of autonomy

The case of Tatiana Tarasoff in California led to the enunciation of which legal principle?

That there is a duty to protect identifiable third parties when a clinician knows, or, pursuant to the standards of the profession ought to know, that the patient presents an imminent threat of danger to that third party.

The Karen Ann Quinlan and Nancy Cruzan cases were both related to:

c. Right to die

Which law led to the requirement that hospitals ask about the presence of Advance Directives? Patient Self-Determination Act

The Oath of Hippocrates includes which of the following?

b. A warning to keep secret knowledge learned from professional contacts as well as knowledge learned “in the daily commerce with men”

Next Time – Wednesday Feb 13

ProfessionalismOptional review

Review

Four principles of medical ethicsEthical principle - basis for informed consentKaren Ann QuinlanNancy CruzanTatiana TarasoffThree elements of informed consent

What does it mean to be professional?

As a preclinical student? Prepared On time Respectful

As a clinical student? Appearance Prepared On time Respectful

Nurses Extra duty

Some Characteristics of a “Professional”

Self-regulatingSpecialized education, training, knowledge

CompetenceBehaviors

Dress Timeliness Preparedness Courtesy Hard working

On Entering a Profession

An oath is taken pledging to uphold the standards of that profession

The Oath of Geneva AT THE TIME OF BEING ADMITTED AS A MEMBER OF THE MEDICAL PROFESSION: I SOLEMNLY PLEDGE myself to consecrate my life to the service of humanity; I WILL GIVE to my teachers the respect and gratitude which is their due; I WILL PRACTICE my profession with conscience and dignity; THE HEALTH OF MY PATIENT will be my first consideration; I WILL RESPECT the secrets which are confided in me, even after a patient has died; I WILL REMAIN by all means in my power, the honor and the noble traditions of the medical profession; MY COLLEAGUES will be my brothers and sisters; I WILL NOT PERMIT considerations of religion, nationality, race, party politics or social understanding to intervene between my duty and my patient; I WILL MAINTAIN the utmost respect for human life from its beginning, even under threat, and I will not use my medical knowledge contrary to the laws of humanity; I MAKE THESE PROMISES solemnly, freely and upon my honor.

“Consecrate My Life”

I SOLEMNLY PLEDGE myself to consecrate my life to the service of humanity

“Respect and Gratitude”

I WILL GIVE to my teachers the respect and gratitude which is their due

“Conscience and Dignity”

I WILL PRACTICE my profession with conscience and dignity

“My First Consideration”

THE HEALTH OF MY PATIENT will be my first consideration

“Confided in Me”

I WILL RESPECT the secrets which are confided in me, even after a patient has died

“Traditions”

I WILL REMAIN by all means in my power, the honor and the noble traditions of the medical profession

“Brothers and Sisters”

MY COLLEAGUES will be my brothers and sisters

No Other Considerations

I WILL NOT PERMIT considerations of religion, nationality, race, party politics or social understanding to intervene between my duty and my patient

“Respect for Human Life”

I WILL MAINTAIN the utmost respect for human life from its beginning, even under threat, and I will not use my medical knowledge contrary to the laws of humanity

“Promises”

I MAKE THESE PROMISES solemnly, freely and upon my honor.

The Oath of Geneva

Challenges to professionalism – But what about . . .?

Consecrate My Life

I SOLEMNLY PLEDGE myself to consecrate my life to the service of humanity What does it mean to “consecrate?” Are you ready when you come to class/rounds? Do you do just the minimum work required (e.g., number of

patients)? Resident work hours – what to do when you’ve reached the

limit and patient continuity of care or a learning might be compromised?

Will you take responsibility for your continuing education, attending meetings, reading journals, obtaining consultations?

Respect Teachers

I WILL GIVE to my teachers the respect and gratitude which is their due An attending asks you to suture a deep facial wound.

You have little experience with this and express your concern. The attending tells you “Well, this is how you learn” and leaves.

An attending asks you to obtain informed consent regarding a complex procedure with which you are unfamiliar and brushes aside your reservations about your ability to describe the procedure, its risks and benefits, prognosis, and alternatives.

An attending deliberately exposes parents of a newborn to a surgical procedure on their baby to demonstrate the futility of further intervention. They are devastated.

Conscience

I WILL PRACTICE my profession with conscience and dignity A recent graduate opens a primary care clinic

advertising itself as catering to gay and lesbian patients. It is one of very few clinics in this rural area. Residents who are not gay or lesbian are reluctant to visit the clinic.

A fertility specialist is approached by a woman who seeks to have six stored fertilized embryos implanted. She has six children at home.

A woman approaches you for advice about an elective abortion, to which you are opposed for religious reasons. Should you refer her to a colleague who performs abortions?

Health of My Patient

THE HEALTH OF MY PATIENT will be my first consideration Your patient comes to you for an exam prior to

traveling to Greece for his wedding. You discover him to have TB and express your concern over his trip.

A woman is brought by her husband to the EC with a history of severe depression, auditory hallucinations, and has been suicidal in the past. She gave birth six weeks ago to a health baby. She tells you “Whatever you do, don’t take my baby or make me come in the hospital. I couldn’t take it.” You are considering involuntary hospitalization (“commitment”).

Brothers and Sisters

MY COLLEAGUES will be my brothers and sisters Another student has been coming to groups late, lives

by himself, and there is concern among other students over his drinking and use of antianxiety (Xanax), pain, and stimulant medications.

During your EC and Internal medicine rotations you become aware of a community physician who seems to have a large number of patients coming to the hospital toxic on pain medications for which the indications are unclear, e.g., “fibromyalgia.”

Secrets

I WILL RESPECT the secrets which are confided in me, even after a patient has died Your patient is going through a painful divorce and, during

his annual physical examination, tells you “Sometimes I think the only way to protect the kids from her is just to get her out of picture entirely, if you know what I mean.”

Respect for Life

I WILL MAINTAIN the utmost respect for human life from its beginning, even under threat, and I will not use my medical knowledge contrary to the laws of humanity Patient Rights groups strongly support the “Death

with Dignity Act” in Oregon and seek to pass a similar law in Georgia. Your local legislator asks for your opinion.

Your hospital is considering a futility of care policy applicable to newborns and adults with severe medical conditions for which medical care is unlikely to provide anything but maintenance of vegetative functions. The policy would permit, after due process, termination of life supports over the objections of family.

Click icon to add pictureThreat to professionalismMangled care

Click icon to add pictureThreat to professionalismMedical Industry

Click icon to add pictureThreats to professionalism“Alternative health care”Social justice and lack of access

Unprofessional Conduct and Board Action

235 MDs disciplined by board 1990-2003469 MDs controlled for school and year of

graduationDisciplined for:

Unprofessional conduct (74%) Incompetence Other

Papadakis et al. Disciplinary Action by Medical Boards and Prior Behavior in Medical School. NEJM 2005;353:2673-82

740 Board Violations by 235 Physicians

Use of drugs or alcohol 108Unprofessional conduct 82Conviction for a crime 46Negligence 42Prescribing/acquisition substances 39Violation of Board order/condition 32Sexual misconduct 29

Other – Failure to meet CME, fraud, billing, failure to maintain adequate records

Disciplined vs. Control Physicians

No gender differencesHighly significant differences (p< 0.05–

0.001) Medical school academic performance USMLE

Unprofessional conduct in school predicted subsequent disciplinary problems 39% of disciplined physicians displayed unprofessional

behaviors in school vs 19% of undisciplined physicians (disciplined physicians twice as likely to have records of unprofessional conduct during school)

P<0.001

Unprofessional Conduct in School

OR

Irresponsibility (>2) 8 Attendance, follow-up

Lack of self-improvement (>2) 3 Response to criticism

ImmaturityPoor initiative

Motivation, enthusiasmRelationships (students, nurses, faculty,

patients)

Lessons

Professionalism starts nowGood news – the two most significant

predictors are modifiable If you have problems with attendance, preparedness –

change! If you have a problem accepting criticism – learn!

Smiling inward is deadly

GroupsPrepare as a professional

Read the cases

Analyze using case analysis format

Discuss with colleagues as you like

Rule #! - Wear white coats to our groups

Review

Case analysis

Principles of Medical Ethics

Which of the following is NOT widely considered a principle of medical ethics? Autonomy Beneficence Respect Social justice Non-Malfeasance

HIPAA

HIPAA is an important piece of federal legislation covering: Privacy of health care information Treatment in emergency rooms The right to privacy in medical decisionmaking

Mandatory Disclosure

In which of the following cases is disclosure of information NOT required: Suspected child abuse New HIV patient Receipt of a subpoena for medical records to be used

at a divorce proceeding Previously undisclosed criminal history

Match case with the concept most closely identified with it

National attention on “right to die” and removal of life sustaining devices

Duty to protect third parties

Removal of feeding tube, Patient Self Determination Act

TarasoffNancy CruzanKaren Ann Quinlan

Autonomy

The principle of autonomy concerns the patient’s Right to be treated with compassion Right to determine what shall be done with one’s

body Right to basic medical care Right to drive an automobile

Capacity (competence)

A capacity determination is A judgment about the patient’s ability to be a

good patient A judgment about the patient’s ability to make

good decisions in general A judgment about the patient’s ability to make

good medical decisions A judgment about the patient’s ability to make a

particular decision about her medical care

Which is the more acceptable view?

Providing the degree of information necessary for genuine informed consent is understood to require Disclosing what a reasonable physician would

disclose in the circumstances Disclosing information that a reasonable person

in those circumstances would judge relevant Both

Best Interests or Substituted Judgment?

When a decision must be made about the medical care of an adult patient who has had, but who no longer has, decisionmaking capacity, the surrogate decisionmaker should Use the “best interest” standard to reach a

decision, i.e., what, in the opinion of the surrogate decisionmaker is in the best interests of the patient

Use the “substituted judgment” standard to reach a decision, i.e., what the patient would have decided if competent

Best Interests or Substituted Judgment?

When a decision must be made about the medical care of a patient who never had decisionmaking capacity, the surrogate decisionmaker should Use the “best interest” standard to reach a

decision, i.e., what, in the opinion of the surrogate decisionmaker is in the best interests of the patient

Use the “substituted judgment” standard to reach a decision, i.e., what the patient would have decided if competent

Neither a nor b

Informed Consent

Which of the following is NOT one of the three elements of a valid informed consent? Information Confidentiality Voluntariness Competence Witnessed

Minors and Medical Decisions

To which medical decisions may a minor in Georgia give consent? Drug abuse treatment STD Treatment of the minor’s child Pregnancy Prevention of pregnancy Abortion with parental notification (except emergency

or with court approval)

Jahi McMath: Judge extends order to keep brain-dead girl on ventilator

Documents

Transcript of Jahi McMath: Judge extends order to keep brain-dead girl on ventilator