ETHICS & DECISION-MAKING I. Definition of Ethics Ethics – The study of a system of...

ETHICS & DECISION-MAKING

I. Definition of Ethics

Ethics – The study of a system of decision-making

based on moral

Principals

Morality-traditions of belief about right/wrong human

conduct.

Values – differences

ETHICS & DECISION-MAKING

“Ethics brings structure & order to the decision-making process about our responsibilities for patient care and institutional management”

Larry McCullough, PhD.

ETHICS & DECISION-MAKING

Ethics should lead the Law Main discipline of Ethics is to follow

the arguments where they lead us

ETHICS & DECISION-MAKING

“Medicine is the science of

uncertainty and the art of

probability”

-W.Osler, M.D.

ETHICS & DECISION-MAKING

Families, Doctors, Nurses,Health care team members

No simple algorithms to follow

We have fiduciary obligations to our patients

ETHICS & DECISION-MAKING Tools for Ethical Analysis

Clarity Consistency Coherence Clinical Applicability Clinical Adequacy

ETHICS & DECISION-MAKING

II. Principles

Do good and Do no harm--Beneficence

(Obligation as foundations of social morality)

1. One should not inflict harm

2. One should prevent harm

3. One should remove harm

4. One should promote good

ETHICS & DECISION-MAKING Principles

Justice – Persons should be treated equally

Many theories of justice

Respect for Autonomy – to allow person to act for

themselves

Responsibility for self and family

This means that the person understands

Consent

Disclosure of risk/benefits/complications

ETHICS & DECISION-MAKING

III. Approaches to Care

Wait until certainty

1. Treatment started on every infant

thought to

have a chance

2. Collect all information before making

decision –

Decision to err on side of maintaining

life

ETHICS & DECISION-MAKING

3. Aggressive approach in accordance

with

society that values individual(ism)

4. Price to pay may have some patients

with

severe handicaps to salvage that one

patient.

ETHICS & DECISION-MAKING

Statistical Approach

1. Categorizes patients into groups which

would

benefit from care

2. Goal is to avoid creating severely

impaired

infants even at cost of those who might

have been normal

ETHICS & DECISION-MAKING

Individualized Approach

1. Initiate care on infants who have a chance

2. Deciding as soon as possible if continuing

is in best interest of infant.

3. Decisions made before all information in

4. Problem – What degree of certainty is

necessary?

ETHICS & DECISION-MAKING

Responsibility – Accountability

Process should be consistent

One needs to ethically justify one’s

decisions

ETHICS & DECISION-MAKING

The technology is imperative -

1. Availability of technology

2. Does it mean we have to use it?

ETHICS & DECISION MAKING

“Tyranny of the Normal”

1. Only acceptable outcome is normal

(subjective & varies from person to

person)

2. Worry about unrealistic expectations

3. Need to understand family value

systems

ETHICS & DECISION-MAKING

IV. Principal of Best Interests

1. Patient can not speak for self.

2. Parents have responsibility for decision-

making.

Who are we treating – the patient or the family?

ETHICS & DECISION MAKING

Certainly want:

1. Relief of suffering

2. Preservation or restoration of function

3. Quality of life – (subjective)

ETHICS & DECISION-MAKING

Outcome

Anecdotal experiences both positive and

negative

How many times have we been wrong?

ETHICS & DECISION-MAKING

IV. Principal of Proportionality

Treatment should lead to greater benefit

than burden.

One needs to agree on expectations

1. Curing the patients

2. Restoring patient to reasonable

quality of life

3. Minimizing pain & suffering

ETHICS & DECISION-MAKING

V. Who Decides?

Decision-making Team

1. Physicians

2. Parents & Family

3. Other members of healthcare

team

ETHICS & DECISION-MAKING

Today there is increased respect for patient autonomy

1. Role of parents in decision-making is increased

2. We should not be afraid to think out-loud

a. This closes the gap between

physician/parent.

b. Demonstrate the trial & error nature

of treatment.

c. Parents need time to process

information

ETHICS & DECISION-MAKING Rationing-using limited resources

wisely Needs Ethical Impact Statement

Needs to meet rigorous standards Scientific Moral Economic

ETHICS & DECISION-MAKING

Summary – Very Important

1. Honest decisions with patients and

family early

2. Awareness of power of decisions made

each hour

3. Responsibility of thinking

4. Justification of thought

ETHICS & DECISION-MAKING

Summary – Very Important

5. Respect for life

6. An acceptable decision may mean no

intervention

7. Physician needs skill to help families explore

their values

8. Cannot leave family alone in decision-making

process

9. Decisions should be difficult

Tools for Ethical Analysis

Clarity Consistency Coherence Clinical Applicability Clinical Adequacy