Ethics

both

patient told psychiatrist he intended to kill a female, doc did not disclose info, patient kills female

Topic: Confidentiality
Established: permissibility of violating confidentiality when clear threat to public welfare or health and safety of individuals

Mary went in for exploratory procedure, to which she consented, and woke up to find tissue had been removed w/o her consent

Topic: the 'consent' part of informed consent

Established: that performing an intervention on a pt w/o express consent constitutes a form of medical battery or assault for which the physician is liable; adult pts have right to control own bodies

Canterbury consented to surgery by Spence on back and shoulder; was not informed of small risk of severe neg side effects (paralysis); tried to get out of bed unassisted, fell, and injured himself

Topic: "informed" part of informed consent

Established: Reasonable Person Standard of informed consent, e.g., medical personal need to tell pt risks, benefits, and alternatives that would make a diff to a reasonable person

Quadriplegic, non-terminal patient Bouvia seeks right to refuse life-sustaining treatment, mainly artificial nutrition and hydration via NG tube which is being forced upon her against her will

Topic: the extent of 'refusal' corollary of informed consent

Established: re-affirmed refusal of medical treatment as a right stemming from right to consent to treatment, and constitutional privacy rights; established that even non-terminal pts w/ long life ahead can refuse treatment; contended nether med personal nor State has right to force pt to live w/ or endure quality of life that pt finds not worth living; minority concurring opinion suggested this may give rise to right to physician-assisted suicide

Cruzan in vegetative state b/c of car accident; state pays for on-going treatment after diagnosed with PVS; parents petition to have her removed from life-sustaining treatment, claiming substituted judgement

Topic: informed refusal and advance directives

Established: pts have a right to have their wishes for treatment respected even after they are no longer decisional. But it is the state's right to require high standard of evidence for what the pt's wishes were.

pt severely burned keeps asking to be killed in order to not feel the painful treatment anymore. Doctor's claim he is incompetent to make decisions during this time and continue treatment against pt wishes. Since deemed incompetent, mother was making all medical decisions.

Topic: Advance directives, Autonomy, Beneficence, non-maleficence, proxy

Established: Advance directive good idea for medical emergencies such as this. If pt deemed incompetent, use proxy as decision-maker.

seeks to maximize good

Impartial: the happiness of all is equally valuable; the suffering of all is equally valuable; cannot be partial to my own

Actions are right as they tend to increase the sum of total happiness and decrease suffering, wrong as they tend to the reverse, for all concerned

apply GHP to policies/rules/guidelines, evaluating whether it will tend to maximize happiness and minimize suffering for all concerned better than other ones; only to have to do this once for each rule, then can compare individual acts against the rule so do utilitarian calculus less often

apply GHP to individual actions, evaluating whether that act-of all available courses of action-best maximizes happiness and minimizes suffering for all concerned; have to do utilitarian calculus for every action you take

ethics should not depend on circumstances (like utilitarianism), but apply in all cases

need categorical (not hypothetical) imperatives

Act always so that the maxim of your action can be a universal law of nature like the law of gravity
A.K.A. the Formula of Universal Law (FUL)

Never use rational being as merely a means to an end
AKA Formula of Humanity (FoH)

Duties (which are now categorical, so if wrong it is wrong in all cases)

the goal of human life is a good life, a happy one of human flourishing and well-being

act in moderation and be moderate; extreme actions to excess or deficiency tend not to lead to the good life

character trait that is in the Golden Mean b/w vices of excess and deficiency;

Confidentiality
Fidelity
Veracity
Beneficence
Non-maleficence
Autonomy
Justice

allowing pt to control who knows info about them

faithfulness

truthfulness

doing actions to help others

not doing harm; avoiding, preventing harm

having the freedom to make choices about one's own life

fairness; people et what they deserve

ppl are self-interested so we can't take our own position into account when designing a fair society lest we rig the system. So, ignore own position behind the veil of ignorance in the original position. You'd come up with 3 principles of Justice.

From Rawls's Justice theory

Each person is to have an equal right to the most extensive system of basic liberties that's compatible w/ everyone else's right to the same thing. This principle is most IMPORTANT, its requirements come first

#2 from Rawls's theory

Ppl w/ similar abilities and skills are to have equal access to offices and positions

Inequalities in social and economic institutions are justified only if allowing them maximally benefits the ppl who are worst off

Uncertainty, Context, multiple stakeholders, power imbalance, extraneous variables, other relevant cases, and degree of urgency

Stage of Ease
Situational Binds (disrupts ease of decision)
State of Resolution
Stage of Reflection

You are a participant, thus a moral agent; You are prevented from taking the action you believe to be most right

You are an observer rather than a participant; A moral agent takes an action you believe to be wrong; implies that the agent could have done right thing

feeling you have when you know you did right thing given the options available, but wish it could have been otherwise; this moral emotion does not indicate that you did wrong thing (that would be guilt)

emotion you feel when you know you did the wrong thing and could have done otherwise but didn't; necessarily implies you had good options

Comparing case with well-justified moral judgements about previous cases.

general moral rules hold true, but their relevance depends on the particulars of the situation; in particular cases, those moral rules that would otherwise hold may be 'defeasible'

should not keep pt from info they need to make decisions
should not undermine fair tx of the pt or impose an additional burden on them
Can perhaps be justified to restore autonomy later or to advance therapy, BUT should be short-term

May be necessary to provide good care in modern healthcare system (insurers); let pts know and get consent for info sharing (Siegler; HIPAA)

Harm Principle and Vulnerability Principle apply

Have ability to understand all info
Have ability to communicate understanding and choices
Have personal values and goals that guide decision
Have ability to reason and deliberate

Autonomous Authorization
Substantial understanding (risks,benefits,alternatives)
In absense of substantial external control by others
Intentionally
Authorizes an intervention

Process-oriented effective consent
Satisfies the law
Satisfies institutional requirements

Project IC&R into the future, to a time when pt is non-decisional: prospective autonomy

Provides guidance for proxy and doctors

specify what tx you want in certain conditions

specify who you want to be your proxy if you are non-decisional; might not give any indication of your wishes or preferences on the form; legally binding

specify that you do not want CPR or other means taken to resuscitate; can be limited to particular situations; legally binding per state laws

good prospective autonomy is ongoing and revisable and starts while pts are healthy and young adults and includes proxy in discussions with doc; AD planning should been seen as part of reg med care plans for all pts

an action is taken, w/o which the patient would live

no action is taken, as a result pt dies

pt does not consent bc non-desicional; left no AD

providing pt w/ medical means to end own life as painlessly/certainly as possible, but not administering; pt does so in a time/place of own choosing