Transcript Medicine, Morals, and Managed Care

to Doing the Right Thing
Medical Ethics
Where Does It Come From?
Robert M. Sade, M.D.
Professor of Surgery
Director, Institute of Human Values in Health Care
Medical University of South Carolina
A History of Ethics Principles
460-377 B.C Hippocrates of Cos
1792
Percival: Manchester Infirmary Committee
1803
Percival: Medical Ethics: A Code of Ethics and Institutes
Adopted to the Professions of Physic and Surgery
1808
1847
Boston Medical Society (self-regulation)
AMA: “Code of Ethics”
1903
1912
1957
1980
AMA: “Principles of Medical Ethics”
AMA: revised “Principles”
AMA: concise “Principles”, “Opinions”
AMA: FTC-imposed Principles revision
1981
AAPS: “Principles of Medical Ethics”
1980s-1990s ACP Code, and many others
2001
AMA: revised “Principles”
Ethics
 Ethics is the discipline that considers how
human beings ought to behave to achieve
certain goals.
– what is the goal?
– what behavior will reach it?
 Ethical problem occurs when:
– several plausible actions available
– unclear which is most likely to achieve the goal.
Solution to a Problem
The good of
What’s right is the
the patient
single goal
greatest good for the
greatest
number
What’s
right
is
The good of
intuitively
the
hospitalself-evident goal a
What’s right is what
serves social justice
goal b
The good of
science
What’s right is what
goal c
Jesus, or Mohammed,
The good
of
or Buddha,
or … says
goal d
society
Science
Ethics
single standard
of truth
standard a
standard b
standard c
standard d
Solutions to Ethical Problems
 Not simple
 Ethics not like science
 Is ethics arbitrary? Or
 Can we discover an ethic for medicine?
Where Does Ethics Come From?
Tradition
“That’s the way it’s
always been.”
Authority
“That’s the way I
was taught to do it.”
Reason
“That’s the way
reality determines
we ought to behave.”
Human nature: what
analysis tells us about
medical ethics
A View of Morality and
Medical Ethics
 Human beings live, must maintain life
 Main tool is intelligence
 Rationality permits percepts
concepts
Understand real world and choose actions
Potentialities can be actualized
–generic (think, choose, walk, talk)
–unique (coordination, abstract thought)
A View of Morality and
Medical Ethics
 Goal: human flourishing
– achieved only through
and actions
of
basicchoices
virtues needed
by
individuals
every human being,
BUT
– specific goals, needs (values)
• health, wealth, friendship
– no instincts, but habits of mind (virtues)
• honesty, integrity, courage, rationality, compassion
– values and virtues require unique ranking
• unique talents, capacities, interests, tastes, etc.
– unique ranking also for professions
Ethics
Virtues
Values
Flourishing life
Basic template for professions:
– identify distinguishing characteristic
– rank virtues for particular profession
– define professional excellence
Medical Ethics
Virtues
Good of the patient
biological-medical good
self-understood good
Excellent physician
Distinguishing Characteristic
 The overarching need for TRUST
– Successful treatment of patients
requires physicians have access to:
• intimate details of personal history
• intimate access to the body itself
– Intimacy greater than anyone else,
including minister, lawyer, spouse.
– The fundamental need for those
intimacies requires that physicians be
trusted to serve patients’ interests before
their own
Virtues
Serving the Good of Patients
 Biological-medical good
– scientific objectivity
– competence (medical/technical)
– integrity in using knowledge/skills
 Patient’s perception of own good
– respecting patients’ self-determination (autonomy)
– honesty in disclosure
– compassion for patients’ humanity
– beneficence in supporting patients’ goals
The Ethical Core of Medicine
The patient’s good is paramount
TRUST is sine qua non
–Effacement of self-interest by MD
•financial (fees, incentives, indigent care)
•own health (epidemics, AIDS)
•inconveniences for patients’ needs
–Secondary goods:
•corporations
•colleagues, partnership
•society
Business Ethics
Virtues
Excellent
businessman
Good of the owners
trading
goods & services
long term profit
Distinguishing Characteristic
 Maximize owner value over long term
– unlike charity, government, family, hobby
Virtues
Serving the Good of Owners
 Making money
– no intimacy-vulnerability
– no effacement of financial self-interest
 Assure confidence in future transactions
– Honesty (no deception--bluffing, puffing, spinning)
– Promise-keeping (reliability)
The Philosopher of Business
“Men
“No man
whocan
drive
be sharp
dishonest
bargains
without soon
with their
being found
customers,
out, and when
acting
hisas
lack
if they
of
never
principle
expect
is discovered,
to see them
again,
nearlywill
every
notavenue
be
to
mistaken.”
success is closed against
him forever.”
Ethics of Science
Virtues
Good of science
Excellent
scientist
Seeking reliable
new knowledge
Distinguishing Characteristic
 Discovering truth: how the world
(human biology) works
– dedication to scientific method (hypothesis,
systematic observation, validation, theory)
– unlike medicine, business, government, etc.
Virtues
Serving the Good of Science
 Integrity/honesty
– Avoid negligence (e.g., sloppiness, premature reporting)
– No dishonesty (e.g., fabrication, falsification, plagiarism)
 Objectivity
– diligent application of ‘scientific method’
 Conscientiousness in applying knowledge/skills
– technical competence
 Respect for subjects
– rights of humans, humaneness toward animals
Potential Conflicts of Obligation

The
physician
as
healer
 The physician as healer
– Goal: the good
the patient
–Goal:
theofgood
of the patient
 The physician as scientist
– Goal: the good of science
 The physician as businessman
– Goal: make money
 The physician as private person
– Goal: the good of self, family, community, etc.
Principles of Medical Ethics
The good of the patient is paramount
– TRUST must be nurtured before all else
• Avoid conflicts of interest (COI)
• Avoid perception of COI
• Respect rights of pt
– safeguard confidentiality
– respect self-determination
• communicate honestly with all
• maintain competence
Caveat:
Self-deception: Human Trait
 Concealing truth to benefit pt
 Deception of insurance companies (e.g.,
miscoding) benefits only pt
 Gifts from industry do not influence
prescribing practices or device use
 Industry-controlled CME activities do not
have biasing influence on clinical practice
Conflicts In Professional Ethics
 Medicine versus business versus science
 Example from real life
Jesse Gelsinger Story
Inst Hum Gene Tx—U Penn
–
–
–
–
–
gene tranfer expt
ornithine transcarbamylase defic.
ammonia, 50% 1 mo, 75% 5 yr
1st direct inj by cath into liver
no problems, 1st 17 pts
Jesse Gelsinger
J.G., 18yo wm:
–OTC def. mild, atypical (low protein
diet, drugs)
“What’s the worse that can happen to me?
I die, and it’s for the babies.”
–18th subject, 9/13/99
–jaundice, 9/14/99
–mult organ systems failure
–dead 9/17/99 (1st hum gene tx)
 Allegations in lawsuit
– Earlier subjects’ serious reactions not reported, study
not D/C
– Death of 2/11 exptl monkeys removed from consent
form w/o notif.
– Upper limit of bld ammonia raised w/o notif.; JG’s
exceeded it
 WHY was protocol violated in these and other
ways? News media revelations, May, 2000:
– Dr. James Wilson (PI) had 30% interest in Genovo
(gene manufacturer)
– U Penn owned 5% of Genovo
– Dr. Wm Kelly, former dean of UPMS, owned several
patents of experiment
– Genovo gave $4 M a year to IHGT/UPenn
Paul Gelsinger
At RAC hearing (Dec 9, 1999) said:
“These guys didn’t do anything
wrong”
After lawsuit settled (2000), P.G.
concluded that “he had been duped
by scientists who cared more about
profit than safety”
Allegations unproved; major
damage from public perceptions
Contemporary Ethical Issues
 Informing patients of errors
 Profiting from company ownership
 Lying to insurance companies
 Crossing interpersonal boundaries
 Accepting gifts from industry
 Telling the truth to terminally ill patients
 Gaming transplant list to gain priority
 Responsibilities to medically indigent
Ferrol Sams
 Advertising of favorable outcome statistics
 Making decisions at the end of life
Types of Ethics
 Medical Ethics: Clinical obligations
– fidelity first to patients’ interests
– telling the truth (cancer, errors)
 Professional Ethics: Obligations of the profession
– self-regulation
– education of self and others
 Bioethics: Guides for public policy
– gene technology, stem cell research
– health system reform
Medical Ethics as Aspirational
 AAPS Principles of Medical Ethics
– Principle 3: The physician shall not condone the taking
of human life in the practice of his profession, but shall
at all times respect the sanctity of human life and seek
to preserve or improve the quality of life.
– Principle 6: …the value of professional services should
be determined only by mutual agreement between the
physician and patient, and in no other way.
 Mother Theresa
Principles of Medical Ethics
 AAPS (best)
 AMA (good)
– Code of Medical Ethics: Current Opinions
 ACP-ASIM (dangerous)
Comparison of Principles:
Common Grounds
Professional behavior, honesty
Report incompetent, unethical colleagues
Free to choose patient, cannot abandon
Fee-splitting prohibited
Continuously self-educate
Privacy and confidentiality respected
Consult colleagues freely
Respect the law, not blindly obey it
Primary professional obligation to patient
Should not solicit patients
AAPS
AMA
ACP
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Comparison of Principles:
Differences
AAPS
AMA
ACP
Participate in betterment of public health
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Explicitly support access to medical care
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Fee set with pt, limited to professional service
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Cannot accept limits on judgment re pt care
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May participate in legal abortions
?
May assist suicide or commit euthanasia
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Collective obligation to care for all patients
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Justice defined as ‘distributive justice’
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With Gratitude:
Plato andAristotle
Osler
Hippocrates
and
Teleological
toolsHalsted
to discover ethics
Transmitting Primacy
knowledge
of the
& ethics
patient’s
to future
good physicians
Thank You!