Transcript THE ETHICS OF PROFESSION

PRINCIPLES OF
BIOETHICS
“What Principles Guide the
Health Professional in
Interacting with
Patients/Clients?
Principles of Bioethics
Are Based on the
Moral Rule...
“Do Your Duty”
For purposes of this discussion we are
going to consider all to be public health
clinicians, as this will enable us to
elucidate the principles more readily.
However, the same principles would
apply to public health professionals
working either with individual clients,
or organizational entities.
Moral Rules Become
Moral Ideals
• The goals of a profession are always
particular expressions of the moral
ideals.
• Professions (specifically the health
professions) exist to positively
benefit those seeking their
assistance.
• The moral rule, “do your duty,” is
played out in the duties the
professional has taken upon
him/herself to do good for those
seeking help.
• Thus violating a specified
professional duty, is violating the
moral rule, “do your duty.”
Professional Duties
• Moral
• Intellectual
Just as in Aristotle’s Concept
of the Virtues (Being Both
Moral and Intellectual), Based
on the Nature of Human-kind.
Moral Component of
Bioethics
(Professional Ethics)
Primary to the notion of a
health profession is benefiting
society. The moral component
of the profession of public
health is doing good for the
health of the public. The moral
rule of not causing harm
becomes the moral ideal of
preventing harm to, and
promoting good for, society’s
health.
Troika
of
Principles of Bioethics
We help promote the public’s
health by observing three
principles of bioethics:
• Beneficence
• Respect for Autonomy
• Justice
BENEFICIENCE
(First Principle)
The goal of the relationship in
which one assumes the role of
public health practitioner and
the other the patient/client is the
benefiting the “well-being” of
the patient/client. This
benefiting is accomplished by
the public health professional
providing the highest quality of
information/care possible
contingent on the profession’s
current scientific understanding,
the (clinical) circumstances, and
the client/patient’s desires.
Hippocratic Oath
“I will use treatment to
help the sick according to
my ability and judgment,
but I will never use it to
injure or wrong them.”
Continuum of
Beneficence
Promote Good
Prevent Evil or Harm
Remove Evil or Harm
Do Not Cause Evil or Harm
(Non-maleficence)
NON-MALEFICENCE
“Do No Harm”
Do not violate any of the
moral rules
Who Decides About
Goods and Harms-Risks and Benefits?
In providing goods or benefits,
clinicians/public health professionals
acknowledge there are inherent risks
of harms. Professionals have the
duty to weigh benefits against
possible harms, and minimize the
risk of harms. But the professional’s
conception of benefits and risks may
be different from the patient’s. An
assessment of benefits and risks is
not necessarily a factual issue, but
judgment of value.
Whose values should prevail?
RESPECT FOR
AUTIONOMY
(Second Principle)
Autonomy derives from the Greek
and literally means self-rule, selfgovernance, selfdetermination…being one’s own
person; the author of one’s life.
The moral rule, “do not deprive of
freedom or opportunity,” means it
is moral or right to grant selfgovernance/self-determination to
others.
Kant’s Reformulation
(Second Formulation)
of the Categorical
Imperative
“Act so that you treat humanity,
whether in your own person or in
that of another, always as an end
and never as a means.”
Said another way, people are always
to be treated as “subjects,” not as
“objects.”
Page 131, 132, 133 in text
• Are Humans Curious?
Are You Curious?
Are Patients/Clients Curious?
• Why?
“Curiosity is the most
insatiable of lusts.”
Michel Foucault
French Philosopher
1926-1984
Patients Want to Know
• In one study, 72% of patients
said they prefer to make
decisions regarding their care
jointly with their physician.
• In contrast, the same study
found that 88% of physicians
believe that patients want
physicians to choose for them
the best alternative.
• We not only are curious, but we
value self-determination.
Balancing
The Two Bioethical Principles
Provide the Ethical Foundation
for
Informed Consent:
• Principle of Beneficience:
Do Good for the Patient by
Promoting Their Well-Being.
• Principle of Respect for Autonomy:
Each Person Should be SelfDetermining, the Author of His/Her
Own Life;deciding what is their
“good.”
Instrumental Value of
Self-Determination
In most cases, the individual’s
well-being is best served by
his/her own subjective
judgment.
Page 44 of assigned reading
from the President’s
Commission
Intrinsic Value of SelfDetermination
“...Unless the patient has requested this
course of conduct, the individual will not
have been shown proper respect as a
person nor provided with adequate
protection against arbitrary, albeit wellmeaning domination by others.”
Even if it could be shown that another
could do a better job of determining what
is in the individual’s interest, there is still a
reason for recognizing self-determination
as an individual’s right.
Page 45 of assigned reading from the
President’s Commission
Quote from
John Stuart Mill
“The human faculties of
perception, judgement,
discriminative feeling, mental
activity, and even moral
preference, are exercised only in
making a choice. He who does
anything because it is the
custom makes no choice. He
gains no practice either in
discerning or desiring what is
best. The mental and moral,
like the muscular powers, are
improved by being used...
He who lets the world, or his
own portion of it, choose his
plan of life for him, has no need
of any other faculty than the
ape-like one of imitation. He
who chooses his plan for
himself employs all his faculties.
He must use observation to see,
activity to gather materials for
decision, discrimination to
decide, and when he has
decided, firmness and selfcontrol to hold his deliberative
decision...
Where, not the person’s own
character, but the traditions and
customs of other people are the
rules of conduct, there is
wanting one of the principle
ingredients of human
happiness.”
John Stuart Mill
English Philosopher
Formulator of Utilitarianism
Beneficence : Autonomy
• The definition of health is imprecise
and indefinite. It depends to some
extent upon the goals and values of
the individual.
• Even when the definition is agreed
upon, there is often no definitive
criterion to determine how to
achieve it.
• In recommending therapy, health
professionals tend to reflect their
own values and preferences, which
may differ from their patients.
• Determining what constitutes health
and how it is best promoted requires
knowledge of the patient’s goals,
values, and preferences.
• For the reasons just given,
determining whether a plan of
therapy/action will, if
successful, promote a
patient/client’s well-being is a
matter of individual judgement.
• In each case the goals and
interests of particular patients
incline them in different
directions not only as to how,
but even as to whether,
treatment should be provided.
It is important to note that the ethical
(and legal) imperative of informed
consent does not give patient the
right to insist upon anything they
might want:
– Health professionals are also
bound by the concept of nonmaleficence, not causing harm
– The choices available to patients
must be limited to medically
accepted options, all of which
scientific evidence indicates will
have some possibility of
promoting the patient’s welfare.
Opinion in
John Canterbury
versus
William Spence
(1972)
“every human being of adult years
and sound mind has a right to
determine what shall be done with
his body… True consent to what
happens to one’s self is the informed
exercise of a choice, and that entails
an opportunity to evaluate
knowledgeably the options available
and the risks attendant upon each.”
Major Components of
Informed Consent
• Disclosure of Adequate
Information with Associated
Adequate Understanding
• Lack of Coercion
• Competence
(Decisional Capacity)
Adequate Information
with
Adequate Understanding
• The concept of adequate
information/understanding can
deteriorate into a mechanical
rehearsal of data to legally protect
the professional unless tempered
with the idea of client/patient
comprehension. This is done by
processing information reciprocally;
asking for client/patient
understanding and validation of the
information.
• Adequate information/understanding
does not require that the
client/patient be told everything
there is to know, but only the
information adequate to make an
‘informed decision;’ information that
a reasonable person would want to
have.
Four Standards
Considered For
Adequate Information
• Full Disclosure
• Customary Disclosure
• Disclosure of all Risks
• Reasonable Person Standard
Full Disclosure
Disclose every benefit and risk,
no matter how small or remote.
Rejected:
Too prohibitive and unrealistic.
If taken literally, full disclosure
is impossible. If taken, as
probably intended, to reveal
adequate information, the
standard provides no guidance.
Customary Disclosure
Disclose all information that other
practitioners would be likely to
disclose under similar
circumstances. (Also called
“community or professional
standard.”)
Rejected:
Customary practice does not
necessarily ensure that the patient’s
right to self-determination is
respected; does not ensure that
adequate information will be
provided.
Disclose All Risks
Disclose every risk that a patient
would deem significant to his
decision.
Rejected:
Places an undue burden on the
practitioner in that it requires
the practitioner to second guess
the patient’s subjective view of
what would count as significant
information.
Reasonable Person
Standard
Disclose the benefits and risks that a
reasonable person, in what the
practitioner knows to be the patient’s
position, would be likely to deem
relevant in deciding whether to
forego a proposed therapy.
Accepted, on the grounds that “ the
scope of the standard is not
subjective as to the practitioner or
the patient; it remains objective with
due regard for the patient’s
informational needs and with
suitable leeway for the practitioner’s
situation.”
Two Exceptions to the
Rule of Disclosure
• Emergency situations where the
patient is incapable of giving
consent, and harm from failure to
treat is imminent and outweighs any
harm threatened by the proposed
treatment.
• When disclosure of risks itself poses
a threat of harm to the patient.
However, this “privilege does not
accept the paternalistic notion that
the practitioner may remain silent
simply because divulgence might
prompt the patient to forego therapy
the practitioner feels the patient
really needs.”
Under the Reasonable
Person Standard, Adequate
Information Generally
Includes:
• Nature of the treatment
• Benefits
• Harms
• Complications/Risks
• Alternatives
• Prognosis
• Non-Treatment
• Costs
From the Reading
• Alternative Rational Choices
(page 153)
• Rational, yet unreasonable choices
(page 154)
• Fair presentation of all alternatives
(page 156)
• Treatment at different sites
(page 160)
• Presenting harms and benefits
(page 162)
• Alternative way of presenting
information
(page 165)
• Patient’s who do not want to know
(page 171)
Lack of Coercion
Modifying Behavior
Education
Persuasion
Manipulation
Psychological Coercion
Physical Coercion
Lack of Coercion
• Coercion is defined as a threat, either
psychological or physical, of
sufficient force that no rational
person would be able to resist it.
• Education and persuasion are not
coercive.
• Manipulation/deception and
psychological or physical
inducements of benefit or threats of
harm are coercive.
• Key idea is that the consent is fully
voluntary, thus voluntariness.
Decisional Capacity
• In much of the ethics literature, the
term competency is used to
designate decisional capacity.
However, the term has taken on legal
connotations with the decision
regarding a person’s competency
determined by the courts. Thus,
increasingly the term decisional
capacity is employed to designate
the third ingredient necessary for a
consent to be informed/valid.
• Implied is also the notion of moral
agency. The individual is to be taken
as an autonomous moral agent.
Decisional Making
Capacity Requires:
• Possession of a set of values and
goals.
• The ability to communicate and to
understand information, and
• the ability to reason and deliberate
about one’s choices.
From: The President’s Commission
for the Study of Ethical Problems in
Medicine and Biomedical and
Behavioral Research
Surrogate Decision
Making
•
•
•
•
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Examples of individuals who
cannot rationally deliberate in
the process of informed consent
are:
minors
persons with dementia
psychotics
persons with extreme anxiety or
fear
the mentally retarded
persons under the influences of
abused substances
Health Care Surrogacy
in Kentucky Law
(KRS 311.631)
• Judicially appointed guardian
• Spouse
• An adult child of the patient; if more
than one, the majority of the adult
children who are reasonable
available for consultation
• The parents of the patient
• The nearest living relative of the
patient, or if more than one relative
of the same relation is reasonable
available for consultation, the
majority of the nearest living
relatives.
Misconceptions About
Informed Consent
• Informed consent is merely a
legal doctrine and has little to
do with a good and ethical
practice.
• Informed consent is a single
event.
• Informed consent merely
involves the listing of risks and
benefits the health professional
believes would best serve the
patient/client’s interests.
• Because of their special
education and training,
practitioners are the best judges
of what would serve their
patient/client’s best interests.
• The primary obligation of the
health professional is to act in
the best interest of the
patient/client’s health, as the
health professional understands
it.
• It is permissible to forego
informed consent so long as you
are acting in the patient/client’s
best interest.
• Patients do not want to be informed
of bad news and are always better
served by practitioners remaining
positive, even if it involves
deception.
• Any individual who would make a
decision that is obvious to the
practitioner as contrary to their
health and well is irrational.
• The practitioner’s obligations do not
extend beyond the legal
requirements concerning informed
consent.
• Informed consent is a legal doctrine
and a way to protect the health
professional from legal action.
• A signature on a form, which
describes the procedure, constitutes
an informed consent.
Paternalism
Assumptions:
• Acting Beneficently … Doing
Good
• Violating a Moral Rule
• Client/Patient has not given an
Informed Consent
• Client/Patient is Competent to give
Consent
Intellectual
Component of
Profession
Life Long Learning
• Philosophical End
• Psychological End
• Practical End
Philosophical End
• Aristotle’s concept of “intellectual
virtue.” We fulfill one of our vital
functions as human being when we
continue to learn.
• “we must cease conceiving of
education (learning) as mere
preparation for later life, and make
it the full meaning of present life…an
activity that does not have worth
enough to be carried out for its own
sake cannot be effective as
preparation for something else.”
John Dewey
American philosopher
Psychological End
• Maslow’s concept of “being all
you can be.” As we are by
nature learning animals, we
actualize our potential when we
learn.
• Csikszentmihalyi’s concept of
“flow.” Having our
intellectuality exercised and
stretched with new ideas,
challenging concepts, and
exciting understandings is to get
in, and be in, flow.
Practical End
• A competent professional must
apply the profession’s current
knowledge base to patient or
client care with integrity.
Standards of care must be
fulfilled, and those standards are
continuously changing through
research.
L’informatique
• 6,000 - 7,000 scientific articles
published every day.
• Now … scientific and
technological information
increases 13% /year -- doubling
every 5.5 years.
• Rates of information expansion
will soon increase 40%/year due
to more powerful information
system and the increasing
population of scientists.
• Then … the scientific
information will double every
twenty months.
“If we indoctrinate our students
in an elaborate set of fixed
beliefs, we are ensuring their
early obsolescence. The
alternative is to develop skills,
attitudes, habits of mind, and
kinds of knowledge and
understanding that will be
instruments of continuous
change and growth. Then we
will fabricate a system that
provides for continuous
renewal.”
John Gardner
in Self-Renewal