Clinical Ethical Issues:Clinical Ethical Issues:Principles, Range of Principles, Range of Cases, History LessonsCases, History LessonsRobert L. Perkel, M.D.Robert L. Perkel, M.D.Chair, Thomas Jefferson University Ethics Chair, Thomas Jefferson University Ethics CommitteeCommitteeThe 2The 2ndnd Annual Healthcare Leadership Annual Healthcare Leadership Network of the Delaware ValleyNetwork of the Delaware ValleySpring Institute, May 2, 2014Spring Institute, May 2, 2014

ObjectivesObjectives

To understand the principles that guide every ethics case discussion and dissection.

To use case examples that describe clinical ethical issues at the beginning, in the prime, and at the end of life.

To underscore the ultimate importance of professionalism with lessons from history

Bioethical PrinciplesBioethical Principles

Autonomy Beneficence Nonmaleficence Justice Truth telling Informed Consent Confidentiality Futility

Practical ConsiderationsPractical Considerations

Particular clinical facts of “this case” Attitudes and beliefs “Culture” of the patient & physician Societal factors

Demographics (aging)Finances (fixed %GDP) Insurance (traditional v. prospective $$)

Ethics Case Discussion:Ethics Case Discussion:What the HEC doesWhat the HEC does

Important “players” represented Case presentation: facts; data; questions Discussion: listen carefully; weigh different

opinions; “try on” opposing viewpoints Arrive at option(s)

Support with underlying principlesCommunicate to all “the players”Don’t tell people what to do

Range of Cases: HECRange of Cases: HEC

Ethics at the Beginning of Life Ethics in the Prime of Life Ethics at the End of Life Ethics of Professionalism

Ethics at the Beginning of LifeEthics at the Beginning of Life

ReproductionHuman genome projectCloningAbortion

The NICU “technology imperative”“I can, therefore I do”“Use it or lose it”Learning how and when to say “No!”

Autonomy vs. Paternalism; Justice; Informed Consent

Ethics in the Prime of LifeEthics in the Prime of Life

Dialysis; plasmapharesis BMT for certain malignancies HIV/AIDs

Autonomy vs. Social Justice

Autonomy vs. Beneficence

Competing Autonomies (“Duty to Warn”)

Bioethical Issues in HIV/AIDSBioethical Issues in HIV/AIDS

Individual vs. Societypatient autonomy vs. social justice

Individual vs. Individualcompeting autonomies: patient vs. provider

End of Life/Medical Futilitybeneficence; nonmaleficence

Allocation of Resourcessocial justice

Ethics at the End of Life:Ethics at the End of Life:Refusing Life Sustaining TreatmentRefusing Life Sustaining Treatmentvs. Requesting Assistance in Dyingvs. Requesting Assistance in Dying

37 yo F Multiple Myeloma Failed Alkeran/Prednisone, VAD “I’m tired … fed up … ready to die” “No CPR, no antibiotics, let me die” “Keep me comfortable” When the time comes, (“help me die”)

The Principle of Double EffectThe Principle of Double Effect

Long history, primarily but not exclusively in Roman Catholic tradition

Supports claims that an act having a harmful effect such as death does not always fall under moral prohibitions such as the rule against killing

There is a morally relevant difference between the intended effects of a person’s action and the nonintended though forseen effects of the action

4 Conditions That Must Be 4 Conditions That Must Be Satisfied to Justify Double EffectSatisfied to Justify Double Effect The action itself must not be intrinsically

wrong The agent must intend only the good effect

and not the bad effect The bad effect must not be a means to the

end of bringing about the good effect The good result must outweigh the evil

permitted

Helping Patients Die with Dignity:Helping Patients Die with Dignity:A Continuum of Life/Death IssuesA Continuum of Life/Death Issues Withholding life support Withdrawing life support Physician assisted suicide Active euthanasia Gov’t & politics: lessons from history

Let History JudgeLet History Judge

The Tuskegee Syphilis Experiment “The Nazi Doctors”

ObjectivesObjectives

To understand the principles that guide every ethics case discussion and dissection.

To use case examples that describe clinical ethical issues at the beginning, in the prime, and at the end of life.

To underscore the ultimate importance of professionalism with lessons from history.