Dynamics of Care in Society

Ethical / Legal Issues in Health Care

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Objectives…

Recognize ethical issues and the moral implications of individual and collective decisions.

Analyze the fundamental question & implications of selected ethical issues in health care.

Propose & defend one’s own position & judgment in the analysis & deliberative resolution of ethical dilemmas.

…are mandatory to which all citizens must adhere or risk civil or criminal liability.

Laws

Contracts…are agreements between two or more parties.

Torts…are wrongful acts that do not involve a contract, a “civil wrong” a breach of legal duty.

You Be the Judge: Legal Components of Health Care

Term

1. Assault2. Battery3. False imprisonment4. Invasion of privacy5. Defamation of

character6. Negligence7. Malpractice8. Reporting Abuse9. Protecting Patients’

Rights10. Confidentiality and

HIPAA

Definition or Example

1. Threatening or attempting to touch a patient without their permission

2. A non-consenting patient is touched3. Any attempt to restrain or restrict a patient’s

freedom4. Intentionally & unreasonably exposes a

patient’s body or personal information without consent

5. Libel (written) or Slander (spoken) false or malicious statements about a person’s character

6. Careless or senseless behavior resulting in harm

7. Illegal, unethical, negligent, or immoral behavior. Results in failure of duties or responsibility

8. Mandatory9. Ex: Consent (informed and implied)10. Protection of patient’s personal health

information

(handout of this)

Ethics Unit - The Law

Abuse (physical, sexual, verbal or psychological) – any mistreatment of people who are unable to protect themselves must be reported by health care providers. Federal laws require the reporting of threats to a child’s mental or physical well-being.

Advocacy – supporting the best interests of all patients, and helping them to secure quality care.

Informed Consent –consent of a patient or other recipient of services based on the principles of autonomy and privacy; this has become the requirement at the center of morally valid decision making in health care and research.

Seven criteria define informed consent: (1) competence to understand and to decide, (2) voluntary decision making,(3) disclosure of material information, (4) recommendation of a plan, (5) comprehension of terms (3) and (4), (6) decision in favor of a plan, (7) authorization of the plan.

Implied Consent – the granting of permission for health care without a formal agreement between the patient and health care provider. 

An example is an appointment made with a physician by a patient with a physical complaint; it is implied that by making the appointment the patient gives consent to the physician to make a diagnosis and offer treatment.

Ethics…• A set of guidelines concerned with questions of right & wrong, of duty & obligation, of moral responsibility.

Morals

An individual’s own code for acceptable behavior involving traditions of belief.

They arise from an individual’s conscience

They act as a guide for individual behavior

They are Learned60 minutes Baby Lab (13 min) http://www.cbsnews.com/8301-18560_162-57551557/babies-help-unlock-the-origins-of-morality/

Bioethics…

• … the moral issues and problems that have arisen as a result of science, modern medicine and medical research.

• Issues in bioethics are often life-and-death issues!

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Comparing Law and Ethics

Law, ethics, and bioethics are different but related concepts.

Laws are mandatory to which all citizens must adhere or risk civil or criminal liability.

Ethics relate to morals and help us organize complex information and competing values and interests to formulate consistent and coherent decisions.

7 Ethical Principles

Autonomy/FreedomVeracity

Privacy/ConfidentialityBeneficence

NonmaleficenceFidelityJustice

1. AUTONOMY (self-determination)

• The right to participate in and decide on a course of action without undue influence. To act independently.

• Healthcare providers need to respect patient’s rights to make choices about healthcare, even if the healthcare providers do not agree with the patient’s decision.

• Ex: informed consent, treatment planning, AMA, AD

ETHICAL PRINCIPLES

Advanced Directives: An opportunity to state your wishes about yourhealth/medical care if you were in a medical situation with no hope for recovery. It includes two parts, you can do either or both….

1) a living will 2) naming a health care representative

* Being prepared for the final days - CBS News

2. BENEFICENCE (do good)

Requires the health professional to go beyond doing no harm

Actively contributing to the health and well being of the patients served.

Ex. In an emergency, when a patient is incapacitated, the health care worker assumes the person would want to be treated.

gives protection to a person who comes to the aid of an injured or ill person, from being sued for contributory negligence as long as the volunteer aid-giver acted with reasonable care.

This rule also aims to remove the fear of bystanders to attend an injured or ill person for fear of being sued for unintentional injury or wrongful death.

The main ingredients for successful invocation of the Good Samaritan doctrine are:(1) the care rendered was performed as the result of the emergency,(2) the initial emergency or injury was not caused by the person invoking the defense, and (3) the emergency care was not given in a grossly negligent or reckless manner.

Good Samaritan Rule

3. NONMALEFICENCE (do no harm)

Requires the health practitioner to first do no harm and to actively prevent harm when possible.

To protect individuals who are unable to protect themselves

Ex. An x-ray tech fails to provide safety precautions so a patient does not fall off the table.

(Read the Hippocratic Oath for physicians…)

4. JUSTICE (fairness)

The principle that deals with fairness, equity and equality and provides for an individual to claim that to which they are entitled.

Ex: equal access to services

5. VERACITY (honesty)

• The physician has a duty to tell the truth to the patient, without deceit.

• Veracity is an important component of building trusting relationships.

The only times this principle may be violated are:

If patients may indicate harm to themselves or othersIf the patient gives permission for the information to be shared

6. CONFIDENTIALITY

Respecting privileged knowledge.

Respecting the “self” of others.

Ex: HIPAA

Professional behavior…there is an appropriate time & place…

Suppose Dr. X is overheard discussing your personal medical information while at a social function…

How would you feel?What would you do?How would that affect your perception of

him/her as a professional?

HIPAA video clip privacy 2:13 min / security 1:40 min

Guidance Materials for ConsumersThe HIPAA Privacy Rule provides federal protections for individually identifiable health information held by covered entities and their business associates and gives patients an array of rights with respect to that information. At the same time,

the Privacy Rule is balanced so that it permits the disclosure of health information needed for patient care and other important purposes. 

7. FIDELITY

Strict observance of promises or duties.LoyaltyAccountability

Ex: The nurse tells the patient that she will come back to check on her. Even though she gets slammed by a heavy workload, she manages to squeeze in a few moments to visit the patient

Dying to Breathe

• What kind of criteria did each group consider in selecting lung recipients?

• How did they decide which criteria were most important?

• How do students feel about an age limit for transplant candidates?

• How might they differentiate between patients who have knowingly abused their bodies, such as cigarette smokers or alcoholics, and individuals who have not engaged in risky behavior?

• How should the ability to pay—through insurance, Medicaid, or personal funds—affect which patients are selected?

See Transplant Video on Dyn DVD

Absolute ContraindicationsAbsolute contraindications for adults and children include, but may not be limited to:Age appropriateness

65 years of age for single lung (must be evaluated before 63rd birthday)65 years of age for double lung transplant55 years of age for heart/lung transplantActive smoker (less than 6 months since quitting)Active substance abuseChronic mechanical ventilation (unless tolerating 3 hours of physical therapy/day and is free of bacterial colonization)Previous lung transplant (rare exceptions for John Hopkins Hospital primary transplant patients)Severe Diffuse Coronary artery disease (especially with poor EF)End-stage renal disease (creatinine clearance < 40 mg/min)End-stage liver diseaseBone marrow dysfunctionHIVSevere local or systemic infectionSevere neurologic deficitsUntreatable psychiatric continue next page

Lung Transplant Patient Selection Criteria (John Hopkins Transplant Center)Lung Transplant Patient Selection Criteria | Johns Hopkins Comprehensive Transplant Center

Lung Transplant Patient Selection Criteria (John Hopkins Transplant Center)

Relative ContraindicationsRelative contraindications for adults and children include, but may not be limited to:Morbid obesity (BMI>30)Severe malnutrition/cachexiaChronic prednisone use > 20 mg / daySymptomatic osteoporosisPsychiatric / social problems (including non-compliance)Financial problems (no prescription coverage)Previous thoracic surgery / procedureLack of family or social supportCancer in the last 5 years except localized skin (never melanoma)Colonization with resistant organisms

The American Disabilities Act

What the disabled have to say…

Ethical Decision Making Process

Describe the problemGather the factsClarify valuesNote reactionsIdentify ethical PrinciplesClarify legal rulesExplore options and alternativesDecide on a recommendationDevelop an action planEvaluate the plan

Ethical Decision-MakingRational & systematicBased on ethical principles, not emotions or intuitionServes patient’s best interestPreserves integrity of all involved

Situations necessitating a choice between two equal (often undesirable) alternatives.

Ethical Dilemma:A need to know the worst n

ews you will ever hear - CBS News 8 min

Selling Kidneys for Transplant 3 min

Ethical, Legal and Social Implications of Genetic Knowledge 1:30 minThen read / highlight article

Examples of ethical dilemmas…Genetic testing23andMe: Could mass DNA testing change health care? - CBS News 5 minStem cell researchCloningPhysician-assisted suicideDesigner babiesMandatory vaccinations or medications

Why call an Ethics Consult?Ethics Consult can help:

Discover and understand the issuesServes as a forum for sharing of concerns

and questionsIdentifies possible treatment alternativesProvides guidance to the staff, patient, and

family membersMultidisciplinary teamsResolves conflictsRequired by Joint Commission for all health

care institutions

Four Questions to always ask in an ethics analysis…

1. Ethical Questions: These are about what a person should do, how

people ought to interact, what sort of person one should be, and whatkind of communities it would be good to live in.

2. Relevant Facts: These are the biological, psychological, sociological,

economic, and historical facts you need for thinking carefully about the

ethical question and answering it.

3. Who or What Could Be Affected: The people and entities affected

by ethical decisions are considered stakeholders. Stakeholders are notalways human beings or human organizations; animals, plants,

organisms,or the environment might be affected by the way an ethical issueis decided, so they can also be stakeholders.

4. Relevant Ethical Considerations: These are particular concepts in

ethics that can help you analyze a case.

ACTIVITIES:

Pre quiz on patient rightsWhat type of question….ethical vs. legal, scientific, personal preferenceReview the following:

ADInformed Consent HIPAAPatient Bill of Rights x2PPT slides on Law, ethical decision making, 4 questions ethical analysis Case Studies

(Dying to breathe, consent, medical morals, vexing case no 1-6, others)Movie notesMajor ethical dilemmas in nursingChapter 11 wrap up

Ethics Project – Role Play

Ethics…A set of guidelines concerned with questions of right & wrong, of duty & obligation, of moral responsibility.

Ethical Dilemma…Situations necessitating a choice between two equal (often undesirable) alternatives.

7 Ethical Principles Autonomy ( _______________ ) Veracity ( _______________ ) Confidentiality ( _______________ ) Beneficence ( _______________ ) Non-maleficence ( _______________ ) Fidelity ( _______________ ) Justice ( _______________ )

Ethical Decision Making Process Describe the problem Gather the facts Identify ethical Principles Clarify legal rules Explore options and

alternatives Decide on a recommendation Develop an action plan Evaluate the plan

ETHICS IN HEALTH CARE HIGHLIGHTS