Ethics for Transfusion Ethics for Transfusion Medicine ResidentsMedicine Residents

Dr. Jerry GroweDr. Jerry GroweProf. Michael McDonaldProf. Michael McDonald

Stop and look around:Stop and look around:

there are Ethical matters of there are Ethical matters of concern in Transfusion concern in Transfusion practice.practice.

Part I. Part I. What is ethics?What is ethics? Ethics as the systematic study of human Ethics as the systematic study of human

conduct and moral judgement, including conduct and moral judgement, including good/bad, good/bad, right/wrongright/wrong virtue/vicevirtue/vice

Critical reflection on moral beliefs and Critical reflection on moral beliefs and practicespractices What are people’s moral beliefs?What are people’s moral beliefs? What choices should we make?What choices should we make?

Moral psychology (Rest)Moral psychology (Rest)

4 Components of Moral Behaviour4 Components of Moral Behaviour1.1. Ability to recognize a situation as having a moral Ability to recognize a situation as having a moral

componentcomponent2.2. Ability to make a judgement as to which action is Ability to make a judgement as to which action is

right, fair, just, appropriateright, fair, just, appropriate3.3. Commitment to morally appropriate actionCommitment to morally appropriate action4.4. Possession of appropriate personal qualities Possession of appropriate personal qualities

(perseverance, courage) to carry out morally (perseverance, courage) to carry out morally appropriate actionsappropriate actions

James RestJames Rest

Acquisition of moral valuesAcquisition of moral values

Many values are “caught” rather than Many values are “caught” rather than “taught”“taught” Importance of peers and workplaceImportance of peers and workplace Socialisation and acculturationSocialisation and acculturation Life experiencesLife experiences

Reflective engagementReflective engagement

Ethical judgementsEthical judgements

Centre on important valuesCentre on important values Based on reason, notBased on reason, not authority authority Override self-interest to assure mutual benefitOverride self-interest to assure mutual benefit Based on impartial considerationsBased on impartial considerations Special words and emotionsSpecial words and emotions ““All things considered judgements”All things considered judgements”

NotNot optional add-on judgements optional add-on judgements Integrative or holisticIntegrative or holistic

Learning objectivesLearning objectives Identify and discussIdentify and discuss

Some ethical issues in transfusion medicineSome ethical issues in transfusion medicine Methods for resolving ethical issuesMethods for resolving ethical issues

Offer resourcesOffer resources Ethical Issues in Transfusion Medicine; aabbEthical Issues in Transfusion Medicine; aabb

Ethical framework Ethical framework • http://http://www.ethics.ubc.ca/people/mcdonald/decisions.htmwww.ethics.ubc.ca/people/mcdonald/decisions.htm

Ethics lit search Ethics lit search • http://bioethics.georgetown.edu/http://bioethics.georgetown.edu/

EthicEthical judgements & principlesal judgements & principles

Ethical judgements involve a dual test:Ethical judgements involve a dual test: ““Are the means acceptable?” Are the means acceptable?” ANDAND ““Are the ends worthwhile?”Are the ends worthwhile?”

Consensus principles in bioethicsConsensus principles in bioethics Treat people with respectTreat people with respect Do no harm Do no harm Do good Do good Act fairlyAct fairly BeBe caring caring

Part 2. Ethics & TransfusionPart 2. Ethics & Transfusion

Clinical practice ethics centres on patient Clinical practice ethics centres on patient carecare

RequiresRequires Patient (or guardian) consentPatient (or guardian) consent Fairness to other patientsFairness to other patients

Within institutional parametersWithin institutional parameters Licensing, medical appointment, general Licensing, medical appointment, general

health care system authorisationhealth care system authorisation

Clinical Case #1Clinical Case #1

You received a phone call from a donor You received a phone call from a donor asking why a "Coombs" test, (DAT), or asking why a "Coombs" test, (DAT), or an HTLV test was done and reported an HTLV test was done and reported positive to her. Should the donor be positive to her. Should the donor be surprised? Did the donor truly give surprised? Did the donor truly give informed consent to the test?informed consent to the test?

Clinical case 2Clinical case 2

The Special Services Nurse has brought cases to The Special Services Nurse has brought cases to you on several occasions as he has wondered you on several occasions as he has wondered about your colleague's interpretation of the about your colleague's interpretation of the medical data, and the acceptance of the medical data, and the acceptance of the donors involved. You also have been informed donors involved. You also have been informed through the grapevine that he frequently is through the grapevine that he frequently is unavailable by pager when on call and, as a unavailable by pager when on call and, as a result, three plateletpheresis donors have been result, three plateletpheresis donors have been disqualified. What should you do?disqualified. What should you do?

How does CBS manage the How does CBS manage the Altruistic Gift of Blood?Altruistic Gift of Blood?

Obligations of the CBS:Obligations of the CBS: Not to harm the donorNot to harm the donor To use the donation appropriatelyTo use the donation appropriately To ensure privacy and confidentialityTo ensure privacy and confidentiality

Obligations of the Donor:Obligations of the Donor: To answer all questions truthfullyTo answer all questions truthfully Not donate if engaged in any risky activitiesNot donate if engaged in any risky activities

Research ethics basicsResearch ethics basics Research involving humans is a privilege, not a Research involving humans is a privilege, not a

right!right! Those who conduct research involving humans Those who conduct research involving humans

must meet norms for ethical researchmust meet norms for ethical research The The onusonus is on those who conduct, house or is on those who conduct, house or

sponsor research to sponsor research to showshow these norms are met. these norms are met.

Three Three centralcentral questions questions

1.1. Does the research meet relevant Does the research meet relevant scholarlyscholarly/scientific/scientific standards? standards?

• Bad science is bad ethicsBad science is bad ethics• Is the science honestly done and accurately reported?Is the science honestly done and accurately reported?

2.2. Will the likely net benefits of the research will Will the likely net benefits of the research will outweigh overall harms?outweigh overall harms?

3.3. Does the research respect the rights of the Does the research respect the rights of the research subject, including research subject, including

• PProtection from undue harmrotection from undue harm & &• IInformed consent?nformed consent?

Norms for clinical researchNorms for clinical research

1.1. Socially valuable researchSocially valuable research2.2. Scientifically sound researchScientifically sound research3.3. Fair subject selectionFair subject selection4.4. Favourable risk-benefit ratioFavourable risk-benefit ratio5.5. Independent review by an REBIndependent review by an REB6.6. Informed consentInformed consent7.7. Respect for actual and potential research subjects Respect for actual and potential research subjects

in the conduct of research in the conduct of research Emmanuel et al. JAMA 2000Emmanuel et al. JAMA 2000

CBS REBCBS REB

RESEARCH REGISTRATIONRESEARCH REGISTRATION RESEARCH ETHICS BOARD RESEARCH ETHICS BOARD

APPLICATIONAPPLICATION GUIDANCE DOCUMENTGUIDANCE DOCUMENT

Research caseResearch case A physician-researcher you know at the A physician-researcher you know at the

provincial cancer agency asks that you provide provincial cancer agency asks that you provide her with left-over blood from routine medical her with left-over blood from routine medical tests of patients with a certain type of tumour in tests of patients with a certain type of tumour in order to test a research hypothesis she has order to test a research hypothesis she has about tumour growth. She also asks that you do about tumour growth. She also asks that you do a chart review of these patients. She offers you a chart review of these patients. She offers you co-authorship on the resulting publication. What co-authorship on the resulting publication. What should you do? Are there are any special rules should you do? Are there are any special rules and procedures to follow with the use of blood and procedures to follow with the use of blood for research purposes? for research purposes?

Blood Contingency Planning in BCBlood Contingency Planning in BC

To ensure a consistent and coordinated To ensure a consistent and coordinated approach to blood shortages.approach to blood shortages.

Guidelines activated at Red Alert phase.Guidelines activated at Red Alert phase.

PBCO and CBS will coordinate.PBCO and CBS will coordinate.

Principles from BC PlanPrinciples from BC Plan All patients in BC should have equal access to the available blood All patients in BC should have equal access to the available blood

on the basis of need. No hospital should stockpile blood for “its” on the basis of need. No hospital should stockpile blood for “its” patients.patients.

When available resources are exceeded, the focus should shift from When available resources are exceeded, the focus should shift from doing the best for the individual patient to the public health goal of doing the best for the individual patient to the public health goal of doing the greatest good for the greatest number.doing the greatest good for the greatest number.

May include suspension of prophylactic transfusions and elective May include suspension of prophylactic transfusions and elective procedures and cessation of transfusion support in terminal or moribund procedures and cessation of transfusion support in terminal or moribund patientspatients

Blood inventory transparency is essential in a shortage. Decision-Blood inventory transparency is essential in a shortage. Decision-makers need to know what inventory is available in the province, makers need to know what inventory is available in the province, regardless of whether it is at CBS or hospitals.regardless of whether it is at CBS or hospitals.

Assumptions from BC PlanAssumptions from BC Plan

The supply of blood is insufficient to meet current or The supply of blood is insufficient to meet current or anticipated demand, despite ongoing efforts to increase anticipated demand, despite ongoing efforts to increase the available supply.the available supply.

Hospitals and CBS will share inventory information.Hospitals and CBS will share inventory information. During a blood shortage, blood use will be triaged to During a blood shortage, blood use will be triaged to

ensure the most urgent cases receive the available ensure the most urgent cases receive the available supply.supply.

Measures to ensure appropriate blood use and reduce Measures to ensure appropriate blood use and reduce waste during non-shortages contribute significantly to waste during non-shortages contribute significantly to blood contingency preparedness.blood contingency preparedness.

Further Points to ConsiderFurther Points to Consider Guidelines for “stopping principles”Guidelines for “stopping principles” How to operationalize guidelinesHow to operationalize guidelines

Under what circumstances will guidelines come into Under what circumstances will guidelines come into effect?effect?

What is the decision-making process?What is the decision-making process? Who will make decisions?Who will make decisions? How will process and decisions be communicated?How will process and decisions be communicated?

• To attending physicians, staff, familiesTo attending physicians, staff, families How will process and decisions be documented?How will process and decisions be documented?