John E. Snyder

Evidence-Based Ethics:Introduction and Applications toMedicine and Public Health

Introduction History of medical ethics Key ethical principles Advance Directives Cases Applications to public health

Outline

A need for practical medical ethics education Recognizes omnipresence

of dilemmas Systematic approach Case-based Offers guidance Doesn’t define right/wrong Incorporates cultural

competence

Introduction

Oath of Hippocrates ~5 B.C. Respect for confidentiality Strict prohibition for

euthanasia Relationship boundaries with

patients Limitations in applicability to

modern world/medicine Oath of Maimonides

~1100 A.D.

H/O Medical Ethics in Super FF

First AMA Code of Ethics in 1847 Doctor’s Trial in Nuremburg in 1947

Nuremburg Code “Voluntary Consent” Good for society and not “random” Based on animals first Risk should be low, or include the scientists

Tuskegee Syphilis Study, 1932-1972 The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research IRBs Informed Consent

Beauchamp & Childress, 1979

H/O Medical Ethics in Super FF

The Principle of Beneficence The Principle of Non-Maleficence The Principle of Respect for Autonomy The Principle of Respect for Dignity* The Principle of Respect for Veracity* The Principle of Distributive Justice

* Snyder/Gauthier

Principles of Medical Bioethics

Medical practitioners should act in the best interests of the patient.

The Principle of Beneficence

Medical practitioners must not harm the patient.

The Principle of Non-Maleficence

Capable persons must be allowed to accept or refuse recommended medical interventions.

The Principle of Respect for Autonomy

Patients, their families, and surrogate decision makers, as well as their health care providers, all have the right to dignity.

The Principle of Respect for Dignity

The capable patient must be provided with the complete truth about her/his medical condition.

The Principle of Respect for Veracity

Health care resources should be distributed in a fair way among the members of society.

The Principle of Distributive Justice

Proposed approach of evidence-based medical ethics

Based on the tenets of evidence-based medicine (EBM), which: Aims to apply the best available evidence (gained from

rigorous application of the scientific method) to clinical decision making

Seeks to assess the strength of evidence of the risks and benefits of treatments (including lack of treatment) and diagnostic tests

Helps clinicians to learn whether or not any treatment will do more good than harm

Evidence-Based Medical Ethics

Evidence-Based Medical Ethics: Aims to apply the best available “evidence” gained from

EBM, widely accepted ethical principles, and legal precedent

Incorporates aspects of cultural competency and an evolving medical knowledge set/technology (we can/but should we?), and an evolving set of laws

Helps clinicians guide patients to make “good decisions” for themselves, particularly when options have potential to do both good and harm

Emphasizes that “right” and “wrong” decisions are personal choices of the patient and are acceptable if they are well-informed (it’s not about you)

Evidence-Based Medical Ethics

Some of the most difficult medical decisions are made when the patient themselves is unable to make them Includes how a patient’s life will end

Natural Death Act, 1976 (California) First time a state allowed citizens to make

their choices for end-of-life care known in advance

Physicians honoring this “directive” cannot be charged with criminal liability or unprofessional conduct

Led to development of the “Living Will” Later led to the “Power of Attorney for Health

Care” These two documents collectively make up

Advance Directives

Advance Directives

Legally executed document by a capable patient

Authorizes physicians to withhold or withdraw life-sustaining medical treatment when the patient, in the future, lacks the capacity to make health care decisions

In some states requires a “terminal condition”, but in others includes states like PVS

Can include decisions on “artificial nutrition and hydration”

Living Will

Legal document a capable patient uses to appoint a “health care agent” (HCA) Aka “representative”, “proxy”,

“surrogate” Rules vary greatly from state to state

That person will make decisions for the patient when they are no longer capable Includes employing/discharging providers Includes consent to admit/discharge from

facilities Includes ability to give, withdraw, or

withhold consent for diagnostic and therapeutic procedures

(Durable) Power of Attorney for Health Care

A patient’s wishes for end-of-life care, in particular, should be discussed in advance with the HCA… but often are not When not, often result in conflicts

between family members Sometimes wishes are discussed but not

legally documented When a patient’s wishes are not

documented, the HCA should act using one of two principles: “Substituted judgment” “Best interests standard”

(Durable) Power of Attorney for Health Care

Come into play when there are no ADs Laws vary to some degree by state with respect to “priority” status

of an individual to be a HCA on behalf of the patient Laws also vary state to state by what determines a “marriage” or

“family”

Surrogate Decision Makers

Breather!

John Doe, 50 year old AAM, found unresponsive in an alleyway by passersby Covered with blood

and dirt ? Homeless No identifying information Weak pulse, shallow

respirations

Case 1: When a Patient is Unidentifiable

In the field: Placed on a backboard, intubated,

and a hard cervical collar placed In the ED:

Fractures to the pelvis and bilateral femurs

Splenic and liver lacerations Collapsed left lung Large intracranial hemorrhage

(subdural hematoma) Police involved, fingerprinting

unrevealing

Case 1: When a Patient is Unidentifiable

Place/keep on a ventilator ?

Insert a PEG tube for nutrition?

Place an IV? A “central line”?

Transfuse blood? Take to the OR?

What do you do next?

How much do you do to help this patient?

How long do you wait before moving forward?

When do you stop efforts/where do you draw the line?

What do you do next?

In patients with CNS injuries, mechanical ventilation may be necessary to support life

Prolonged need for ventilation and placement of a tracheostomy may be observed

The goal of any patient on a ventilator is weaning

Study of 100 patients by Namen, et al.: GCS < 8: 33% success rate of

extubation GCS > 8: 75% success rate

The Medicine

X

Canterbury V. Spence [1972] 464 F 2d 772, U.S. Court of

Appeals, District of Columbia Circuit Legally-recognized exceptions to

Informed Consent:“… when a patient is unconscious or otherwise incapable of consenting, and harm from a failure to treat is imminent and outweighs any harm threatened by the proposed treatment”

The Law

The Principle of Beneficence The Principle of Non-Maleficence The Principle of Respect for

Autonomy The Principle of Respect for Dignity The Principle of Respect for Veracity The Principle of Distributive Justice

The Ethics

The Principle of Beneficence Injuries have been initially treated Immediate death has been prevented Life sustained until chances for recovery could be determined Pain was treated

The Principle of Non-Maleficence The Principle of Respect for Autonomy The Principle of Respect for Dignity The Principle of Respect for Veracity The Principle of Distributive Justice

The Ethics

The Principle of Beneficence The Principle of Non-Maleficence

Risks of interventions to date were weighed against benefits Further plan is being considered carefully with respect to this

principle Must consider a “line” to draw re: possible futility of efforts

The Principle of Respect for Autonomy The Principle of Respect for Dignity The Principle of Respect for Veracity The Principle of Distributive Justice

The Ethics

The Principle of Beneficence The Principle of Non-Maleficence The Principle of Respect for Autonomy

Does not apply here Patient cannot be identified Family cannot be contacted No “substituted judgment” can be made A legal guardian must be sought Must use “best interests standard” based on above two principles

▪ Take likelihood for recovery/improvement and contrast with pain/suffering and QOL may attain

▪ Will reasonable goals be met or will the end of life be artificially postponed? Are there aspects of culture that should be considered here?

The Principle of Respect for Dignity The Principle of Respect for Veracity The Principle of Distributive Justice

The Ethics

The Principle of Beneficence The Principle of Non-Maleficence The Principle of Respect for Autonomy The Principle of Respect for Dignity

Important as the patient is vulnerable and has no “voice” Must protect privacy and bodily integrity to greatest extent

possible Invasive life-sustaining measures should not be initiated

simply because the patient’s own wishes cannot be known The Principle of Respect for Veracity The Principle of Distributive Justice

The Ethics

The Principle of Beneficence The Principle of Non-Maleficence The Principle of Respect for Autonomy The Principle of Respect for Dignity The Principle of Respect for Veracity

The legal guardian must receive all possible and relevant information

Information must be presented clearly and without bias/leading

The Principle of Distributive Justice

The Ethics

The Principle of Beneficence The Principle of Non-Maleficence The Principle of Respect for Autonomy The Principle of Respect for Dignity The Principle of Respect for Veracity The Principle of Distributive Justice

Does not apply here Resources are not limited in this case*** Decisions to withdraw or withhold medical treatment

cannot be made because: ▪ Patient cannot be identified▪ Patient’s “societal value”

The Ethics

Delve further to assist in sound decision-making

} Review

Medical evidence Legal precedence Ethical principles

Decide Act Attempt to foresee/preempt

challenges

The Formulation

Breather!

Represented on the PHLS Public Health Code of Ethics Committee are public health professionals from: Local and state public health Academia The Centers for Disease Control

and Prevention (CDC) The American Public Health

Association (APHA) Guide is published on the APHA

website Has 12 guiding principles Has a different perspective

than medical bioethics

Public Health Ethics

1. Public health should address principally the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes.

2. Public health should achieve community health in a way that respects the rights of individuals in the community.

3. Public health policies, programs, and priorities should be developed and evaluated through processes that ensure an opportunity for input from community members.

4. Public health should advocate and work for the empowerment of disenfranchised community members, aiming to ensure that the basic resources and conditions necessary for health are accessible to all.

5. Public health should seek the information needed to implement effective policies and programs that protect and promote health.

6. Public health institutions should provide communities with the information they have that is needed for decisions on policies or programs and should obtain the community’s consent for their implementation.

Public Health Ethics

7. Public health institutions should act in a timely manner on the information they have within the resources and the mandate given to them by the public.

8. Public health programs and policies should incorporate a variety of approaches that anticipate and respect diverse values, beliefs, and cultures in the community.

9. Public health programs and policies should be implemented in a manner that most enhances the physical and social environment.

10. Public health institutions should protect the confidentiality of information that can bring harm to an individual or community if made public. Exceptions must be justified on the basis of the high likelihood of significant harm to the individual or others.

11. Public health institutions should ensure the professional competence of their employees.

12. Public health institutions and their employees should engage in collaborations and affiliations in ways that build the public’s trust and the institution’s effectiveness.

Public Health Ethics

Principles offer guidance but not answers

Principles should be considered when working on public health initiatives

Principles often need to be thought of in light of medical bioethics

Who “polices” this?

Public Health Ethics

Please stop talking Dad!

José M., 34 year old Latino male in NC Known HIV infection x5 years, not on

ART Had not seen an MD x2 years as is

uninsured Last known CD4+ count was 201/μL 2 months of cough, malaise, fevers,

15# weight loss Progressive shortness of breath,

weakness Encouraged to come in by partner of

4 years, Justin (HIV neg.)

Case 2: When a Partner is Excluded

In the ED: Fever High heart and respiratory rates Low oxygen saturation Chest x-ray suggestive of diffuse

pneumonia in both lungs Sputum examination indicates

presence of Pneumocystis jirovecii

CD4+ count reported now as 12/μL

Case 2: When a Partner is Excluded

Hospital course: Symptoms worsened Transferred to the ICU Developed acute respiratory

distress syndrome (ARDS) and progressive multi-system organ failure (MSOF)

Sedated and placed on mechanical ventilation

Had not completed a Living Will or HCPOA paperwork previously

Case 2: When a Partner is Excluded

Hospital course: José’s parents notified Although he had been in

close contact with his parents, José had never disclosed his S.O. or HIV status to them

Had never introduced them to Justin out of concern they would not be accepting

Case 2: When a Partner is Excluded

Hospital course: José’s father asks

“does my son have AIDS?”

José’s mother says “that man” (Justin) should not be allowed into the ICU room any more

Case 2: When a Partner is Excluded

How much information do you disclose to José’s family?

What decisions do they need to make now? What decisions might they need to make

soon? What rights does Justin have? Should José’s parents be told that Justin is

HIV negative? Can José’s parents make “good” medical

decisions for him? What cultural aspects are important in this

case? How does one best balance the principles of

beneficence, autonomy, non-maleficence, veracity, and dignity in this case?

What do you do next?

FIN