THE PHYSICIAN

P. Of reciprocity

GOLDEN RULE

ConscienceDefinition is the inner voice that tells what to do and not do and subsequently judges our action.Doing things without qualms of conscience does not speak well of the individual. E.g. konsensyang Filipino.But this is better than not having a conscience at all even it was only qualms of conscience. In the native tongue without a conscience is walang budhi.Walang budhi morally insensitive person who is not even bothered by IMMORAL AND INHUMAN ACTIONS.

Biblical themesSt. Paul calls it spiritual function which is personal and spontaneous reaction. 2Cor (5:11)(Rom 2:14) a universal endowment of men. A witness by which one can point to the substance of the law engraved in ones heart by which one accuses and defends oneself. --- ones own inner mental dialogue.CONSCIENCE is a response to Gods law, though it involves individual response.

Veritatis SplendorPope John Paul 11 reaffirmed the biblical fact that all persons are endowed with a conscience and that conscience is witness to the individuals desire, thoughts, plans decisions, and actions. Ethical reflections- conscience is considered in the broad sense as a moral faculty that makes known to each person his or her moral obligations and urges him or her to fulfill them.

Conscience, Filipino styleConscience is the other self , deep thought that might not appeal to the Western world. Other considerations are the budhi, kalooban, , hiya, kabutihan,utang na loob. These are thoughts that might bother the Filipinos especially in the terminally ill patients.Dilemma regarding the use of contraception and poverty, almost desperate concern for her family.

Factors, Filipino conscience

Authority, (Parents, priests), academic mentors, They matter a lot in the decision for appropriateness or inappropriateness. Also in health care, the Physicians, kayo na ho ang bahala.

Conflicts

Family and Catholic interplay in their decisions in CONTRAST Profit-oriented culture invading the Filipino Physicians = CONCERN for Physicians and nurses.COOPERATION, formal and material.

Conscience of the PhysicianQuestions a Physician should answer to help him find his conscience in the practice of Medicine, (Greg F. Burke, F.A.C.P. Department of General Internal Medicine, Gelsinger Medical Center, Danville, Pennsylvnia)1. Have I been neglectful in my responsibility to be available within reason to my patients when needed?2. Have I been disrespectful to or humiliated others in my practice, including colleagues, support staff, or patients?3. Have I been dishonest in the filing of insurance claims or billings?4. Have I sincerely made all efforts to stay current with medical science and the literature to remain competent in my field?5. Have I recommended abortion, artificial contraception or sterilization to my patients?

Conscience and the Physician6. Have I prescribed illicit birth control methods?7. Have I participated in physician assisted suicide or failed to appropriately recommend life-sustaining treatments for those not terminally ill?8. Have I maintained a sense of modesty and chastity in my medical practice?9. Am I willing to offer services without consideration of economic benefit or personal gain?

Conscience and the Physician10. Do I pray for my patients?11.Do I avoid scurrilous conversations and refrain from bad humor?12. Do I give good example of Christian life to all I meet professionally?13. Have I recommended illicit forms of fertility treatment such as artificial insemination, in vitro-fertilization, or surrogate motherhood?

Conscience and the Physician14. Have I shown due respect for my own body in order to give good example to my patients?15. Have I been addicted to drugs or alcohol?16. Have I harmed a patient through negligence due to sloth (laziness), pride (lack of appropriate consultation), or lack of temperance (impairment due to the use of illicit drugs or alcohol?17. Have I allowed the inappropriate influence of pharmaceutical companies or other business institutions to compromise my medical judgment?

Conscience and the Physician19. Have I inappropriately acquired gifts or financial rewards in my medical practice.?20. Have I made myself available to all seeking my care including those with addictive disorders, human immunodeficiency virus, and those with financial constraint.?21. Am I ashamed of my Catholic identity or have I failed to defend Jesus name and His Church publicly.?

Chito g. Moreno

In the Vineyard of the LORD by Marco BardazziThe Life, Faith and Teachings of JOSEPH RATZINGER, POPE BENEDICT XVI

Cardinal Joseph Ratzinger (Pope Benedict XVI)Abortion 1987 Any legalization of abortion implies the idea that force is what founds law and thus mostly unaware, the very foundations of any authentic democracy, based on the justice system, are undermined People thus become blind to the a. right of the other, b. of the small and the weak, c. of the voiceless. The rights of the others should not be affirmed by the loss of the fundamental right to life of the other person.(The right to life and Europe Conference, Aula Magna Augustinianum,Rome 19 December 1987 (fromObservatore Romano)

In His Own WordsCLONING 1997- To fabricate man and make him a product of our chemical arts or any other technology is a fundamental attack on the dignity of man, who is no longer considered, no longer realized as an immediate creature of God and his immortal vocation (Through cloning, the human person) becomes our product, a product of our art; thus his dignity as a human person is violated from the start. Vatican Radio, interview with Cardinal Ratzinger (from ANSA, 7 March 1997)

Crisis of Culture (2005)The true contrariety that characterizes the world of today is not among diverse religious cultures, but rather between the radical emancipation of man from GOD, from the roots of life, on the one hand and the great religious cultures on the other hand. This culture will forever coEXIST but it is the conflict between this emancipation of man and the great historic cultures.Conference held 1 April 2005, at the Saint Scholastica Monastery, Subiaco

Families, Domestic Partners, Gays (2004)Families & marriage threatened by eroding the indissolubility through easier forms of divorce by means of new and more widespread lifestyle, cohabitation of man and woman w/o the juridical form of marriage.Request for communion of life between homosexuals, who demand a juridical form having the same value as marriage. Question of a human person, man & a woman can be given a juridical form. Lectio magistralis on Spiritual Roots of Europe, Sala Capitolare. 13 May 2004 (Archive of Italian Senate)

FAITH (1993)

FAITH is the hearts obedience to the form of teaching to which we have been consigned.Conference of Cardinal Ratzinger, in Florence Italy

FREEDOMDefinition- in order to be true, human freedom, freedom in truth needs communion. Cannot be an isolated freedom, a freedom only for the I would be a lie, and would destroy human communion. Communion with TRUTH itself, with CHRIST, w/ the Trinitarian God. This is the community that creates freedom and gives JOY.

Subject Matter1. Human life and its relationship to others, 2. Physician - Patient relationship, 2.a Rights & duties of the Physicians, 2.b. Rights & duties of the patients,2.c Truth telling & the professional secrecy, 2.d. Well-informed consent, proxy consent, 2.e. interview & communication, 2.f. Honoria

Subject Matter

3. Physician & Society, 3.a. Human rights & social justice, 3.b. Health & culture, 3.c. Allocation of scarce resources, 3.d. Dumping of drugs.

Subject Matter4. Other relationships, 4.a. Physician to Physician, 4.b. Physician to nurses, 4.c. Physician student relationship, 5. Physician & Bioethics committee, 6. Human experimentation & research, 7. Mental health therapies, drugs, behavior, 8. Health care ministry & spirituality.

Ethics

NORMATIVE What is morally right, wrong, good or evil, proper & inappropriate. METAETHICS a. analyze nature of moral judgments, b. specifying appropriate methods for the justification of particular moral judgment & theoretical system.

Virtues, necessaryIf the end is a healing relationship, these virtues are required if that end has to be attained:

1. Fidelity to Trust & Promise- entailed in the ineradicability of trust in the patient-nurse or patient-physician relationship, the invitation of the professional to trust when the relationship is initiated, the importance of trust in healing, and the fact that, ultimately , the patient has no choice but to trust the professional.

Virtues, necessary2. Benevolence The virtue intends the good of the patient. It is a sine qua non since the patient obviously seeks to be helped not harmed. Intending every act to be in the patients interest is the gold standard of medical ethics.3. Effacement of Self-interest - Given the exploitability & vulnerability of patients, a certain degree of self-effacement is entailed since without it the patient can become merely the means to advance the physicians power, prestige, profit or pleasure. In these days of managed and for profit care, the need for effacement of self-interest is urgent if the patient is to be protected against exploitation.

Virtue, necessary4. Compassion and Caring If the patient is to be healed in the fullest sense, the physician or nurse must have compassion i.e. the health professional must be able to feel something of the patients experience of the predicament of illness. Such feelings are essential to adjusting the treatment to the particularities of this patients life story, time of life, and so forth. Compassion is the prelude to care to concern, empathy, and consideration to the patients plight. On this view, caring in its several meanings (cf Pellegrino 1985) is more on the realm of virtue ethics than being an ethical theory of its own.

Virtues, necessary

5. Intellectual Honesty By virtue of the trust that health professionals enjoy and the power of knowledge and skill they exercise, physicians and nurses can be agents of great harm as well as great good. Acknowledging when one does not know something and being humble enough to admit ignorance is a virtue of healing. Knowing when to say I do not know is a virtue counseled by sources as different as the Babylonian Talmud and Galileo.

Virtues, necessary

6. Justice In the healing relationship per se, the virtue of commutative justice is implicit throughout. Commutative justice dictates that in interpersonal relationships what is owed to each is rendered to each and equals are treated equally. Taken as a principle, justice is blindfolded and applied strictly. By removing the blindfold & adjusting what is owed to the specific ends of the patient , even if those needs do not fit the definition of what is strictly owed.

Virtues, necessary7. Prudence Practical wisdom, the virtue of deliberation & discernment was central to Aristotle virtue theory as phronesis to Aquinas as prudence. It is equally central to any theory of virtue in the health professions since all clinical decision of note requires prudent weighing of the alternatives institutions of uncertainty and stress. These are the minimum seven virtues, they can be supplemented but they might only be variants.

Relevance for todays physiciansFIRST- human condition as far as the illnesses & pain are concerned has not changes in the last millenia, blindness & crippling diseases were common then as now. A copycut of the great HEALER, JESUS. SECOND Jesus healed miraculously conveying the message, that spiritual healing was as necessary to gain the kingdom of heaven as was physical healing to function on earth.

Relevance

THIRD Christ downplayed his healing & this modesty might be a good advise for todays physician following therapeutic success.FINALLY- we must be compassionate, empathetic toward the illnesses & suffering of our patients, frequently recorded the touching that mediated Jesuss cures

HierarchyANIMALSSENSITIVE

Aristotle, beings

Human being Rational animalPolitical animal a being who needs company of others, e.g. parents, humans cannot be fully developed without language & language is a cultural social creation.

Rationality1. Ability to FORMULATE appropriate goals especially long term in nature, 2. Ability to ESTABLISH its priorities, 3. UTILIZE best means to achieve a chosen GOAL, 4. ACT effectively to realize the GOAL, 5. Can either ABANDON chosen goals or MODIFY, them if consequences of every available means are undesirable or inadequate.

Ethics, utilitarian

ACT (situation ethics) person ought to act so as to produce greatest balance of GOOD over evil, with everyone considered.Ethical Egoism- person acts so as to produce the greatest balance of GOOD over evil for oneself

Ethics, utilitarianACT- 1. act to produce balance between GOOD over evil, everyone considered, 2. single staged unrestrained or unrestricted.RULE 1. Act accordingly to a rule that if generally followed could produce the greatest balance between GOOD over evil, 2. based on accepted moral values, (restricted).

Kantian Deontology 1724 -1804

First Formulation GOLDEN RULE

Second Formulation Treat Humanity as a MEANS but always at the same time as an END.

W.D. Rosss Prima Fascie duties

Which is more or less incumbent on me according to the circumstances of the case, considered decisions or to which compelling PRIMA FASCIE duty has the priority on a given situation.

Prima Fascie duties1. Duties of fidelity, e.g. as a doctor, teacher, arises out of explicit & implicit agreement a person enters while functioning in a professional capacity, 2. reparation, 3. Gratitude, 4. Beneficence, 5. Nonmaleficence, 6. Justice, 7. Self-improvement.

Liberty limiting principle1. Harm principle justifiably restraining a person from inflicting harm to others, 2. Offending principle, 3. Paternalism prevent person to harm himself, 4. Legal moralism restricted to prevent person from acting morally, 5. Social welfare principle for the benefit of others, e.g. medical missions, serving in the clinical division.

Mesopotamia & Egypt (medicine)HAMMURABI King of Babylon 2,000 B.C. Initiated Code of Laws for the practice of Medicine 500 years before 10 commandments, He sets the FEES (origin of professional fees) now Honoraria, according to a. social status of the patient, b. and sets punishment for the poor performance of the physicians.

HISTORY, Egyptian papyri (16th century, B.C.)Priest-Physician relationship (Paternalism), 1. Outlines the diagnosis, 2. Making decisions to treat and if , (Judicium difficile)3. What to treat, If the physician followed the tradition healing & patient dies (non-culpable), If tried non-traditional & patient DIES, M.D. dies with the patient. (Deus autem, habet potestatem vita et mortis)

What is a physician ?Disposition ordered in accord with that righteousness, Aristotle & St. Thomas Aquinas considered essential to virtue. Medicine is itself ultimately an exercise of practical wisdom and a right way of acting in different & uncertain circumstances fro an specific end.

PHYSICIANS confronted with?It is not necessarily IMMORAL but not consistent with the higher levels of moral sensitivity that VIRTUE ethics demand: a. practice involving opportunities for profit from the illness of others, b. narrowing concept of SERVICE for personal convenience, c. proprietary attitudes towards medical knowledge, d. pricing loyalty to profession above loyalty to patient.

Ethical Principles in health careRELATIONSHIPS 1. Do no harm (Primum non nocere), extend to do GOOD weighs benefits from harm, 2. JUSTICE- give everyone its due, fairness, what he deserves, entitled against injustice, wrongful act, , omission, denies people benefits due them, a. distributive - equitable, appropriate distributions, b. criminal, c. rectification just compensation, d. material justice, to each person, equal share, according to need, effort or contribution.

Ethical principles (3 & 4)

3. RESPECT for persons, treating them as ends and not only as means. Allowing self governance (autonomy),

4. SOLIDARITY brother as in one family.

PHYSICIAN to patient relationshipPHYSICIAN- duty to provide care;PATIENT right to seek care.

PHYSICIAN counselor advises about health issues BUT the decisions are not made by him alone, (paternalism autonomy).

PHYSICIAN -PATIENTSUBJECTIVE

OBJECTIVE

ASSESSMENT

TREATMENTSupplies DATA, objective

DONE by physician

Decision both (physician +patient) well-informed consent, autonomy, paternalism.

Physician & Patient relationship(1)(Childress & Siegler) (5) metaphors: 1. PATERNALISM Relationship between parent to child, 2. PARTNERSHIP both parties collaborating, sharing the same goals, patients beneficence, 3. CONTRACTUAL , 4. FRIENDSHIP, & 5. TECHNICAL ASSISTANCE.

Paternal-Parental, priest-penitent (2) by T. Szasz, M. Kollender

A. Parent infant, e.g. anesthesia, coma, acute trauma, delirium, B. Parent adolescent guiding, advising or suggesting what to do, to EXPECT from the patient in return, e.g. patient with infection, may or may not take the medications.

PATERNALISMCARE

NEEDS

PHYSICIANS discretionRESPECT

RIGHTS

AUTONOMY or self discretion

PARTNERSHIP

(Eric Cassells) autonomy for the sick person cannot exist OUTSIDE of a good and properly functioning Physician patient relationship.

Szasz & Hollender (adult to adult) equality, mutually interdependent , activities satisfying to both.

CONTRACTUAL (3), FRIENDSHIP (4)(Robert Veatch) CONTRACTUAL1. emphasis on equality & autonomy, 2. May neglect virtues of benevolence, care, & compassion. (P. Lain Entralgo) FRIENDSHIP man is a part of nature & health as aspect of this nature & objective good medical relationship develops into comradeship.

FRIENDSHIP (4) & TECHNICIAN (5) (Charles Fried) FRIENDSHIP - medical phillia, equality, autonomy & rights of both parties, the friend and the befriended. (Kant ) union of 2 persons through equal, mutual love, & respect w/ some paternalism (love & care), antipaternalism, (equality & respect.) TECHNICIAN rise of scientific medicine, physician is the expert engineer of the body as a machine.

Deita & DecorumDEITA helps the sick according to my ability & judgment but never in a view of injury & wrongdoing. Regimen of conducting a whole life.DECORUM to do everything for the beneficence of the patient with clarification and serenity but w/o informing of the true nature of the disease.

HIPPOCRATESGREEK m.d. 460 B.C.maybe 85, 90 or 104 yrs oldPYTHGOREAN transcribed the oath. EXCERPTS- I swear by Apollo, Physician, Asclepius , Hygeia & Panaceia & all the gods & goddesses, making them my witnesses, that I will fulfill according to my ability & judgment this OATH & covenant. Restatement 1995 A.D. EXCERPTS I swear in the presence of the ALMIGHTY, and before my family, my teachers and my peers that according to my ability & judgment I will keep this OATH & stipulation.

HIPPOCRATIC OATHTo hold him who has taught me this art as equal to my parents & to live my life in partnership w/ him, and if he is in need of money to give a share of mine , and to regard his offspring as equal to my male lineage and to teach him this art if they so desire to learn w/o fee or covenant ; to give a share of precepts & oral instructions and all the other learning to my sons and to the sons of him.To reckon all who, have taught me this art equally dear to me as my parents and in the same spirit and dedication to impart knowledge of the art of medicine to others. I will continue w/ diligence to keep abreast of advances in medicine . I will treat w/o exception all who seek my ministrations, so long as the treatment of others are not compromised thereby, & I will seek the counsel of particularly skilled physicians where indicated for the benefit of my patient.

HIPPOCRATIC OATHI will apply dietetic measures for the benefit of the sick, according to my ability & judgment. I will keep them from harm & injustice (beneficence & solidarity). I will neither give any deadly drug to anyone even if asked for it, nor will I make any suggestion to this effect, (euthanasia) Whatever houses I will visit, I will come for the benefit of the sick, remaining free from any intentional injustice, of all mischiefs & in particular sexual relationships w/ both female & males whether slaves or free.I will follow that method of treatment which according to my ability & judgment. I consider for the benefit of my patient and ABSTAIN for whatever is harmful & mischievous (beneficence) I will neither prescribe nor administer a lethal dose of medicine to any patient even if asked nor counsel any such thing nor perform act or omission with direct intent deliberately to end a human life. (euthanasia) I will maintain the utmost respect for every human life from fertilization to natural death & reject abortion that deliberately takes a unique human life.

Hippocratic OathWith purity, holiness & beneficence I will pass my life & practice my art. Except for the prudent correction of an imminent danger, I will neither treat any patient or carry out any research on any human being without the valid consent of the subject or the appropriated legal protector thereof, understanding that research must have its own purpose the furtherance of the health of that individual. Into whatever patient setting I enter, I will go for the benefit of the SICK & will abstain from every voluntary act of mischief or corruption & further from the seduction of any patient.

Hippocratic oath,What I may see or hear in the course of the treatment or outside in regard to the life of men, which on no account one must SPREAD abroad, I will keep to myself holding these things shameful to be spoken about. (P. privacy) If I fulfill this OATH& do not violate it, may it be granted to me to enjoy life & art being honored among men of all time to come BUT if I transgress it & swear falsely, may the opposite of this be my lot. Whatever in connection with my professional practice or not in connection with it I may SEE or HEAR in the lives of my patients which ought not to be spoken abroad I will not divulge, reckoning that all such be kept a secret. While I continue to keep this Oath unviolated may it be granted to me to enjoy life & the practice of the art & science of medicine with the blessings of the Almighty and respected by my peers and society, but should I trespass and violate this Oath, may the reverse be my lot.

Oath of MaimonidesThe eternal providence has appointed me to watch over the life and health of thy creatures.May the love of my art actuate me at all times: may neither avarice nor miserliness nor thirst for glory or for a great reputation engage my mind : for the enemies of truth and philanthropy could easily deceive and make me forgetful of my lofty aim in doing good to my children. May I never see in the patient anything but a fellow creature in pain.

Oath of Maimonides

Grant me the strength, time opportunity always to correct what I have acquired, always extend its domain, for knowledge is immense and the spirit of man can extend indefinitely to enrich itself daily with new requirements.

Oath of Maimonides

Today he can discover the errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today. Oh God Thou has appointed me to watch over the life and death of thy creatures: here I am ready for my vocation and now I turn unto my calling.

Quotations of Maimonides

Teach your tongue to say I do not know and you will progress.The risk of a wrong decision is preferable to the terror of indecision. You must accept the truth from whatever source it comes. We are obligated to be more scrupulous in fulfilling the commandment of charity than any other positive commandment because charity is the sign of a righteous man.

Quotes from MaimonidesAnticipate charity by preventing poverty, assist the reduced man either by a considerate gift or a sum of money, or by teaching him a trade or putting him in the way of business so that he may earn an honest livelihood and not to be forced to the dreadful alternative of holding out his hand for charity. This is the highest step and the summit of charitys golden ladder.

Chito g. Moreno

Epistle of Love, Apostolic letter of John Paul llResponse to Tertio Millenio Adveniente

Lumen Christi, True God & True Man You shall love the Lord your God,with all your heart, with all your soul, with all your mind, with all your strength, and you shall love your neighbor as yourself.

The Promise of a Christian Doctor(1)

1. To IMPROVE my professional abilities continually in order to give my patient the best care I can, 2. To RESPECT my patients, putting their interest ahead of political, and economic considerations and treat them without prejudice arising from religious, racial, ethnic, socio-economic or sexual differences.

Promise of a Christian Doctor (2)

3. To DEFEND and protect life from conception to its natural end, believing that human life, transmitted by parents, is CREATED by GOD and has an eternal destiny that belongs to HIM. 4. To REFUSE to become an instrument of violent or oppressive applications of medicine.

The promise of a Christian Doctor(3)5. To SERVE the public health, promoting health policies respectful of life and of the dignity and nature of the human person.6. To COOPERATE application of just law does not respect human rights especially the right to life. 7. To WORK with openness towards every person, independently of their religious beliefs. 8. To DONATE part of my time towards free and charitable care of the poor.

To achieve the goal

1. To RECOGNIZE the word of God as the inspiration of all my actions, to be faithful to all teachings of the Church, and to form my professional conscience in accord with them. 2. To CULTIVATE a filial relationship with God, nourished by prayer, and to be a faithful witness of Christ.

Goals3. To PRACTICE Catholic moral principles, in particular those related to biomedical ethics. 4. To EXPRESS the benevolence of Christ in my life, and in my relationship with patients, colleagues and society. 5. To PARTICIPATE in evangelization of the suffering world , in cooperation with the pastoral ministry of the Church.

Euthanasia, def. types

Senator Hubert Humprey- a society will be judged how it treats those in the DAWN of life, those in the TWILIGHT of life & those in the SHADOW of life.

Euthanasia, defDefinition- means any action committed or omitted for the purpose of causing or hastening the death of a human being after birth allegedly for the purpose of ending the persons suffering. Vaticans declaration in other words By euthanasia is understood an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated.

Physicians right to refuse

1.CAN Refuse a specific intervention or management if it does not conform to his good judgment, 2. MUST be guided by medical standards, 3.If he DISAGREES with the intervention based on his acceptable morality transfer may be affected to another equally competent colleague.

Physicians right to refuse4. He is free to CHOOSE whom he wish to serve, he may refuse calls for reasons satisfactory to his professional conscience, HOWEVER in emergency he must respond and give the measures necessary, 5. SHOULD give first aid then accordingly refer to a more competent qualified colleague for more appropriate management.

Other duties, M.D.GENERIC 1. Must EXERCISE in good faith and strict honesty in expressing his opinion as to the diagnosis, prognosis, treatment of the case, 2. He should in all confidentiality SAFEGUARD the trust given by the patient that he may discover even after death.

Physicians duties, W.D. Ross Theory of prima fascie more or less incumbent on me according to the circumstances of the case. E.g. do the best under the situation.OTHER DUTIES fidelity, reparation, gratitude, beneficence, nonmalbeneficence, justice or self improvement, solidarity

Physicians duties, Howard Brody

1. May tell truth, but may suddenly dash the hope of the patient, e.g. partial disclosure, 2. HOPE- this is so resilient that it might be more important to the patient than survival, 3. DEATH may even be painless for the loved ones if they knew ???

Chito g. Moreno

Patients Rights Act 199510th Congress of the Republic of the Philippines (first regular session Senate S.B. no 676)

Patients rights actSection 1. short title this act shall be known as Patients Act of 1995. Section 2. Declaration of Policy The Philippine constitution, in section 1 Article XIII states that Congress shall give the highest priority to the enactment of measures that protect and enhance the right of all people to human dignity. Towards this end it is hereby declared the policy of the state to ENSURE, and PROTECT the rights of the patients to decent, humane, quality health care.

Rights to medical care & treatmentPATIENTS IN EMERGENCY- who are in danger of dying and /or who may have suffered serious physical injuries shall be EXTENDED immediate medical care and treatment without any deposit, pledge, mortgage or any form of advance payment for confinement or treatment.

Patients rights1. Rights to medical care & treatment,2. Right to informed consent,3. Right to privacy,4. Right to information,5. Right to privileged communication,6. Right to choose physician, 7. Right to self determination, 8. Right to religious beliefs, 9. Right to medical records,

Patients rights10. Right to leave, 11. Right to participate in medical research, 12. Right to correspondence & to receive visitors, 13. Right to express grievances, 14. Right to be informed of his rights & obligations as a patient, 15. Rights & obligations of the institutions.

Right to medical careHas the right to health & medical care of good quality. In this connection his human dignity , conviction & integrity shall be respected. If any person cannot immediately be given treatment medically necessary, he SHALL depending on his state of health be directed to a. WAIT, b. referred, c. or be sent elsewhere where appropriate management can be instituted, d. and if he has to wait to be given the reason for such and the estimated waiting time.

Right to informed consentHas a right to CLEAR explanation, in laymans terms, of all proposed procedure whether diagnostic, or therapeutic, including the identity of the person who going to do the procedure, possibilities of any risk of mortality or serious side effects, problems related to recuperation, and probability of success, and he will not be subjected to any procedure without his informed consent, PROVIDED in cases of emergency, is unconscious, cannot give consent, and there is no one who can give consent then the physician, according to his judgment & ability may perform any procedure deemed necessary for the beneficence of the patient, PROVIDED that when the law makes it compulsory for everyone to submit to a procedure, a consent is not necessary.

Right to informed consent

Informed consent shall be obtained from the patient if, a. he is of legal age, 2. a. and of sound mind, b. from next of kin in case the patient is incapable to give consent c. or from the parents or legal guardian in the case of a minor or a mentally incapacitated individual.

2. Right to informed consentPROVIDED: a. That parents or legal guardian refuse to give consent to a medical or surgical procedure necessary to SAVE the life of the patient, the court upon the petition of the physician or any person interested in the welfare of the child or patient , may issue an order giving such consent. ( Taking sides 10th edition) feels that it is quite cumbersome for the courts to come in especially in cases of emergency. B. The opinion of the minor patient concerning care or treatment measures shall be assessed based on his age or level of development & whenever possible care shall be administered with his agreement.

3 Right to privacyThe patient has the right to be left alone when this will not prejudice the provision of necessary medical care. The patient has the right to be free from unwarranted publicity EXCEPT in the ff. cases a. when his physical & mental condition is in controversy & the appropriate court in its discretion orders him to submit to a physical or mental examination by a physician, b. when public health & safety so demand, c. when the patient waives his right.

4. Right to informationThe PATIENT has a right to a CLEAR, complete & accurate information of the nature & extent of his disease, the contemplated medical & surgical procedure & its probable outcome, economic costs, etc a. impact on life style, b. & work including side effects & after effects of the treatment, c. possible complications & others regarding his illness. (Taking sides 10th edition) It cannot be as clear because of the illness, cannot understand medical language and then it becomes only a legal consent.

4. Right to information

However if the disclosure of the information to the patient a. WILL cause mental suffering & further impair his health or b. CAUSE the patient not to submit to medically necessary treatment such disclosure maybe WITHHELD or deferred to some opportune time , PROVIDED that his next of kin shall be consulted or informed & given the relevant information.

4. Right of information

The PATIENT has the right to know the name & credentials of the physician responsible for his care or for coordinating such care. He will likewise REQUEST for similarly relevant information about other health care provider directly involved in his case.

4. Right to informationThe PATIENT: a. has the right to examine and be given itemized bill for services rendered in the facility or by his physician & other health providers, regardless of the manner and source of payment, b. is entitled to a thorough explanation of such bill should he find them incomprehensible.

4. Right to informationThe PATIENT: has the right to be informed by the physician or his delegate of his continuing health care requirements following discharge including instructions about home medications, a. diet, b. physical activity, c. and other pertinent information to promote earlier health & well-being.

5. Right to privileged communicationThe PATIENT has the right to demand that all information, communications & records pertaining to his care be treated as CONFIDENTIAL.. A physician is not authorized to divulge any information to a third party who has no concern with the care & welfare of the patient, EXCEPT: a. when the disclosure will benefit public health & safety, b. when it is in the interest of justice, c. and when the patient waives the confidential nature of such information.

5. Right to P. communicationINFORMING the spouse or the family, to the first degree of the patients medical condition, shall be considered as breach of confidentiality. Such disclosure shall be considered a fulfillment of the health care providers duty to inform, a. in the case of the patient, who has not reached the age of discretion or is mentally incapacitated such information shall be given to the parents, legal guardian or to the next of kin.

6. Right to choose physicianThe PATIENT is free to choose the physician to serve him EXCEPT when he seeks: a. medical treatment in a government hospital, b. he is confined in a charity ward (clinical division as in our case) and c. he has entered to a contract with a health maintenance organization or any other health insurance organization which stipulates that the patient can only be served by a physician affiliated with the organization.

6. Right to chooseThe PATIENT has the right to discuss his condition with a consultant specialist, at the patients request, in case of doubt, for a second opinion from another physician before agreeing to a : a. treatment, b. surgical operation, c. or therapeutic procedure entailing a risk in health or life. Is this practical ???

7 Right to self determinationThe PATIENT has the right to refuse diagnostic & treatment procedures, PROVIDED that a. he is of legal age & sound mind, b. he is informed of the medical consequences of his refusal, c. he releases those involved in his care from any obligation relative to the consequences of his decision; and d. his refusal will not jeopardize public health & safety.

7 Right to self determinationAn adult with a sound mind may execute an *(advance directive)* for the physician not to put him on prolonged life support if in the future his condition is such that there is little or no HOPE of reasonable recovery under the ff. conditions, a. legal age & sound mind, b. informed of the consequences of his refusal, c. release for any legal problems the ones who will be involved in his care. Advanced directive or living will.*

Advance directive, living willBasic objections (Human life international) a. living will is unnecessary because everyone already has the right to make informed consent decisions about their own medical treatment, b. because doctors are already FREE to withhold or withdraw useless procedures that provide no comfort or profit to terminal patients, c. unworkable because it is theoretically impossible to make well-informed & logical decisions regarding health care before illness or accidents happen, etc.

8. Right to religious belief

The PATIENT has the right to refuse medical treatment which may be contrary to his religious beliefs subject to limitations, PROVIDED that such a right shall not be imposed by parents upon their children who have not reached the age of legal discretion.

9. Right to medical recordsThe PATIENT is entitled to a summary of his medical record & condition which shall be accomplished by the attending physician. He has the right to VIEW the contents of his medical record upon consultation with his attending physician, and lastly at his expense & within reasonable time, he may obtain from the health care institution a reproduction of the same record, whether or not he has not settled his financial obligations with the physician or institution concerned.

9. Right to medical record

The health care institution shall issue a medical certificate, FREE of charge, to the patient upon discharge from the institution. Any other document that the PATIENT may require for insurance claims shall also be made available to him within a reasonable period of time.

10. Right to leaveThe PATIENT has the right to leave the hospital or any other health care institution regardless of physical condition, PROVIDED, a. of age & sound mind, b. informed of the medical consequences of his medical condition, c. nobody can be held responsible, d. will not jeopardize public safety & health. (Filipino parlance DAMA, discharged against medical advise.)

10. Right to leaveNo PATIENT shall be detained against his will in any hospital on the sole basis of his failure to fully settle his financial obligations with the physician or health care institution PROVIDED he executes a promissory note covering the unpaid obligation, secured either with a mortgage, or by the guarantee of a co-maker acceptable to the hospital who shall be jointly and solidarity liable with the patient for the unpaid obligation. Furthermore when the patient dies, his relatives have the right to claim his cadaver subject to condition above.

11. Right to refuse participation in medical research

The PATIENT has the right to be advised if the health care provider plans to involve him in medical research, including but not limited to human experimentation that may affect his care or treatment.. Such human experimentation may be performed only with written informed consent of the patient. Other conditions that included namely may get out of the research anytime, research should have been done already in animals, no research of this nature has been done in the past, etc.

12. Right to correspondence & to receive visitors

The PATIENT has the right to communicate with relatives, and other persons and to receive visitors

SUBJECT to reasonable limits prescribed by the rules & regulations of the hospital.

13. Right to express grievances

The PATIENT has the right to express complaints & grievances about the care the services rendered. The DOH, in consultation w/ the health providers consumer groups & other agencies shall establish a grievance system wherein the patients may seek redress of their grievances, such a system should be able to mediate & settle the problem amicably.

14. Right to be informed of his rights

Right to be informed of his rights & obligations as a Patient.. Agencies mentioned should launch a massive information drive regarding this right.15. rights to express grievances: 16. Rights & obligations. It shall be the duty of the health institutions to inform patients of their rights as well as of the institutions rules & regulations that APPLY to the CONDUCT of the patient while in the care of the institution.

Physicians duties - Patients rightsKANTIAN DEONTOLOGY What is it? It is an ethics of respect for the person, a person with rationality. Not only respect as a person a. others (love thy neighbor) act only on the maxim through which you can at the same time will that it should be a universal law, (Golden rule),& but to begin with yourself. b. act in such a way that always treat humanity not only as a means but also at the same time an end.

Kantian deontology

By RATIO Which one & why ? That which pertains to the person. Human life is the basis of all goods, and is the necessary source of every human activity & of all society. (Medicine & Christian morality)

Kantian deontologyPerfect duties ; a. duty not to kill, (P. stewardship), not to commit criminal abortion b. not to tell a lie (truth telling), truth of diagnosis, prognosisc. duty to keep promises, regards # 2 & including honoraria. Imperfect duties 1. goodness & welfare of others (beneficence) do good do no evil, 2. preventing evil to others, removing the present evil, 3. doing good to someone, anyone & everyone.

Aristotle & St. Thomas

Medicine 1. is itself ultimately an exercise of practical wisdom, 2. a right way of acting in a difficult and uncertain circumstances, 3. for an specific end.

T. Beauchamp & James F. ChildressPRINCIPLES a. respect for autonomy, not to interfere w/ exercise of patients freedom of choice, action unless there are liberty limiting principles involved for the sake of the patients. b. nonmaleficence primum non nocere, nil nocere c. beneficence & d. justice

T. Beauchamp & James F. Childress

P. beneficence to promote the well-being of the patient from ill to health physically, emotionally, psychologically, (Kantian deontology), no abortion etc.P. justice social benefits, health care services, social burdens equally distributed, to all no discrimination. (Be they slaves or free) Hippocratic oath.

Patients rights & dutiesRIGHTS- 1. considerate respect due on the dignity as a person, humanity on your person & on others,2. well-informed consent, 3. to information, Dx, prognosis (truth telling)DUTIES 1. cooperate & communicate openly in all information needed, not to mislead the historian, 2. mutually achieve agreed goals with healthgiver. 3. not to regard health giver infallible

PatientsRIGHTS 4. to secure second opinion, 5. privacy, 6.confidentialityDUTIES 4. not to demand maltreatment, (euthanasia), 5. not to play as malingerer to shrink from responsibilities

METAPHORS1. Parental or paternalistic, physician is most powerful, has moral authority, hierarchical (priest & penitent) 2. Partnership, (Eric Casell) autonomy is one inherent right BUT cannot be realized w/o a good relationship, collegial, colloboration w/physician, 3. Friendship, medical phillia patient expresses faith, confidence & trust to his physician,4. Rational contractors, patients & Md. related through contracts, 5. Technicians e,g, physicians as plumbers, no moral authority but only technical authority.

Antepartum

PATERNALISTIC physician prescribes & patient may or may not follow, cooperation of the patient needed.

AUTONOMY- for both the M.D. & patient BUT for the healthgiver, one is after beneficence, (Kant) respect for the person.

Intrapartum - PostpartumPPATERNALISM under sedation she is not competent to make decisions, AUTONOMY cannot be given her.POST- Patient must cooperate with M.D. for earlier well-being. Friendship, partnership, technician since the patient may be under sedation.Post- is contractual mission is realized. Goods have been delivered time for honoraria.

PHYSICIAN - PHYSICIANPHYSICIANS 1.should labor together in harmony, each giving freely to others whatever advantages he may contribute. 2. Physicians should gratuitously give service to a colleague, to his wife, and minor children or even to parents especially if aged & if not married & being supported by the colleague for whatever reasons. 3. AVOID rivalry, insincerity or hypocrisy BUT solidarity towards each other, of importance is the PATIENT, unaffected by professional jealousy.

Physician- PhysicianCOOPERATE w/ any colleague asking for help, advise, information or professional aid, assistance or guidance especially in emergency cases. DO NOT INDULGE in fault finding, REFRAIN from unsavory & unwarranted criticism against another colleague or to DISCREDIT him, and if JUSTIFIED criticism should be constructive & made directly & in private to physician concerned.

Physician - PhysicianIf there is DISAGREEMENT in the diagnosis for the patient both should AGREE to refer to proper authorities or a competent body for decision. When the disagreement is between the attending & the patient despite respectful discussion on the matter it SHOULD be referred to another as more competent physician w/permission of the patient.

Referral to another physicianThe referred physician should have no vested interest in the outcome & should make every effort not to pre-empt or INTERFERE w/ the original physician-patient relation and not to UNDERMINE confidence or authority. ETHICAL consideration should always for the benefit of the patient.

Physician -Physician

COLLUSION- should never be the case to cover up or to protect the inadequacy of the former attending, Consultants & referred physicians should meet & discuss the case jointly regarding the total health care needs & the recommendation be LOUD & clear & given to the patient..

Policy on referralsREFERRAL made with the knowledge & consent of the patient,REASON for the referral and the possible outcome or results to be clarified to the patient, or the next of kin if he is incompetent,CONSULTANT or attending must be informed directly by the physician to whom the case was referred to.

Policy on referralPURPOSE of the referral must be specific, e.g. for evaluation & management or for co-management, or transfer of the case as it would be decided after the referral, a CONSULTANT may refuse but once he accepts he cannot delegate the responsibility to another w/o the consent of the attending & the patient.

Policy on referralsOnce a physician ACCEPTS, the following are the guidelines; a. duty to answer stat, b. if referral is for only evaluation then his responsibility is only to the attending, c. if for co-management then it stands to reason that the responsibility is the same as the attending, d. Consultant must not delegate the responsibility to an assistant, e. for any eventuality the referred Consultant must notify the attending.

Policy on referral

CONSULTANTS: should not make cross referrals w/o the knowledge & permission of the patient, once the CONDITION has been acted upon then CONSULTANT may end services and charge accordingly unless agreed upon otherwise, FOLLOW-UPS & future treatments should be rendered by the attending.

Policy on referrals

EMERGENCY- in the absence of the attending, any physician involved in the case, MAY & should do what he deems is necessary for the best interest of the patient, in case of a new complaint this has to be acted upon by the Attending and if needs referral then it should be done.

Physicians limitationsIn difficult, seriousness of the case or outside the expertise of the ATTENDING, one should always seek consultation, seek an experienced or senior member of the profession that might be suited to the situation.

Guidelines in consultation

For second opinion the attending must uphold the honor & dignity of the profession by not consulting somebody who is not QUALIFIED for the purpose sought for, PUNCTUALITY is to be observed & if the physician alluded to does not come enough allotted, then another can be called for the beneficence of the patient.

Physicians-Pharmaceutical relationshipEthical Drug- a drug which is advertised only to physicians & other prescribing health professionals.Drug manufacturers that make primarily such drugs are referred to as ethical drug industry. United States & New Zealand allow DTC advertising (direct to consumer) Barbara Mintzes supports the view that European consumers should have access to DTC. Silvia Bonaccorso & JeffreyL. Sturchio offer the opposing views.

Physician-Pharmaceutical relationship, guidelinesPatient care not based on monetary, academic or scientific gain, PHYSICIANS must not be influenced by monetary incentives that will make them act in a manner contrary to the best interests of the patient.Gifts to M.D.s should redown for the benefit of the patients, form of books, other gifts serving as educational function, no cash should be involved.Individual gifts, pens & notepads permitted, for note taking etc.

Physician Pharmaceutical relationship

Physicians should be given funds for traveling expenses, modest board & lodging & for medications just incase needed by the physician. BUT this does not apply if the physician is no longer in the practice of medicine. However even if he is no longer in practice but his line of work can still be called for then??? May be compensated for expenses.

Physician-Pharmaceutical relationship

Subsidies for CME, permissible, subsidies should not be in cash but indirectly.Hospitalities should be modest, Lecturers may accept honoraria, lodging & traveling expenses, SCHOLARSHIP- permitted provided it is not directly given to the individual but to the institution.

Chito g. Moreno

DumpingFrom Beyond a Western Bioethics Voices from developing World

Dumping

Involves disposal usually to a developing country of: 1.surplus of pharmaceutical products, 2. medical facilities, 3. even medical services.

Circumstances excess from developed countries to developing ones at a lower purchase price.

DumpingRATIONALITY- the safer drug is so prohibitive in cost that the POOR cannot afford. The risk is to HAVE a drug that might cause harm occasionally but not always than no drug at all. Many options for the rich as compared for the POOR e.g. education, habitat, recreation. Ethical issues the discrepancy SHOULD not be so evident and the position of the poor is not too unacceptable.

DumpingDEVELOPED: excess products, tax shelter, provide public image of generosity, get rid of unwanted products, to exploit the possibility of research on part of the recipient.DEVELOPING, availability of drugs at a lower price, BUT the possibility of safety is also to be considered, at least it is better than no drug at all, anyway harm is not total & absolute, Better to have a treatment than none at all.

DumpingINFORMED CONSENT- about the harm the drugs may PRODUCE but under supervision it certainly can provide care that is better than none at all. Beggars cant be choosers but they should be treated as such &DIGNITY each person deserves.RECIPIENTS are treated with dignity, ISSUE is national pride.

Dumping2. FACILITIES- Brand new hospital beds, etc BUT they are better than our canvass beds, 3. MEDICAL MISSIONS- Issue of the patients being practiced by the resident staff, again better than no procedure at all any way the procedures are done under the SUPERVISION of the Consultants. These patients cannot afford the professional honoraria and the hospital fees so the same principle can be applied.

Chito g. Moreno

Physician/Nurse relationshipEthical decision making Biomedical Ethics 4th edition

Doctors-Nurses Game 1967, Leonard I. Stein, M.D. NURSES- The object of the game is for the nurse to BOLD, have INITIATIVE&BE RESPONSIBLE for making recommendations while apparently not being too obvious. PHYSICIAN- it should appear he has given the recommendations and finally the decision. BOTH should be aware of subtle non-verbal cues. OPEN disagreement should be avoided. at all costs. Doctors/Nurses game 1999 revision have had very minor changes.

D/N gameOrganizational spheres- subordinates use passive voice to make suggestions. Traditional job descriptions , (+) ministering self sacrificing angels, nurturing mothers.(-) sexpots, battle axes DOCTORS(+) noble, decisive leaders, captain of the ship,(-) egotistical arrogant dictators. NEGATIVE stereotypes in Medicine & nursing are typically, only the men & women in society at large.

D/N gameNurses direct revenue from the hospital, hospital cannot function without them. Their work are not so obvious but nonetheless essential. RECEIVE little pay, respect & recognition for their work contribution.PHYSICIANS exercise a great deal in the health care system, although some problems came up relegating the same as GATEKEEPER in the triage but still they are the ones that determine who are to be admitted , types of management & procedures.

D/N gameRarely do they socialize together, (professional jealousy) limiting opportunity to get to know each other better.Informal chat would open venues for communication, understand each others values, motivation making the endeavor a little workable. Nurses have lesser education (?) preparation for their job description, e.g. however now md goes gn.

Approaches to ethical decision making

Carol Gilligan, PhD significant differences between males & females to make them out morally.FEMALES- acknowledges peoples lives are embedded in relationship and that relationship are central to moral decisions. They are responsive & responsible to people , considering the specifics of the situation when making a decision.

ApproachesMales rights & rules perspectives directed towards justice & fair play. Using this as a basis for moral reasoning. SEEK general rule that can be applied to specifics.May have some difficulties in implementing particularly for Surgeons who are rewarded handsomely for their expertise and decisiveness to act quickly under pressure. Makes ethical decisions upon themselves with little or no collaboration at all.

SolutionsFORM an interdisciplinary ethics committee to REVIEW particularly difficult cases, ESTABLISH common guidelines for these cases, SHARED OPINIONS-will allow for better decisions that can emerge especially in the ethical perspective,HOPE for commitment, compassion justice & solidarity.

Chito g. Moreno

RationingAging and the ends of Medicine, Taking sidesContemporary Issues in Bioethics Sixth edition ( Tom L. Beauchamp & LeRoy Walters)

Rationing What does it mean to be a just and caring society when we have only limited resources & virtually unlimited health care needs that must be met..OREGON system its citizens chose to a. make explicit, visible, systematic rationing decisions b. that would be a product of democratic deliberations that were morally & rationally justifiable.

Rationing (Oregon)Is Oregon rationing FAIR? a. problems of health reform in general & health care rationing in particular b. are fundamentally moral & political problemsc. & only secondarily economic & organizationalDANIELS argued access to needed & effective health care is essential to protecting fair equality of opportunity in our society. Thus he says further health care should be thought of as a public good, as a public interest & hence as a legitimate object of public policy.

Rationing (Oregon)Second Claim that JUSTICE not beneficence, is the fundamental moral value to be followed & govern debates about health reform option.OREGON- (2) health policy objectives a. expand access to needed health care for the uninsured, and b. control health care costs for the state.

Rationing (Oregon)John Kitzhaber physician president of the Oregon Senate, 1990. (8) publicly approved principles and specifically he emphasized the first- universal access for the States citizens to a basic level of health care, fourth the obligation of the society to provide sufficient resources to finance a basic level of care of those who cannot pay for it themselves. But again there are limitations that these only possible in the number of related areas such as allocation that includes, housing, education highways which are all public goods.

Rationing (Oregon)There are questions & rationalizations to the answers:Legislations made for the funding e.g. below a certain limitation there will be no funds BUT the citizens were still given marginally beneficial care where the benefits were very uncertain or relatively small especially in relationship to costs. (Oregon felt that the poor and uninsured do not have a moral claim to a middle class standard of care but to basic care.

Rationing (Oregon)E.G. Case of Coby Howard, Cobys death came when it did as it did because of a deliberate social choice not to fund bone marrow transplants. Middle class children in Oregon in the same medical circumstances as Coby did receive bone marrow transplants paid by their parents health insurance. Question Is it morally right that middle class children should have an opportunity for survival denied to poor children?

RationingSeems MORALLY objectionable??? WHY??1. needed, potentially beneficial health care is directly denied an identifiable individual, 2. the denial of coercively imposed, not freely chosen 3. the benefits that they are denied may be very substantial,, such as life itself, & often irreplaceable & uncompensatable, 4. the individuals denied these benefits are SICK & vulnerable, 5. the denial of benefits may be arbitrary because the primary reason for the denial is economic,

Rationing

6. the ultimate source of the rationing decision disadvantaging this individual will be government, & government is supposed to protect equally the rights of all, 7. the proximate source of the rationing decision will often be an individuals personal physician, ideally a loyal uncompromised advocate for the individual.

Rationing, alternativesWays to effectively CONTROL health costs: HOW?The unholy trinity of WASTE, FRAUD & ABUSE usually cited & proposed remedies include more effective utilization review (Angell 1985) better technology assessment, banning self referral by physician (Rodwin 1993) & REDUCING administrative wastes (Himelstein & Woolhandler 1994)

Oregon & health care rationing, Key moral lessons(1&2)Lesson (1) rationing decisions made piecemeal, uncoordinated fashion are very likely to be arbitrary & unjust. It must a product of a comprehensive, systemic rational deliberations. It must always imply trade-offs. These can now be open to rational & moral assessment. Lesson (2) Rational decisions made public are open to critical assessment & correction & are more likely to be just. Oregon was the first state to have denied a life-sustaining medical care, (Hadley 1991; Lurie 1984 was routine occurrence in Medicaid program without health insurance.

Oregon moral lessons (3)Lesson (3) The whole process of health reform & health rationing must be guided by explicit moral considerations, such as health care justice, & only secondarily be economic or managerial or organizational considerations. There are those who need technological advances that can prolong their lives and cannot be solved by only economic issues we need to ADDRESS this problem in a moral point of view. The presence of these advances are not oddities of today, they are at the Heart of this our century.

Rationing (4 & 5)Lesson 4 -Fair rationing decisions of informed democratic decision making processes that include ALL who will be affected by the decision.

Lesson 5 If all who will be affected by rationing decisions have a fair opportunity to shape these decisions, then these rationing decisions will be freely-imposed, which is an essential feature of JUST rationing decisions.

Rationing (6)Lessons 4,5, & 6 are principles of community for health care rationing. All not only the experts are to be involved in the decisions making for rationing. Expert knowledge cannot substitute for public moral judgment & public moral responsibility. To be just the decisions SHOULD be freely self imposed not imposed, by some healthy individuals on others (sick & vulnerable individuals. Liberal society embedded in this principle of community must be a principle of autonomy with respect to health rationing, just rationing must be freely-imposed.

Rationing (6&7)

Lesson 6 - Rationing protocols all who have a voice in shaping those protocols & priorities must be ongoing members of that community so that all are more or less equally at risk of having to accept the burdens of rationing.

Lesson 7 JUSTICE requires that there must be limits that health care makes on total societal resources and these limits be expressed in the form of hard budgets. Hard budgets means the trade offs clear & visible among competing health needs.

Rationing (8&9)Lesson 8 Hard budgets give structure & coherence to a process of prioritizing health needs & services. This process protects the weak & the sick fairness against special pleading. IN the Filipino pakikisama.Lesson 9 Those who are at least well-off health wise have presumptively stronger moral claims to needed health resources as long as they benefit most, health needs are fairly judged of sufficient high priority from a larger social perspectives.

Rationing (9 & 10)Lesson 9 No individual has a right to unlimited health care resources: & no individual has a moral right to have their health needs met at the expense of the more JUST (higher priority) health claims of others.Lesson 10 Physicians are advocates of their patients. However they should look at rationing, making decisions in the framework of a fixed global budget & a system of health priorities that have been freely agreed to by all who are part of the health care system.

Rationing (11)Lesson 11 Equity & efficiency must be achieved together. It has to be a balance of the two or else we lose one at the expense of the other.What can be our conclusion? Oregon had exposed the problems that we could try to minimize. There is some comments with the community principle since it appears that the healthy & powerful are imposing rational protocols on the sick & poor who are not in a good bargaining power.

Rationing, questions & remediesCriticisms posed: 1. The poor was not properly represented in the Oregon priority setting & were the ones who ended up in the short end of the risks & burdens of rationing. Solutions, a. we must all belong to one or another accountable health plan meaning there will only be no morally objectionable sorting of individuals according to socio-economic status, b. belonging to a plan mean there is a single health budget to purchase all necessary plan holders, c. knowledge that the budget cannot satisfy all health requirements of all plan holders,

Rationing, questions & solutions

c. knowledge that the budget might not be able to answer all the needs,d. limit demands on the budget through a priority setting processes mutually agreeable to all members of the plan, e. must be largely ignorant of the future health care needs.

Oregon,2nd criticismDemocratic problem- Democracy is about respecting expressed preference (Daniels 1993), e.g. assured access to family planning services, vasectomy was a higher priority to hip replacement for the elderlies, this should open to discussion,Fair chances/ best outcome (Daniels 1993 p.25), Betty &Alice need a transplant, all controls are exactly the same, but Alice will only live (2yrs) post procedure, Betty (20yrs). Fair chances ? Excellent outcome. no matter how fine-grained a conception of health care justice we develop, it will never be fine-grained enough to generate a uniquely correct complete set of just rationing protocols.

Alice & BettyThis case cannot be settled by a lottery since there are still many factors that can be considered, such as, ages, post procedural quality of life , number of years of survival etc. Democratic principles that can be utilized, a. publicity principle aimed at eliminating invisible rationing, b. fair equality of opportunity principle, c. equality principle- to assure each citizen equal moral consideration, d. autonomy principle,e. just maximizing principle,f. distinguish health needs from health preferences, g. priority setting principles, h. neutrality principle.

Rationing, Daniel CallahanHealth care resources are SCARCE, elderly individuals who have lived a natural life span should be offered care that a. relieves SUFFERING but b. should be denied expensive life-prolonging technologies.

Rationing

TWO OBJECTIVES a. averting premature death, death prior to completion of the natural life span, b. relief of suffering, rather than extension of life, after that natural span of life has been completed.

Scarce resources, questions to be askedIs it SENSIBLE to spend too much resources for the elderlies? Is it possible to control expenses that could have been spent instead for researches?FACTS in the USA a. fastest growing age group 85^ ^10% q 2 years b. and by 2040 elderly will represent 21% of the population and consume 45% of all health care expenditures.

Allocation of scarce resourcesMACRO, MESO & MICRO levels:MACRO- support policy decision on how the resources have to be spent?MESO broad institutional decisions regarding distribution, MICRO- local or individual resource usage, e.g. low-cost high yield VERSUS high cost/ low yield allocation.

Scarce resources, historyHistorical (P.I.) there is maldistribution of health care resources whether it is personnel man power because of the brain drain, facilities or supplies, 1996- metro-Manila has 169 tertiary hospitals perimeter of 63,000 hectares, Western Mindanao 78 hospitals environment of 1,599,734 hectares. Rural areas none. Personnel 1N/16,061.

Scare Resources

Filipinos cannot afford high cost of medicines, transportation cost to the clinic. Income lost when they go to the clinics (voices from the developing countries), Issues brought out fundamental values, goals and attitudes that influences the distribution of the scarce resources.

Scarce resources

Patients rights Pinoy style- ISSUES 1. tension between traditional treatment & scientific & its impact with limited resources, e.g. TBA & PGI have a hidden tension between them, 2. low-cost health care plans are offered affordable in an in-patient or out patient basis.

Chito g. Moreno

Biomedical research & technologyEthical Issues in the design & conduct of clinical trials in Developing countries, by Harold Shapiro & Eric M. Meslin

Scientific Research & Human dignity (2004)Unconditionality with which human dignity & human rights must be presented as values that precede any jurisdiction on the part of the state. These basic rights are not creator by a legislator, nor conferred on the citizens, but rather exist in their own right, are always to be respected by the legislator, are given previously to him as values of a superior order. This validity of human dignity, previous to every political action & to every political decision refers back ultimately to the CREATOR..

Human dignity (2004)But in the concrete sphere of the so-called progress of Medicine, there are very real threats to these values; whether we think of cloning or the conservation of human fetuses for organ donation or of the whole field of genetic manipulation no one can ignore the gradual erosion of human dignity that threatens us here. Conference held on 1 April 2005, at the Saint Scholastica Monastery, Subiaco. In His own words p127 in the Vineyard of the LORD.

Research, biomedical, humansGeneralities 1990 renaissance of interest in research ethics. BUT the locus has moved from the academic to commercial or semi-commercial. Definition of RESEARCH- class of scientific activities designed to develop or contribute to generalize knowledge, e.g. comparison of (2) drugs for AIDS, review of patients charts to detect a correlation between smoking & cancer.

Researchs umbrella Involves a. diagnosis, treatment or preventive of illness in the subjects themselves, b. discovery of newer methods in the detection of a disease, etc. CLINICAL RESEARCH- a. e.g. a study of a new polio vaccine in children at risk for contracting polio. b. may or not be directly related to an illness or susceptibility, e.g. healthy humans to examine the duration of a new drug that remains in their bodies.

Ethical issues in human researchJustification for research -human organism responds to biomedical interventions or other stimuli in ways that cannot be predicted on the basis of studies with human cells. In plain language human physiology involves complex interactions among genes, cells and organs that cannot be modeled by computer simulations.

Ethic in medical researchExclusively patient benefit ethic, (2)1. (Primum non nocere, do no harm). Do nothing that is not intended for the direct benefit of the patient. Principle of Beneficence- Social benefits that would be gained from the activity should be more good than harms after the termination of the project.2. Justice It requires of everyone to do something GOOD for our fellow human beings. Our well-being come from the past efforts to make our lives more comfortable & w/ quality also through researches. e.g. use of vaccines, penicillins, etc. Hans Jonas, in non-participation does not mean injustice but LESS altruism.

Research general ethical guidelinesIdentified by philosophers necessary & sufficient conditions for proper conduct ,Common morality.(2) central conditions identified by U.S. National Bioethics Advisory commission for ethical conduct namely, 1. independent review of past researches, assess its potential benefits & harms for the subjects, 2. the opportunity of the future subjects to decide freely whether to become participants in the project.

(7) Conditions that allows clinical research ETHICAL GlobalEzekiel Emanuel, David Wendler, & Chrisitine Grady1. Social or scientific value 2. Scientific validity, 3. fair subject selection, 4. a favorable risk benefit ration (involving either a risk benefit or a risk knowledge calculus), 5. Independent review, 6.Informed consent of the subjects or their proxies, 7. Respect for potential & enrolled subjects.

Ethical issues in developing countries (Shapiro & Meslin)Procedures must adopted in line with LOCAL CUSTOM, CONDITION & CULTURE.If intervention being tested is a. NOT likely to be affordable in the host country, b. or if the health care infrastructure cannot SUPPORT its proper distribution and use THEN it is UNETHICAL to ask persons in that locality to participate in any research, since they will not enjoy the benefits.

Other dangers1.Will health care benefits reach the citizens of the host country? 2. Developed country might be exploiting the poorer country, less powerful & THEREFORE more vulnerable? Because of pervasive poverty, & disease or ignorance of the project, & role of the project etc??? 3. Will the distribution of the benefits be equitable?

Special ethical issuesThese ISSUES are unique they pertain to all researches BUT how they are to be interpreted & addressed may be UNIQUE. Informed consent generic but has to be applied according to the locality, signatures etc, ??but there are those who question the validity of a signature, free or coerced. Written or oral must be witnessed. Research design e.g. for zidovudine means a longer trial in all subjects irrespective of countries where the research is going on. In some exceptions for life threatening conditions researches should not be done in all areas for certain reasons.

U.S. Biotechnology company 2003Surfactant drug for RDS- (Latin American countries) 3 groups 1. receiving the new drug, 2. surfactant drug approved by FDA, 3. placeboResolutions involving a life threatening & there is an existing drug, placebo should not be used,& if the beneficiaries would be the developed countries only & if it is not be of benefit for the host country.

Declaration of HelsinkiThe benefits, risks, burdens, effectiveness of the new method should be tested against those of the best current prophylactic, diagnostic & therapeutic methods.This stands for deviation in the following condition if it requires in order to address an urgent health problem in the host country.

10/90

Less than 10% of global health care expenditures are devoted to diseases that account for 90% of the global burden of the disease.

We were born by chance & after life is over, we will be as if we had never been born at all.Our breath is no more than a puff of smokeOur mind is nothing more than a spark thrown off by the beating of the heart.There is no escape from the day of our death, it is fixed & no one can postpone it.