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Ethics and Professionalism
 

Ethics and Professionalism

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by Ihab Tarawa, MD, Consultant Physician, Soba University Hospital

by Ihab Tarawa, MD, Consultant Physician, Soba University Hospital
Vice President of SAMA

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    Ethics and Professionalism Ethics and Professionalism Presentation Transcript

    • Introduction toProfessionalism &Medical ethicsIHAB B ABDALRAHMAN, MBBS, MD, ABIM, SSBB.CONSULTANT OF ACUTE CARE MEDICINE,SOBA UNIVERSITY HOSPITAL.ASSISTANT PROFESSOR OF MEDICINE, U OF K
    • Aims To highlight the concept of professionalism To introduce the concepts of Ethics & Medical Ethics To discuss ethical principles  Beneficience, do good  Non Maleficience, do no harm  Autonomy,  Privacy & confidenciality  Self determination  Justice Ihab B Abdalrahman (Tarawa) 12/31/2012 2
    • Compartmentalization of life One man cannot do right in one department of life, whilst he is occupied in doing wrong in any other department Ihab B Abdalrahman (Tarawa) 12/31/2012 3
    • Ihab B Abdalrahman (Tarawa) 12/31/2012 4
    • You make me cry Ihab B Abdalrahman (Tarawa) 12/31/2012 5
    • Compartmentalization of life One man cannot do right in one department of life, whilst he is occupied in doing wrong in any other department Ihab B Abdalrahman (Tarawa) 12/31/2012 6
    • Ihab B Abdalrahman (Tarawa) 12/31/2012 7
    • SYSTEMS GOVERNING HUMAN SOCIAL BEHAVIOUR CUSTOM ETIQUETTE ETHICS LAW MORALITYMores Professional Professional State, Statutes Spirituality Etiquette Values LegislatureTradition Courtesy Competence Enforcement Religious Integrity Compulsion Good vs Evil Fairness Judiciary Right vs Wrong Goodwill Punishment Truth Justice Ihab B Abdalrahman (Tarawa) 12/31/2012 8
    • What type of professional? or a good doctor Ihab B Abdalrahman (Tarawa) 12/31/2012 9
    • Definition Profession An occupation whose core element is work “ based upon the mastery of a complex body of knowledge and skills. In which knowledge and practice of an art is used in the service of others. Its members are governed by codes of ethics they are committed to the promotion of the public good within their domain. Professions and their members are accountable to those served and to society.” • Derived from the Oxford English Dictionary
    •   Ihab B Abdalrahman (Tarawa) 10/1/2011 11
    •     Ihab B Abdalrahman (Tarawa) 10/1/2011 12
    • Why is ProfessionalismImportant?“ Neither economic incentives, nor technology, nor administrative control has proved an effective surrogate for the commitment to integrity evoked in the ideal of professionalism ” Sullivan, 1995
    • The Physician Has TwoRoles  Healer  Professional
    • P h y s ic ia n H e a le r P ro fe s s io n a lCaring and compassion Autonomy CompetenceInsight Commitment Self-regulationOpenness ConfidentialityRespect for the Responsibility Altruism to society healing function Integrity and Team workRespect patient dignity and honesty autonomy Morality and ethicsPresence Responsibility to the profession
    • The Social Contract The social contract in health care is based on professionalism. It serves as the basis for the expectations of medicine and society.
    • The Social ContractSociety ProfessionPatient expectations Physician obligations Professionalism
    • The Social ContractThis Contract Has Always Been  Implicit (largely unwritten)  Evolving (being constantly renegotiated)
    • The Social Contract Society’s Expectations of Medicine’s Expectations of Society Medicine  trust  autonomy to fulfill the role of the healer  self-regulation guaranteed competence  Health Care System altruistic service  value-laden morality, integrity, honesty  adequately funded  role in public policy accountability  rewards – non-financial transparency • respect source of objective advice • status promotion of the public good – financial Individual and Collective Responsibilities
    • The ContractDepends On  mutual trust  reasonable demands on both sides  communication
    • Professionalism CommunicationEthics Behavior Ihab B Abdalrahman (Tarawa) 12/31/2012 22
    •  Components of Medical Professionalism identified to be suitable for trainees: Behavior:  Collaboration.  Professional health care [e.g. Risk management, Management of conflicts, Exerting maximum effort, Appropriate relations within the health system].  Self regulation [Self health care, Continuous Professional Development, Compliance with regulation of Health authorities such as the Medical Council].  Health advocacy. Ihab B Abdalrahman (Tarawa) 12/31/2012 23
    •  Ethics:  Beneficence (do good).  Nonmaleficence (do no harm) & malpractice [e.g. serious professional misconducts highlighted in the Capital As: Abortion, Association, Advertisement, Alcohol, Adultery].  Justice.  Autonomy [with its three components: Self determination, Privacy, Confidentiality].  Probity [e.g. Integrity, Truth telling, Trust].  Sensibility in dealing with sensitive issues e.g. dying patient, futility & organ transplant.  Appropriate doctor-patient relationship Ihab B Abdalrahman (Tarawa) 12/31/2012 24
    •  Components of Medical Professionalism identified to be suitable for trainees: Communication – including effective and professional communication with:  Patients [e.g. History Taking, Consultation, Delivering Information, Discussing Results, etc ].  Relatives and Family,  Colleagues (e.g. Medicals, Para-medicals, Nurses, Admin & Supporting Staff, etc..).  Public – including communication with Health Authorities, Police, Courts, etc..  Other Methods, such as communicating In Writing & Electronically (e.g. Record keeping, Prescribing skills, Referrals and Transfer letters, etc. Ihab B Abdalrahman (Tarawa) 12/31/2012 25
    • Professionalism E CommunicationEthics Behavior Ihab B Abdalrahman (Tarawa) 12/31/2012 26
    • Medical Technician Skills & Knowledge Ihab B Abdalrahman (Tarawa) 12/31/2012 27
    • Ethical principlesSkills & knowledge Moral Character Ihab B Abdalrahman (Tarawa) 12/31/2012 28
    • EthicsSkills & knowledge Moral Character Ihab B Abdalrahman (Tarawa) 12/31/2012 29
    •  What is Ethics? Ihab B Abdalrahman (Tarawa) 12/31/2012 30
    •  Ethics is the branch of study dealing with What is the proper course of action. Ihab B Abdalrahman (Tarawa) 12/31/2012 31
    •  It is the study of right and wrong. Ihab B Abdalrahman (Tarawa) 12/31/2012 32
    •  It answers the question,"What do I do?" Ihab B Abdalrahman (Tarawa) 12/31/2012 33
    • The last of human freedoms Every thing can be taken from a man, but one thing: To choose one’s attitude in a given set of circumstances, to choose one’s way Viktor Frankl Ihab B Abdalrahman (Tarawa) 12/31/2012 34
    •  It is your choice  Emotion based  Principle based Ihab B Abdalrahman (Tarawa) 12/31/2012 35
    • Why Ethics is important? Ethics is a requirement for human life. It is our means of deciding a course of action. Ihab B Abdalrahman (Tarawa) 12/31/2012 36
    • Moment of thoughtIn many casesit might help to put yourselfin your patient shoes.Seek to understand, before to be understoodWhat do you want if you are a patient? Ihab B Abdalrahman (Tarawa) 12/31/2012 37
    •  What is medical ethics?It is just, Doing the right thing. Ihab B Abdalrahman (Tarawa) 12/31/2012 38
    • But what is right? Beginning of life End of life Limited resources When patient demands unacceptable measures  What is acceptable? Futility of care  How to define futility? Ihab B Abdalrahman (Tarawa) 12/31/2012 39
    • Medical ethics Refers to those guidelines and behaviors that we expect  a medical professional  with moral integrity  to exhibit. Ihab B Abdalrahman (Tarawa) 12/31/2012 40
    • Medical Ethics Beneficence Non-maleficence & malpractice Justice?” Principles Respect of autonomy  Privacy  Confidentiality  Right to self-determination Probity (honesty & integrity) Moral Values Sensitivity in dealing with the dying, futility & organ donation Situation Appropriate doctor-patient relationship 12/31/2012 Ihab B Abdalrahman (Tarawa) 41
    • Ihab B Abdalrahman (Tarawa) 12/31/2012 42
    • Ethical Principles BENEFICENCE &NON-MALEFICENCE
    • objectives Definition of beneficence Definition of Non-maleficence Interaction of these principles Ihab B Abdalrahman (Tarawa) 8/4/2011 44
    • The practice of medicine &ethics are inseparable Practice of medicine Practice of ethics Ihab B Abdalrahman (Tarawa) 12/31/2012
    • Every medical decision Involve anethical decision Ihab B Abdalrahman (Tarawa) 12/31/2012
    • What weMedicine can do not be apparent be apparent and clear be apparent and messy/ conflictingWhat we should Ethics do Ihab B Abdalrahman (Tarawa) 8/4/2011 47
    •  Beneficence  Non-maleficence (Do Good)  (Do No Harm)  Ihab B Abdalrahman (Tarawa) 8/4/2011 48
    • Good Vs Bad What is good What is bad Ihab B Abdalrahman (Tarawa) 8/4/2011 49
    • The context of GoodGood Bad Strong  Weak Fortune  Misfortune Beautiful  Sickly Advantageous  Unlucky Gender  Opposite Gender Ihab B Abdalrahman (Tarawa) 8/4/2011 50
    • Ihab B Abdalrahman (Tarawa) 8/4/2011 51
    • Ihab B Abdalrahman (Tarawa) 8/4/2011 52
    • Ihab B Abdalrahman (Tarawa) 8/4/2011 53
    • Ihab B Abdalrahman (Tarawa) 8/4/2011 54
    • Ihab B Abdalrahman (Tarawa) 8/4/2011 55
    • Beneficence Beneficence is action that is done for the benefit of others. Ihab B Abdalrahman (Tarawa) 8/4/2011 56
    • Beneficence Beneficent actions can be taken to;  help  prevent  remove harms  simply improve the situation of others. Ihab B Abdalrahman (Tarawa) 8/4/2011 57
    • Beneficence To do good. To act on the best interest of your patient. To promote patient health and well being. Simply helping your patient. Ihab B Abdalrahman (Tarawa) 8/4/2011 58
    • Non-maleficence: Definition: Non-maleficence means to “do no harm.” Physicians must refrain from  providing ineffective treatments  acting with malice toward patients. Ihab B Abdalrahman (Tarawa) 8/4/2011 59
    • Non-maleficence:the Capital As Alcohol Adultery. Abortion Association Advertisement Ihab B Abdalrahman (Tarawa) 8/4/2011 60
    • Do goodDo no harm• Capital As Ihab B Abdalrahman (Tarawa) 8/4/2011 61
    • Do goodDo no harm• Carelessness• Malice• Vengeance• Dislike Ihab B Abdalrahman (Tarawa) 8/4/2011 62
    • Why do good & do no harm The goal of medicine is to promote the welfare of patients. Physicians possess skills and knowledge that enable them to assist others. Ihab B Abdalrahman (Tarawa) 8/4/2011 63
    • Beneficence Examples of beneficent actions:  Resuscitating a drowning victim,  providing vaccinations for the general population,  encouraging a patient to  quit smoking  start an exercise program,  Treat HTN & DM. Ihab B Abdalrahman (Tarawa) 8/4/2011 64
    • Non-maleficence: Examples Stopping a medication that is shown to be harmful, Refusing to provide ineffective treatment. Ihab B Abdalrahman (Tarawa) 8/4/2011 65
    • Sami & samir are brothers and engineers in petroleum companyThey came for routine medical check Sami 44 year  Samir 48 year No medical problems  No medical problems Mother has DM & HTN  Mother has DM & HTN Father has HTN  Father has HTN BMI 28kg/m2  BMI 32 Kg/m2 BP 154/96 in several  BP 134/84 in several occasions occasions Ihab B Abdalrahman (Tarawa) 8/4/2011 66
    • We should weigh and balancepossible benefits againstpossible risks. Do good  Do no harm We have an obligation  We are expected to to help our patients refrain from causing harm. Ihab B Abdalrahman (Tarawa) 8/4/2011 67
    • Challenges Many beneficial therapies also have serious risks. The pertinent ethical issue is whether the benefits outweigh the burdens. Ihab B Abdalrahman (Tarawa) 8/4/2011 68
    • Balancing Beneficence and Non-maleficence It plays a role in nearly every medical decision:  Whether to order a particular test  Medication  Procedure  Operation  Treatment Ihab B Abdalrahman (Tarawa) 8/4/2011 69
    • Types of risk Physical Financial Social Moral Religious Ihab B Abdalrahman (Tarawa) 8/4/2011 70
    • BenefitBenefit Harm Harm Ihab B Abdalrahman (Tarawa) 8/4/2011 71
    • Balancing Beneficence and Non-maleficence Physicians give patients the information necessary to understand the  Scope  Nature  Potential risks and benefits. Ihab B Abdalrahman (Tarawa) 8/4/2011 72
    • Balancing Beneficence and Non-maleficence  One of the most common ethical dilemmas arises in the balancing of beneficence and non-maleficence.Bad Good Ihab B Abdalrahman (Tarawa) 8/4/2011 73
    • Ihab B Abdalrahman (Tarawa) 8/4/2011 74
    • Ihab B Abdalrahman (Tarawa) 8/4/2011 75
    • Case study36 years male presented 36 years pregnant lady presented  Fever 39.2,  Fever 39.2,  Cough,  Cough,  Production of green sputum  Production of green sputum  Rt sided Pleuritic chest pain  Rt sided Pleuritic chest pain  Shortness of breath.  Shortness of breath.  He has bronchial breathing  He has bronchial breathing  TWCC 14.000  TWCC 14.000 Ihab B Abdalrahman (Tarawa) 8/4/2011 76
    • Case study Dr. X did his internship in obstetrics 20 years ago. He did 15 CS. After the 7 CS, the registrar felt, Dr X was competent enough to supervise junior HS. Now he is an internist. No surgical training for the last 15 year. Ihab B Abdalrahman (Tarawa) 8/4/2011 77
    •  Last week he was called to manage 25 years lady (G1P0) at 34 weeks, pneumonia and DKA. The lady went into premature labor. She went into maternal distress. Is it justifiable for Dr to do a CS? What is the appropriate course? Ihab B Abdalrahman (Tarawa) 8/4/2011 78
    •  What about if the same situation happened in a rural area What is the appropriate course? Ihab B Abdalrahman (Tarawa) 8/4/2011 79
    • In dilemmas, we see thecontent within the context Ihab B Abdalrahman (Tarawa) 8/4/2011 80
    • Autonomy Ihab B Abdalrahman (Tarawa) 12/31/2012 81
    • Reflect Definition of autonomy Prerequisite to acknowledge autonomy – conditions need to be satisfied Limitations of autonomy Ihab B Abdalrahman (Tarawa) 12/31/2012 82
    •  72 male DM for 30 years HTN 20 years Stage 4 CKD withCreatinine 4.6 Ihab B Abdalrahman (Tarawa) 12/31/2012 83
    • Case study 36 years old male Work as an engineer in Gulf area Visiting Sudan for 2 weeks vacation Has no significant pass medical history. came to the ER with acute right lower quadrant pain. Ihab B Abdalrahman (Tarawa) 12/31/2012 84
    • Case study General examination revealed an ill patient who is alert awake and oriented. His interaction with the staff was appropriate. Abdominal exam suggested an appendicitis. Urinalysis was normal & TWCC 14,800 Ihab B Abdalrahman (Tarawa) 12/31/2012 85
    •  The patient had some doubts regarding the diagnosis. He requested a second opinion. What would be the most appropriate actions? Ihab B Abdalrahman (Tarawa) 12/31/2012 86
    • Case study Arrangement was made for a second opinion. Appendicitis was re confirmed. At this point he requested a CT Ihab B Abdalrahman (Tarawa) 12/31/2012 87
    •  CT scanning has high diagnostic accuracy of 95-98%. CT scanning is highly accurate, time-efficient, cost-effective way to evaluate adult patients with equivocal presentations for appendicitis. Ihab B Abdalrahman (Tarawa) 12/31/2012 88
    •  Opinion varies as to whether these modalities should be performed in all patients with suggested appendicitis or if radiology should be reserved for select patients with atypical or confusing clinical presentations. Ihab B Abdalrahman (Tarawa) 12/31/2012 89
    • Case study CT scan confirmed the diagnosis. Urgent appendectomy was recommended. At this point the patient declined surgery and requested to be treated with antibiotics. What was most appropriate action at thas point? Ihab B Abdalrahman (Tarawa) 12/31/2012 90
    • Autonomy Autonomy is a key component in medical professionalism. Professional medical care depends on  a well trained and competent physician,  who delivers his care with empathy,  to a willing patient. Ihab B Abdalrahman (Tarawa) 12/31/2012 91
    • Autonomy Patient’s independence . A competent adult has the right to make decisions. Patient must be capable of rational thought. Not manipulated. He can refuse intervention. Ihab B Abdalrahman (Tarawa) 12/31/2012 92
    • AutonomyCapacity is a prerequisite A competent patient has the right to determine for himself Ihab B Abdalrahman (Tarawa) 12/31/2012 93
    •  Treating patients with respect requires doctors to accept the medical decisions of persons who are informed and acting freely. Individuals place different values on health, medical care, and risk. Ihab B Abdalrahman (Tarawa) 12/31/2012 94
    • It is grey & uncertain In most clinical settings:  different goals and approaches are possible,  outcomes are uncertain,  an intervention may cause both benefits and harms. Ihab B Abdalrahman (Tarawa) 12/31/2012 95
    •  Thus competent, informed patients may refuse recommended interventions and choose among reasonable alternatives Ihab B Abdalrahman (Tarawa) 12/31/2012 96
    • Could make sense or not Satisfy his values Well informed Not manipulated Sound mind •Capable Ihab B Abdalrahman (Tarawa) 12/31/2012 97
    •  Autonomy should prime all the time It is important to recognize the boundaries of sound decision. The decision could be sound to the patient since it satisfies certain values. The same decision might not make sense to the physician. Ihab B Abdalrahman (Tarawa) 12/31/2012 98
    • Ihab B Abdalrahman (Tarawa) 12/31/2012 99
    •  Dr P K Bansal is an orthopaedic surgeon, who practices near New Delhi. He too performs amputations on beggars. Dr Bansal belongs to a network of doctors who amputate beggars for money. CNN-IBN Posted Saturday , July 29, 2006 at 19:24 Updated Saturday , July 29, 2006 at 20:57 Ihab B Abdalrahman (Tarawa) 12/31/2012 100
    •  Beggars comes to your office Autonomously He is competent Demanding amputation of his leg He is paying cash Ihab B Abdalrahman (Tarawa) 12/31/2012 101
    •  Should we do it? Why Ihab B Abdalrahman (Tarawa) 12/31/2012 102
    • When patient askfor unacceptableintervention Ihab B Abdalrahman (Tarawa) 12/31/2012 103
    •  Autonomy should not be seen as synonymous with freedom. Freedom to choose treatment is not absolute, rather, it is subject to constraints and thus only involves a substantial degree of freedom of choice. Ihab B Abdalrahman (Tarawa) 12/31/2012 104
    •  Mr Z recently diagnosed with HIV and PCP. He is confused His brother asked you not to tell the wife. Ihab B Abdalrahman (Tarawa) 12/31/2012 105
    • Public hazards Ihab B Abdalrahman (Tarawa) 12/31/2012 106
    • case study 73 year female with metastatic adenocarcinoma of the ovary She has deposits in the spine, brain and lung She received palliative radiotherapy. She was found to be coagulopathic, thrombocytopenic and anemic. Ihab B Abdalrahman (Tarawa) 12/31/2012 107
    • case study Evaluation by a hematologist confirmed malignancy induced chronic DIC. He stated that it will be extremely difficult to cure the DIC without curing her malignant disease first. Ihab B Abdalrahman (Tarawa) 12/31/2012 108
    •  She was tender all over her body. Respiratory distress was noted. She was debilitated, malnourished and cachexic. Edematous legs and ascites were noted. Her renal function was worsening with a creatinine of 4.3mg/dl, K 5.4mg/dl, Hb 8.2 gm/dl, platelets 23,000 and INR 3.2. Ihab B Abdalrahman (Tarawa) 12/31/2012 109
    • Is it futility? Ihab B Abdalrahman (Tarawa) 12/31/2012 110
    •  Futility is defined as a judgment that further medical treatment of a patient would have no useful result. Ihab B Abdalrahman (Tarawa) 12/31/2012 111
    •  Medical futility is not a new concept. It was reflected in Hippocratic collections “Whenever the illness is too strong for the available remedies, the physician surely must not expect that it can be overcome by medicine” . Ihab B Abdalrahman (Tarawa) 12/31/2012 112
    •  It is fundamental to recognize that the power of medicine is limited. It is well established that sometimes the disease process exceeds our medical capability . Ihab B Abdalrahman (Tarawa) 12/31/2012 113
    • Examining patient’s autonomy Autonomy entitles a patient to choose from among medically acceptable treatment options (or to reject all options). It does not entitle patients to receive whatever treatments they ask for . Ihab B Abdalrahman (Tarawa) 12/31/2012 114
    • Limitations on Autonomy Patient with limited capacity Emergency care Futility of care When patient ask for unacceptable intervention Public hazards Ihab B Abdalrahman (Tarawa) 12/31/2012 115
    • Privacy & Confidentiality Ihab B Abdalrahman (Tarawa) 12/31/2012 116
    • ConfidentialityWalking the fine line 23 years old unmarried female admitted with severe right lower abdominal pain. She reported 2 fainting episodes. As patient’s symptoms were worsening, she was taken for exploration surgery. Ihab B Abdalrahman (Tarawa) 12/31/2012 117
    •  She was found to have ruptured ectopic pregnancy in the right ovarian tube.  Right salpingo-opherectomy plus appendectomy were done. Ihab B Abdalrahman (Tarawa) 12/31/2012 118
    •  Next day the patient was informed about the finding. She admitted that she missed her cycle for 50 days and she was worried that she was pregnant. She asked you to keep her information confidential. Ihab B Abdalrahman (Tarawa) 12/31/2012 119
    • The unspoken Her mom who did not know the outcome “she thought it was just appendicitis”“ felt that surgery was delayed and her daughter life was risked”. She complained to the medical manager that the on call team was negligent. Ihab B Abdalrahman (Tarawa) 12/31/2012 120
    • Privacy & Confidentiality They go hand in hand. The difference between privacy and confidentiality can be confusing. Ihab B Abdalrahman (Tarawa) 12/31/2012 121
    • Privacy & Confidentiality Privacy is the right of individuals to keep information about themselves from being disclosed. Patients decide who, when, and where to share their health information. Ihab B Abdalrahman (Tarawa) 12/31/2012 122
    • Privacy & Confidentiality On the other hand, confidentiality is how we, as health-workers, treat private information once it has been disclosed to us or others. Ihab B Abdalrahman (Tarawa) 12/31/2012 123
    • Privacy & Confidentiality Confidentiality can be breached in case of public hazard Ihab B Abdalrahman (Tarawa) 12/31/2012 124
    • justice Ihab B Abdalrahman (Tarawa) 12/31/2012
    • Ihab B Abdalrahman (Tarawa) 12/31/2012
    •  Being in a society this requires:  Peace  Harmony Justice  Others Ihab B Abdalrahman (Tarawa) 12/31/2012
    • "Justice is the first virtue of social institutions, Ihab B Abdalrahman (Tarawa) 12/31/2012
    • Justice is a basic need "Fairness is activating the same part of the brain that responds to food in rats... This is consistent with the notion that being treated fairly satisfies a basic need". Ihab B Abdalrahman (Tarawa) 12/31/2012
    • Justice Means giving others what is due to them; it is fair distribution of  benefits,  risks,  costs. Ihab B Abdalrahman (Tarawa) 12/31/2012
    • Injustice,historical reflection Patient Vs Sick Poor Ihab B Abdalrahman (Tarawa) 12/31/2012
    • He also claimed The life of a sick person can be shortened not only by the acts, but also by the words or Injustice murders manner of a physician. the soul Ihab B Abdalrahman (Tarawa) 12/31/2012
    • Justice in Medical practice In a medical setting, justice involves the allocation of health-care resources in a fair way. Egalitarianism This may be an equal distribution Utilitarianism maximization of the total or average welfare across the whole society. Ihab B Abdalrahman (Tarawa) 12/31/2012
    • Aristotle definition, more than 2000 years ago "equals should be treated Ihab B Abdalrahman (Tarawa) 12/31/2012
    • Aristotle definition, more than 2000 years ago "Individuals should be treated the same, unless they differ in ways that are relevant to the situation in which they are involved." Ihab B Abdalrahman (Tarawa) 12/31/2012
    • as justifying differentialtreatment, need, desert, contribution, and effort Ihab B Abdalrahman (Tarawa) 12/31/2012
    • ? We are spending 2/3 of our budget in dialysis. Ihab B Abdalrahman (Tarawa) 12/31/2012
    • Justice Fairness with respect to the distribution of medical resources. Who should receive scarce medical resource. How should we distribute them What is the best outcome. Ihab B Abdalrahman (Tarawa) 12/31/2012 138
    • Thanks Ihab B Abdalrahman (Tarawa) 12/31/2012 139