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- 2. The Culture of Health Care Ethics and Professionalism Lecture c This material (Comp 2 Unit 8) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. This material was updated in 2016 by Bellevue College under Award Number 90WT0002. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.
- 3. Ethics and Professionalism Learning Objectives ā¢ Discuss foundational concepts in medical ethics and professionalism (Lecture a). ā¢ Examine the relationships among ethical ideals, professionalism, and legal duties (Lectures a, b). ā¢ Apply the general principles of ethics and professionalism to specific topics (Lectures c, d). ā¢ Examine ethical issues in health informatics (Lecture d). 3
- 4. Contemporary Topics in Medical Ethics ā¢ Informed consent ā¢ End-of-life issues ā¢ Conflicts of interest ā¢ Health care disparities ā¢ Conscientious objection 4
- 5. Informed Consent Patients must ā¢ Be capable of making medical decisions ā¢ Be provided with all relevant information ā¢ Understand the information given ā¢ Communicate a decision ā¢ Make voluntary decisions 5
- 6. Relevant Information ā¢ Nature of the treatment ā What is the purpose? ā What will be done? ā¢ Availability of reasonable alternatives ā¢ Risks and benefits of proposed treatment 6
- 7. Examples of Exceptions to Informed Consent Requirement ā¢ Patient lacks mental capacity ā Adult with severe developmental disability ā Adult has severe dementia ā Children usually lack legal capacity ā¢ Implied or presumed consent in an emergency ā Patient is unconscious OR lacks capacity AND ā No surrogate decision-maker is available 7
- 8. End-of-Life Issues ā¢ Definition of death can be unclear ā Can a person be āaliveā if his/her heart has stopped beating? ā Can a person be ādeadā if he/she is still breathing? ā¢ Other prominent end-of-life issues ā Medical futility ā Advance directives 8
- 9. Medical Futility ā¢ Treatment would not improve the patientās condition ā Decision considers the unique situation of an individual patient ā Should be consistent with general professional standards ā¢ Relationship to health care ārationingā ā Advocates say there is no cost/benefit analysis ā Question is benefit of treatment for individual 9
- 10. Arguments about Futility Pros Cons ā¢ Spares patient pain, expense, and inconvenience of unnecessary treatment ā¢ Care could be labeled as futile to divert resources from disadvantaged populations ā¢ Increases chances that patient will receive more appropriate care ā¢ Definitions of what is futile are unclear ā¢ Saves health care resources ā¢ Treatments that patients consider beneficial could be limited or eliminated if providers consider them futile 8.7 Table: Pros and cons of medical futility (CC BY-NC-SA, 2012). 10
- 11. Advance Directives ā¢ Living will ā āDo not resuscitateā ā Wishes regarding artificial food or drink ā¢ Durable power of attorney for health care ā Designates someone to make decisions ā Can be combined with instructions in living will 11
- 12. Arguments about Advance Directives Pros Cons ā¢ Preserves patient autonomy ā¢ May lead to undertreatment ā¢ Prevents waste of resources ā¢ May be motivated by fear ā¢ Helps family know patientās wishes ā¢ Can waste providersā time 8.8 Table: Pros and cons of advance directives (CC BY-NC-SA, 2012). 12
- 13. Conflict of Interest āA conflict of interest is a set of circumstances that creates a risk that professional judgment or actions regarding a primary interest will be unduly influenced by a secondary interest.ā āInstitute of Medicine (2009) 13
- 14. Primary and Secondary Interests in Medical Practice Primary Secondary ā¢ The welfare of patients ā¢ Financial gain ā¢ The integrity of medical research ā¢ Desire for professional advancement ā¢ The quality of medical education ā¢ Recognition for personal achievement ā¢ Favors to friends and family or to students and colleagues 8.9 Table: Primary and secondary interests in medical practice (CC BY-NC-SA, 2012). 14
- 15. Physician Compensation ā¢ Payment for each service ā Can motivate physicians to inappropriately increase the number of services they provide ā Can motivate selection of services that have a high profit margin ā¢ Flat fee per patient ā Can motivate undertreatment 15
- 16. Health Care Disparities ā¢ Differences in access to health care ā¢ Differences in quality of health care ā¢ Differences in overall health ā¢ Most frequent comparisons are by ā Socioeconomic status ā Race ā Presence or absence of disability 16
- 17. Causes of Health Differences ā¢ Natural biological variation ā¢ Voluntary participation in potentially health-damaging activities, such as certain sports ā¢ Exposure to unhealthy, stressful living and working conditions ā¢ Inadequate access to essential health services and other basic services 17
- 18. Systematic Discrimination ā¢ Three features, when combined, turn a mere difference in health into a social inequity in health: ā The difference is systematic ā The difference is socially produced and therefore modifiable ā The difference is unfair 18
- 19. Conscientious Objection ā¢ A health care professionalās moral or religious objection to a certain medical intervention ā¢ Health care professionals have refused to provide medical interventions, for example: ā Abortions ā Sterilization procedures, such as vasectomy ā Pain medications for terminally ill patients ā Emergency contraception 19
- 20. Conscience, Ethics, and Law ā¢ Laws protect patientsā rights to access to medical interventions ā¢ Laws protect medical professionalsā rights to refuse to provide certain medical interventions ā¢ Laws vary from state to state 20
- 21. Ethics and Professionalism Summary ā Lecture c ā¢ Informed consent is based in the duty to respect patient autonomy ā¢ Caring for terminally ill patients involves thorny ethical questions about the definition of death, medical futility, and the use of advance directives ā¢ Conflicts of interest can pose temptations ā¢ Health inequities require society-wide solutions ā¢ Conscientious objection represents a clash between professionalsā rights and patientsā rights 21
- 22. Ethics and Professionalism References ā Lecture c References Braveman, P. (2014). What are health disparities and health equity? We need to be clear. Public Health Reports, 129. Committee on Bioethics, American Academy of Pediatrics. (2009). Policy statement: Physician refusal to provide information or treatment on the basis of claims of conscience. Pediatrics, 124(6),1689ā 1693. De Bord, J. (2014). Ethics in medicine: Informed consent. University of Washington School of Medicine. Retrieved from http://depts.washington.edu/bioethx/topics/consent.html del Carmen, M. G., & Joffe, S. (2005) Informed consent for medical treatment and research: A review. Oncologist, 10(8), 636ā641. Institute of Medicine. (2009). Conflict of interest in medical research, education, and practice. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK22942 Jecker, N. S. (2014). Ethics in medicine: Medical futility. University of Washington School of Medicine. Retrieved from https://depts.washington.edu/bioethx/topics/futil.html Kong, W. M. (2015). What is good medical ethics? A clinicianās perspective. Journal of Medical Ethics, 41(1), 79ā82. Retrieved from http://jme.bmj.com/content/41/1/79.full Marmot, M., Allen, J., Bell, R., Bloomer, E., & Goldblatt, P. (2012). WHO European review of social determinants of health and the health divide. Lancet, 380(9846), 1011ā1029. 22
- 23. Ethics and Professionalism References ā Lecture c Continued Oakley, J. (2015). Good medical ethics, from the inside outāand back again. Journal of Medical Ethics, 41(1), 48ā51. Pope TM.(2010). Legal briefing: Conscience clauses and conscientious refusal. Journal of Clinical Ethics, 21(2), 163ā176. Rich, BA. (2015). Your morality, my mortality: Conscientious objection and the standard of care. Cambridge Quarterly of Healthcare Ethics, 24(2), 214ā220. Schneiderman, L. J., Jecker, N. S., & Jonsen, A. R. (1990). Medical futility: Its meaning and ethical implications. Annals of Internal Medicine, 112, 949ā954. Tillyard, A. R. (2007). Ethics review: āLiving willsā and intensive careāAn overview of the American experience. Critical Care, 11(4), 219. University of Minnesota Center for Bioethics. (2005). End of life care: An ethical overview. Retrieved from http://www.ahc.umn.edu/img/assets/26104/End_of_Life.pdf Wade, J., Donovan, J., Paramasivan, S., Lane, A., Neal, D., & Hamdy, F. (2013). Evaluating best practice in informed consent discussions: A new method of evaluating information provision and patient understanding during trial recruitment consultations. Trials, 14(Suppl 1), O70. Whitehead, M. (1990). The concepts and principles of equity and health. World Health Organization Regional Office for Europe. Retrieved from http://publicaciones.ops.org.ar/publicaciones/piezas%20comunicacionales/cursoDDS/cursoeng/Te xtos%20Completos/the%20concepts%20and%20principles%20of%20equity%20and%20health.p df 23
- 24. Ethics and Professionalism References ā Lecture c Continued 2 Whitehead, M., & Dahlgren, G. (2006). Levelling up (part 1): A discussion paper on concepts and principles for tackling social inequities in health. World Health Organization Regional Office for Europe. Retrieved from: http://www.who.int/social_determinants/resources/leveling_up_part1.pdf Tables, Charts, Figures 8.7 Table: Pros and Cons of medical futility (CC BY-NC-SA, 2012). 8.8 Table: Pros and Cons of advance directives (CC BY-NC-SA, 2012). 8.9 Table: Primary and secondary interests in medical practice (CC BY-NC-SA, 2012). 24
- 25. The Culture of Health Care Ethics and Professionalism Lecture c This material was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. This material was updated in 2016 by Bellevue College under Award Number 90WT0002. 25
Editor's Notes
- No audio. Recording preparation.
- Welcome to The Culture of Health Care: Ethics and Professionalism. This is Lecture c. The component, The Culture of Health Care, addresses job expectations in health care settings. It discusses how care is organized within a practice setting, privacy laws, and professional and ethical issues encountered in the workplace.
- The objectives for Ethics and Professionalism are to: Discuss foundational concepts in medical ethics and professionalism Examine the relationships among ethical ideals, professionalism, and legal duties Apply the general principles of ethics and professionalism to specific topics Examine ethical issues in health informatics
- This lecture discusses contemporary topics in medical ethics. It provides several examples and top-line descriptions of some of the complicated issues that health care professionals face. This lecture focuses on informed consent, end-of-life issues, conflicts of interest, health care disparities, and conscientious objection.
- Informed consent is based in the duty to respect patient autonomy. Health care professionals are required, as both a legal and an ethical duty, to obtain informed consent from patients before administering treatment. Lack of informed consent is often the basis for a malpractice case. One of the basic tenets [ten-its] of informed consent is that the patient must be capable of making medical decisions. Most adults are presumed to have this capacity unless there is strong evidence to the contrary. An adult who is capable of making his or her own medical decisions must be given all the relevant information necessary to give valid informed consent. The information must be provided in a way that is understandable to the patient, and the patient must voluntarily communicate a decision to accept the treatment.
- Before giving informed consent, a patient needs to know the nature of the proposed treatment. This includes the purpose of the treatment and a description of how the treatment will be administered or performed. In order to give informed consent, a person also needs to know about the alternatives to the proposed treatment and the risks and benefits of each option. Physicians and nursing staff primarily have the responsibility of discussing treatment options and details with the patient and ensuring that the patient has a proper understanding of the medical treatment, associated risks, and benefits. Once the patient signs the informed consent, the document becomes part of the patientās legal medical record.
- If an adult doesnāt have the ability to make informed decisions, that person is said to lack the mental capacity to give informed consent. Examples are an adult with a severe developmental disability and an adult with dementia. Typically, in these cases, another person is designated to make decisions for the patient. That person is called a surrogate decision-maker. A child might have the mental ability and understanding to make his or her own decisions, but the law may deny them that right. In that case, the child is said to lack legal capacity to give informed consent. Sometimes an emergency situation is an exception to the rule of getting informed consent before treatment. For example, if a patient is unconscious and a surrogate decision-maker is not available in a life-threatening situation, it may be determined that the patient has given implied consent to treatment. Furthermore, some experts say that the principle of beneficence [beh-neff-fuh-sense] requires that treatment be provided under these circumstances.
- One definition of death is the point at which vital physical functions cease. However, medical advances have made it possible to blur the line between life and death. Cardiac resuscitation has made it possible to restart a dead heart. Ventilators have made it possible to keep a body breathing after brain function has ended. There are a multitude of ethical issues about how death is defined and when an individual person can be considered dead. The next few slides look at two other prominent issues related to end-of-life care: medical futility and advance directives.
- Medical futility is the term for a situation in which a physician concludes that providing treatment would not appreciably improve the patientās condition. This decision is made by considering published evidence from studies of other patients and the physiciansā estimates about whether the individual patient would receive some benefit from the treatment being considered. Advocates of the concept of medical futility say that denying futile treatment is not health care rationing. The decision is not made by considering how much the treatment will cost but rather whether an individual patient will benefit.
- The concept of medical futility is controversial for many reasons. Some people fear that the concept will be used to divert health care resources from disadvantaged populations. For example, some people worry that treatments could be labeled as futile in order to save money that would otherwise be spent on expensive treatments for elderly people in the last weeks of life or on patients who have a diagnosis such as cancer. People who support the concept of medical futility say that denying futile treatment makes it more likely that patients will receive the best treatment individualized to their situation. For example, rather than giving an expensive drug that is unlikely to save the life of a patient with late-stage cancer, a patient would be given hospice [ha-spis] care to improve his or her quality of life until the end. This is another area where lines may be blurred between the movement toward pay-for-performance reimbursement, covered services by insurance companies, the patientās wishes, and clinical practice.
- Respect for autonomy is a core element of medical ethics. However, sometimes patients reach a point where they are no longer able to decide for themselves about their health care. People use advance directives to make their wishes known in advance if such a situation arises. Two kinds of advance directives are living wills and durable powers of attorney for health care. Sometimes they are contained in one document. The laws governing these documents vary from state to state, but the basic aspects are governed by a federal law called the Patient Self-Determination Act. In a living will, a person describes his or her wishes about life-prolonging care. For example, some people may say they donāt want to be resuscitated if their heart stops beating, which is a ādo not resuscitate,ā or DNR order. Others may request not to be fed through tubes if they slip into a permanent vegetative state. In a durable power of attorney for health care, individuals assign someone else to make medical decisions for them when they are no longer able to. This document can be combined with a living will. For example, a living will might specify that the person doesnāt want artificial feeding but that all other important decisions are left to the judgment of the person named in the power of attorney.
- One of the arguments in support of advance directives is that they help preserve patient autonomy. In addition, itās argued that they can help prevent the waste of limited health care resources. Furthermore, proponents say that advance directives can help family members know the patientās wishes and help provide the family with peace of mind. Opponents of advance directives say that directives may make health care providers limit care inappropriately, leading to denying a patient potentially beneficial treatment. In addition, itās argued that some people are motivated by fear when writing a living will and therefore give unrealistic instructions. For example, they may underestimate their ability to handle pain or disability, or they may underestimate what their own will to live would be. Itās also argued that powers of attorney can waste health care providersā time. For example, health care professionals may need to spend time finding the person who is designated to make decisions.
- According to a report by the Institute of Medicine, [quote] āA conflict of interest is a set of circumstances that creates a risk that professional judgment or actions regarding a primary interest will be unduly influenced by a secondary interest.ā [end quote]
- Primary interests include such ideals as ethical obligations and professional duties. Secondary interests are an individual health care professionalās personal motivations. Itās not wrong for a physician to make a fair profit or to want respect from peers. A problem arises only when these personal goals have the potential to compromise decision-making about a primary interest, such as the best possible patient care. An example of a potential conflict of interest is the practice of pharmaceutical companies giving gifts to physicians. Some researchers argue that even small gifts, such as pens and coffee mugs, can influence physicians to prescribe the companyās drugs more often.
- One major area in which physicians face conflicts of interest is compensation for their services. Whether physicians are paid by the service or by the patient, their method of compensation involves potential conflicts of interest. When physicians are paid for each service they provide, they may find reasons to maximize their number of services. If they inappropriately provide unnecessary services, they are increasing health care spending at the expense of the patient and society. In addition, physicians might be motivated to select services with a high profit margin, such as diagnostic imaging, when it may not be appropriate. Physicians who are paid a flat fee per patient may be motivated to minimize the number of services they provide to each person. Compensation is just one example of the many kinds of conflicts of interest that physicians face in clinical practice.
- A topic of much ongoing study is health care disparities. Itās well documented that, on average, middle-class and rich people receive better health care than poor people do; white people receive better health care than people of color do; and people who have no disabilities receive better health care than people who have disabilities. In addition, within each of these groups there are differences in average overall health.
- There are numerous reasons why the health of one group of people differs from that of another group. One reason is that groups of people have different biological characteristics. Another reason is that people in one group may have higher rates of participation in potentially health-damaging activities. Exposure to unhealthy work environments or neighborhoods can also vary between members of different groups. In addition, there are differences in access to health care.
- A combination of factors can turn a difference in health into a social inequity in health. The difference must be systematic, socially produced, and unfair. How to address discrimination in health care is the topic of vigorous, ongoing debate.
- The term conscientious objection refers to a situation in which a health care professional has a moral or religious objection to providing a particular medical intervention. There have been numerous situations in which medical professionals have refused to provide medical interventions on the basis of their beliefs. In fact, recently some medical students have been refusing to even learn about certain procedures. The flip side of a health care professionalās right to refuse to provide certain interventions is the right of patients to determine the course of their own health care. For example, if a woman who needs emergency contraception has access to only one pharmacy, and the pharmacist refuses to provide emergency contraception, then patient autonomy is lost.
- Laws address the clash between the conscientious objections of health care professionals and the respect for patient autonomy. These laws vary widely among states. For example, some states have laws that protect the right of physicians and pharmacists to refuse to dispense emergency contraception. Other states require these professionals to provide women with such drugs. Given the strong competing individual rights of health care professionals and patients, issues of conscientious objection are likely to be the topic of passionate debate for the foreseeable future.
- This concludes Lecture c of Ethics and Professionalism. In summary, health care professionals face numerous difficult ethical questions, including informed consent, end-of-life issues, conflicts of interest, health care disparities, and conscientious objection. Informed consent is based in the duty to respect patient autonomy and is one of the pillars of the physician-patient relationship. End-of-life care presents difficult questions about the definition of death, whether medical futility is a useful concept, and whether patients should be encouraged to complete advance directives. Conflicts of interest can pose temptations for physicians as they attempt to balance their personal interests with their ethical duties. Health differences have many causes, and inequities require society-wide solutions. Conscientious objections represent a clash between health care professionalsā rights and patientsā rights. They are addressed by laws that vary from state to state and that continue to evolve.
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