This document discusses several core ethics principles: autonomy, beneficence, nonmaleficence, justice, informed consent, confidentiality, and others. It provides definitions and examples for each principle. Several case studies involving ethical dilemmas in healthcare are also presented, including conflicts between patient/family wishes and physician recommendations for treatment. The document advocates using an ethical decision-making process and calling an ethics consultation to help resolve complex cases.

1. Core ethics principles
Ethics Consultation Process
Dr Thana Ram Patel
Assistant Professor
Department of general surgery
Dr SN medical college jodhpur

2. Morals
 An individual’s own code for acceptable
behavior
 They arise from an individual’s
conscience
 They act as a guide for individual
behavior
 They are Learned

3. Ethics
 Ethics deals with the
“rightness” or
“wrongness” of human
behavior
 Concerned with the
motivation behind the
behavior
 Bioethics is the
application of these
principles to life-and-
death issues

4. Ethical Principles
 Four core ethics
 Autonomy
 Nonmaleficence
 Beneficence
 Justice
 Other terms
 Fidelity
 Confidentiality
 Veracity
 Accountability

5. Autonomy
 The freedom to make decisions about oneself
 The right to self-determination
 Healthcare providers need to respect patient’s
rights to make choices about healthcare, even if the
healthcare providers do not agree with the patient’s
decision.

6. autonomy
 Obligation to respect patients as
individuals (truth-telling,
confidentiality), to create conditions
necessary for autonomous choice
(informed consent), and to honor their
preference in accepting or not
accepting medical care.

7. confidentiality
 Confidentiality respects patient privacy and
autonomy. If the patient is incapacitated or the
 situation is emergent, disclosing information to
family and friends should be guided by
 professional judgment of patient’s best interest.
The patient may voluntarily waive the right to
 confidentiality (eg, insurance company request).
 General principles for exceptions to
confidentiality:
 ƒ
Potential physical harm to self or others is
serious and imminent
 ƒ
Alternative means to warn or protect those at
risk is not possible
 ƒ
Steps can be taken to prevent harm

8. confidentiality
 Examples of exceptions to patient confidentiality (many are
state specific) include the following (“The physician’s good
judgment SAVED the day”):
 ƒ
Patients with Suicidal/homicidal ideation
 ƒ
Abuse (children, older adults, and/or prisoners)
 ƒ
Duty to protect—state-specific laws that sometimes allow
physician to inform or somehow protect potential Victim from
harm
 ƒ
Patients with Epilepsy and other impaired automobile
drivers
 ƒ
Reportable Diseases (eg, STIs, hepatitis, food poisoning);
physicians may have a duty to warn public officials, who
will then notify people at risk. Dangerous communicable
diseases, such as TB or Ebola, may require involuntary
treatment.

9. Informed consent
 Patients must have a comprehensive
understanding of their diagnosis and
the risks/ benefits of proposed
treatment and alternative options,
including no treatment.
 Patients must be informed of their
right to revoke written consent at any
time, even orally.

10. Informed consent – 3
components
 A process (not just a
document/signature) that requires:
 ƒ
Disclosure: discussion of pertinent
information, including risks/benefits
(using medical interpreter, if needed)
 ƒ
Capacity: ability to reason and make
one’s own decisions (distinct from
competence, a legal determination), ƒ
Understanding: ability to comprehend
 ƒ
Voluntariness: freedom from coercion
and manipulation

11. Decision making capacity
 Four major components of decision-making:
 Understanding (what do you know about
your condition/proposed procedure/
treatment?)
 ƒ
Appreciation (what does your condition mean
to you? why do you think your doctor is
recommending this course of treatment?)
 ƒ
Reasoning (how are you weighing your
options?)
 ƒ
Expressing a choice (what would you like to
do?)

12. Decision making capacity
 Physician must determine whether the patient is
psychologically and legally capable of making a
particular healthcare decision.
 Note that decisions made with capacity cannot be
revoked simply if the patient later loses capacity.
 Intellectual disabilities and mental illnesses are not
exclusion criteria unless the patient’s condition
presently impairs their ability to make healthcare
decisions.
 Capacity is determined by a physician for a specific
healthcare-related decision (eg, to refuse medical care).
 Competency is determined by a judge and usually
refers to more global categories of decision-making (eg,
legally unable to make any healthcare-related decision).

13. Exceptions to informed consent
(WIPE it away):
 ƒ
Waiver—patient explicitly
relinquishes the right of informed
consent
 ƒ
Legally Incompetent—patient lacks
decision making capacity (obtain
consent from legal surrogate)
 ƒ
Therapeutic Privilege—withholding
information when disclosure would
severely harm the patient or undermine
informed decision-making capacity
 ƒ
Emergency situation—implied
consent may apply

14. Surrogate decision maker
 If a patient loses decision-making
capacity and has not prepared an
advance directive, individuals
(surrogates) who know the patient
must determine what the patient would
have done.
 Priority of surrogates: spouse Ž
adult
children Ž
parents Ž
adult siblings Ž
other relatives (the spouse chips
in).

15. Consent for minors
 A minor is generally any person < 18
years old.Parental consent laws in
relation to healthcare vary by state. In
general, parental consent should be
obtained, but exceptions exist for
emergency treatment (eg, blood
transfusions) or if minor is legally
emancipated (eg, married, self-
supporting, or in the military).

16. Consent for minors
 Situations in which parental consent is usually not
required:
 Sex (contraception, STIs, prenatal care - usually not
abortion)
 ƒ
Drugs (substance use disorder treatment)
 ƒ
Rock and roll (emergency/trauma)
 Physicians should always encourage healthy minor-
guardian communication.
 Physician should seek a minor’s assent (agreement of
someone unable to legally consent) even if their
consent is not required

17. Beneficence
 This principle means
“doing good” for others
 Nurses need to assist
clients in meeting all their
needs
◦ Biological
◦ Psychological
◦ Social

18. beneficence
 Physicians have a special ethical
(fiduciary) duty to act in the patient’s best
interest. May conflict with autonomy (an
informed patient has the right to decide)
or what is best for society (eg,
mandatory TB treatment). Traditionally,
patient interest supersedes.
 Principle of double effect—facilitating
comfort is prioritized over potential side
effects (eg, respiratory depression with
opioid use) for patients receiving end-of-
life care.

19. Nonmaleficence
 Requires that no harm be caused to an
individual, either unintentionally or
deliberately
 This principle requires nurses to protect
individuals who are unable to protect
themselves

20. nonmaleficence
 “Do no harm.” Must be balanced
against beneficence; if the benefits
outweigh the risks, a patient may
make an informed decision to proceed
(most surgeries and medications fall
into this category).

21. Justice
 Every individual must be treated
equally
 This requires nurses to be
nonjudgmental

22. justice
 To treat persons fairly and equitably.
This does not always imply equally
(eg, triage).

23. Other ethics terms

24. Fidelity
 Loyalty
 The promise to fulfill all
commitments
 The basis of accountability
 Includes the professionals
faithfulness or loyalty to
agreements &
responsibilities accepted as
part of the practice of the
profession

25. Confidentiality
 Anything stated to nurses or health-
care providers by patients must
remain confidential
 The only times this principle may
be violated are:
◦ If patients may indicate harm to
themselves or others
◦ If the patient gives permission for the
information to be shared

26. Veracity
 This principle implies
“truthfulness”
 Nurses need to be truthful
to their clients
 Veracity is an important
component of building
trusting relationships

27. Accountability
 Individuals need to be
responsible for their own
actions
 Nurses are accountable
to themselves and to
their colleagues

28. Ethical Dilemmas
 Occur when a problem
exists between ethical
principles
 Deciding in favor of one
principle usually violates
another
 Both sides have
“goodness” and
“badness” associated with
them

29. Why call an Ethics Consult?
 Ethics Consult can help:
◦ Discover and understand the issues
◦ Serves as a forum for sharing of concerns and
questions
◦ Identifies possible treatment alternatives
◦ Provides guidance to the staff, patient, and
family members
◦ Resolves conflicts

30. Using the Nursing Process
 Assessment
 Planning
 Implementation
 Evaluation

31. Approach to Ethical Dilemma
What Values are in conflict
Collect
the facts
Am I involved
Assessment
List and
Rank the options
Identify
Decision-Makers
Determine goals
of treatment
Planning
Use of
discussion and
negotiation
Work towards
a mutually
acceptable decision
Implementation
Re-evaluate as necessary
Determine
whether desired
outcomes have been
reached
Evaluation
Approach

32. Ethical Decision Making Process
 Describe the problem
 Gather the facts
 Clarify values
 Note reactions
 Identify ethical Principles
 Clarify legal rules
 Explore options and alternatives
 Decide on a recommendation
 Develop an action plan
 Evaluate the plan

33. Case #1
Patient is an 89 year old male admitted with
Hyperkalemia, ESRD, HTN, and Bladder Cancer.
Patient’s past medical history includes recurrent
bladder carcinoma, CVA, hernia repair and
hemodyalisis. Patient was admitted due to weakness
and 2 weeks of diarrhea for which he had refused to
be dialyzed for 7 days.
Patient lives at home with wife and daughter who
are both his healthcare surrogates. Based on
patient’s poor prognosis, oncologist had
recommended on previous admissions that patient
be made Hospice Care with comfort measures.

34. Case #1 Cont.
Daughter and wife have refused Hospice care and
want patient to be dialyzed and continue
aggressive treatment to include full
resuscitation if cardiopulmonary arrest.
Daughter and wife have requested all
physicians to refrain from speaking to patient
about his prognosis.
At this time all physicians have followed
daughter and wife’s request not let patient know
that his cancer has returned, except for the
“new” attending physician.

35. • Autonomy?
• Nonmaleficence?
• Beneficence?
• Justice?
• Fidelity?
• Confidentiality?
• Veracity?
• Accountability?
Is there an Ethical dilemma?

36. What would you do?
 Tell “new” physician to get on board with
the rest of the healthcare providers in
following the wife and daughter’s request…
 Tell the patient that his wife and daughter
are keeping information from him…
 Do nothing…
 Call for an ethics consult?

37. Ethical Decision Making Process
 Describe the problem
 Gather the facts
 Clarify values
 Note reactions
 Identify ethical Principles
 Clarify legal rules
 Explore options and alternatives
 Decide on a recommendation
 Develop an action plan
 Evaluate the plan

38. Resolution
 Ethics spoke with Attending physician and plan
was to speak first with daughter and wife
regarding their role as health care surrogates.
 Attending physician, healthcare team, and
ethics would then meet with patient and inquire
if he wanted information regarding his prognosis
and/or medical care.
 After speaking with daughter, wife, and patient
individually and obtaining a clearer
understanding of the patient’s wishes, and the
clarification of the healthcare surrogates role, a
family conference would be scheduled with
health care team and family to summarize the
findings…

39. Resolution
 Things never go as you plan them…
 Daughter refused to have wife speak with
the team
 Daughter wanted to be part of the
conversation when attending spoke to her
father to inquire if he wanted information or
not…
 Attending agreed to let daughter be present
during the conversation (mistake)

40. Case # 2
88 year old male with extensive medical history including end stage
Parkinson's disease. He was admitted due to pneumonia and was
intubated and now is in Intensive care unit. Patient’s wife was
identified as proxy since patient had never completed an Advance
Directive or had a Living Will.
2 weeks have passed and patient has been unable to be weaned from
ventilator.
Wife continues to indicate she wants to take patient home on the
ventilator…
Attending physician did not feel that wife’s request to take patient
home were realistic nor did he feel patient would have “a good
quality of life.”
His recommendations were Comfort Measure/Withdraw of life
support.

41. Case # 2 Continued
Palliative Care is involved and many family
conferences have been held. Wife refuses to
make patient a Do Not Resuscitate, or sign any
type of withdrawal papers. She wants “full care”
She continues to verbalize she wants to take patient
home.
Wife had full time 24 hour care team at home
taking care of patient and she wants to take him
home.
Ethics consult is called by attending physician….

42. What would you do?
 Try to convince wife that a DNR would
be the best for the patient in his
condition…
 Speak to physician to find out what he
plans to do next…
 Call for an ethics consult

43. Ethical Decision Making Process
 Describe the problem
 Gather the facts
 Clarify values
 Note reactions
 Identify ethical Principles
 Clarify legal rules
 Explore options and alternatives
 Decide on a recommendation
 Develop an action plan
 Evaluate the plan

44. Resolution
Palliative Care and ethics consultant met with wife and
she understood that if he went home, he would have to
have a tracheotomy. Recommendations from team
was to arrange Respiratory department to show
caregivers and wife how to take care of patient once
he was at home with tracheotomy.
Wife agrees to tracheotomy and a consult is requested.
Wife was also informed of him having to go to a skilled
nursing facility first and then after he was stronger
would be able to go home.
Patient was trached and discharge to skilled nursing
facility for rehab.

45. Case #3
54 year old male - history of previous subdural hematoma, HTN,
and atrial fibrillation. Patient aspirated and coded. He is in
intensive care unit on ventilator and Dopamine for
hemodynamic stability.
Attempts at weaning have been unsuccessful…wife (healthcare
surrogate) signed consent for tracheotomy in order for patient to
be weaned off ventilator as recommended by pulmonologist…
On the same day wife signed consent for tracheotomy, Primary
Care Physicians during rounds feels that his prognosis is poor,
and his recommendation for plan of care is to have patient made
CMO and eventually withdrawal of life support should be
initiated, he did not agree with pulmonologist
recommendations…
Pulmonologist does not agree with current plan to make patient
CMO and withdrawal and wants to continue therapy…”he can
improve, give him time”.

46. Case #3 Cont.
Pulmonologist contacts wife regarding the scheduling of
the tracheotomy, and is surprised to find out that she
has signed papers for Comfort Measures Only &
withdrawal of ventilator…
Family is now confused with conflicting goals of
care…wife has agreed to CMO and withdrawal of
vent after speaking with attending but is still not sure
she is doing the right thing…she would like to give
time but “how long?”
Staff is torn between wife’s decision and her
verbalization of “confusion” and physician’s
recommendations and conflicting opinions by
pulmonologist and attending physician…
Pulmonologists calls for ethics consult…patient is not
withdrawn awaiting ethics recommendations…

47. What would you do?
 Tell wife attending is right and she should
sign the CMO papers…
 Tell wife she should get a pulmonologists
second opinion…
 Call Risk Management because of the
conflict between the attending and
pulmonary doctor…
 Call attending and tell him wife is
confused…
 Do NOTHING!
** Ethics Consult was requested by
pulmonologist…

48. Ethical Decision Making Process
 Describe the problem
 Gather the facts
 Clarify values
 Note reactions
 Identify ethical Principles
 Clarify legal rules
 Explore options and alternatives
 Decide on a recommendation
 Develop an action plan
 Evaluate the plan

49. Resolution
 Social Work and ethics chair spoke individually to
attending and pulmonologist to clarify goals of care and
prognosis.
 Social Work and ethics consultant spoke with patient's wife
and she verbalized her confusion but had agreed to sign
CMO and Withdrawal of life support at the time because
she didn’t really understand what that meant…
 Wife wanted to give her husband a chance to be weaned off
ventilator and she rescinded the CMO and Withdrawal of
Life Support forms
 Patient had the scheduled trache done the following day
 Patient was transferred to vent floor and was transferred to
long term care facility for rehab…