This document provides an overview of medical ethics. It defines ethics and medical ethics, and outlines key ethical principles like autonomy, beneficence, and nonmaleficence. It also discusses ethical duties such as veracity and confidentiality. The document then examines important topics in medical ethics including decision-making capacity, surrogate decision-makers, and advanced care planning. It presents three case studies that illustrate common ethical challenges and conflicts providers may face at the bedside. The document emphasizes the importance of communication, collaboration, and applying ethical frameworks when navigating complex clinical decisions.

1. Medical Ethics 101
Balancing obligation, outcomes, and risk
in clinical decision-making
Jill Ann Jarrell, MD, MPH
Complex Care Program, Academic General Pediatrics
Texas Children’s Hospital, Baylor College of Medicine

2.  Dr. Jarrell has no relevant conflicts of interest to
disclose
Disclosures

3. Patient-Provider Relationship

4. Patient-HealthcareTeam Relationship

5. “Ethics is a branch of philosophy; the
formal, rational, systemic examination
of the rightness and wrongness of
human actions.”1
What is “Ethics”?

6.  Evaluating the rightness and wrongness of human
actions in medicine
 Bioethics
What is “Medical Ethics”

7. Principles and Duties of Medical Ethics
Principles
• Autonomy
• Justice
• Beneficence
• Nonmaleficence
Duties
• Veracity
• Confidentiality
• Role Fidelity
• Respect for Societal
Institutions

8. Autonomy
• Individual liberty, dignity, and capacity
Justice
• What is fair or deserved
Beneficence
• An obligation to do good
Nonmaleficence
• An obligation to not harm
Ethical Principles

9. Veracity
• Truth telling
Privacy and Confidentiality
Role Fidelity
• Professional responsibility and autonomy
Respect for Societal Institutions
• Life, culture, family, religion
Ethical Duties

10. • Surrogate or substitute decision-making
• Advanced care planning
• Principle of double effect
• Informed consent
• Futility
HotTopics in Ethics

11. Able to understand medical treatment and
make informed decisions.
Decision-Making Capacity

12. Unable to understand the benefits, risks,
alternatives to treatment.
Incapacitated

13. Individual with authority to consent to
medical treatment for an incapacitated
patient.
Surrogate Decision-Maker

14. • Spouse
• Adult child with POA or majority of adult
children
• Parents
• Clearly identified individual
• Nearest living relative
• Patient’s clergy
Surrogate Decision-Makers

15. Parents available
• Natural parents
• Adoptive parents
• Sole managing conservator
• Possessory conservator (non-invasive
procedures during possession)
Surrogacy in Minors

16. Parents not available
• Grandparent
• Adult sibling
• Adult aunt/uncle
• Educational institution with written
authorization
Surrogacy in Minors

17. Parents not available (cont’d)
• Adult with custody and written
authorization
• Court with jurisdiction
• Adult with care of child subject to
juvenile court
• Peace officer
Surrogacy in Minors

18. Schizophrenic Child
With Absent Family

19. • 17 yo male with paranoid
schizophrenia
• Attempted suicide
• Survived - multiple orthopedic and
internal injuries
History

20. • Poorly compensated from a
psychiatric perspective
• Mother quit visiting/answering calls
• Patient turned 18 during care
Conflict

21. Who is the decision-maker?
• Patient
• Mom
• CPS/APS
• Legal Guardian
Who is in charge?

22. • Beneficence
• Autonomy
• Social Responsibility
Ethical challenges

23. Pregnant patient with
terminal cancer

24. • 30 yo woman
• 24 weeks gestation
• Stage IV breast cancer
Pregnant Patient With Cancer

25. • Intractable pain
• Progressive encephalopathy
• Previously told herOB/GYN she wanted
to “have this baby”
Pregnant Patient With Cancer

26. • Patient’s condition declined
• Patient’s mother asked for hospice care for
her daughter
Pregnant Patient With Cancer

27. Pregnant Patient With Cancer
Two patients?

28. Pregnant Patient With Cancer
Who is the decision-maker?
• Patient
• Mother
• Healthcare team

29. Pregnant PatientWith Cancer
Ethical Challenges?
• Beneficence
• Nonmaleficence
• Social responsibility
• Role Fidelity

30. To trach or not to
trach…

31. • 5 yo withTrisomy 21, repaired CHD, CP
admitted for pneumonia
• PICU, intubated, difficult wean, trach
was discussed with family
• Palliative care consulted on HD 55 to
discuss “options”
History

32. • Palliative care recommended not to trach and
for medical team to collectively advise palliation
• ENT “just a technician” and uncomfortable
• PCP andCCM wish to proceed with trach
• Ethics committee consult requested
Conflict

33. • Benificence
• Non-maleficence
• Respect for family
• Autonomy (but how much?)
• Role fidelity
Ethical challenges

34. • Listening
• Conflict resolution
• Tolerance for ambiguity
• Ability to apply ethical principles and
carry out duties
Skills for Resolving Ethical Dilemmas2

35. • Medical indications
• Patient preferences
• Quality of life
• Contextual features
Framework for Ethical Decisions3

36. • Continue to LEARN about your discipline
and the ever-changing milieu in which it
is practiced
• COMMUNICATION and
COLLABORATION between care team
members and decision-makers is key to
success
Take Home Messages

37. Questions?

38. 1. Pellegrino, E.Toward a Reconstruction of Medical Morality.The
American Journal of Bioethics 2006; 6-65-71
2. “Legal and Ethical Issues” Physician Board Review Course in Hospice
and Palliative Medicine, MDAnderson Cancer Center, 10/12/2010.
3. JonsonA, Seigler M,WinsladeW. Clinical Ethics: A PracticalApproach
to Ethical Decisions in Clinical Medicine. 6th ed, page 11.
References