ETHICS & DECISION-MAKING

I. Definition of Ethics Ethics The study of a system of decision-making based on moral Principals Morality-traditions of belief about right/wrong human conduct. Values differences

ETHICS & DECISION-MAKING

Ethics brings structure & order to the decision-making process about our responsibilities for patient care and institutional management Larry McCullough, PhD.

ETHICS & DECISION-MAKING

Ethics should lead the Law Main discipline of Ethics is to follow the arguments where they lead us

ETHICS & DECISION-MAKING

Medicine is the science of uncertainty

and the art of probability

-W.Osler, M.D.

ETHICS & DECISION-MAKING

Families, Doctors, Nurses,Health care team members No simple algorithms to follow We have fiduciary obligations to our patients

ETHICS & DECISION-MAKING

Tools for Ethical Analysis

Clarity Consistency Coherence Clinical Applicability Clinical Adequacy

ETHICS & DECISION-MAKING

II. Principles Do good and Do no harm--Beneficence (Obligation as foundations of social morality) 1. One should not inflict harm 2. One should prevent harm 3. One should remove harm 4. One should promote good

ETHICS & DECISION-MAKING

Principles Justice Persons should be treated equally Many theories of justice

Respect for Autonomy to allow person to act for

themselves
Responsibility for self and family This means that the person understands Consent Disclosure of risk/benefits/complications

ETHICS & DECISION-MAKING

III. Approaches to Care Wait until certainty 1. Treatment started on every infant thought to have a chance 2. Collect all information before making decision Decision to err on side of maintaining life

ETHICS & DECISION-MAKING

3. Aggressive approach in accordance with society that values individual(ism) 4. Price to pay may have some patients with

severe handicaps to salvage that one

patient.

ETHICS & DECISION-MAKING

Statistical Approach 1. Categorizes patients into groups which would benefit from care 2. Goal is to avoid creating severely impaired infants even at cost of those who might have been normal

ETHICS & DECISION-MAKING

Individualized Approach 1. Initiate care on infants who have a chance 2. Deciding as soon as possible if continuing is in best interest of infant. 3. Decisions made before all information in 4. Problem What degree of certainty is necessary?

ETHICS & DECISION-MAKING

Responsibility Accountability Process should be consistent One needs to ethically justify ones decisions

ETHICS & DECISION-MAKING

The technology is imperative 1. Availability of technology 2. Does it mean we have to use it?

ETHICS & DECISION MAKING

Tyranny of the Normal 1. Only acceptable outcome is normal (subjective & varies from person to person) 2. Worry about unrealistic expectations 3. Need to understand family value systems

ETHICS & DECISION-MAKING

IV. Principal of Best Interests 1. Patient can not speak for self. 2. Parents have responsibility for decision-making. Who are we treating the patient or the family?

ETHICS & DECISION MAKING

Certainly want: 1. Relief of suffering 2. Preservation or restoration of function

3. Quality of life (subjective)

ETHICS & DECISION-MAKING

Outcome Anecdotal experiences both positive and negative How many times have we been wrong?

ETHICS & DECISION-MAKING

IV. Principal of Proportionality Treatment should lead to greater benefit than burden. One needs to agree on expectations 1. Curing the patients 2. Restoring patient to reasonable quality of life 3. Minimizing pain & suffering

ETHICS & DECISION-MAKING

V. Who Decides? Decision-making Team 1. Physicians 2. Parents & Family 3. Other members of healthcare team

ETHICS & DECISION-MAKING

Today there is increased respect for patient autonomy 1. Role of parents in decision-making is increased 2. We should not be afraid to think out-loud a. This closes the gap between physician/parent. b. Demonstrate the trial & error nature of treatment. c. Parents need time to process information

ETHICS & DECISION-MAKING

Rationing-using limited resources wisely Needs Ethical Impact Statement

Needs to meet rigorous standards

Scientific
Moral

Economic

ETHICS & DECISION-MAKING

Summary Very Important 1. Honest decisions with patients and family early 2. Awareness of power of decisions made each hour 3. Responsibility of thinking 4. Justification of thought

ETHICS & DECISION-MAKING

Summary Very Important 5. Respect for life 6. An acceptable decision may mean no intervention 7. Physician needs skill to help families explore their values 8. Cannot leave family alone in decision-making process 9. Decisions should be difficult

Tools for Ethical Analysis

Clarity Consistency Coherence Clinical Applicability Clinical Adequacy