managing ethical situations & decisions mr. rob sibbaldms. marleen van laethem clinical ethicist...
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Managing Ethical Situations & Decisions
Mr. Rob Sibbald Ms. Marleen Van LaethemClinical Ethicist Clinical Ethicist London Health Sciences Centre St Joseph’s Health Care London
February 15, 2013
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
Agenda
0800 - 0820 - intro to ethics/decision making, clinical and organizational (Marleen)0820 - 0900 - consent / capacity / frameworks (Rob)0900 - 0930 - Catholic ethics, research ethics (Marleen)0930 - 0945 - recent cases (Rob)
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
How to manage ethical situations?
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
How to manage ethical situations?
1) Discern when issues have ethical implications2) Access supports and resources3) Know the minimum standard (legal as well as
hospital policies)4) Identify the appropriate decision-maker(s) 5) Reflect on values & alternative perspectives 6) Strive to be more than simply within limits;
strive to conduct ourselves ethically
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
What is ethics? (1/2)
• Ethics is concerned with principles and values, issues of right and wrong, and what we owe each other as persons
• A branch of philosophy concerned with the “right” and “virtuous” behavior
• Moral Theories• Rational Thought/Deliberation• Deciding which particular need, action,
value, or belief should have precedence over another
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
What is ethics? (2/2)
• When ethical issues are clear, Black & White, laws or guidelines are written
• E.g. get informed consent before diagnostics and treatments
• Mostly shades of grey
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
Reflective Practice
A challenge due to: fiscal restraints, scarce resources, “doing more with less”
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
Some ethical dilemmas – 1
A patient, recently diagnosed as HIV+, requests that his wife not be informed of his HIV status. Should his wish be respected? OrShould his wife be told?
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
Consider…
• To whom is your duty? Husband? Wife?
• Competing claims / priorities– His autonomous decision-making over
his Personal Health Information (PHI)– Her potential harm of infection
• Laws (protecting PHI, preventing spread of disease)
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
One Approach
Ethical Principles• Respect for autonomy• Beneficence – doing good• Non-maleficence – do no harm• Justice - fairness
Limitation: no specific priority of principles
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
Some ethical dilemmas – 2
An elderly patient has carcinoma of the prostate. Should he be told of his diagnosis against his son’s instructions?
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
Common signs of an ethical issue
The “ick” factor
the “six o’clock news” test
Uncertainty, disagreement or conflict about what ought to be done
Dignity or fairness is at stake
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
Resources
• Royal College of Physicians and Surgeons of Canada Ethics Tutorials
http://rcpsc.medical.org/test/research/learning_materials/ethics/tutorials/index.php
• CMA Code of Ethicshttp://policybase.cma.ca/dbtw-wpd/PolicyPDF/PD04-06.pdf
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
CMA CODE OF ETHICS
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
CMA Code of Ethics
• Fundamental Responsibilities• Responsibilities to the Patient• Responsibilities to Society• Responsibilities to the
Profession• Responsibilities to Oneself
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
10 Fundamental Responsibilities
1. Consider first the well-being of the patient.
2. Practise the profession of medicine in a manner that treats the patient with dignity and as a person worthy of respect.
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
30 Responsibilities to the Patient
– General Responsibilities– Initiating and Dissolving a Patient-
Physician Relationship– Communication, Decision Making
and Consent– Privacy and Confidentiality– Research
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
General Responsibilities
12. Inform your patient when your personal values would influence the recommendation or practice of any medical procedure that the patient needs or wants.14. Take all reasonable steps to prevent harm topatients; should harm occur, disclose it to thepatient.
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
Communication, Decision Making and Consent
21. Provide your patients with the information they need to make informed decisions about their medical care, and answer their questions to the best of your ability.22. Make every reasonable effort to communicate with your patients in such a way that information exchanged is understood.
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
Respect patient’s wishes
24. Respect the right of a competent patient toaccept or reject any medical care recommended.26. Respect your patient's reasonable request for a second opinion from a physician of the patient'schoice.27. Ascertain wherever possible and recognize your patient's wishes about the initiation, continuation or cessation of life-sustaining treatment.
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
Patients without capacity
28. Respect the intentions of an incompetent patient as they were expressed (e.g., through a valid advance directive or proxy designation) before the patient became incompetent.29. When the intentions of an incompetent patient are unknown and when no formal mechanism for making treatment decisions is in place, render such treatment as you believe to be in accordance with the patient's values or, if these are unknown, the patient's best interests.
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
Decision-making at various levels
• 1 patient (± family) + at least 1 member of the health care team = Clinical Ethics
• Affects multiple patients, potentially multiple stakeholders = Organizational Ethics
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
ORGANIZATIONAL ETHICS
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
Different from Clinical Ethics?
Clinical EthicsThe moral agent is the individual who is making the decisione.g. Patient, Substitute Decision Maker, Health Care Provider
If there is conflict, it is typically:• between patient and health care team, or • between family members, or • between health care team members.
Organizational EthicsThe organization is the moral agent.
Mission/Vision/Values are akin to the physician/nurse code of ethics.
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
Conflict in Organizational Ethics
Conflict is more likely than in clinical ethicsBecause there are many more stakeholders: LHIN, public, community partners, all professions, University, etc.
Process becomes even more importantBecause agreement on substantive values is unlikely.
Most organizational ethics issues are managed through procedural values – ensuring there is a fair process by which to manage ethical dilemmas.
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
Values
Organizational Ethics Values • Rationality • Transparency • Accountability
Specific wording in the Catholic context• Stewardship of resources • Social Justice (Engagement on behalf of the less
powerful, the marginalized and the dispossessed)
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
Top Organizational Ethics Issues
Resource Allocation• Resources are, by definition, scarce
(We don’t always acknowledge this basic fact.)• Applies to human capital as well as financial
Mission / Culture • How do we define ourselves? • How do we live in such a way as to honour our
identity / values? • How do we bridge the gap between who we are
and who we want to be?
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
More Organizational Ethics Issues
End of Life Care• How to support physicians and other staff? • How to appropriately educate and assist patients /
SDM to make difficult end of life decisions?
FundraisingGovernance HR related issuesUninsured patients Business development
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
Standards for Business Conduct
• Gifts/favours (what is nominal?)• No payment from a supplier if you
are in a position to make decisions about their service at the hospital
• Hiring family members• Conflicts of interest• Use of hospital resources
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
How to manage ethical situations?
1) Discern when issues have ethical implications2) Access supports and resources3) Know the minimum standard (legal as well as
hospital policies)4) Identify the decision-maker(s) 5) Reflect on values & alternative perspectives 6) Strive to be more than simply within limits;
strive to conduct ourselves ethically