Prevent the infliction of needless pain
Prevent incapacitating others.
Do not kill
Do not cause needless pain.
Do not incapacitate others
Who benefits from my action and in what way?
What steps can I take to minimize this harm?
Which parties may be harmed by my action?
Have I communicated risks involved in a truthful and open manner?
In the event of a disaster, how can I avert the possible harm caused?
BF=Demand for positive benefit, Demands action
NMF= Avoidance of positive harm, Principle can be met by doing nothing
There are limits on what each person can do
Many treatment options contain both chance of benefit and risk of harm, Beneficence = chose acts that are likely to do more good than harm
Non-maleficence = NOT to do what produces more harm than good
HCP must consider various social agreements, about what is in the interest of the patient, standard of care within the profession, what patient agrees to., AND satisfies principles of non maleficence and beneficence.
What happens if not all these conditions are met? Rules of thumb:, If conflict, non-maleficence trumps the principle of beneficence., If two good kidneys from an almost dead man could help two patients on dialysis, we should NOT, Two good outcomes do not allow us to harm patients, Treatment offered: patient’s informed decision trumps HCPs offer, whether, obligatory (medically indicated), or optional, When a procedure has both harmful and beneficial outcomes,, treatment likely to bring significant benefit with only small risk is obligatory (language of Beauchamp) or indicated (language of Garrett) within limits of informed consent., treatment most likely to bring significant harm with only small chance significant benefit, is obligatory NOT to offer, even if the patient wants it, a treatment that is not likely to produce significantly more benefit than harm is optional (neither medically indicated nor medically not indicated).
Can we consider quality of life?, Ought HCPs distinguish medical benefit from questions of quality of life?, Some argue you cannot make judgments about medical benefit without estimates of quality of life. (Beauchamp and Childress and Garrett), AMA code recognizes quality of life for treatment decisions, Do quality of life considerations mean that we can decide not to treat the mentally retarded or severely disabled neonate? NO, mental retardation or disability ought not be a decisive factors by themselves in determining treatment, mental retardation or disability of a person, provides the horizon from which to produce quality of life estimates for the person, does not by itself eliminate quality from that person’s life, she can lead a life of some satisfaction even if it departs from a “normal life”, Note: We cannot use family financial or emotional burden as a main factor in determining how principles are used, the interest of the patient is fundamental, How to determine what counts as quality of life + medical benefit?, Competent patients; give most weight to patient’s views of benefit, Not competent; consult living will or surrogate, Communication that can resolve conflicts is the key
This “patient interest” approach to classifying treatment replaces more traditional accounts, Traditional accounts attempt to classify obligatory (or NOT) treatments in term of common sense notions of the differences between, preserving life / causing death, withholding treatment / withdrawing treatment, letting die / causing death, withholding medication / withholding nutrition and hydration, ordinary treatment / extraordinary treatment, Well known problems with these common sense distinctions, we can imagine cases where preserving life is against a patient’s interest; causing death might be a benefit
Distributing goods and services fairly
Have I identified all vulnerable groups affected by my action?
Is my proposed action equitable? How can I make it more equitable?
How are we to distribute expensive, scarce, medical services, The formal principle of justice, HCPS treat equal cases equally, This principle does not tell which needs are most important.
Understanding needs; their significance for fair distribution, claim to any basic good is based on needs, disregarding individual’s needs amounts to neglect
What factors determine medical need?, Criteria to use:, likely benefit to the patient, urgency of need, change in quality of life,, duration of benefit., Criteria not to use:, ability to pay, social worth, patient contribution to illness, use of past resources
Three different levels of social justice questions, National level, Determine medical needs, Costs of basic goods must be considered, No society can provide everything that everyone needs/ wants., Economic considerations; prevent destroying the economy., Emphasize the need for due process, ensure that acceptance of rationing, proceeds through an open process, which, produces a general consensus, Failure of due process results in procedural unfairness., Institutional level, Often conceived on the military model of medical triage, sorting sick and wounded, based on urgency and type of problem, for proper treatment, Good of the group has precedence over the individual, Note that triage disregards everything but determining which patients to treat first, based on, medical indications, needs of the individual patients, The triage model is appropriate for situations of scarcity (ICU), government hospitals (open to all), grant priority to the disadvantaged based on medical need, assumption: those with health insurance or sufficient wealth can obtain services elsewhere., Academic medical centers:, preference to cases which increase knowledge, allocation based on contribution to society, Individual HCP provider-patient level, HCPs ought not to ration at the bedside (AMA Code), Rationing, not a part of HCP’s traditional, will violate, the formal principle of justice ("treat similars similarly"), demand for due process in est. rationing policies., HCP, Is an advocate for patient in institutional setting, has a larger responsibility, as citizen and expert
Does my action impinge on an individual's personal autonomy?
Do all relevant parties consent to my action?
Do I acknowledge and respect that others may choose differently?
In health care, translates into the principle of informed consent, not treat a patient without informed consent or that of lawful surrogate, except in narrowly defined exceptions
Informed consent requirements, >18 + or “emancipated minor” (granted the status of adulthood by a court order), Patient / surrogate be competent and, capable of understanding consequences, capable making a free choice, capable of rational conduct, free from coercion or undue influence., What is required for ‘competent’?, presume that adult patients are competent, minors are , by definition, incompetent, Know that she is authorizing medical treatment; understands, effects of treatment, options in terms of, health, life/ lifestyle, religious beliefs/ values
Issues relating to competence, Competence = competence to make specific treatment decision, The patient has values different HCP does not make him incompetent, Standards for competence; higher the greater the consequences
What to do in case a patient is incompetent? Hierarchy:, Living will? Not legally binding but expresses wishes, Not? consult surrogate decision maker:, designated durable power of attorney, family member, healthcare durable power of attorney, spouse, children of legal age, parents / siblings of legal age, other relative, close friend or caregiver.
Determining incompetence; consider inability to:, express preference, understand one’s situation and its consequences, understand relevant information, give a rational reason, give risk/benefit reasons, medical practitioners should assess medical decision making capacity, MacArthur Competency Assessment Tool for Treatment, Mini Mental State Examination, The tools appear to be an objective measure of competence
Decision-making if no longer competent; hierarchy of approaches, So far as possible, in order not to violate autonomy, Look up evidence of known prior preferences, patient’s chart, consulting people who know
If the HCP does not know preferences, make a substituted judgment; what would patient prefer, requires substantial information about the patient's views, not just preferences or interests of HCP or surrogate, If no sufficient basis for substituted judgment, HCP/ surrogate decide based on best interest (based on what a rational, normal person would…), If disagreement, A meeting should with all parties, hospital chaplain/ rabbi can help, if unsuccessful, consult institutional ethics committee, Courts can be consulted to order treatment or appoint a conservator.
HCP provide and make understandable necessary information for, making a free, intelligent treatment decision, make sure that the patient or surrogate understands, using reflective conversation with patient, HCP spend time getting to know patient, health care provider must recommend optimal option
Satisfying the demand for consent - two possible standards, The prudent person rule requires the patient knows and understands:, The diagnosis, The treatment, Nature and purpose, Risks and consequences (excluding remote probabilities), Doctor’s / hospital’s success rate, The benefits expected, All alternatives treatments, The prognosis if no treatment, All costs and burdens, Subjective substantial disclosure rule, HCP describes to patient everything important to that patient, this rule invalidates any blanket disclosure policy, "Could this information change the decision of this particular person in this particular circumstance?", not informing patient’s of improbable risks violates this rule
Exceptions to explicit informed consent, Consent is implied and procedures not risky or invasive, Therapeutic privilege, If believed that information given will results in adverse effects, studies show that HCps misestimate adverse responses, therapeutic privilege is almost never justified, Emergencies, patient not competent, no surrogate available, patient’s advance wishes are not known, there is danger to life; danger of serious impairment to health, immediate treatment is necessary, Patient’s mentally incapacitated, Patient’s reason and sense of values affected by, illness, some transitory mood, lack of treatment would bring about an irreversible state, Here health care provider justified in postponing treatment
When is violating informed consent clearly unjustified?, Non-emergencies with incompetent patients, If no surrogate and no living will, Garrett: courts should appoint a guardian, Beauchamp and Childress: “a hospital, a physician, or family member my justifiably be placed in a decision making role or go before a court or other authority to seek resolution of the issues before a decision is implemented”, As manipulation; HCP influences decision by withholding information
Medical paternalism, overriding a patient’s autonomous preference, acting without consent in order to benefit the patient or prevent harm
Strong paternalism,, overriding of a competent patent’s explicit wishes, generally rejected, it violates autonomy, falsely presumes knowledge of what is best for the patient, falsely presupposes a clear set of values governing such decisions, Patients have the right to refuse treatment. Right to refuse treatment might be limited in court by appeal to:, parental obligations, suicide laws, when autonomy interest is weak in comparison to benefit to the patient, raising bed rails against a competent patient’s wishes, This sort of exception would not work for a Jehovah’s Witnesses refusing blood transfusion, since his or her autonomy interest would be strong.
Weak paternalism, acting for the benefit of an incompetent patient, justified in some cases in order to, restore competence,, protect a confused patient from harm