Disclosure I am not an Ethics Expert MOL State Mandate Kathleen Cowling, MS,DO,MBA, FAAEM, FACEP Goals Conflict Law stems from legislative statutes, administrative agency rules or the courts. Physicians are not always Ethical Ethical principles, however, are derived from the values of the society in which they are imposed. 1
1/26/18 Experiments Trials at Nuremberg Declaration of Geneva-1948 At the time of being admitted as a member of the medical profession: I SOLEMNLY PLEDGE to dedicate my life to the service of humanity; THE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration; I WILL RESPECT the autonomy and dignity of my patient; I WILL MAINTAIN the utmost respect for human life; I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient; I WILL RESPECT the secrets that are confided in me, even after the patient has died; I WILL PRACTICE my profession with conscience and dignity and in accordance with good medical practice; I WILL FOSTER the honor and noble traditions of the medical profession; I WILL GIVE to my teachers, colleagues, and students the respect and gratitude that is their due; I WILL SHARE my medical knowledge for the benefit of the patient and the advancement of healthcare; I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard; I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat; I MAKE THESE PROMISES solemnly, freely and upon my honor. 2
Where the expertise is Professional organizations Books Research IRB s Foundations 3
1/26/18 Founded in 1969, The Hastings Center is the world s first bioethics research institute. It is a nonpartisan, nonprofit organization of research scholars from multiple disciplines, including philosophy, law, political science, and education. Our team includes other staff members with expertise in communications, publishing, and finance and a worldwide network of elected Fellows, an active board, and an advisory council. The Hastings Center and its scholars produce books, articles, and other publications on ethical questions in medicine, science, and technology that help inform policy, practice, and public understanding. What makes EM special? Limited time to gather information No prior relationship Patients often in critical condition or lack capacity (dementia, intoxication, etc ) EMTALA obligation Institutional regulations ( Religion based) Societal expectations Community resource 4
It s 2 AM- Who can you ask guidance from? Ethics committee? Call the Chaplain Call the Administrator on-call Call Risk Management Phone a friend More than a gut feeling Impartiality- Would you do it yourself? Universality- Would you apply to all? Impersonal justifiability- Could you defend it? 5
THE FOUR PILLARS First- Do they have capacity? What is your understanding of your condition? Autonomy Physician respects the patient s ability to choose their own healthcare goal according to their own values What are the risks? What are the odds that you could have a bad outcome? What do you think will happen to you if you don t do this? What issues are important to you as you make your decision? 6
Autonomy and informed consent Self determination ability to make own decisions Autonomy Physician respects the patient s ability to choose their own healthcare goal according to their own values Paternalism occurs when the physician tries to convince the patient to choose a direction not in accordance with their own values, but with that of the physician s or society s Requires patient to have capacity Disclosure of risks for treatment by provider Patient must comprehend the significance risks Patient must voluntarily consent Most common challenge to Autonomy Refusal of care Reasons may stem from Family Religion Cultural Financial Fear 7
Document capacity They re leaving AMA Document discussion Witnesses Invitation to return Provide Rx s Beneficence Providers practice with the intent of doing good for the patient Promise no judgment Most common challenge to Beneficence When does Beneficence trump autonomy? 8
When does Beneficence trump autonomy? Suicidal or homicidal In these cases the beneficence to society trumps the patient s autonomy The case of the tattoo End of Life State law dictates who can say what to do Next of kin vs power of attorney Document who wants what Go with the higher level of care Nonmaleficence Do no harm is obvious it s why patients trust us 9
A Case of nonmalficence? Nonmaleficence Do no harm may seem obvioushowever restraining from overtreatment that could cause harm, or utilize unnecessary diagnostics is more subtle The case of Dr. Anna Pou Justice Is the pillar that is invoked when there are limited resources and a decision must be made regarding stewardship of said resources This is based on human equality, however this also involves the obligation to diagnose and treat patients in a cost-effective manner 10
Most common challenge to Justice What do we face daily that challenges justice? Triage- Trier to sort A system of clinical risk management when clinical needs exceeds capacity Prioritization based on threat to life Psychosocial harm to those who wait, from fear of being neglected Must reassure that limited resources are distributed fairly Treat with no bias for : gender race age sexuality faith insured status demeanor Impartiality 11
Futile care When we continue to provide care despite knowing that the outcome will not change Criteria for appropriate use of finite resources should include? a) Urgency of the patient s medical condition? b) Likelihood magnitude and duration of the medical benefit to the patient c) Burdens and costs of care to the patient d) Cost to society e) All of the above Ethics and EMTALA In 2000, CMS issued new amendments to the rules under 42 CFR 489.24, expanding the responsibility of the emergency room to respond to any "presentation" on the hospital campus or at any provider-based off-campus facility of the hospital Called 250 yard rule 12
References http://dx.doi.org/10.1136/medethics-2016-103531 http://dx.doi.org/10.1136/jme.2002.002832 http://dx.doi.org/10.1136/jme.25.6.435 http://dx.doi.org/10.1136/jme.26.4.291 https://cdemcurriculum.com/ethical-issues/ https://www.ncbi.nlm.nih.gov/pubmed/16877129 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4909960/ http://journals.lww.com/ccmjournal/citation/2016/12000/ Ethical_Dilemmas_in_Emergency_Medicine.61.aspx http://naemsp.org/documents/position%20papers/ POSITION%20EthicalChallengesinEMS.pdf http://www.nursingworld.org/mainmenucategories/anamarketplace/ ANAPeriodicals/OJIN/TableofContents/Vol-20-2015/No2-May-2015/Harmin-the-Emergency-Department.html https://depts.washington.edu/bioethx/tools/princpl.html#prin4 13