Introduction to Medical Ethics

1. Introduction to Medical Ethics Paul Dassow, MD, MSPH MD 815 November 15, 2006

2. Objectives • Explain the difference between morality and ethics • Describe the Standard Medical Ethic in place in today’s medical environment • Apply this Ethic to a real world situation • Understand the inherent difficulties with the current medical ethic • Know alternatives to the standard ethic

3. The case of Terri Schiavo • The facts: • Born Theresa Marie Schindler December 3, 1963 • In 1983, Terri met Michael Schiavo at Bucks County Community College and the two began dating. He was the first romantic interest Terri had. • The couple was engaged within a few months and married a year later at Terri’s church in Southampton, Pa. She was 21.

4. The case of Terri Schiavo • The facts: • In 1990, at the age of 26, Terri suffered a mysterious cardio-respiratory arrest for which no cause has ever been determined. She was diagnosed with hypoxic encephalopathy – neurological injury caused by lack of oxygen to the brain. Terri was placed on a ventilator, but was soon able to breathe on her own and maintain vital function. She remained in a severely compromised neurological state and was provided a PEG tube to ensure the safe delivery of nourishment and hydration

5. Terri Schiavo • Video clips from the last year of Terri’s life:

6. The case of Terri Schiavo • The facts: • On March 18, 2005, Terri Schiavo had her feeding tube removed under the order of Circuit Court Judge, George W. Greer of the Pinellas-Pasco’s Sixth Judicial Court. On March 31, 2005, Terri Schindler Schiavo died of marked dehydration following more than 13 days without nutrition or hydration. Terri was 41.

7. What was the right thing to do here?

8. Morals and Ethics • Moral: Of or concerned with the judgment of the goodness or badness of human action and character • Ethic: A principle of right or good conduct or a body of such principles

9. 1. What was the morality of the decision to pull Terri’s feeding tube?

10. 2. How do we decide what is the moral choice?

11. The Standard Medical Ethic • Rooted in the 1979 Belmont Report from the Committee on the use of Human Subjects in research • Principles: • Autonomy • Beneficence • Non-malfeasance • Justice

12. Autonomy • The principle that persons should be able to decide for themselves what action, if any, should be taken in regards to their medical care • Assumes appropriate informed consent • Assumes capacity • Needs clarification when a patient cannot speak (or think) for themselves

13. Beneficence • The principle that physicians should always do what is in the best interest of the patient • May vary from physician to physician (Kevorkian) • Is this what the physician would want done to them (the golden rule), or what they think the patient would want for themselves?

14. Non-malfeasance • The principle that physicians should not harm patients nor treat with intent to harm • Often decisions must be made regarding which course of action will likely cause the least harm • Again, physician dependent

15. Justice • The principle that persons should be treated equally and fairly, without prejudice in regard to gender, race, or personal creed. • Very difficult in our present system

16. So, back to Terri

17. Autonomy • Did Terri want her feeding tube removed? • No living will • Conflicting reports from husband and parents regarding “what Terri would have wanted.” • Since Terri deemed not to have the capacity to make decisions for herself, her next of kin (husband) is assigned the duty to make these decisions for her. • Terri’s next of kin said, “Yes.”

18. Capacity • Involves the demonstration of 3 characteristics: • Can understand the diagnosis and prognosis for a given condition • Can understand the treatment options • Can understand the possible consequences involved in the various treatment options

19. Beneficence • What would be the right course of action to benefit Terri? • Can death ever be considered a benefit for a patient? • Consider the Hippocratic Oath • Would pulling Terri’s feeding tube benefit her? • If so, how? • Was artificially feeding Terri just prolonging her suffering?

20. Non-malfeasance • Would pulling Terri’s feeding tube cause her harm? • Suffering from dehydration? • Is death the ultimate harm? • Were other motives at play in this decision • Money • Husband’s desire to “get on with life.”

21. Justice • Is there precedent for this decision. That is, are other similar patients treated the same way? • Neurologically impaired vs persistent vegetative state vs brain dead • Is there a national policy regarding how to treat these patients (only brain death)

22. What happens when principles conflict?

23. What happens when principles conflict? • In life and death decisions, typically Autonomy trumps others • Exception: Assisted suicide in most states not legal • In Terri’s situation, the legal case surrounded whether she was in a persistent vegetative state or not. • From this medical ethics framework, if autonomy trumps others, then pulling the tube was the right decision

24. A side note: Why did they pull the tube? Why not just not feed her?

25. So you’re the physician. Do you comply with the court decision?

26. The embattled physician • If you disagree with the court’s decision, most states would allow you to “opt out” of performing the act. • Examples: As a physician, you do not have to provide contraception or abortion services • However, some states do force behavior deemed essential to the job (eg, pharmacists must dispense emergency contraception)