Clinical Ethical Issues:
Principles, Range of
Cases, History Lessons
Robert L. Perkel, M.D.
Chair, Thomas Jefferson University Ethics
Committee
The 2nd Annual Healthcare Leadership
Network of the Delaware Valley
Spring Institute, May 2, 2014
Objectives
To understand the principles that guide
every ethics case discussion and
dissection.
 To use case examples that describe
clinical ethical issues at the beginning,
in the prime, and at the end of life.
 To underscore the ultimate importance
of professionalism with lessons from
history

Bioethical Principles








Autonomy
Beneficence
Nonmaleficence
Justice
Truth telling
Informed Consent
Confidentiality
Futility
Practical Considerations
Particular clinical facts of “this case”
 Attitudes and beliefs
 “Culture” of the patient & physician
 Societal factors

 Demographics
(aging)
 Finances (fixed %GDP)
 Insurance (traditional v. prospective $$)
Ethics Case Discussion:
What the HEC does
Important “players” represented
 Case presentation: facts; data; questions
 Discussion: listen carefully; weigh different
opinions; “try on” opposing viewpoints
 Arrive at option(s)

 Support
with underlying principles
 Communicate to all “the players”
 Don’t tell people what to do
Range of Cases: HEC
Ethics at the Beginning of Life
 Ethics in the Prime of Life
 Ethics at the End of Life
 Ethics of Professionalism

Ethics at the Beginning of Life

Reproduction
 Human genome
 Cloning
 Abortion

project
The NICU “technology imperative”
 “I can, therefore I do”
 “Use it or lose it”
 Learning how and when
to say “No!”
Autonomy vs. Paternalism; Justice;
Informed Consent
Ethics in the Prime of Life
Dialysis; plasmapharesis
 BMT for certain malignancies
 HIV/AIDs

Autonomy vs. Social Justice
Autonomy vs. Beneficence
Competing Autonomies (“Duty to Warn”)
Bioethical Issues in HIV/AIDS

Individual vs. Society
 patient

autonomy vs. social justice
Individual vs. Individual
 competing

autonomies: patient vs. provider
End of Life/Medical Futility
 beneficence;

nonmaleficence
Allocation of Resources
 social
justice
Ethics at the End of Life:
Refusing Life Sustaining Treatment
vs. Requesting Assistance in Dying
37 yo F Multiple Myeloma
 Failed Alkeran/Prednisone, VAD
 “I’m tired … fed up … ready to die”
 “No CPR, no antibiotics, let me die”
 “Keep me comfortable”
 When the time comes, (“help me die”)

The Principle of Double Effect
Long history, primarily but not exclusively
in Roman Catholic tradition
 Supports claims that an act having a
harmful effect such as death does not
always fall under moral prohibitions such
as the rule against killing
 There is a morally relevant difference
between the intended effects of a person’s
action and the nonintended though
forseen effects of the action

4 Conditions That Must Be
Satisfied to Justify Double Effect
The action itself must not be intrinsically
wrong
 The agent must intend only the good effect
and not the bad effect
 The bad effect must not be a means to the
end of bringing about the good effect
 The good result must outweigh the evil
permitted

Helping Patients Die with Dignity:
A Continuum of Life/Death Issues
Withholding life support
 Withdrawing life support
 Physician assisted suicide
 Active euthanasia
 Gov’t & politics: lessons from history

Let History Judge
The Tuskegee Syphilis Experiment
 “The Nazi Doctors”

Objectives
To understand the principles that guide
every ethics case discussion and
dissection.
 To use case examples that describe
clinical ethical issues at the beginning,
in the prime, and at the end of life.
 To underscore the ultimate importance
of professionalism with lessons from
history.
