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.