John E. Snyder
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Introduction
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History of medical ethics
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Key ethical principles
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Advance Directives
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Cases
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Applications to public health
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A need for practical
medical ethics education
 Recognizes omnipresence
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of dilemmas
Systematic approach
Case-based
Offers guidance
Doesn’t define right/wrong
Incorporates cultural
competence
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Oath of Hippocrates ~5 B.C.
 Respect for confidentiality
 Strict prohibition for euthanasia
 Relationship boundaries with
patients
 Limitations in applicability to
modern world/medicine
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Oath of Maimonides ~1100 A.D.
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First AMA Code of Ethics in 1847
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Doctor’s Trial in Nuremburg in 1947
Nuremburg Code
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“Voluntary Consent”
Good for society and not “random”
Based on animals first
Risk should be low, or include the scientists
Tuskegee Syphilis Study, 1932-1972
The Belmont Report: Ethical Principles and
Guidelines for the Protection of Human Subjects
of Research
 IRBs
 Informed Consent
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Beauchamp & Childress, 1979
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The Principle of Beneficence
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The Principle of Non-Maleficence
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The Principle of Respect for Autonomy
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The Principle of Respect for Dignity*
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The Principle of Respect for Veracity*
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The Principle of Distributive Justice
* Snyder/Gauthier
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Medical practitioners should act in the best
interests of the patient.
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Medical practitioners must not harm the
patient.
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Capable persons must be allowed to accept or
refuse recommended medical interventions.
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Patients, their families, and surrogate decision
makers, as well as their health care providers,
all have the right to dignity.
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The capable patient must be provided with the
complete truth about her/his medical
condition.
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Health care resources should be distributed in a
fair way among the members of society.
Proposed approach of evidence-based medical ethics
 Based on the tenets of evidence-based medicine
(EBM), which:
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 Aims to apply the best available evidence (gained from
rigorous application of the scientific method) to clinical
decision making
 Seeks to assess the strength of evidence of the risks and
benefits of treatments (including lack of treatment) and
diagnostic tests
 Helps clinicians to learn whether or not any treatment will
do more good than harm
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Evidence-Based Medical Ethics:
 Aims to apply the best available “evidence” gained from EBM,
widely accepted ethical principles, and legal precedent
 Incorporates aspects of cultural competency and an evolving
medical knowledge set/technology (we can/but should we?),
and an evolving set of laws
 Helps clinicians guide patients to make “good decisions” for
themselves, particularly when options have potential to do both
good and harm
 Emphasizes that “right” and “wrong” decisions are personal
choices of the patient and are acceptable if they are wellinformed (it’s not about you)
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Some of the most difficult medical decisions are
made when the patient themselves is unable to
make them
 Includes how a patient’s life will end
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Natural Death Act, 1976 (California)
 First time a state allowed citizens to make their
choices for end-of-life care known in advance
 Physicians honoring this “directive” cannot be
charged with criminal liability or unprofessional
conduct
 Led to development of the “Living Will”
 Later led to the “Power of Attorney for Health
Care”
 These two documents collectively make up
Advance Directives
Legally executed document by a
capable patient
 Authorizes physicians to withhold
or withdraw life-sustaining medical
treatment when the patient, in the
future, lacks the capacity to make
health care decisions
 In some states requires a “terminal
condition”, but in others includes
states like PVS
 Can include decisions on “artificial
nutrition and hydration”
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Legal document a capable patient uses to
appoint a “health care agent” (HCA)
 Aka “representative”, “proxy”, “surrogate”
 Rules vary greatly from state to state
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That person will make decisions for the
patient when they are no longer capable
 Includes employing/discharging providers
 Includes consent to admit/discharge from
facilities
 Includes ability to give, withdraw, or
withhold consent for diagnostic and
therapeutic procedures
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A patient’s wishes for end-of-life care, in
particular, should be discussed in advance
with the HCA… but often are not
 When not, often result in conflicts between
family members
 Sometimes wishes are discussed but not
legally documented
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When a patient’s wishes are not
documented, the HCA should act using one
of two principles:
 “Substituted judgment”
 “Best interests standard”
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Come into play when there are no ADs
Laws vary to some degree by state with respect to “priority” status
of an individual to be a HCA on behalf of the patient
Laws also vary state to state by what determines a “marriage” or
“family”
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John Doe, 50 year old
AAM, found unresponsive
in an alleyway by
passersby
 Covered with blood
and dirt
 ? Homeless
 No identifying information
 Weak pulse, shallow
respirations
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In the field:
 Placed on a backboard, intubated,
and a hard cervical collar placed
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In the ED:
 Fractures to the pelvis and
bilateral femurs
 Splenic and liver lacerations
 Collapsed left lung
 Large intracranial hemorrhage
(subdural hematoma)
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Police involved, fingerprinting
unrevealing
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Place/keep on a ventilator ?
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Insert a PEG tube for
nutrition?
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Place an IV? A “central
line”?
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Transfuse blood?
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Take to the OR?
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How much do you do to
help this patient?
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How long do you wait
before moving forward?
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When do you stop
efforts/where do you draw
the line?
In patients with CNS injuries,
mechanical ventilation may
be necessary to support life
 Prolonged need for
ventilation and placement of a
tracheostomy may be
observed
 The goal of any patient on a
ventilator is weaning
 Study of 100 patients by
Namen, et al.:
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 GCS < 8: 33% success rate of
extubation
 GCS > 8: 75% success rate
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Canterbury V. Spence [1972]
464 F 2d 772, U.S. Court of Appeals,
District of Columbia Circuit
 Legally-recognized exceptions to
Informed Consent:
“… when a patient is unconscious or
otherwise incapable of consenting, and
harm from a failure to treat is
imminent and outweighs any harm
threatened by the proposed
treatment”
X
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The Principle of Beneficence
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The Principle of Non-Maleficence
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The Principle of Respect for Autonomy
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The Principle of Respect for Dignity
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The Principle of Respect for Veracity
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The Principle of Distributive Justice
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The Principle of Beneficence
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Injuries have been initially treated
Immediate death has been prevented
Life sustained until chances for recovery could be determined
Pain was treated
The Principle of Non-Maleficence
 The Principle of Respect for Autonomy
 The Principle of Respect for Dignity
 The Principle of Respect for Veracity
 The Principle of Distributive Justice
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The Principle of Beneficence
The Principle of Non-Maleficence
 Risks of interventions to date were weighed against benefits
 Further plan is being considered carefully with respect to this
principle
 Must consider a “line” to draw re: possible futility of efforts
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The Principle of Respect for Autonomy
The Principle of Respect for Dignity
The Principle of Respect for Veracity
The Principle of Distributive Justice
The Principle of Beneficence
 The Principle of Non-Maleficence
 The Principle of Respect for Autonomy
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Does not apply here
Patient cannot be identified
Family cannot be contacted
No “substituted judgment” can be made
A legal guardian must be sought
Must use “best interests standard” based on above two principles
▪ Take likelihood for recovery/improvement and contrast with pain/suffering and QOL may
attain
▪ Will reasonable goals be met or will the end of life be artificially postponed?
 Are there aspects of culture that should be considered here?
The Principle of Respect for Dignity
 The Principle of Respect for Veracity
 The Principle of Distributive Justice
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The Principle of Beneficence
 The Principle of Non-Maleficence
 The Principle of Respect for Autonomy
 The Principle of Respect for Dignity
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 Important as the patient is vulnerable and has no “voice”
 Must protect privacy and bodily integrity to greatest extent
possible
 Invasive life-sustaining measures should not be initiated simply
because the patient’s own wishes cannot be known
The Principle of Respect for Veracity
 The Principle of Distributive Justice
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The Principle of Beneficence
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The Principle of Non-Maleficence
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The Principle of Respect for Autonomy
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The Principle of Respect for Dignity
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The Principle of Respect for Veracity
 The legal guardian must receive all possible and relevant
information
 Information must be presented clearly and without
bias/leading
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The Principle of Distributive Justice
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The Principle of Beneficence
The Principle of Non-Maleficence
The Principle of Respect for Autonomy
The Principle of Respect for Dignity
The Principle of Respect for Veracity
The Principle of Distributive Justice
 Does not apply here
 Resources are not limited in this case***
 Decisions to withdraw or withhold medical treatment
cannot be made because:
▪ Patient cannot be identified
▪ Patient’s “societal value”
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Review
 Medical evidence
 Legal precedence
 Ethical principles
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}
Delve further to assist in
sound decision-making
Decide
Act
Attempt to foresee/preempt challenges
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Represented on the PHLS Public
Health Code of Ethics Committee
are public health professionals
from:
 Local and state public health
 Academia
 The Centers for Disease Control
and Prevention (CDC)
 The American Public Health
Association (APHA)
Guide is published on the APHA
website
 Has 12 guiding principles
 Has a different perspective than
medical bioethics
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1.
Public health should address principally the fundamental causes of disease and
requirements for health, aiming to prevent adverse health outcomes.
2.
Public health should achieve community health in a way that respects the
rights of individuals in the community.
3.
Public health policies, programs, and priorities should be developed and
evaluated through processes that ensure an opportunity for input from
community members.
4.
Public health should advocate and work for the empowerment of
disenfranchised community members, aiming to ensure that the basic
resources and conditions necessary for health are accessible to all.
5.
Public health should seek the information needed to implement effective
policies and programs that protect and promote health.
6.
Public health institutions should provide communities with the information
they have that is needed for decisions on policies or programs and should
obtain the community’s consent for their implementation.
7.
Public health institutions should act in a timely manner on the information they
have within the resources and the mandate given to them by the public.
8.
Public health programs and policies should incorporate a variety of approaches
that anticipate and respect diverse values, beliefs, and cultures in the
community.
9.
Public health programs and policies should be implemented in a manner that
most enhances the physical and social environment.
10.
Public health institutions should protect the confidentiality of information that
can bring harm to an individual or community if made public. Exceptions must
be justified on the basis of the high likelihood of significant harm to the
individual or others.
11.
Public health institutions should ensure the professional competence of their
employees.
12.
Public health institutions and their employees should engage in collaborations
and affiliations in ways that build the public’s trust and the institution’s
effectiveness.
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Principles offer guidance but not answers
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Principles should be considered when
working on public health initiatives
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Principles often need to be thought of in light
of medical bioethics

Who “polices” this?
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José M., 34 year old Latino male
in NC
 Known HIV infection x5 years, not
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on ART
Had not seen an MD x2 years as is
uninsured
Last known CD4+ count was 201/μL
2 months of cough, malaise, fevers,
15# weight loss
Progressive shortness of breath,
weakness
Encouraged to come in by partner of
4 years, Justin (HIV neg.)
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In the ED:
 Fever
 High heart and respiratory rates
 Low oxygen saturation
 Chest x-ray suggestive of diffuse
pneumonia in both lungs
 Sputum examination indicates
presence of Pneumocystis jirovecii
 CD4+ count reported now as 12/μL
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Hospital course:
 Symptoms worsened
 Transferred to the ICU
 Developed acute respiratory distress
syndrome (ARDS) and progressive
multi-system organ failure (MSOF)
 Sedated and placed on mechanical
ventilation
 Had not completed a Living Will or
HCPOA paperwork previously
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Hospital course:
 José’s parents notified
 Although he had been in close
contact with his parents, José
had never disclosed his S.O. or
HIV status to them
 Had never introduced them to
Justin out of concern they
would not be accepting
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Hospital course:
 José’s father asks “does
my son have AIDS?”
 José’s mother says “that
man” (Justin) should not
be allowed into the ICU
room any more
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How much information do you disclose to José’s
family?
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What decisions do they need to make now?
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What decisions might they need to make soon?
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What rights does Justin have?
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Should José’s parents be told that Justin is HIV
negative?
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Can José’s parents make “good” medical decisions
for him?
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What cultural aspects are important in this case?
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How does one best balance the principles of
beneficence, autonomy, non-maleficence, veracity,
and dignity in this case?
FIN