Category Archives: Ethics

Using ethical frameworks and reasoning to justify a course of action in response to ethical conflict or uncertainty in medical practice.

Key Ethics Term: Trust & Trustworthiness

Trust and the virtue of trustworthiness are integral to the moral life. At a very basic level, society requires trust to function (e.g. what if you couldn’t trust your bank to hold your money?, or e.g. what if you couldn’t trust that teachers were doing their best to provide accurate information?, or e.g. what if you couldn’t trust your doctors to keep their interactions with you confidential?). In order to survive and flourish with those around us, we must be able to trust each other.

It is important to note that trust also makes us vulnerable. To trust in another is to make oneself vulnerable to that person or system. This point is a key feature of patient care. Physicians depend on patient’s to trust them in their care for them to be successful. Likewise, patients depend on physicians not to abuse their trust. When physicians and patients are able to engage in trusting relationships and be trustworthy, we have a better chance of enhancing the wellbeing of the patient, the physician, and the relationship.

Relations of trust are also vulnerable to social norms and history. Norms that categorize a particular population as not trustworthy can affect patient care and pose significant challenges to clinician-patient relationships. For instance, it is common for clinicians to distrust the demands of patients with Sickle Cell Disease, particularly by doubting the validity of their requests for stronger pain medications in a crisis. This mistrust is tied up in social perception of opioids as well as the visible identity of being black (as many sickle cell patients are). So, when building trust and trustworthiness in relations with patients, we must acknowledge how social norms and history can affect those efforts.


Key Ethics Term: Treatment as Not Medically Feasible or Beneficent (“Medically Futile”)

“Medical futility” refers to interventions that are unlikely to produce any significant benefit for the patient.” (Jecker, Ethics in Medicine Website, UWSOM)

But the meaning of ‘benefit’ can be difficult to determine in a particular case. For some patients, for instance, quantity of life will matter more than quality of life. There will be instances when clinicians may feel a treatment does not offer benefit even if it does extend life in the short term, while the patient may feel that any extension in quantity (even if only days or hours) is a benefit. Likewise, there may be times when clinicians disagree among themselves as to whether a treatment is medically feasible or beneficent. Herein lies the conflict.

The term ‘medical futility’ is complicated by the normative valence of ‘futile’, which can have negative connotations and consequences for patients and families. For this reason, many prefer the terminology ‘not medically feasible or beneficent’ to ‘medically futile’.


Key Ethics Term: Surrogate Decision Making

When patients are lacking in decisional capacity, we depend on others to make decisions for them. This surrogate decision maker may be formally appointed by the patient (e.g. through durable power of attorney or DPOA), may be a legal next of kin (LNOK) as defined by the state, or (in absence of the former options) a guardian appointed by the state.

Surrogate decision makers are expected to make decisions for the patient using a (1) substituted judgment standard (i.e. deciding as the patient would under the circumstances, e.g. did the patient ever talk about not wanting to be on a ventilator?) or (2) best interest standard (i.e. deciding according to what seems to be in the best interests of the patient based on what we know about the patient, e.g. does an intervention provide reasonable benefit and minimal risk based on the patient’s circumstances?).


Key Ethics Term: Decision Making Capacity

Decisional capacity is decision specific (e.g. one might be able to choose what one wants for lunch but not whether or not a surgical interventions is appropriate) and it can wax/wane over time (e.g. directly following TBI I may not have decisional capacity, but may regain it over time).

Decisional capacity depends on the following (Applebaum 2007):

  1. ability to communicate a choice
  2. ability to understand the relevant information
  3. ability to appreciate consequences
  4. ability to reason about treatment choices.

Decisional capacity also comes in degrees and requires support. A number of things can affect one’s ability to demonstrate capacity or be capable (e.g. language barriers, fear of medical professionals, depression, etc.). But many patients with internal or external impairments that affect decisional capacity in the above regards can be capable with sufficient support. This is often called supported decision making and is growing formal legal support/actualization across the country.


Ethics of Brain Death

Review these Key Terms:

First Read:

  • Setta and Shemie. An explanation and analysis of how world religions formulate their ethical decisions on withdrawing treatment and determining death. Philosophy, Ethics, and Humanities in Medicine (2015) 10:6
  • Taylor, J. Confronting ‘‘Culture’’ in Medicine’s ‘‘Culture of No Culture’’, Academic Medicine, 2003, 78:2.

These two articles help us to see how both patients and clinicians participate in and value cultural norms. Note the discrepancy between our use of ‘cultural’ ascriptions to patients and to the medical profession.

Second Read:

  • Gostin, L. Legal and Ethical Responsibilities Following Brain Death: The McMath and Muñoz Cases, JAMA Online, January 24, 2014.
  • Williams, MA. Ask the Ethicist: When is postponing removal of the ventilator after the diagnosis of brain death justifiable? Lahey Clinic Journal of Medical Ethics, Spring 2011, p. 3, 8.

These two articles discuss the ethics terms above in greater detail and help us to apply them in the case of brain death. As you read these articles, consider how the first articles on cultural norms and ascriptions night affect our ethical judgments and reasoning.

 

Review the 4-Box Method and Complete the blank worksheet for each of the below cases…

CASE 1:  J

J is a 16-year-old girl with a history of depression and ADHD who presents with coma. J was diagnosed with depression when she was 13 and had never attempted suicide before. Her parents are divorced and barely on speaking terms. She was at her mother’s place, talked to her father on the phone, who sent her grandparents to get her from her mother’s place. J had gotten into an argument with her mother about playing a video game. She was then found hung with a taekwondo belt around her neck tied to the bedpost. CPR was initiated by the mother. EMS found her to be in PEA arrest. She was given epinephrine. Circulation returned, but she was thereafter non-responsive. She was intubated and transferred to the ICU for care.

Over the next two days, she does not respond to painful stimuli or voice; does not grimace to pain; has no gag reflex; has no limb movements to pain; pupils are fixed and dilated; no spontaneous respirations; no volitional activity.

After she lost all brainstem reflexes, an apnea test was performed. It was positive and confirmed the absence of a respiratory drive when the patient is allowed to accumulate CO2 when not providing artificial ventilation.

The patient’s physicians in the ICU, palliative care, and neurology teams have been preparing the mother and father and their families for this possibility.

J’s family members, like most in this situation, feel like they’re in the midst of a terrible nightmare.  How could J be playing board games with her brother three days ago and be dead now? Her mother is in despair, thinking their argument prompted this tragedy. Her brother is taciturn and has not slept since J was admitted.  He is angry, afraid, and misses his sister.  J’s father vacillates between grieving and blaming her mother.  All of them keep hoping and praying for her recovery.

Two days after admission, the neurologist explains that J has died and asks if they would like to have time with her before the ventilator is removed. J’s dad replies, “She’s warm. Her heart is beating. She’s breathing. She’s not dead. There must be more tests you can do. She’s in there somewhere. As long as she’s breathing, her soul has not left her body.” And J’s Mom asks for a second opinion. She insists, “we need more time. This can’t be happening. I won’t give up on her.”

While some religious traditions do not recognize brain death, J’s family simply genuinely believes she is not dead.  In their view, withdrawing the ventilator would cause her death, so when the time comes to extubate, they throw themselves over J’s body and say they will not let anyone ‘stop any of the machines’. 

J’s medical team feels compassion for her family and wants to give them time, but also does not want to confuse the family by acting as though J is still alive.  A colleague provides a second opinion and confirms brain death.  J’s family requests another opinion and further tests. The medical team does not think it would be right to order tests for a dead person.

*Pulseless electrical activity or PEA refers to a clinical diagnosis of cardiac arrest in which a heart rhythm is observed on the electrocardiogram that should be producing a pulse, but is not.

Consider:

  • What might hamper the clinician-patient/family relationships in this case?
  • How ought healthcare providers respond to this situation? What steps should they take and why (use the concepts of relational autonomy, beneficence/non-maleficence, virtue, etc. to guide you)?
  • What rights do patients and families have in this situation? How ought they be respected?
  • What rights do health care providers have in this situation?  How would you recommend they exercise them?

 

CASE 2: Marlise Munoz:

“Marlise Muñoz was 33 years old and the mother of a 15-month-old when she collapsed on November 26, 2013, from what was later determined to be a massive pulmonary embolism. Initially described as apneic but alive, she was brought to the county hospital where her family was soon told that she was brain dead. Ms. Muñoz and her husband, both emergency medical technicians (EMTs), had discussed their feelings about such situations. So Erik Muñoz felt confident in asserting that his wife would not want continued support. Her other family members agreed, and they requested withdrawal of ventilation and other measures sustaining her body’s function.

In most circumstances, this tragic case would have ended there, but Marlise was 14 weeks pregnant and lived in Fort Worth, Texas. Texas law states that a “person may not withhold cardiopulmonary resuscitation or certain other life-sustaining treatment designated . . . under this subchapter (the Texas advance directive law) . . . from a person known . . . to be pregnant.”1 The hospital caring for Ms. Muñoz interpreted this exception as compelling them to provide continued support and declined the family’s request to end such interventions. The attorney representing the hospital indicated that the law was meant to “protect the unborn child against the wishes of a decision maker who would terminate the child’s life along with the mother’s.” After weeks of discussion and media attention with the hospital remaining intransigent, Mr. Muñoz sued in state court to have his wife’s and family’s wishes respected.”

From: Ecker, J. Death in Pregnancy—An American Tragedy, NEJM, 2014, http://www.nejm.org/doi/full/10.1056/NEJMp1400969#t=article.

FIND A MORE ON THE CASE HERE: http://www.npr.org/sections/health-shots/2014/01/28/267759687/the-strange-case-of-marlise-munoz-and-john-peter-smith-hospital

Consider:

  • What might hamper the clinician-patient/family relationships in this case?
  • How ought healthcare providers respond to this situation? What steps should they take and why (use the concepts of relational autonomy, beneficence/non-maleficence, virtue, etc. to guide you)?
  • What rights do patients and families have in this situation? How ought they be respected?
  • What rights do health care providers have in this situation?  How would you recommend they exercise them?

 


If you’re eager for more, here is a section of Siegler and Winslade’s Clinical Ethics (add link) that overviews the different ethical considerations in Brain Death.

And here is another more targeted article on Cultural Competence, called “Transforming Cultural Competence into Cross-cultural Efficacy in Women’s Health Education” (add link) by Dr. A. Núñez.

Key Ethics Term: Respectfulness

Respectfulness is a kind of virtue, which can be broadly understood as a trait of character in which one recognizes, assumes, or even promotes the moral worth of others. A respectful person consistently and reliably treats others as “ends in themselves” (to use Kant’s language) or valuable in their own right. This can come in a number of different forms. While we commonly think of respect in bioethics in relation to respect for autonomy, we can also be respectful of person’s beliefs, emotions, relationships, etc. Thus, while ‘respect for autonomy’ is an integral principle in bioethics, we must also think more broadly about how to be respectful in the clinical setting.


Key Ethics Term: Empathy

Empathy is about knowing or understanding how another person feels. Unlike sympathy (feeling badly for another), or emotional sharing (sharing in an emotion with another), they key is that we come to some understanding of how another person feels in their own shoes (i.e. NOT how you would feel in another person’s shoes aka “perspective taking”).

Empathy is controversial. Some argue it isn’t possible or that it requires too much of us (e.g. is overburdensome in the clinical context). Others worry about its tendency to rely on stereotypes (e.g. greater accuracy with ‘in-groups’) or the potential for false/paternalistic empathy (e.g. a failure to ask another but just assume to know how they feel). However, the medical profession also relies on empathy for two important reasons:

  1. When appropriately sensitive and responsive, it can lead to knowledge about how a patient feels that can be critical to medical care.
  2. When appropriately sensitive and responsive, empathic engagement, on its own, manifests respect for the patient and can be critical to building a trusting relationship.

Key Ethics Term: Virtue

Virtue Ethics can be traced back to Mencius and Confucius, as well as Plato and Aristotle. In this course, we will be primarily using an Aristotelian framework for understanding virtue. The virtues are defined as excellent traits of character. Though there is disagreement over what it means for a trait of character to be excellent, most agree that it is the sort of trait that is fundamental to flourishing or living well (what Aristotle calls eudaemonia). For instance, courage, compassion/sympathy, truthfulness, trustworthiness, humility, empathy, respectfulness, these are all traits that are taken to be critical to flourishing as individuals and as a society.

The key for Aristotle is that our traits of character depend on excellent habitualization (we learn from others and practice habits with others). So, virtues are significantly dependent on social support. This can mean that being trustworthy is something that comes easily to you in part because you were raised to be trustworthy, but it also means choosing to be trustworthy because it is an excellent trait as you develop greater capacity to make choices. Some contemporary interpretations of Aristotle add that virtue can be dependent on sociality in another sense, virtue requires normative structures and systems that encourage and support it. For instance, when hospitals place higher value on numbers of patients than time with patients, it could be at the cost of empathy. Likewise, oppressive -isms (racism, chauvinism, ablism, etc.) can hamper virtue (e.g. being respectful of someone when social norms tell us that a feature of their identity is not worthy of equal respect, or e.g. being trustworthy when no one trusts me).

Some key virtues in the medical profession include (but are not limited to): empathy, sympathy, compassion, beneficence, respectfulness, justice, curiosity, humility, courageousness, trustworthiness, truthfulness, etc.


Review these Key Ethics Terms:

Read: Excerpts from Aristotle’s Nicomachean Ethics

Reading Aristotle is hard! But we think you can do it! It will create some discomfort for everyone. We do NOT expect you to master these concepts – it is more important in this session to be open, brave, vulnerable, and interested in growth than it is to be ‘right’. See what you can gather from the reading and use the PDF’s highlighting and prompts to guide you if you’re having trouble.

Consider: the role of empathy in medical student education while reading Walking a mile in their patients’ shoes:empathy and othering in medical students’ education. The article discusses the barriers for medical education to promote empathy and offers up a paradigm that may help trainees deal with these barriers and possible ideas of how they could be surmounted.

 

Read over this Facebook Post and reflect on how values and virtues can or cannot be demonstrated on social media.

 

If you’re feeling eager for more… explore this article on How to Teach Doctors Empathy which talks about the growing emphasis on empathy training for health care professionals and describes a few such trainings across the country.

IPE: Teamwork and Values Conflicts, Working with Challenging Patients

Teamwork and Values Conflicts

  1. We share core professional values but sometimes our values conflict with those of another (perfectly reasonable) team member. The training and practice of an occupational therapist emphasizes safety, which was in direct conflict with patient autonomy in this specific patient case.
  2. Conflicting opinions are a normal part of working in teams.  Successful teams a) assume positive intent, b) listen to each other, c) make sure every person on the team expresses their view, and d) concludes conflicts by negotiating a plan for next step/s.
  3. Place the patient at the center of the team.  Understanding the patient’s perspective on health and healthcare places the patient at the center of the team’s conversation, and can help all team members get behind a plan that meets the patient’s needs.
  4. Listening and speaking up are critical team skills.  Listen as much (or more) than you speak.  But speaking up is important for all team members to share their concerns or new information.
  5. We can’t always be the hero.  Sometimes we can’t “save” a patient. When we have different goals or health beliefs than a patient, we may not always feel good about our what we are able to do (allowed to do) for a patient or the patient’s outcome.
  6. Don’t take it personally.  When you feel challenged by a patient, ask other team members how it’s going for them. Don’t assume you’re the problem, or are the only one having difficulty.  If you’re frustrated, it’s likely others on the team are too.
  7. Talk to your team first.  When you feel challenged by a patient, don’t go it alone. Use your team to help you problem solve. Difficult patients can split us as teams. Knowing other’s roles and responsibilities and using them to full potential can share the burden of high maintenance patients.
  8. Think broadly when you think “team”.  Physicians, nurses, pharmacists and social workers practice in close proximity, often rounding together, but other team members may not be in the loop.  Remember to include everyone in challenging care decisions.
  9. Support your team members.  Especially when we have a challenging patient, we need to rely on and trust our team members to do their jobs.  Work together to adopt a common approach.

Working with Challenging Patients

  1. “Difficult” patients:  Challenging behavior is often a sign that, from the patient’s perspective, her/his needs aren’t being met.
  2. Engaging patients:  Exploring patient’s preferences in a non-judgmental way is key to enhancing motivation and engagement, both of which are essential to effective care.
  3. Respect for patient autonomy:  Ultimately, patients make their own decisions. The challenge for providers is to take the journey with them, work creatively to bridge medical aims and patient priorities, and provide support.