Category Archives: Ethics

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

Justice in Healthcare: Difficult Encounters

This lecture discusses an approach called “DEAR” to responding to difficult encounters.  This will be used to form responses to cases.

  • Describe: “I notice…”
  • Express: “I feel/think…”
  • Assert: “I want…” or “I plan to…”
  • Reinforce: (“This will work out well for you because…”)

Optional Resources:

Watch the Experts: Justice in Healthcare: Bedside Rationing

WATCH the experts respond to the case from Satel and Aronson (2008) “Transplant Tourism: Treating Patients when They Return to the U.S.” American Medical Association Journal of Ethics 10(5):271-277. (https://mediasite.hs.washington.edu/Mediasite/Play/4cb3214702c1459d90e52d85e4187b491d)

Mr. Lawrence, a 50-year-old man with diabetes, is on dialysis for chronic renal failure and on the waiting list for a kidney transplant. Because he is in relatively good health, he is low on the list. His physicians advise him that he could be on the list for up to 3 years and that his health during that time would not be jeopardized, aside from the risks and inconveniences associated with long-term dialysis. Mr. Lawrence is divorced and on bad terms with his ex-wife; he has no children and has contacted his sister and her family to see if any of them could be a living donor. His sister is obese, at risk for diabetes, and is not a suitable donor candidate; no other family members or friends are willing to consider donating a kidney to Mr. Lawrence.

Unable to find a living donor and dismayed at the thought of remaining on dialysis for years, Mr. Lawrence decided to use his financial resources to purchase a kidney and undergo a transplant in China. He spent 2 months in China after the surgery, where he was cared for by a local transplant team that provided postoperative care, including monitoring his renal function and managing his immunosuppressant medications. The surgery occurred without any significant complications, and Mr. Lawrence’s recovery was excellent.

A month after his return to the United States, Mr. Lawrence ran out of the medications that his doctors in China had prescribed, including his immunosuppressants. He knew that failing to take the medication could cause graft rejection, so he made an appointment with Dr. Roberts, a nephrologist at a local academic center who specialized in care of renal transplant patients. Dr. Roberts was aware that many of the organs secured in China came from executed prisoners who did not always consent to organ donation. Further, Dr. Roberts was wary because purchasing organs was illegal in the U.S. Having worked in the transplant field for several decades and witnessed numerous changes in the regulations about and care of transplant patients, Dr. Roberts understood how difficult it was to secure an organ, but didn’t want to be perceived as condoning Mr. Lawrence’s actions.

  • How would you frame the central ethics question in this case?
  • What are the key features of the case that would guide an ethically appropriate response from your perspective?
  • What might make this case challenging from your perspective?

 

Justice in Healthcare: Bedside Rationing

Justice in healthcare is a substantial part of ethics in medicine, here we will cover some of the distinctive aspects of justice-based concerns and some basic ethics language to help wade through these interesting ethical issues.

READ: this short piece by Dr. Jonsen and Dr. Edwards goes into some detail about resource allocation in the medical setting.

Now start to apply what you’ve learned. This reading provides some preliminary perspectives on a case of transplant tourism. This is just one among many forms of distributive justice where we see an inclination to ration at the bedside.

READ: Satel and Aronson. (2008). “Transplant Tourism: Treating Patients when They Return to the U.S.”, Virtual Mentor, American Medical Association Journal of Ethics. Volume 10, Number 5: 271-277.  

As you read CONSIDER:

  1. What does bedside rationing mean in this case?
  2. What is the central ethical question the physician faces in this case?
  3. What do you think should be done? Why?
  4. How does this case affect your vision of collective efforts towards social justice?

WATCH: When thinking about justice, it is important to explore the perspectives of all stakeholders and consider the procedures through which they interact. In the case of transplant tourism, this means knowing where organs can come from as well as who seeks them out. See this short video from BBC News that portrays one family’s experience.

 

 


For further reading (not required)…

There are several impressive documentaries on transplant tourism, here is one from the UK that is slightly older (2004) but provides extensive insight into the perspectives of various stakeholders including patients, families, and transplant surgeons on multiple sides of the debate: The Transplant Trade. There is another newer documentary that investigates China’s illegal organ trade called Human Harvest, which can be accessed through the library here.

What is Bioethics?

We all face ethical questions, uncertainties and conflicts. Sometimes they are mundane, everyday sorts of inquiries (should I keep a promise to meet a friend on time?), others are much bigger, character affirming and even life altering (should I withdraw life sustaining treatment for this patient?).

Bioethics, specifically medical ethics, helps us to reason through some of the difficult ethical questions that arise in medicine.

WATCH this video of Dr. Maggie Little offering an introductory look at bioethics. It will provide the necessary groundwork for thinking about the meaning of ethics in medicine as we start to look at both paradigm historical cases and contemporary cases.

 

Then READ this article to see what Bioethics means to clinicians at the bedside:

Berwick, Donald. (2017) “Moral Choices for Today’s Physician”, JAMA 318(21):2081-2082.

As you read this article, CONSIDER:

  • How are moral choices different from other choices (e.g. choosing what to eat for dinner or what to wear to class)?
  • How might moral choices be particularly important to you in your role as a physician?

REVIEW — here are some of the Key Ethics Concepts that arise in the above material:

You can find more Key Ethics Concepts on the Ethics Resources Page

 


If you’re looking for more, you can find physicians’ stories of ethics at the bedside in a number of journals and books, here are a couple of samples (COMPLETELY OPTIONAL) …

Complexities in Decision-Making Capacity

REVIEW THESE KEY ETHICS TERMS:

READ this seminal article by Paul Applebaum on the criteria for assessing a patient’s capacity to make medical decisions: Applebaum, Paul S. (2007). “Assessment of Patients’ Competence to Consent to Treatment”, The New England Journal of Medicine, 357(18): 1834-1840.

Keep in mind Applebaum’s 4 Criteria because they are frequently used today as the standard for assessing decisional capacity and assessing for capacity to consent to treatment. :

CRITERIA FOR ASSESSING DECISION-MAKING CAPACITY
  1. Communicate a Choice
  2. Understand the Relevant Information
  3. Appreciate the Situation and its Consequences
  4. Reason About Treatment Options

REVIEW THESE TWO CASES:

CASE 1

A 64-year-old woman with MS is hospitalized. The team feels she may need to be placed on a feeding tube soon to assure adequate nourishment. They ask the patient about this in the morning and she agrees. However, in the evening (before the tube has been placed), the patient becomes disoriented and seems confused about her decision to have the feeding tube placed. She tells the team she doesn’t want it in. They revisit the question in the morning, when the patient is again lucid. Unable to recall her state of mind from the previous evening, the patient again agrees to the procedure.

Is this patient competent to decide? Which preference should be honored?

CASE 2

A 55-year-old man has a 3-month history of chest pain and fainting spells. You feel his symptoms merit cardiac catheterization. You explain the risks and potential benefits to him, and include your assessment of his likely prognosis without the intervention. He is able to demonstrate that he understands all of this, but refuses the intervention.

Can he do that, legally? Should you leave it at that?

 

**Cases taken from: http://depts.washington.edu/bioethx/topics/consent.html

 


For further investigation (not required):

Relational Ethics

1) Review Ethics Key Terms

GOAL: Develop a preliminary grasp of using ethical frameworks that focus on social relations (see Ethics Worksheet Explained) and compare them to other ethical approaches covered thus far in the course.

Review these key ethics terms before turning to the video and reading:

  1. Care Ethics
  2. Communitarianism
  3. Interdependency

2) Watch video of Carol Gilligan on Moral Development and Care Ethics.

GOAL: Understand the basics of care ethics and how it might apply to the clinical setting.

Consider what is different about the approach that Gilligan is suggesting (i.e. a relational or Care Ethics based approach) from what you typically think of in terms of your ethical obligations as physicians.

3) Read Baby Aaron and the Elders by Ellen Wright Clayton and Eric Kodish

GOAL: Consider what you learned from Gilligan’s video and the above ethics key terms in this complex case of refusal of life sustaining treatment (LST).

Consider this is just one instance among a myriad of different clinical-community interactions. It will help us to begin to see the importance and sometimes the difficulty of respecting and valuing different community-based and relationship-based values and beliefs.

Have you ever found your own personal and community-based beliefs to be in tension with the norms of the institution of medicine?

 


For further research on The Amish and healthcare, see S. Talpos’ “The Amish understand a crucial thing about modern medicine that most Americans don’t“.

You can also find substantial research on many diverse communities of Americans here in a “Diversity Toolkit” created by Cleveland Clinic: https://my.clevelandclinic.org/-/scassets/files/org/about/diversity/2016-diversity-toolkit.ashx.

Epistemic Injustice and Sickle Cell Disease

This ethics session is part of a multidisciplinary session on sickle cell disease. For the ethics portion, begin by listening to this podcast:

https://www.npr.org/2016/02/16/466942135/remembering-anarcha-lucy-and-betsey-the-mothers-of-modern-gynecology 

It is a short podcast but addresses some of the issues of racism and injustice in the clinical context that concern us here. The podcast focuses on Dr. Judd’s poem “In 2006 I Had an Ordeal with Medicine”, which comes from her collection patient. This poem, and the collection overall, articulates her own unjust experience with medicine and helps us to see and feel its connection to a history of like experiences of injustice. We can only summarize here and you can find a bit more on the podcast linked to above, but Judd experienced prolonged suffering with multiple providers as her ovarian torsion was continuously misdiagnosed (as menstrual cramps, as pregnancy, as a bladder infection). She was continuously not believed, not heard, and not treated appropriately, and so disrespected and dehumanized, all the while experiencing significant pain.  This poem (and the collection more fully) interweaves this experience with the advent of gynecology in which enslaved African-American women were experimented on by Dr. Marion Sims (the so-called “father of modern gynecology”). At least three of the women Dr. Sims’ experimented on (Anarcha Wescott, Betsey Harris and Lucy Zimmerman) went through multiple procedures without anesthesia despite it recently being available. We highly recommend (though it is not required) an article in the New York Times, which reveals some of the historic details of these experiments and the forms of torture experienced by the women under Dr. Sims’ supposed care (including the fact that “Sims’ records show that he operated on Anarcha 30 times”).

While we might hope that the experiences of Anarcha, Betsey, and Lucy among so many other African-Americans were not so deeply tied to the experiences of persons of color in contemporary society, Dr. Judd’s experience and work, and this session on sickle cell prove otherwise. We will discuss how palpable and dangerous continued racial bias can be. This bias manifests in health disparities in the multifold ways, only some of which will we be able to address in this session. Black and brown children, teenagers and adults continue to face health disparities even when other social factors are controlled for (e.g. education and income). As Judd says, these ghosts haunt. And it is for this reason among others that we ought remember, honor, understand, and discuss.

Now let’s do some ethics! After listening to the podcast, read this snippet from Miranda Fricker’s Epistemic Injustice (click here)…

Epistemic injustice takes a number of forms.

One example in the healthcare setting is skepticism regarding the testimony of a patient (e.g. because they are overweight or because they use drugs). This can happen in the other direction as well, a healthcare provider may face skepticism from a patient (e.g. because of their race or gender). These are forms of epistemic injustice because one person is unjustly treated as not knowing because of some form of bias.

A second form of epistemic injustice revolves around divulging information. In other words, providers might not give a patient certain information or the patient might not disclose information to providers if the other is not deemed (typically unconsciously) as deserving or capable of knowing. For instance, a provider might focus on telling an overweight patient to lose weight when they could/should also be discussing something like physical therapy (optional: for more on this read: http://www.ijfab.org/blog/2017/11/what-you-dont-know-can-hurt-you-epistemic-injustice-and-conceptually-impoverished-health-promotion/).

Fricker’s conceptualization of epistemic injustice offers one theoretical perspective that is helpful for articulating some of the injustice that occurs in the context of sickle cell disease. This terminology is helpful to both understand some of the injustice that occurs and, more importantly, find the best course of responding to that injustice.

Consider the application of the term epistemic injustice in the following case…

TA (at 20yo) is admitted to the ER for the fifth time this year. He complains of intense pain, which he attributes to an intensive finals week followed by celebrating with friends. He is started on a morphine PCA, which seems to temper the pain for a couple of days, but then on day 3 he requests an increase in his pain meds. He doesn’t think the allotted morphine is doing enough. However, his inpatient team is reluctant to increase the dose of IV morphine, which is already quite high. His current dose could be easily converted to an oral narcotic and managed in the outpatient setting. The inpatient team holds a care meeting with TA and explain their rationale for recommending discharge. They think he should go home on the oral narcotic, where he will be more comfortable and his pain will be more easily controlled through both medical and non-medical means. They council TA that it would be better for him to return home given the benefits of being at home. But TA says that he is not ready for discharge.

Using the Ethics Case Analysis Tool, respond the following questions about this case:

  1. Fill out the 4-Boxes just based on this small snippet (there isn’t a lot of information here, so there will not be a lot in each box, that’s ok).
  2. Name the interactions (or lack thereof) that might reflect a form of epistemic injustice. (e.g. the team may not have demonstrated concern for TA’s pain when he requested an increase in his pain med dosage). 
  3. Name one or more ethical principles or virtues that you think would be important to manifest in our response to TA. (e.g. empathy for TA’s experience of pain)

No matter what we can accomplish in this short session, it is not possible to do justice to the narratives we have considered here and the history we have glimpsed. We hope that the reading and reflecting on the podcast encourages us all to continue to delve deeply into the historical narratives and current lived experiences as you move forward with your education and practice.

Conflict of interest

Activities:

  1. READ: Fromme E. Requests for Care from Family Members. Virtual Mentor.May 2012, Volume 14, Number 5: 368-372
    • Goal: Explain the ethical conflicts involved in deciding if and when to provide medical care for family members.
    • Instructions/context for reading:  Almost all medical students and physicians will receive requests for medical advice from family or friends at some point in their career. These requests can range from simple questions about routine medical care to complex inquiries about serious health issues or medications. Read this article about handling a request for medical care from a family member and consider how you might respond as a medical professional.
  1. READ: AMA Code of Medical Ethics’ Opinion on Physicians Treating Family Members.
    • Goal: Explain the implications of the policy statements from the AMA Board of Ethics and explore the ramifications of providing medical care for family and friends
    • Instructions/context for reading:  Responding to requests for medical care from family and friends in a manner that maintains professional integrity without compromising a personal relationship takes introspection and practice. Participating in class discussion will help students begin to analyze the nuances of these interactions and the ethical dilemmas involved in approaching requests from family and friends.

Optional readings:

Key Ethics Term: Interdependency

The concept of interdependency is most prevalent in care ethics, feminist ethics, virtue ethics, and communitarianism. The idea is that we are not independent but rather interdependent beings in the world. We depend on others when we are young/old, sick, etc., but also in our everyday lives. We would not get along without schools, daycares, public transportation, electricity, and so on. In care ethics and virtue ethics, this is not a feature of humans that is to be overcome, but actually something valuable about our lives. It is not just that we need relationships to survive, but they are also important to meaning and flourishing in the world.

This feature of our humanity can be easy to forget in the clinical setting where patients and clinicians seem removed from the particular relationships that make them who they are and able to live in the world as they do. Sometimes it can make all the difference to recognize both the interdependency of the clinician-patient relationship, but also the other interdependent relationships that can support or impede care. Beginning from a perspective of interdependency might have a more positive effect than thinking in terms of individual independence and rights.


Key Ethics Concept: Communitarianism

The communitarian approach on the values of the community over and above the values of individuals within that community. This approach looks to the particular context, community beliefs, and societal relations to formulate standards of justice and responsibility.

This approach can significantly affect how we make and respect decisions in clinical contexts. Some medical communities may decide not to offer particular therapies to individuals based on the needs of the community. Likewise, some families may decide not to accept particular interventions in light of their community’s resources and values. See the case of Baby Aaron below for a good example of a communitarian ethos.