Tag Archives: Autonomy

Virtues Ethics in Clinical Practice

In this session, we will be focusing on the Ethical Framework of VIRTUES (see Ethics Worksheet). We will investigate one of the primary obligations of clinicians: respect for patient autonomy, and consider what this might mean in more complex clinical cases. We will also explore another primary obligation of clinicians: the obligation to build trusting relationships with patients. This second obligation is often required for fulfilling the first, and these cases help us to see why.

(1) WATCH THIS VIDEO:

Insert mediasite recording of lecture here…

The video reviews the following concepts:

  1. Virtue
  2. Value
  3. Empathy
  4. Trust and Trustworthiness

**Keep in mind that this session will focus on cases that are meant to draw out population level biases, discrimination and other ethical concerns in particular clinical interactions. We will return to addressing societal, systematic, and broader justice issues in other sessions (see Justice in Healthcare). Likewise, we will come back to system level methods of advocacy (including advocacy for clinicians with underrepresented minority identities) in other sessions. Here, our intention is to start thinking creatively about how to be in relationship with particular patients in complex contexts.**

(2) READ: 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.

Physicians and patients alike will agree that empathy is integral to patient care. But it is not as easy as we might think. Empathy is not unlike other clinical skills and practices. Take learning to listen to a heart. We begin with simple instructions about how to use a stethoscope and then slowly build more precise attunement to any irregularities in heartbeat. In empathy, we begin with simple questions like “how do you feel today?”, but experience, practice, and knowledge will create greater attunement to the feelings of others. This article by Dr. Shapiro is just one step in the direction of building the knowledge necessary to becoming an excellently empathically attuned physician. 

(3) WATCH: Examined Life – Judith Butler & Sunaura Taylor

The conversation in this video is an excellent example of what it means to be curious, humble, trustworthy and empathic in conversation with others and across similarities and differences. Sunaura Taylor is an artist and writer, she articulates the social model of disability and demonstrates its presence in her life excellently. Taylor and Butler call on us to think about how what our bodies can do in the world depends on what the world allows physically and through social norms. Most importantly, Taylor and Butler show us how important it is to know about the experiences of others by talking with them and privileging their perspective by always remaining curious and open.  

 

SHIFTING GEARS A LITTLE… We’re going to look at the intersection of virtue and the complicated context of IV drug use and addiction. This reading will be directly relevant to an in-class exercise in which students will be expected to participate in a mock family meeting.

(4) READ this publication by Dr. Kirkpatrick (Cardiologist and Ethics Consultant at UWMC): 

“Infective Endocarditis in the Intravenous Drug User” in AMA Journal of Ethics. 2010;12(10):778-781.

Dr. Kirkpatrick uses a case and casuistic comparisons to critically reflect on the meaning of the term ‘futility’ in contexts where a patient’s addiction to IV drugs might be taken as a reason against pursuing a particular medical intervention.

As you read HIGHLIGHT the central ethics rules/obligations that Dr. Kirkpatrick applies in his discussion.

(5) OPTIONAL PREP FOR MOCK FAMILY MEETING: in light of what you’ve read in Dr. Kirkpatrick’s article, review the following case…

Moira is 28yrs old with two children (7 and 9yrs old). She has a history of injection opioid and meth use, and is admitted for fever and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. Moira has been admitted several times over the past 6 years for S. aureus endocarditis, had a mitral valve repair for an anterior leaflet perforation 5 years ago, and then a bioprosthetic valve replacement 2 years ago. Although she has tried rehabilitation programs a number of times in the past, she relapsed 2 months ago and continues to inject heroin. Each time she’s been admitted, staff have been surprised by her ability to recover, but also frustrated by each new admission. When an echocardiogram is done during this current admission, she is found to have a large vegetation on her bioprosthetic mitral valve, with a small perivalvular abscess.1 She is currently receiving antibiotics and being considered for a valve replacement. Her surgeon believes that a mechanical valve would be the best option for long-term cardiac function, but is concerned that she won’t adhere to anticoagulation therapy and could reinfect the valve, given her ongoing injection drug use.

Moira alternates between passive acceptance of her care and anger at staff. She will sometimes knock food off her tray, throw her bedpan, or verbally lash out at medical staff (e.g. “just leave me alone!” or “don’t pretend you care!”). Because of this, staff members have warned each other to take caution when entering her room. Moira has a “behavior contract” and often behaves more passively when her father (Rick) is in the room. So, the medical team typically waits until the father is present to conference with the patient. Moira is often alone in her room as her father is very busy with his job and taking care of Moira’s two children.

The surgical team disagrees about whether or not to offer the valve surgery to Moira. While one of her nurses doesn’t understand why it has not yet been offered, another feels burnt out from caring for Moira over several admissions and is frustrated by Moira’s lack of participation in her care. Similarly, while the attending surgeon is reluctant to do another valve replacement knowing it will not fix Moira’s underlying disease (her addiction), the resident believes that she is a sufficiently good candidate medically and it will likely allow her more time (months to years) with her family.

Moira and her family have been consistently homeless or houseless. She had been staying in a shelter with her children prior to the current admission. While the children’s father is not present, Moira’s father Rick is very involved in her care and is in the process of adopting the two children.

Should Moira be offered a third heart surgery?

Family Meeting: The care team, Moira and her dad will meet in a family meeting to explore Moira’s goals, and the previous challenges in her care, in order to inform future care decisions, including the possibility of a future valve replacement.

 


For further investigation on addiction, see…

  • Dr. Maté’s website: https://drgabormate.com/.
  • This short article describing the power of narrative to see different viewpoints on the fentanyl poisoning crisis: Living with Pain and Opioid Addiction: Bioethics Narratives 
  • If you’re feeling eager for more on empathy… 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.
  • Also, we highly recommend watching this TED Talk on addiction and social connection: Everything you think you know about addiction is wrong | Johann Hari

 

Adherence in Treatment of Adolescents: Cystic Fibrosis Case Study

Review the 4-box explanation sheet and complete a blank 4-box method worksheet while reading Ryan’s Case.  

Before delving into the case you may find it useful to read more about the following terms:

While reading the case consider the following:

  • Imagine empathizing with each stakeholder.  Consider their different or shared beliefs, emotions, and values.
  • Can you frame 1-2 ethical issues that arise in this case in a single sentence?  For example, you might find that one professional obligation (e.g. benefiting the patient from a medical perspective) seems to conflict with another (e.g. respecting the patient’s autonomy).  

And remember your Ethics Toolkit if you’re feeling lost or want to dig deeper… (we’ll go over this in Week 1 of EHM, but feel free to explore it now)


If you are interested in further reading:

Lessons from Tuskegee, Havasupai, and HeLa for Health Research Today

In this module, we review three landmark cases for U.S. research ethics history and explore their impact on contemporary research practices.  Today, it is routine to use residual samples collected for clinical practice, or medical records, to answer research questions. We often do this with waivers of consent (without asking or informing patients). This is changing, and our history helps us understand why….

Start by reviewing the Ethics Case Analysis Toolkit

Remember some of the fundamental ethics concepts we’ve covered so far:

Read this seminal article on the Tuskegee Syphilis study (the study was originally/officially titled “The Effects of Untreated Syphilis in the Negro Male”), which provides an overview of the study and the injustices found within the study itself and its aftermath…

Baker S.M., O.M. Brawley, L.S. Marks. Effects of Untreated Syphilis in the Negro Male, 1932 to 1972: A closure comes to the Tuskegee study, 2004. Urology (2005): http://usrf.org/uro-video/Tuskegee_2004/Tuskegee_study.html [NOTE: Embedded videos give you a bit more background and are recommended, but not required.]

As you’re reading, consider the following:

In 1932 when the U.S. Public Health Service Study of Untreated Syphillis began, there was no effective treatment for syphilis. When penicillin became available in the 1950s, researchers ‘justified’ their decision to continue the observational study without treatment because they wanted to make good on the time the men had already invested in the study.  In their mind, good science required they continue to get the longitudinal data.  They justified their decision further noting that men in the study were from poverty and did not have access to healthcare without the study.

  • How were the research subjects harmed or otherwise treated unjustly? For instance, what obligations or rights were violated? Which virtues were neglected or failed?
  • Can you imagine similar reasoning being used now, with other studies, other participants?

Then take a look at a more contemporary piece in the NYTimes, which focuses on a recent manifestation of similar norms…

Harmon A. Where did you go with my DNA? New York Times (2010): http://www.nytimes.com/2010/04/25/weekinreview/25harmon.html?_r=0

As you’re reading, consider the following:

In 1951, clinical researchers grew cells from Mrs. Henrietta Lacks’ cervical cancer biopsy. These cells became an immortal cell line that contributed to several ground-breaking health innovations, including the polio vaccine. Mrs. Lacks was never asked to contribute to research or told about the cell line. In keeping with the ethics of the day (and now), consent was not required to use residual tissues for research purposes if de-identified so no regulations or laws were broken.

  • How was Ms. Lacks harmed?
  • How was the Lacks family harmed?
  • In 2013, European researchers published the DNA of the HeLa cell line without asking permission of the family. Later that year, UW researchers did it differently. Who had the best approach, and why?

Here is a second more contemporary piece in the NYTimes…

Harmon A. Indian Tribe Wins Fight to Limit Research with DNA. New York Times (2010): https://www.nytimes.com/2010/04/22/us/22dna.html

As you read, consider…

In 1999, an Arizona State University researcher approached the Havasupai tribe with a proposal to study genetics of diabetes, which was a condition from which many in the tribe suffered. After building relationships with tribal leaders, they gave consent for the blood draws and genetic study of diabetes, in hopes that something could be found that would help their people. The genetic analysis did not find anything specific so the samples were de-identified and frozen. Later, other researchers including graduate students in the research group used the samples for other research, such as migration patterns, schizophrenia, and inbreeding.

  • How were the Havasupai people harmed by these additional uses of their samples?
  • What could be done differently to bridge the gap between research regulations and what the tribe needed for ethical research conduct?

Finally, WATCH this TED Talk on the demand for diversity in genetic research and why current research is insufficient: Fox K. Why genetic research must be more diverse. TED Talk, February 2016.

As you’re watching consider…

  • What does Keolu Fox tells us about how medical practitioners and researchers can make research practices more trustworthy and respectful?
  • Can you think of other ways to support these ethical obligations going forward?

As always, your Ethics Resources are there to help guide your reasoning in these complex moral issues. Remember to push yourself by considering how a skeptic might respond.


For further investigation…

You can see the OHRP Guidance on Research Involving Coded Private Information and Biospecimens: http://www.hhs.gov/ohrp/policy/cdebiol.html.

The Belmont Report is a thorough report on the ethical principles and guidelines for research with human subjects. It was a significant interdisciplinary effort in response to grievous harms on human subjects as seen above. You can find it here: http://www.hhs.gov/ohrp/humansubjects/guidance/belmont.html.