Case-Based Medical Ethics in Practice Preface by the authors Foreword Chapter 1: A brief introduction to medical ethics in Internal Medicine Definitions of ethics and medical ethics Why is medical ethics important? (teaching competency in ethics, teaching professionalism) Evolution of medical ethics and its importance/role in modern medicine (from paternalism to informed consent) Who determines ethical guidelines for medicine? Difference/similarities between ethics and law Purpose of the book (i.e. to stimulate thought and discussion, not cover all details of all ethical principles) Chapter 2: The underlying principles of ethical patient care Beneficence - a practitioner should act in the best interest of the patient. (Salus aegroti suprema lex.) Non-maleficence - "first, do no harm" (Primum non nocere). Autonomy - the patient has the right to refuse or choose their treatment (Voluntas aegroti suprema lex.) Justice - concerns the distribution of scarce health resources, and the decision of who gets what treatment. Dignity - the patient (and the person treating the patient) have the right to dignity. Veracity - the patient should not be lied to, and deserves to know the whole truth about his/her illness and treatment. Chapter 3: Putting ethics into practice ??? realities, limitations, and roadblocks Practitioners and personal belief systems Cultural competency and practice of ethical care Statement about pharmaceutical company influence on education and practice Medical oaths ??? Are they valid for medicine today? Are they fulfilled by practitioners? The Patient Bill of Rights Federal, state, local, and institutional regulations ??? how they intertwine and affect each other Chapter 4: Advanced Directives, Living Wills, and the Health Care Power of Attorney (HCPOA) Chapter 5: Case-based ethical dilemmas How the reader should approach these cases Where to find more information if needed ?? Case 1 Topic: Consent in the mentally ill or otherwise unfit (and ???in between??? situations: delirium, psychiatric decompensation) Subtopic: When does forcing an incompetent patient to undergo treatment limit their right to dignity and the principle of ???do-no-harm???? ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 2 Topic: When the HCPOA neglects their responsibility, or has other personal interests/potential gains ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 3 Topic: When the patient/their family bullies practitioners into unnecessary diagnostics/therapeutics "C.Y.A." medicine ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 4 Topic: When an estranged family member or spouse suddenly appears to make decisions ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 5 Topic: How to deal with an inpatient behaving badly (psych consults, behavioral contracts, room restriction etc.) Outbursts Substance abuse Illegal activity (e.g. drug-dealing) Known criminal warrants Inappropriate actions or remarks Admitted for ulterior motives (secondary psychologic gains, homelessness, etc.) ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 6 Topic: When DSS consults are needed Child abuse/neglect Elder abuse/neglect Spousal abuse ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 7 Topic: When a patient has ???burned all bridges??? and no discharge planning is possible No nursing home or rehab center will accept the patient No home health services will accept the patient ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 8 Topic: Can a practitioner refuse to admit a patient? To see a patient in the office (e.g. administrative discharge)? ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 9 Topic: When a patient makes ???bad??? decisions (e.g. will accept some therapies and not others, such as some blood products but not others, some procedures but not others, DNI but not DNR, etc.) Does a practitioner follow the patient???s wishes? Do they refuse to treat? Subtopic: When a patient is guided by incomplete, or misinformation (e.g. from the internet) ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles ?? ?? Case 10 Topic: When a patient???s same-sex partner has no legal rights and is excluded by a family ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 11 Topic: When a patient has a contagious disease (e.g. HIV) and their partner is not aware Subtopic: When a partner/family does not have all the information needed to make decisions for a patient (e.g. when to disclose diagnoses such as HIV-positivity, substance abuse, suicidality) Subtopic: When confidential information is inadvertently leaked to those who ???don???t need to know??? Subtopic: What diseases are ???reportable???? Subtopic: Do patients avoid testing for confidentiality fears? ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 12 Topic: When a family will not accept a terminal prognosis (i.e. futile ???full codes???) Should a family be present during the code? Subtopic: When a patient themselves is unrealistic about prognosis Subtopic: When is a patient ???terminal???? (i.e. definition of brain death) Subtopic: When is it appropriate to change the focus of care to comfort/hospice? How do a practitioner???s personal beliefs affect this guidance? The concept of dignity/therapeutic death v. Euthanasia ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 13 Topic: When there is no one to make decisions for a patient (e.g. John/Jane Doe in ICU, wards of the state) ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 14 Topic: When a mistake has been made by a practitioner (what/how to/how much to disclose) Mistake by primary practitioner; mistake by other/outside practitioner Subtopic: Caring for a patient after a poor outcome or mistake (i.e. how is care affected) Subtopic: When a patient makes a reference to a grievance or verbally disparages another practitioner ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 15 Topic: When what a patient needs cannot be obtained (e.g. financial/insurance limitations) Tests/procedures (e.g. colonoscopy in an uninsured/pre-Medicare patient aged 50 to 64 years old) Treatments A different medical team ("I want a new doctor"), especially when no others will take your "difficult" patient ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 16 Topic: When next-of-kin (NOK) disagree with each other Subtopic: Which of the NOK has ???seniority???? Are legal definitions for NOK equivalent to ethically ???best??? choices? ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 17 Topic: When a toxicology screen is ordered without patient consent and comes back positive Subtopic: When tests are ordered ???in emergency situations??? without patient consent (e.g. HIV tests) Subtopic: When a practitioner is potentially exposed to infectious agents (e.g. via a needlestick) and a patient is refusing further testing ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 18 Topic: When a patient ???signs out against medical advice??? Practitioner obligations How can competence be quickly assessed and assured? What about a patient with contagious disease (e.g. TB)? Can they be allowed to leave? ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 19 Topic: When a patient requests a clinical interaction be recorded ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 20 Topic: When a family member requests patient information not be shared with the patient, or with other persons ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 21 Topic: When a patient requests to not be seen by a (specific, or any) medical resident or student ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 22 Topic: When a patient requires or demands large amounts of time from a practitioner ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 23 Topic: How to prescribe medications to someone who has attempted suicide (e.g. with pills) Subtopic: How to accurately assess and document safety in a depressed patient ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 24 Topic: When a colleague demonstrates suspicious behavior Memory problems Substance abuse Outbursts Inappropriate relationships with or behavior toward patients, coworkers, etc. Dishonesty ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 25 Topic: When a language translator is not available (or only a family member/hospital employee is) ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 26 Topic: When a patient is repeatedly readmitted to the hospital due to non-adherence (e.g. with therapy, diet, etc.) Where does a patient???s responsibility for their own care and well-being begin? The ???cry wolf??? syndrome Should a procedure be repeated if a patient???s behavior may have caused failure of the first one? ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 27 Topic: When lawyers or law enforcement want to know patient information (HIPAA/confidentiality and the law) Blood alcohol level or toxicology testing Rape exam results Hidden drug stores (e.g. body cavities) When should access to a crime victim be allowed? To a suspected perpetrator? What right to privacy do prisoners have with regard to history, physical exam? Can/should discharge plans be shared with prisoners? ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 28 Topic: When a patient requests disability certification, handicap plates, etc. ??? or when they request renewal of a revoked driver???s license (e.g. can a practitioner-patient relationship be maintained when a patient doesn???t get what they want?) ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 29 Topic: How much resources should be spent on a single patient???s case? (i.e. public health cost v. value of human life) Subtopic: When do you stop looking for answers to a patient???s ???mystery problem???? Subtopic: When if ever do you call a case futile based on cost/public burden of care? Subtopic: What resources need to be made available at a hospital for ???rare??? situations or patients? MRI for the morbidly obese Male Pap smear equipment ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 30 Topic: How much information must a practitioner share with a patient? Explanation of logic for decisions/opinion/treatment plan, explanation of test results Explanation of all potential side-effects How much information is needed for ???informed consent???? ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 31 Topic: How to deal with a patient seeing two or more practitioners (same specialty, overlapping meds, etc.) ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 32 Topic: How to manage chronic pain (e.g. are ???pain contracts??? ethical?; how is pain objectively assessed?) ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 33 Topic: At what age, if any, do you stop health maintenance disease screening? Subtopic: At what age, if any, to you stop invasive procedures? Placing pacemakers? ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 34 Topic: When can a practitioner withhold therapy from a patient based on their behavior? Examples: HAART therapy for HIV, HepC treatment, anti-coagulation Behavior: Non-adherence to therapy, substance use/abuse, continued tobacco use/abuse Subtopic: When does a patient qualify for a transplant? Is 6 months sobriety appropriate? ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 35 Topic: When a Jehovah???s witness needs a blood transfusion Are blood substitutes allowed? Should surgery/organ transplantation be withheld if transfusion will not be allowed by the patient? ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles Case 36 Topic: How far does screening go? Breast cancer genes, hypercoaguability work-up in family members of a patient with a new diagnosis Will this lead to insurance decisions re: ???pre-existing conditions???? ??? Narrative of clinical scenario with specific example of ethical dilemma ??? Questions for thought/discussion ??? Explanations of underlying ethical and legal principles ?? Comprehensive Exam Suggested reading and internet resources Glossary of terms Index
