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Managing Ethical Situations & Decisions Mr. Rob Sibbald Ms. Marleen Van Laethem Clinical Ethicist Clinical Ethicist London Health Sciences Centre St Joseph’s Health Care London February 15, 2013
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Page 1: Managing Ethical Situations & Decisions Mr. Rob SibbaldMs. Marleen Van Laethem Clinical Ethicist London Health Sciences CentreSt Joseph’s Health Care London.

Managing Ethical Situations & Decisions

Mr. Rob Sibbald Ms. Marleen Van LaethemClinical Ethicist Clinical Ethicist London Health Sciences Centre St Joseph’s Health Care London

February 15, 2013

Page 2: Managing Ethical Situations & Decisions Mr. Rob SibbaldMs. Marleen Van Laethem Clinical Ethicist London Health Sciences CentreSt Joseph’s Health Care London.

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

Agenda

0800 - 0820 - intro to ethics/decision making, clinical and organizational (Marleen)0820 - 0900 - consent / capacity / frameworks (Rob)0900 - 0930 - Catholic ethics, research ethics (Marleen)0930 - 0945 - recent cases (Rob)

Page 3: Managing Ethical Situations & Decisions Mr. Rob SibbaldMs. Marleen Van Laethem Clinical Ethicist London Health Sciences CentreSt Joseph’s Health Care London.

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

How to manage ethical situations?

Page 4: Managing Ethical Situations & Decisions Mr. Rob SibbaldMs. Marleen Van Laethem Clinical Ethicist London Health Sciences CentreSt Joseph’s Health Care London.

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

How to manage ethical situations?

1) Discern when issues have ethical implications2) Access supports and resources3) Know the minimum standard (legal as well as

hospital policies)4) Identify the appropriate decision-maker(s) 5) Reflect on values & alternative perspectives 6) Strive to be more than simply within limits;

strive to conduct ourselves ethically

Page 5: Managing Ethical Situations & Decisions Mr. Rob SibbaldMs. Marleen Van Laethem Clinical Ethicist London Health Sciences CentreSt Joseph’s Health Care London.

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

What is ethics? (1/2)

• Ethics is concerned with principles and values, issues of right and wrong, and what we owe each other as persons

• A branch of philosophy concerned with the “right” and “virtuous” behavior

• Moral Theories• Rational Thought/Deliberation• Deciding which particular need, action,

value, or belief should have precedence over another

Page 6: Managing Ethical Situations & Decisions Mr. Rob SibbaldMs. Marleen Van Laethem Clinical Ethicist London Health Sciences CentreSt Joseph’s Health Care London.

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

What is ethics? (2/2)

• When ethical issues are clear, Black & White, laws or guidelines are written

• E.g. get informed consent before diagnostics and treatments

• Mostly shades of grey

Page 7: Managing Ethical Situations & Decisions Mr. Rob SibbaldMs. Marleen Van Laethem Clinical Ethicist London Health Sciences CentreSt Joseph’s Health Care London.

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

Reflective Practice

A challenge due to: fiscal restraints, scarce resources, “doing more with less”

Page 8: Managing Ethical Situations & Decisions Mr. Rob SibbaldMs. Marleen Van Laethem Clinical Ethicist London Health Sciences CentreSt Joseph’s Health Care London.

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

Some ethical dilemmas – 1

A patient, recently diagnosed as HIV+, requests that his wife not be informed of his HIV status. Should his wish be respected? OrShould his wife be told?

Page 9: Managing Ethical Situations & Decisions Mr. Rob SibbaldMs. Marleen Van Laethem Clinical Ethicist London Health Sciences CentreSt Joseph’s Health Care London.

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

Consider…

• To whom is your duty? Husband? Wife?

• Competing claims / priorities– His autonomous decision-making over

his Personal Health Information (PHI)– Her potential harm of infection

• Laws (protecting PHI, preventing spread of disease)

Page 10: Managing Ethical Situations & Decisions Mr. Rob SibbaldMs. Marleen Van Laethem Clinical Ethicist London Health Sciences CentreSt Joseph’s Health Care London.

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

One Approach

Ethical Principles• Respect for autonomy• Beneficence – doing good• Non-maleficence – do no harm• Justice - fairness

Limitation: no specific priority of principles

Page 11: Managing Ethical Situations & Decisions Mr. Rob SibbaldMs. Marleen Van Laethem Clinical Ethicist London Health Sciences CentreSt Joseph’s Health Care London.

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

Some ethical dilemmas – 2

An elderly patient has carcinoma of the prostate. Should he be told of his diagnosis against his son’s instructions?

Page 12: Managing Ethical Situations & Decisions Mr. Rob SibbaldMs. Marleen Van Laethem Clinical Ethicist London Health Sciences CentreSt Joseph’s Health Care London.

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

Common signs of an ethical issue

The “ick” factor

the “six o’clock news” test

Uncertainty, disagreement or conflict about what ought to be done

Dignity or fairness is at stake

Page 13: Managing Ethical Situations & Decisions Mr. Rob SibbaldMs. Marleen Van Laethem Clinical Ethicist London Health Sciences CentreSt Joseph’s Health Care London.

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

Resources

• Royal College of Physicians and Surgeons of Canada Ethics Tutorials

http://rcpsc.medical.org/test/research/learning_materials/ethics/tutorials/index.php

• CMA Code of Ethicshttp://policybase.cma.ca/dbtw-wpd/PolicyPDF/PD04-06.pdf

Page 14: Managing Ethical Situations & Decisions Mr. Rob SibbaldMs. Marleen Van Laethem Clinical Ethicist London Health Sciences CentreSt Joseph’s Health Care London.

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

CMA CODE OF ETHICS

Page 15: Managing Ethical Situations & Decisions Mr. Rob SibbaldMs. Marleen Van Laethem Clinical Ethicist London Health Sciences CentreSt Joseph’s Health Care London.

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

CMA Code of Ethics

• Fundamental Responsibilities• Responsibilities to the Patient• Responsibilities to Society• Responsibilities to the

Profession• Responsibilities to Oneself

Page 16: Managing Ethical Situations & Decisions Mr. Rob SibbaldMs. Marleen Van Laethem Clinical Ethicist London Health Sciences CentreSt Joseph’s Health Care London.

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

10 Fundamental Responsibilities

1. Consider first the well-being of the patient.

2. Practise the profession of medicine in a manner that treats the patient with dignity and as a person worthy of respect.

Page 17: Managing Ethical Situations & Decisions Mr. Rob SibbaldMs. Marleen Van Laethem Clinical Ethicist London Health Sciences CentreSt Joseph’s Health Care London.

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

30 Responsibilities to the Patient

– General Responsibilities– Initiating and Dissolving a Patient-

Physician Relationship– Communication, Decision Making

and Consent– Privacy and Confidentiality– Research

Page 18: Managing Ethical Situations & Decisions Mr. Rob SibbaldMs. Marleen Van Laethem Clinical Ethicist London Health Sciences CentreSt Joseph’s Health Care London.

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

General Responsibilities

12. Inform your patient when your personal values would influence the recommendation or practice of any medical procedure that the patient needs or wants.14. Take all reasonable steps to prevent harm topatients; should harm occur, disclose it to thepatient.

Page 19: Managing Ethical Situations & Decisions Mr. Rob SibbaldMs. Marleen Van Laethem Clinical Ethicist London Health Sciences CentreSt Joseph’s Health Care London.

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

Communication, Decision Making and Consent

21. Provide your patients with the information they need to make informed decisions about their medical care, and answer their questions to the best of your ability.22. Make every reasonable effort to communicate with your patients in such a way that information exchanged is understood.

Page 20: Managing Ethical Situations & Decisions Mr. Rob SibbaldMs. Marleen Van Laethem Clinical Ethicist London Health Sciences CentreSt Joseph’s Health Care London.

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

Respect patient’s wishes

24. Respect the right of a competent patient toaccept or reject any medical care recommended.26. Respect your patient's reasonable request for a second opinion from a physician of the patient'schoice.27. Ascertain wherever possible and recognize your patient's wishes about the initiation, continuation or cessation of life-sustaining treatment.

Page 21: Managing Ethical Situations & Decisions Mr. Rob SibbaldMs. Marleen Van Laethem Clinical Ethicist London Health Sciences CentreSt Joseph’s Health Care London.

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

Patients without capacity

28. Respect the intentions of an incompetent patient as they were expressed (e.g., through a valid advance directive or proxy designation) before the patient became incompetent.29. When the intentions of an incompetent patient are unknown and when no formal mechanism for making treatment decisions is in place, render such treatment as you believe to be in accordance with the patient's values or, if these are unknown, the patient's best interests.

Page 22: Managing Ethical Situations & Decisions Mr. Rob SibbaldMs. Marleen Van Laethem Clinical Ethicist London Health Sciences CentreSt Joseph’s Health Care London.

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

Decision-making at various levels

• 1 patient (± family) + at least 1 member of the health care team = Clinical Ethics

• Affects multiple patients, potentially multiple stakeholders = Organizational Ethics

Page 23: Managing Ethical Situations & Decisions Mr. Rob SibbaldMs. Marleen Van Laethem Clinical Ethicist London Health Sciences CentreSt Joseph’s Health Care London.

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

ORGANIZATIONAL ETHICS

Page 24: Managing Ethical Situations & Decisions Mr. Rob SibbaldMs. Marleen Van Laethem Clinical Ethicist London Health Sciences CentreSt Joseph’s Health Care London.

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

Different from Clinical Ethics?

Clinical EthicsThe moral agent is the individual who is making the decisione.g. Patient, Substitute Decision Maker, Health Care Provider

If there is conflict, it is typically:• between patient and health care team, or • between family members, or • between health care team members.

Organizational EthicsThe organization is the moral agent.

Mission/Vision/Values are akin to the physician/nurse code of ethics.

Page 25: Managing Ethical Situations & Decisions Mr. Rob SibbaldMs. Marleen Van Laethem Clinical Ethicist London Health Sciences CentreSt Joseph’s Health Care London.

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

Conflict in Organizational Ethics

Conflict is more likely than in clinical ethicsBecause there are many more stakeholders: LHIN, public, community partners, all professions, University, etc.

Process becomes even more importantBecause agreement on substantive values is unlikely.

Most organizational ethics issues are managed through procedural values – ensuring there is a fair process by which to manage ethical dilemmas.

Page 26: Managing Ethical Situations & Decisions Mr. Rob SibbaldMs. Marleen Van Laethem Clinical Ethicist London Health Sciences CentreSt Joseph’s Health Care London.

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

Values

Organizational Ethics Values • Rationality • Transparency • Accountability

Specific wording in the Catholic context• Stewardship of resources • Social Justice (Engagement on behalf of the less

powerful, the marginalized and the dispossessed)

Page 27: Managing Ethical Situations & Decisions Mr. Rob SibbaldMs. Marleen Van Laethem Clinical Ethicist London Health Sciences CentreSt Joseph’s Health Care London.

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

Top Organizational Ethics Issues

Resource Allocation• Resources are, by definition, scarce

(We don’t always acknowledge this basic fact.)• Applies to human capital as well as financial

Mission / Culture • How do we define ourselves? • How do we live in such a way as to honour our

identity / values? • How do we bridge the gap between who we are

and who we want to be?

Page 28: Managing Ethical Situations & Decisions Mr. Rob SibbaldMs. Marleen Van Laethem Clinical Ethicist London Health Sciences CentreSt Joseph’s Health Care London.

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

More Organizational Ethics Issues

End of Life Care• How to support physicians and other staff? • How to appropriately educate and assist patients /

SDM to make difficult end of life decisions?

FundraisingGovernance HR related issuesUninsured patients Business development

Page 29: Managing Ethical Situations & Decisions Mr. Rob SibbaldMs. Marleen Van Laethem Clinical Ethicist London Health Sciences CentreSt Joseph’s Health Care London.

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

Standards for Business Conduct

• Gifts/favours (what is nominal?)• No payment from a supplier if you

are in a position to make decisions about their service at the hospital

• Hiring family members• Conflicts of interest• Use of hospital resources

Page 30: Managing Ethical Situations & Decisions Mr. Rob SibbaldMs. Marleen Van Laethem Clinical Ethicist London Health Sciences CentreSt Joseph’s Health Care London.

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

How to manage ethical situations?

1) Discern when issues have ethical implications2) Access supports and resources3) Know the minimum standard (legal as well as

hospital policies)4) Identify the decision-maker(s) 5) Reflect on values & alternative perspectives 6) Strive to be more than simply within limits;

strive to conduct ourselves ethically


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