Medicine and Ethics

Copyright © 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 1

Medicine and EthicsMedicine and Ethics

Chapter 6


IntroductionIntroduction

Ethics concerns itself with the philosophies Ethics concerns itself with the philosophies underlying ideal relationships between human underlying ideal relationships between human beings, as well as the promotion of the highest beings, as well as the promotion of the highest good for humanity as a whole.good for humanity as a whole.

Decisions that people make based on ethical Decisions that people make based on ethical beliefs can quite possibly alter the course of beliefs can quite possibly alter the course of human existence.human existence.


This chapter will examine:This chapter will examine:

Rights and duties as related to ethicsRights and duties as related to ethics Four types of ethical problemsFour types of ethical problems Making ethical decisionsMaking ethical decisions The impact that CEJA has had on ethical The impact that CEJA has had on ethical

decisions made by healthcare professionalsdecisions made by healthcare professionals The reasons that confidentiality is an ethical The reasons that confidentiality is an ethical

issueissue CEJA opinionsCEJA opinions


History of Ethics in MedicineHistory of Ethics in Medicine

Ethics explores the moral right or wrong of an Ethics explores the moral right or wrong of an issue.issue.

Ethics should not be confused with etiquette.Ethics should not be confused with etiquette.

Etiquette refers to courtesy, customs, and Etiquette refers to courtesy, customs, and manners.manners.


Code of HammurabiCode of Hammurabi

Earliest written code of ethicsEarliest written code of ethics Written in approximately 2250 Written in approximately 2250 B.C.B.C. Elaborated on the conduct expected of a Elaborated on the conduct expected of a

physicianphysician Set the fees a physician could chargeSet the fees a physician could charge


Oath of HippocratesOath of Hippocrates

Written in approximately 400 B.C. by Written in approximately 400 B.C. by HippocratesHippocrates Greek physicianGreek physician Known as the Father of MedicineKnown as the Father of Medicine

Administered to medical school graduates even Administered to medical school graduates even todaytoday


Percival’s Code of Medical EthicsPercival’s Code of Medical Ethics

Thomas PercivalThomas Percival Physician, philosopher, and writer from Physician, philosopher, and writer from

Manchester, EnglandManchester, England Published his Code of Medical Ethics in 1803Published his Code of Medical Ethics in 1803


AMA Code of EthicsAMA Code of Ethics

Formulated in 1847 at the first annual AMA Formulated in 1847 at the first annual AMA meetingmeeting

Specifically acknowledged Percival’s Code of Specifically acknowledged Percival’s Code of Ethics as its foundationEthics as its foundation


American Medical AssociationAmerican Medical Association

AMA was established in 1846AMA was established in 1846 Provides information and support to physiciansProvides information and support to physicians


Council on Ethical and Judicial AffairsCouncil on Ethical and Judicial Affairs

CEJA consists of nine active members of the CEJA consists of nine active members of the AMAAMA

Includes one resident physicianIncludes one resident physician Includes one student memberIncludes one student member CEJA is responsible for interpreting the AMA CEJA is responsible for interpreting the AMA

Principles of Medical Ethics as adopted by the Principles of Medical Ethics as adopted by the House of DelegatesHouse of Delegates


Components of theComponents of the AMA AMA Code of EthicsCode of Ethics

Four components:Four components: Principles of medical ethicsPrinciples of medical ethics Fundamental elements of the patient-physician Fundamental elements of the patient-physician

relationshiprelationship Current opinions of the CEJA with annotationsCurrent opinions of the CEJA with annotations Reports of the CEJAReports of the CEJA


PublicationsPublications

Code of Medical Ethics: Current Opinions with Code of Medical Ethics: Current Opinions with AnnotationsAnnotations Contains the first three componentsContains the first three components Contains discussion of more than 135 ethical Contains discussion of more than 135 ethical issues encountered in medicine issues encountered in medicine

Reports of the Council on Ethical and Judicial Reports of the Council on Ethical and Judicial AffairsAffairs Discusses the rationale of the Council’sDiscusses the rationale of the Council’s opinions opinions


Making Ethical DecisionsMaking Ethical Decisions

We must first understand…We must first understand… the elements of ethics.the elements of ethics. types of ethical problems.types of ethical problems. the decision-making process.the decision-making process.


Elements of EthicsElements of Ethics

Three general elements of ethicsThree general elements of ethics Duties: Obligations that a person has or Duties: Obligations that a person has or

perceives himself or herself to haveperceives himself or herself to have Rights: Claims that a person or group makes on Rights: Claims that a person or group makes on

society, a group, or an individualsociety, a group, or an individual Character traits: A disposition to act in a certain Character traits: A disposition to act in a certain

wayway


Types of DutiesTypes of Duties

NonmaleficenceNonmaleficence Refraining from harming oneself or another Refraining from harming oneself or another

personperson

BeneficenceBeneficence Bringing about goodBringing about good

FidelityFidelity Concept of promise-keepingConcept of promise-keeping

VeracityVeracity Telling the truthTelling the truth


Types of DutiesTypes of Duties

JusticeJustice Fair distribution of benefits and burdens among Fair distribution of benefits and burdens among

individuals and groups in society having individuals and groups in society having legitimate claims on those benefitslegitimate claims on those benefits

ReparationsReparations Righting a wrongRighting a wrong

GratitudeGratitude

** Feeling grateful after being the beneficiary of Feeling grateful after being the beneficiary of someone’s goodnesssomeone’s goodness


Rights Versus PrivilegesRights Versus Privileges

The Bill of Rights guarantees certain liberties The Bill of Rights guarantees certain liberties that we enjoy as U.S. citizens.that we enjoy as U.S. citizens.

Americans do not have the RIGHT to healthcare Americans do not have the RIGHT to healthcare services; it is a privilege.services; it is a privilege.

Rights apply to all people within a group without Rights apply to all people within a group without prejudice.prejudice.

Consider the phrase “the RIGHT to life.”Consider the phrase “the RIGHT to life.”


Character TraitsCharacter Traits

Not always an indication as to how a person will Not always an indication as to how a person will act in every situation.act in every situation.

No human being is perfect.No human being is perfect. Humans are often unpredictable.Humans are often unpredictable.


Types of Ethical ProblemsTypes of Ethical Problems

Ethical DistressEthical Distress

A situation in which certain course of action is A situation in which certain course of action is indicated, but some type of hindrance or barrier indicated, but some type of hindrance or barrier prevents that actionprevents that action


Ethical DistressEthical Distress

From Purtilo R: Ethical dimensions in the health professions, ed 4, Philadelphia, 2005, WB Saunders.



Ethical DilemmaEthical Dilemma

A situation in which an individual is faced with A situation in which an individual is faced with two or more choices that are acceptable and two or more choices that are acceptable and correct, but doing one precludes doing anothercorrect, but doing one precludes doing another


Ethical DilemmaEthical Dilemma




Dilemmas of JusticeDilemmas of Justice

Focuses on the fair distribution of benefits to Focuses on the fair distribution of benefits to those who are entitled to themthose who are entitled to them


Dilemmas of JusticeDilemmas of Justice




Locus of AuthorityLocus of Authority

Two or more authority figures have their own Two or more authority figures have their own ideas about how a situation should be handled, ideas about how a situation should be handled, but only one of those authorities will prevailbut only one of those authorities will prevail


Locus of AuthorityLocus of Authority



Recognizing Ethical ProblemsRecognizing Ethical Problems

It is not always easy to recognize the type of It is not always easy to recognize the type of ethical problem present.ethical problem present.

Sometimes, a mixture of problems exists.Sometimes, a mixture of problems exists.


The Ethical Decision-Making ProcessThe Ethical Decision-Making Process

Purtillo presents a five-step method for making Purtillo presents a five-step method for making ethical decisions:ethical decisions: Gather relevant informationGather relevant information Identify the type of ethical problemIdentify the type of ethical problem Determine the ethical approach to useDetermine the ethical approach to use Explore practical alternativesExplore practical alternatives Complete the actionComplete the action


Current Opinions of CEJACurrent Opinions of CEJA

AbortionAbortion

Should a woman who has been raped and Should a woman who has been raped and become pregnant have an abortion?become pregnant have an abortion?



AbuseAbuse

What harm can come to a patient’s family if What harm can come to a patient’s family if medical professionals are incorrect about their medical professionals are incorrect about their assessment of abuse?assessment of abuse?



Allocation of Health ResourcesAllocation of Health Resources

If the CEO of American Airlines, the winner If the CEO of American Airlines, the winner of last year’s Best Actor Oscar, and a of last year’s Best Actor Oscar, and a drug-abusing mother of three were all equally drug-abusing mother of three were all equally ill and needed a liver transplant, who should ill and needed a liver transplant, who should receive it?receive it?



Artificial InseminationArtificial Insemination

A man fertilized eggs that were frozen for later A man fertilized eggs that were frozen for later use, but he died without having made provision use, but he died without having made provision for the use of those eggs after his death. Should for the use of those eggs after his death. Should the man’s wife be able to use the eggs?the man’s wife be able to use the eggs?



Stem Cell ResearchStem Cell Research

A medical student is recruited to work with a A medical student is recruited to work with a physician who is researching paralysis. Once physician who is researching paralysis. Once the project is underway, the student discovers the project is underway, the student discovers that the physician is using embryos that have that the physician is using embryos that have been questionably obtained. What should the been questionably obtained. What should the student do?student do?



Surrogate MotherhoodSurrogate Motherhood

What is a fair length of time to give a surrogate What is a fair length of time to give a surrogate mother to petition to void a surrogacy contract?mother to petition to void a surrogacy contract?



Human CloningHuman Cloning

If a couple loses their child through death but it If a couple loses their child through death but it were possible to clone the child, what concerns were possible to clone the child, what concerns would be present for the family?would be present for the family?



Genetic CounselingGenetic Counseling

What could happen if parents were to “design” a What could happen if parents were to “design” a baby, but it arrived flawed in some way or did baby, but it arrived flawed in some way or did not meet their expectations?not meet their expectations?



Physician-Assisted SuicidePhysician-Assisted Suicide

If a patient mentioned in passing that he or she If a patient mentioned in passing that he or she would want the right to commit suicide in the would want the right to commit suicide in the event of a terminal illness, would you support event of a terminal illness, would you support that decision if the situation did arise?that decision if the situation did arise?



Surrogate Decision MakingSurrogate Decision Making

A physician recommends that a patient be taken A physician recommends that a patient be taken off life support. The patient lives with his off life support. The patient lives with his homosexual partner and has not seen his homosexual partner and has not seen his parents in 10 years. The partner does not wish parents in 10 years. The partner does not wish to remove life support, stating that the patient to remove life support, stating that the patient would want every opportunity to live. If the would want every opportunity to live. If the parents disagree, whose decisions should parents disagree, whose decisions should prevail?prevail?



Withholding or Withdrawing Life-Prolonging Withholding or Withdrawing Life-Prolonging TreatmentTreatment

How would a medical assistant handle the family How would a medical assistant handle the family of a patient who asks for advice about of a patient who asks for advice about withdrawing life-prolonging treatment? To whom withdrawing life-prolonging treatment? To whom should the medical assistant defer the question?should the medical assistant defer the question?



Quality of LifeQuality of Life

A mentally ill single woman who is institutionalized A mentally ill single woman who is institutionalized becomes pregnant and refuses to give up her becomes pregnant and refuses to give up her maternal rights so that the child can be adopted. maternal rights so that the child can be adopted. Even if she were to reconsider, what Even if she were to reconsider, what complications would result if the child were born complications would result if the child were born deaf and with a severe liver disorder? Should the deaf and with a severe liver disorder? Should the child be fed and cared for by the hospital staff?child be fed and cared for by the hospital staff?



Clinical Trial and InvestigationClinical Trial and Investigation

If your brother were homosexual and wanted to If your brother were homosexual and wanted to participate in clinical trials for a vaccination participate in clinical trials for a vaccination against HIV, would you support his decision?against HIV, would you support his decision?



Cost of Healthcare ServicesCost of Healthcare Services

Should an 87-year-old patient with Should an 87-year-old patient with cardiovascular disease and stomach cancer cardiovascular disease and stomach cancer undergo expensive breast reconstructive undergo expensive breast reconstructive surgery?surgery?



Organ DonationOrgan Donation

A woman dies with a living will that states that A woman dies with a living will that states that she wishes her organs to be donated. Her she wishes her organs to be donated. Her mother, still living, disagrees and does not want mother, still living, disagrees and does not want her daughter’s organs donated. What should her daughter’s organs donated. What should the health professional do in this situation?the health professional do in this situation?



Capital PunishmentCapital Punishment

A very emotional patient, the parent of a child A very emotional patient, the parent of a child who was raped and killed, has been given the who was raped and killed, has been given the opportunity to attend the execution of the opportunity to attend the execution of the murderer. During a visit to her family physician, murderer. During a visit to her family physician, she expresses concerns about being able to she expresses concerns about being able to cope with the memory of her daughter during cope with the memory of her daughter during the execution and asks you if you would attend the execution and asks you if you would attend in the same situation. How to you handle this?in the same situation. How to you handle this?


Ethical Issues Surrounding HIVEthical Issues Surrounding HIV

HIV-positive individuals deserve privacy, as do HIV-positive individuals deserve privacy, as do all patients.all patients.

Unique identifiers help maintain confidentiality.Unique identifiers help maintain confidentiality.


Ethics and the Human GenomeEthics and the Human Genome

Human Genome Mapping Project was Human Genome Mapping Project was completed in 2003.completed in 2003.

Data will be studied for years to come.Data will be studied for years to come. Access to genetic information presents privacy Access to genetic information presents privacy

concerns as to who owns the genetic concerns as to who owns the genetic information and who controls it.information and who controls it.

As genetic technology advances, the application As genetic technology advances, the application of ethics to that technology must also be of ethics to that technology must also be considered.considered.


Other Ethical IssuesOther Ethical Issues

Interprofessional RelationshipsInterprofessional Relationships Medical professionals should speak up when Medical professionals should speak up when

errors by other professionals are suspected.errors by other professionals are suspected. Referrals to other professionals should be made Referrals to other professionals should be made

only when one is confident in his or her ability.only when one is confident in his or her ability. Physicians in private practices are free to Physicians in private practices are free to

decide whom they will treat.decide whom they will treat. Sports medicine physicians must consider the Sports medicine physicians must consider the

patient first and not make medical decisions patient first and not make medical decisions based on potential game outcomes.based on potential game outcomes.



Confidentiality and Patient PrivacyConfidentiality and Patient Privacy It is unethical and unacceptable to divulge any It is unethical and unacceptable to divulge any

information about a patient to any person not information about a patient to any person not directly involved in the patient’s care.directly involved in the patient’s care.

All information in the record must be kept in All information in the record must be kept in strict confidence.strict confidence.


Confidentiality restrictions apply to all patient Confidentiality restrictions apply to all patient medical records, including separately filed medical records, including separately filed x-rays, etc.x-rays, etc.



AdvertisingAdvertising

Only deceptive trade practice regulations Only deceptive trade practice regulations govern advertising by medical facilities and govern advertising by medical facilities and practitioners.practitioners.



Communications with the MediaCommunications with the Media

Medical professionals cannot discuss any Medical professionals cannot discuss any patient with any member of the media without patient with any member of the media without his or her written permission.his or her written permission.



Physician Obligations in Disaster Preparedness Physician Obligations in Disaster Preparedness and Responseand Response

Physicians are ethically obligated to providePhysicians are ethically obligated to provide emergency care during disasters. emergency care during disasters. Examples include natural disasters, such as aExamples include natural disasters, such as a severe hurricane, epidemics, and terrorist severe hurricane, epidemics, and terrorist attacks. attacks.



Malevolent Use of Biomedical ResearchMalevolent Use of Biomedical Research

Physicians must assess the possible Physicians must assess the possible ramifications of participation in research before ramifications of participation in research before engaging in projects.engaging in projects.



Racial and Ethnic Healthcare DisparitiesRacial and Ethnic Healthcare Disparities

Patients are entitled to the same quality of care Patients are entitled to the same quality of care regardless of their race or ethnic backgroundregardless of their race or ethnic background



Diagnostic Imaging on RequestDiagnostic Imaging on Request

Physicians should perform diagnostic imaging Physicians should perform diagnostic imaging only when they believe that the benefits of the only when they believe that the benefits of the imaging service outweigh the risks involved.imaging service outweigh the risks involved.



ComputersComputers

All authorized personnel must comply with All authorized personnel must comply with HIPAA regulations with regard to computer use.HIPAA regulations with regard to computer use.



Charging or collecting an illegal or excessive fee Charging or collecting an illegal or excessive fee is prohibitedis prohibitedFee Splitting and Contingent FeesFee Splitting and Contingent Fees The practices of fee splitting and acceptingThe practices of fee splitting and accepting contingent fees are unethical contingent fees are unethicalFee SplittingFee Splitting Accepting a payment from another physicianAccepting a payment from another physician solely for the referral of a patient solely for the referral of a patientContingent FeesContingent Fees Accepting a patient and collecting fees basedAccepting a patient and collecting fees based on the outcome of treatment on the outcome of treatment



Insurance FormsInsurance Forms

Facilities are allowed to charge for completing Facilities are allowed to charge for completing multiple insurance forms.multiple insurance forms.



Waiver of Insurance CopaymentsWaiver of Insurance Copayments

Routine waiver of insurance copayments may Routine waiver of insurance copayments may violate the contracts with the insurance violate the contracts with the insurance company or managed care organization.company or managed care organization.



Professional CourtesyProfessional Courtesy Physicians may offer professional courtesy Physicians may offer professional courtesy

discounts, but this practice has become less discounts, but this practice has become less common in recent years.common in recent years.

The office policy manual should provide strict The office policy manual should provide strict details and guidelines about the issue of details and guidelines about the issue of professional courtesy.professional courtesy.



Appointment ChargesAppointment Charges It is completely ethical to charge a reasonable It is completely ethical to charge a reasonable

fee for missed appointments that are not fee for missed appointments that are not cancelled or rescheduled in accordance with the cancelled or rescheduled in accordance with the office policy manual.office policy manual.

Patients must be informed as to the policy Patients must be informed as to the policy regarding missed appointments.regarding missed appointments.



Prescribing Drugs and DevicesPrescribing Drugs and Devices

Physicians should not be influenced in the Physicians should not be influenced in the prescribing of drugs, devices, or appliances by prescribing of drugs, devices, or appliances by a direct or indirect financial interest in the a direct or indirect financial interest in the supplier.supplier.



Professional and Contractual RelationshipsProfessional and Contractual Relationships

Physicians should negotiate the wording of Physicians should negotiate the wording of contracts such that there is no question of contracts such that there is no question of financial incentives for the physician that would financial incentives for the physician that would in any way compromise professional judgment in any way compromise professional judgment or integrity.or integrity.



Health Facility Ownership by a PhysicianHealth Facility Ownership by a Physician

Physicians may own a health facility or have a Physicians may own a health facility or have a financial interest in such a facility but must financial interest in such a facility but must disclose this connection to the patients before disclose this connection to the patients before referring them to the facility.referring them to the facility.



Ghost SurgeryGhost Surgery

It is unethical to substitute surgeons without It is unethical to substitute surgeons without patient knowledge and consent.patient knowledge and consent.



Discipline within MedicineDiscipline within Medicine

Physicians should expose incompetent, corrupt, Physicians should expose incompetent, corrupt, dishonest, or unethical conduct by members of dishonest, or unethical conduct by members of the profession.the profession.



Physician Health and WellnessPhysician Health and Wellness

A physician who knows that he or she has an A physician who knows that he or she has an infectious disease should not engage in any infectious disease should not engage in any activity that would cause a significant risk to activity that would cause a significant risk to patients.patients.



Substance AbuseSubstance Abuse It is unethical for physicians to practice It is unethical for physicians to practice

medicine when under the influence of a medicine when under the influence of a controlled substance.controlled substance.

Healthcare providers who are aware of Healthcare providers who are aware of colleagues who engage in such activities must colleagues who engage in such activities must be reported to the appropriate authorities.be reported to the appropriate authorities.



Unethical ConductUnethical Conduct Be absolutely sure of all information.Be absolutely sure of all information. Decide whether the information should be Decide whether the information should be

reported, and to whom it should be reported.reported, and to whom it should be reported. Determine if working for the professional who Determine if working for the professional who

engages in unethical behavior is in the best engages in unethical behavior is in the best interest of the medical assistant.interest of the medical assistant.


Summary of ScenarioSummary of Scenario

There are always at least two sides to each There are always at least two sides to each ethical situation. ethical situation.

Be nonjudgmental toward patients and Be nonjudgmental toward patients and coworkers.coworkers.

Never inflict personal opinions onto patients.Never inflict personal opinions onto patients. Periodically perform a self-evaluation Periodically perform a self-evaluation

regarding ethical views.regarding ethical views.


Closing CommentsClosing Comments

Keep abreast of current issues that have Keep abreast of current issues that have ethical implications. ethical implications.

Study of ethics requires serious thought and Study of ethics requires serious thought and introspection. introspection.

Determine personal views about each of the Determine personal views about each of the opinions in the text.opinions in the text.

Belief systems should be personally created, Belief systems should be personally created, not adhered to simply because parents held not adhered to simply because parents held certain beliefs.certain beliefs.

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