Medical Ethics and Health Care Risk Management

A personal membershipgroup of

Medical Ethics and Risk Management

Josh Hyatt DHSc (c), MHL, CPHRMSenior Risk Management Specialist NORCAL Mutual


Today’s webinar is being presented by:

Josh Hyatt, DHSc (c), MHL, CPHRMSenior Risk Management Specialist NORCAL Mutual Insurance


Objectives

Apply a learning model to analyze and provide recommendations to common medical ethics issues

Discuss and critically analyze three key clinical ethical areas and ideas to implement effective risk reduction strategies

Apply and discuss the six principles in bioethics

Analyze the critical components of where law and medical ethics intersect

Identify the key components of an effective medical ethics program.

Identify the five R’s in medical ethics decision making


Questions to Ponder

Are we providing ethical care to the patient?– From whose perspective– Do we ask about whether patients felt as if they were treated ethically?

How do we or can we quantify ethical behavior?

Do we have ethical decision-making process in our organization?

Do we have competencies in our institution that evaluate ethical decision-making?


Gallup Poll, November 2012

Highest Rated Ethical Professionals:

– 1. Nurses (85% very high or high)– 2. Pharmacists (75% very high or high)– 3. Medical Doctors (70% very high or high)– 8. Clergy (52% very high or high)– 9. Psychiatrists (41% very high or high)– 15. Lawyers (19% very high or high)– 21. Senators (14% very high or high)– 25. Members of Congress (10% very high or high)– 26. Car Salesmen (8% very high or high)


Ethics Overview

Ethics•The branch of philosophy that studies the nature of and the justification for general principles governing right conductIntent of Ethics• Ethics attempts to bring to a conscious level the underlying ideals of behavior.


Ethical Behavior

Values

Moral Imperatives:

Traditions or belief about what is right or wrong in human conduct

The worth or desirability of something, whether is it moral or non-moral (i.e. efficiency, honesty, compassion)


Science & Ethics Decision Making Models

ScienceSearches for answers through “explanation”

Question

HypothesisLaw

Theory

Explanation

Ethics/BioethicsSearches for answers through “moral justification”

Question

Moral Value Judgment

Rule

Principle

Theory

Moral JustificationAdapted and expanded from T. Beauchamp and L. Walters, Contemporary Issues in Bioethics (4th ed. 1994) at 10-11


Ethics Scenario #1At 4:30PM on a Friday afternoon, you as the administrator for a 300-bed acute care hospital, receive a telephone call from a physician, Dr. Smith, asking for your advice.

Dr. Smith has been caring for the patient Mr. Jones, a 37-year-old man with a wife and 2 children, for some time and he is now in the late stages of lung cancer. It has metastasized to his bones. Dr. Smith predicts he will live for another month or so if treatment of the chemotherapy and pain medication continues.

The pain medication reduces the pain but does not eliminate the pain. Mr. Jones has a pacemaker to regulate his heart beat. Mr. Jones has recently been admitted to the hospital and is requesting that chemotherapy be stopped and the pacemaker be deprogrammed immediately, resulting in his heart malfunctioning and the cause of his death in a very short amount of time. Mr. Jones is very coherent and understands the effects of his actions.

How does this apply situation apply to our ethics model?Developed by Joan Gibson, Director of Health Sciences Ethics Program at the University of New Mexico, Thinking about the ‘Ethics” in Bioethics (1985)


Ethics Scenario #1

Ethics Question


Rule

Principle

Theory

Moral Justification

Mr. Jones’ Outcome #1Why should we NOT deprogram Mr. Jones’s

pace-maker?

It is not within my belief structure that we should actively kill Mr. Jones by deprograming his pacemaker. Why?

Because of the rule that you should not

kill another person. Why?

Because of the principle of nonmaleficence (i.e. you should never do something that will cause another harm).

Why?

Because of the theory of (take your pick) Christianity, Judaism, Islam,

Aristotelian virtue, Secular Humanism, etc.

Therefore, we will NOT deprogram Mr. Jones’s pacemaker to preserve his life.


Ethics Scenario #1

Ethics Question


Rule

Principle

Theory

Moral Justification

Mr. Jones’ Outcome #2Why should we deprogram Mr. Jones’s pace-

maker?

It is within my belief structure that we should honor Mr. Jones wish by

deprograming his pacemaker. Why?

Because of the rule that you should honor patient wishes. Why?

Because of the principle of autonomy (i.e. every person ought to control his/her own body and mind). Why?

Because of the theory of (take your pick) patient’s right to self-determination,

futility of medical care, utilitarianism, etc.

Therefore, we will deprogram Mr. Jones’s pacemaker to preserve his individual

choice.

Or it could go this way…


Kohlberg's Stages of Moral Development(Kohlberg, 1973)

Level 1 (Pre-Conventional) 1. Obedience and punishment orientation

(How can I avoid punishment?)2. Self-interest orientation

(What's in it for me? Paying for a benefit)Level 2 (Conventional)

3. Interpersonal accord and conformity (Social norms)(The good boy/good girl attitude)

4. Authority and social-order maintaining orientation

(Law and order morality)Level 3 (Post-Conventional)

5. Social contract orientation6. Universal ethical principles

(Principled conscience)


Bioethics

So what is Bioethics?

It is the branch of ethics that specializes in the study of health-science ethical decision-making.

Bioethics

Health Professional/Institutional Ethics

Public Health Policy Ethics



Health Professional/Institutional

Ethics

Individual Patient

Research and Development of

Drugs and Medical Equipment

Institution Providing Health Care Services


Bioethics

Bioethics encompasses two aspects:

Clinical Ethics

Biomedical Ethics

(Integrated Publishing, n.d.)


BioethicsWhat makes up how we view and talk about bioethics though? That is what makes it a vital and important conversation!

Some issues addressed by bioethics on a daily basis:

Abortion Cloning

Physician Assisted Suicide Stopping Medical Care to Prolong Life

Organ Transplant Human Subject Research

Health Care Financing and Reform Shortages of Medical and Nursing Personnel

Malpractice Reform to end Multimillion Dollar Settlements HIV Disclosure and Privacy Do Not Resuscitate Orders

Patients or Families Refusing Life Sustaining Medical Treatment


Professional Responsibility

The “meta-principle” which is often used by those engaged in bioethics discussions centering around the medical provider is PROFESSIONAL RESPONSIBILITY.

This principle provides that:

Any provider (physician, nurse, etc.), as a professional, has an obligation to observe the rules, principles and

moral precepts governing relations with patients, colleagues, the profession as a whole, and the community

at large.

(Arras & Rhoden, 1989)


Professional Responsibility

Health Care Professions’ Statements on EthicsDifferent professional organizations, cultures and traditions dictate that individuals entering a certain profession take an oath which generally geared to improving the knowledge and application of that profession.

In health care, the various oaths include, but are not limited to:Oath of Hippocrates (for Physicians)Oath of Maimonides (for Physicians)

American Medical Association, Principles of Medical Ethics (for Physicians)Islamic Code of Medical Ethics- Oath of the Doctor (for Physicians)

Florence Nightingale Pledge (for Nurses)American Nurses Association, Code for Nurses (for Nurses)

Code of Ethics of the American College of Healthcare Executives (for Administrator)


Professional Codes of Conduct/Ethics

Criticisms of Professional Codes of Conduct/Ethics

Failure to reflect the full range of moral principles

Not enough emphasis on patient's rights

Codes written by the professionals themselves and not subject to outside scrutiny

Too vague and abstract

(Integrated Publishing, n.d.)


Personal v. Professional Ethics

Healthcare providers are faced with personal ethical dilemmas probably on a daily basis.

The dilemmas rise from a variety of sources (religion, values, culture, etc.) and often create tension in the workplace and poor patient outcomes.

How does a medical professional reconcile his or her personal ethics with the professional code of ethics?


Ethics Scenario # 2Catholic Nurse Ordered to Help with Abortion

1. Should an employee that has repeatedly expressed personal values concerns about abortion, or any other procedure type, be required to assist, even if it is within her scope of practice?

2. Was it ethical for her employer to threaten her with termination if she did not comply?

3. Should an employer enforce that an employee do something that morally offends them or should employees not accept position that they know may significantly violate their morals?

4. If there are guidelines to protect the employee from this event by the employer, who and where do these boundaries get drawn?



Basic Principles of Medical Ethics:

AutonomyNon-maleficence

BeneficenceConfidentiality

Distributive JusticeTruth Telling

(Clouser & Gert, 1990)


Autonomy

The principle of autonomy is that:

The independent actions and choices of the individual should not be constrained by others.


Non-Maleficence

This is the concept of “Do No Harm.”

The basis of this principle is:

The provider has a duty NOT to inflict evil, harm, or risk of

harm onto others


Beneficence

The principle for beneficence is:

The provider has a duty to help others by doing what is best for

them.


Confidentiality

The principle for confidentiality is:

When information is divulged by a patient

to the provider, there is an implicit promise that the information will not

be provided to any other person.


Distributive Justice

The principle for distributive justice is:

Benefits and burdens ought to be equally distributed, that resources out to be

fairly allocated, and that the provider should act in such a manner that no one person or group bears a disproportionate

share of the benefits or burdens.


Truth Telling

The principle for truth telling is:

A provider ought to disclose all pertinent information about a condition, procedure, outcome or service to the patient.


CLINICAL ETHICS ANALYSIS

Clinical Approach to Ethical Principles at the Bedside

This information in this section is adapted from Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine (7th Ed)(Jonsen, Siegler, & Winslade, 2010)


Clinical Ethics Analysis

When evaluating a clinical ethics situation, the following areas should be examined:

Medical Indications Patient Preferences

Quality of Life Contextual Features

Paradigm Cases

(Jonsen, Siegler, & Winslade, 2010)


Clinical Ethics Analysis

– Autonomy- Patient Preferences, Quality of Life

– Nonmaleficence- Medical Indications, Quality of Life

– Beneficence- Medical Indications, Quality of Life

– Confidentiality- Quality of Life

– Distributive Justice- Contextual Features

– Truth Telling- Patient Preferences, Quality of Life


MEDICAL INDICATIONS

Clinical Approach to Beneficence and Nonmaleficence

“Cure sometimes, relieve often, comfort always.”


Medical Indications

Five questions that help define the scope of Medical Indications

1.What is the patient’s medical problem and overall clinical condition? Is the injury or illness acute, chronic, critical, reversible, emergent or terminal?

2.What are the goals of treatment/intervention?

3.In what circumstances are medical treatments not indicated?


Medical Indications


4. What are the probabilities of success of various treatment options?

5. How can this patient be benefitted by medical and nursing care, and how can harm be avoided?


Ethics Scenario # 3 Emile Nighthorse is a 77 year-old man who has been hospitalized on a ventilator with a serious kidney disease that will require him to have dialysis indefinitely. Additionally, he has severe dementia and he does not understand his condition or even where he is.

The physician has determined that his dementia is getting more severe and he is showing signs of multi-system failure. It is unlikely he will ever be stable enough to be discharged from the hospital but that he will likely live another few months on a ventilator.

There is no Advance Directive and no evidence of his wishes. He has an estranged wife of 50 years and 2 children, all of whom live in another city. He has an adult friend, Ben, who visits him daily and have been close friends since his wife left 10 years ago. Ben asks the physician to discontinue dialysis and the ventilator.

The wife says she doesn’t care but the children insist everything should be done to save their father, neither of which are willing to come to the hospital to visit him. What does the physician do?


Ethics Scenario #3

Primary Medical Indication Considerations

for Mr. Nighthorse:

Severe kidney disease, indefinite dialysis

Dementia, deteriorating conditionMulti-system failureLikely only to live a few months with aggressive treatment


Medical Indications- Emile


1.What is the patient’s medical problem and overall clinical condition? Is the injury or illness acute, chronic, critical, reversible, emergent or terminal? 1.Chronic and non-curative condition

2.What are the goals of treatment/intervention?1.Maintenance. Are actions heroic in nature?

Futile?3.Are the medical treatments not indicated?1.Physiologically Futile Patient, Incurable


Medical Indications- Emile

4. What are the probabilities of success of various treatment options?

1. Scientific and ethical futility 5. How can this patient be benefitted by medical and nursing care, and how can harm be avoided?

1. Maintenance of biological life


PATIENT PREFERENCES

Clinical Approach to Autonomy and Truth-Telling

It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has. William Osler


Six questions that assist Identifying and assessing ethical problems centered around patient

preferences

1. Has the patient been informed of the benefits, risks, understood this information and given consent?

2. Is the patient mentally capable and legally competent, and is there evidence of incapacity?

3. If mentally capable, what preferences about treatment is the patient stating?

Patient Preferences


Patient Preferences

4. If incapacitated, has the patient expressed prior preferences?

5. Who is the appropriate surrogate to make decisions for the incapacitated patient?

6. Is the patient unwilling or unable to cooperate with medical treatment? If so, why?


Ethics Scenario # 3 Emile Nighthorse is a 77 year-old man who has been hospitalized on a ventilator with a serious kidney disease that will require him to have dialysis indefinitely. Additionally, he has severe dementia and he does not understand his condition or even where he is.

The physician has determined that his dementia is getting more severe and he is showing signs of multi-system failure. It is unlikely he will ever be stable enough to be discharged from the hospital but that he will likely live another few months on a ventilator.

There is no Advance Directive and no evidence of his wishes. He has an estranged wife of 50 years and 2 children, all of whom live in another city. He has an adult friend, Ben, who visits him daily and have been close friends since his wife left 10 years ago. Ben asks the physician to discontinue dialysis and the ventilator.

The wife says she doesn’t care but the children insist everything should be done to save their father, neither of which are willing to come to the hospital to visit him. What does the physician do?


Ethics Scenario #3

Primary Patient Preference Considerations

for Mr. Nighthorse:

No Advance Directive, written wishesEstranged wife and children with no contact

An adult friend wishing to discontinue treatments

Children want treatments continued


Six questions that assist Identifying and assessing ethical problems centered around patient

preferences

1. Has the patient been informed of the benefits, risks, understood this information and given consent?1. Not applicable to patient, but it is to

decision-maker2. Is the patient mentally capable and legally

competent, and is there evidence of incapacity?1. Patient has decisional incapacitation &

dementia3. If mentally capable, what preferences about

treatment is the patient stating?1. Not applicable

Patient Preferences


Patient Preferences

4. If incapacitated, has the patient expressed prior preferences?

1. None in writing, possibly expressed to friend5. Who is the appropriate surrogate to make decisions for the incapacitated patient?

1. Wife, children, adult friend? Can be a state specific issue

2. Probably need legal involved at this point3. Substituted judgment or best interest

judgment6. Is the patient unwilling or unable to cooperate with medical treatment? If so, why?

1. Not applicable


Beneficence v. Autonomy

When in conflict, the provider should consider the following 5 questions:

» Was the critical situation explained in a clear, understandable manner

» Are the barriers such as language, education level, hearing that impair the patient’s understanding

» Are fear, pain, or a lack of trust affecting the decision

» Are there reasons to believe there are differences in values or beliefs

» Is the patient’s decisional capacity impaired by psychiatric or medical problems


QUALITY OF LIFE

Clinical Approach to Autonomy, Non-Maleficence, Beneficence, Confidentiality and Truth-Telling


Quality of Life

Four questions that assist Identifying and assessing ethical problems centered around

patient preferences1. What ethical issues arise concerning improving or

enhancing a patient’s quality of life?

2. What level of effect on quality of life does the disease have?

3. What are plans and rationale to forgo life sustain treatment?

4. What is the legal and ethical status of suicide and is it different than refusal of life sustaining medical care?


Quality of Life

Discontinuation of life support Guidelines for Consideration:

» No medical goals other than life support will be achieved

» There are no known patient preferences that contradict this

» The patient no longer has the neurological ability to feel satisfaction with state


Quality of Life

Artificially administered nutrition and hydration

» Ethically permissible to consider withdrawal if:» No significant medical goal other than maintenance of organic life exists

» The patient is so mentally incapacitated that no preferences can be expressed now or in the future

» No prior preferences for continued sustenance in such a situation have been expressed

» The patient’s situation is such that no discomfort or pain will be experienced


Quality of Life

Legal Implications» Physicians are generally acting in accordance with the law when recommending discontinuation when:» It is a virtual certainty that further medical intervention will not attain any goals other that organic life

» The preferences of the patient are not known or expressed

» Quality of life is severely or profoundly diminished

» Families are in accord» Institutions should have legal counsel prepare clear instructions for the medical staff based on prevailing law.


Quality of LifeCategories of judicial decisions in this area:

»Competent patients expressing wish to discontinue treatment»Bartling v. Superior Court, 1984»Cruzan v. Missouri Dept of Health, 1990

»Incompetent patients whose guardians wish to terminate»Teri Schiavo »Courts generally endorse the “best interests” standard when the preferences of the patient were never known.


Ending Medical Treatment

If a patient chooses to either refuse treatment to stop treatment that could reasonably result in a negative outcome to the patient, the provider should:– Comply with the patients wishes– Unless the patient is deemed incompetent or incapacitated

However, courts have ruled that the state does have the right to intervene on the behalf of a patient in order to:– Preserve Life– Prevent Suicide– Protect an Innocent 3rd Party


Ethics Scenario #3

Primary Quality of Life Considerations for Mr. Nighthorse:

On a ventilatorTreatment not effective for long-term improvement

Unable to be discharged safely to the community

Continuous deterioration of mental and physical conditions


Ethics Scenario #3

Four questions that assist Identifying and assessing ethical problems centered around

patient preferences

1. What ethical issues arise concerning improving or enhancing a patient’s quality of life?1. Improving and enhancing quality of life not

likely.

2. What level of effect on quality of life does the disease have?

1. Severely diminished quality of life


Ethics Scenario #3

3. If stopped, what are plans and rationale to forgo life sustain treatment?

1. Ensure appropriate medication and comfort2. Monitor for double effect principle and

palliative sedation

4. What is the legal and ethical status of suicide and is it different than refusal of life sustaining medical care?

1. The stopping of treatment should be based on: a. Determination of decision-maker, b. Informed consent to the decision-maker, and c. Respect for body integrity


CONTEXTUAL FEATURES

“The death of a single Russian soldier is a tragedy. A million deaths is a statistic.” Joseph Stalin

Clinical Approach to Social Distribution and Fairness


Contextual Features

Although clinical ethics focuses more on medical indications, patient preferences, and quality of life, medical decisions are not just decisions by two people; rather it is constrained by outside elements and social policy.

» Some of these elements include:» Other healthcare providers» Professional organizations» Administration» State and federal agencies» Families» Professional and community standards» Financing» Access to healthcare» Research


Contextual Features

– The primary ethical principles related to contextual features are:» Justice

» Moral distribution of benefits and burdens in a society that is fair and equitable.

» Fairness » Moral characteristic in which transactions and relationships give each participant what is deserved and reasonable to expect.


Ethics Scenario #3

Primary Contextual Considerations for Mr. Nighthorse:

Patient utilizing critical services with minor benefit

Financial and human resources be utilized for futile care

Waiting list for dialysis patients


Ethics Scenario #3- Nighthorse Summary Medical Indications

Scientifically and Ethically Futile Care

Maintenance Oriented

Patient Preferences Unknown from Patient

Conflict Between Estranged Family & Close Friend


Ethics Scenario #3- Nighthorse Summary

Quality of LifeSeverely diminished quality of lifeEnsure appropriate medication and

comfortContextual Features

Financial and Human ResourcesOthers that are not futile could

benefit


Ethics Scenario #3- Nighthorse SummaryPossible actions the facility could

take:– Consult with legal to discuss the decision-making issue

– Provide education and consultation with the decision-maker regarding the futility of the case and the options, based on the organizational code ethics

– Consider a palliative care approach with the decision-maker

– Develop clear guidelines and expectations when particular steps are to be taken

– Informed consent when addressing the possibility of termination of life support


ETHICS AND THE LAW

The perpetual questions of “Can We” and “Should We.”


Law and Ethics Relationship

“Good ethics has been described as beginning where the law ends.

The moral conscience is a precursor to the development of legal rules for social order. Law and medical ethics thus share the goal of creating and maintaining social good.”

(Annas, 1993).


Conceptual Models

Law Identifies:

An expression of social value through rule.

Expresses:

How things “have to be”

Medical EthicsIdentifies:

A method of proper and humane practice.

Expresses:

How things “ought to be”


Sources of Authority

LawsActs of government based on Federal and State:Constitutions,Statutes, Regulations, Administrative rules, andCase law Violations can have both criminal and civil ramifications.

Medical Ethics

Based on:Existing laws Institutional policies/practices

Policy of professional organizations

Professional standards of care

Fiduciary obligations


Risk Management and Ethics

The Risk Manager is often very involved in the Ethics Committee process and decisions that will affect the operations and potential losses of the organization.

Risk Managers continuously monitor new laws and statutes to ensure the facility is in compliance with them and evaluates trends within and outside of the organization to reduce the likelihood of negative events.

Risk Managers are involved at every level of administration and clinical care at a facility and often advise all the departments on liability issues.


ETHICAL SYSTEMS

Does your organization have an effective ethics infrastructure in place that includes a structured process to address ethical conflicts?


Ethics Scenario # 4

“The management team of Memorial Medical Center must make a decision regarding the continuation of one of its outpatient clinics. To provide better community service, MMC developed three outpatient clinics throughout a large metropolitan area. Over the past several years, one of the clinics has consistently been a financial loser. The losses have grown even as the costs of maintaining the clinic have increased. A primary reason for the negative financial performance is the high amount of non-reimbursed healthcare services—the clinic provides needed healthcare to a low-income part of the metropolitan area. Several members of the executive management team believe MMC has no alternative other than closing the clinic. One member of the management team, however, believes that the situation raises ethical concerns, and that executive seeks an ethics-grounded response to the problem” (Nelson, 2005).


Responding to Organizational Ethical ConflictsThe following process reflecting procedural justice can help healthcare executives respond to common, yet challenging, organizational ethical conflicts in a planned, systematic manner (Nelson, 2005).1. Clarify the Ethical Conflict 1. What is the specific ethical question or conflict?2. Is it even an ethical issue? Is it a legal issue

and need to be referred? 2. Identify All of the Affected Stakeholders

and Their Values 1. Who is impacted by this ethical issue?2. What are the core values in play?


Responding to Organizational Ethical Conflicts(Nelson, 2005) Cont.

3. Understand the Circumstances Surrounding the Ethical Conflict

1. Fact-finding as to why this is an ethical concern

2. What are the economic, patient care, legal, community concerns

4. Identify the Ethical Perspectives Relevant to the Conflict

1. What are the ethical concepts in place?2. Codes of ethics, professional standards?3. Literature review, community standards?



5. Identify Different Options for Action1. What is the ethical reasoning for each option?

6. Select among the Options Have1. Have you systematically and quantitatively

evaluated each option?

2. Is the option practical? 3. Does one ethical concept or stake-holder value

appear to be stronger than the others?

4. Can you publically support the decision?



7. Share and Implement the Decision1. Public disclosure2. Explain reasoning

8. Review the Decision to Ensure It Achieved the Desired Goal

1. Assess the outcomes formally and informally2. If the situation got worse, consider a new

approach


The Medical Ethicist

Medical Ethicists:– Oversee ethical conferences– Conduct teaching rounds– Contribute to committee meetings– Consult with healthcare teams on ethical issues

– Developing and contributing to policies and processes to encourage an ethical environment that encourages open communication


Medical Ethics- Systems Thinking

Key Considerations when developing an ethics program:

–Purpose –Membership

–Institutional Values–Research–Committee


Purpose and Direction

How does the program operate:

Authority

Consultative

Direction

Scope of program

Frequency of Meeting


Members

Ethics Committee Membership composition considerations:

Multi-Disciplinary

Lop-sided with one Profession

Other Service Areas Represented

Lay-Person and Non-Clinical Members


Institutional Values

Are there underlying principles and values that your organization has which need to be considered?

Healthcare institutions affiliated with religious or civic organizations often have to meet a higher ethical standard than general or for-profit institutions.


Research

Does the institution engage in human or animal research?

If it conducts human subject research, how does it comply with human subject standards and IRBs?

If it conducts animal research, what guidelines and laws are in place to address the ethical treatment of animals in the research process?


Ethics Committees

There are federal and state requirements that specific types of institutions such as hospitals have them in place.

The requirements generally include:

Diverse backgrounds

Consultation

Policies pertaining to clinical ethics

Education


Ethics Committees

The underlying goals of Ethics Committees are:

Consultation

Patient Rights

Shared Decision Making

Fair and Just Policies and Procedures

Culture of Ethics


Ethics Education

Ensure that all staff, including contracted physician and ancillary medical staff, are trained initially upon starting the organization and annually thereafter, about the Ethics Committee.

It should focus on:– Organizations commitment to “doing the right thing”– Supervisors and managers are held to the same or even higher standards of ethical conduct

– What to report or refer to the Ethics Committee – There is a non-retaliation policy. An employee that reports an issue in good-faith, retaliation is prohibited by the organization

– How to handle events if they occur prior to reporting


Ethics Reporting

Ensure there is a system in place by which patients and families:

– Know the existence of the Ethics Committee

– Know how contact the committee when needed

– Know who the contact individual to the committee is

– Know that a referral to the Ethics Committee will not compromise the patients treatment


Making Ethical Decisions: A Procedural Approach

Approach to resolving ethical issues by the Committee

The Five Rs1. Review2. Respond 3. Reduce 4. Recast 5. Resolve(Gillette, 1996)


Medical Ethics Education

Understanding the importance and application of medical ethics is critical in todays healthcare industry.

Medical ethics has increasingly become a common component of the curriculum in many undergraduate, graduate and medical schools.

It is often either offered with a philosophical bent, within a humanities program, or clinical and legal bent, within a clinical program.


Medical Ethics Education

Many studies have demonstrated that a robust medical ethics program during training in college often will provide critical tools and awareness of the issue.

Additionally, the method of learning is a critical component of how the future practitioner addresses ethical issues as they arise in the future.

An expressed understanding of the principles, critical evaluation and the application of the principles to specific circumstances has been shown to most effective when teaching medical ethics.


Take Away Message

Truth in ethics does not come from coming to a “one size fits all” answer to a question, rather it requires a continuous process of analysis, questioning and re-evaluation of judgments, rules, principles, and theories.


Resources Strengthening Ethical Decision Making: An article that offers strategies senior leaders can use to enhance their ethical awareness and make better ethical decisions

Using ACHE’s Code of Ethics: An explanation of the history and purpose of the Code of Ethics and how it can be used in practical, everyday situations

Using ACHE’s Ethical Policy Statements: Strategies for applying ACHE’s specific policy statements, such as “Decisions Near the End of Life,” to your decisions and your organization’s policy development

Using ACHE’s Ethics Self-Assessment: Tips for getting the most out of an ethics self-audit, and how to address potential red flags that you may identify in the process

Additional Ethics Resources: A list of books, magazine and journal articles, periodicals, and Web sites that can provide additional ethics guidance


References

Annas, G. (1993). Standard of Care: The Law of American Bioethics, Oxford University Press: New York

Arras, J. & Rhoden, N. (1989). Ethical Issues in Modern Medicine, 3rd ed, 6-28

Beauchamp, T. & Walters, L. (1994). Contemporary Issues in Bioethics. 4th ed. 10-11

C A Critique of Principlism, Journal of Medicine & Philosophy, 15, 20

Dictionary.com. (2005). Ethics. Retrieved from http://dictionary.reference.com/browse/ethics

Gallup. (2012, November). Honesty/Ethics in professions. Retrieved from

http://www.gallup.com/poll/1654/honesty-ethics-professions.aspx#1 Gibson, J. (1985). Thinking about the ethics in bioethics.


References

Gillette, M. (1996). Putting it all Together. Retrieved from ttp://www.bsvinc.com/ethics_alltogether.htm

Integrated Publishing. (n.d.) Healthcare ethics. Retrieved from

http://www.tpub.com/content/armymedical/MD0066/MD00660017.htm Jonsen, A.R., Siegler, M., & Winslade, W.J. (2010). Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine (7th Ed), McGraw Hill Medical: New York

Kohlberg, L. (1973). The claim to moral adequacy of a highest stage of moral judgment. Journal of Philosophy, 70 (18): 630–646. doi:10.2307/2025030


References

Nelson, W.A. (2005, July/Aug). An organizational ethics decision-making process. Healthcare Executive, 9-14.

University of Washington School of Medicine. (n.d.). Ethics in Medicine. Retrieved from http://depts.washington.edu/bioethx/topics/consntd1.html


QuestionsJosh Hyatt

DHSc (c), MHL, CPHRM

Medical Ethics and Health Care Risk Management

Documents

Transcript of Medical Ethics and Health Care Risk Management