Bioethics in Health Care

BIOETHICS IN HEALTH CARE: Tools and Applications

Med Ethics III June 13, 2008

Ma. Cecilia C. Cuaresma-Cruz, MD, FPAFP (Lifted from the lecture materials of Evangeline O. Olivar-Santos MD, Institute of Ophthalmology, Institutes of Health, UPM)

Trans group: Maan, Lainey, Spog Bioethics in Health Care Rationale • Decisions made by physicians, patients, health policy makers and health insurers determine the quality of health care that is needed and provided for. • These decisions are based, not only on human values, but also on tradition, existing laws, and new, some controversial, advances in the field of health care. Key action: decision-making What is Involved in Decision Making for Health Care? If it is the Physicians’ responsibility “to do no harm” and “to develop a care plan that will benefit the patient most”

 Then he has the Moral obligation • to be competent in his field; • to make the patient understand his plan and the alternatives currently available It is a competent physician who can defend his decision in offering a particular treatment to a patient. His competency is based on his training, track record, experience, and continuing education. Traditional Roles Physicians are to use their knowledge and skills for healing, restoring health, and relieving suffering when possible, and to offer comfort always, but never to kill. Expanded Role of Physicians To have professional integrity, this role is expanded to include relief of suffering in respect to the patient’s voluntary choices, including aiding a patient to achieve a peaceful and dignified death. (By proponents of physician-assisted suicide) ***What does Bioethics say? • At all times, if decisions have to be made or “indicated” re euthanasia, IVF, abortions, cloning experiments, etc, where the integrity of the physician vs. his decision is at stake, there should always be respect for the physician’s personal, moral and /or religious convictions. If it is the Patients’ responsibility: -to understand the plan of action of his physician; -to choose the treatment based on his aims and values; and -to communicate his reasons for his choice

 Then he must be a competent patient. The Competent patient understands the basis for and the consequences of his decision and that his decision is based upon rational reasons. How about the Patient’s Family? • The role of the family in a patient’s decision making has become an issue in recent years. • Families have traditionally exercised considerable control over medical treatment of minors, but today their role in adult decision-making is a challenge.

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This is the communitarian concept (Hardwig).

***What does Bioethics say? • Family members would have no veto power over a patient’s decision and would have to honor the choice ultimately made, no matter how foolish or idiosyncratic. Yet where the physician or health provider feels it needed, the family must be invited for conferences regarding their sick member, especially if the latter is vulnerable. If it is the responsibility of Health Policy Makers and Health Insurers - to decide what to promote, what to discourage, and what to pay for; and - to ensure that medical benefits are fair and distributed equally

 Then they must do so on the basis of both legal and moral rights of patients to health care. Some issues for Health Care Policy Makers/Institutions • Self-determination act (US) re advance directives (living wills) provide guidelines to institutions and health facilities. • To provide patients with written information about his rights under this act as well as the providers’ written policy concerning implementation of these rights. Other Issues for Health Policy Makers • Organs for donation (except corneas and skin) have to removed from a “breathing donor” • Definition of death, criterion for death, tests for death. • Prioritization of patients (recipients) • Fee for donors

***What does Bioethics say? • The definition of death is “permanent cessation of functioning of the organism as a whole.” There may be a need to return to this traditional definition of death. • Shift the ethical foundations for organ donation to the principles of nonmaleficence and consent and not be stumped by definitions of death. • Killing (to stop breathing) may be a justifiable necessity for procuring organs from patients who are brain dead, in a prolonged vegetative state, and where chances of recovery of brain function are considered absent. • No moral justification for fees to be paid to donors. In short, in the process of all the decision-making that takes place in the care of the health of patients conflicts can arise. -

Ethical (moral) principles are then applied in the resolution of conflicts.

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They are not considered absolute; however these rules and principles serve as powerful action guides in clinical medicine. Page 1 of 2

He may have the moral duty but is not obliged to benefit the community. Tools of Bioethics in Health Care 1. Basic theories (deontological theories, teleological theories, casuistry, etc) 2. Principles of Bioethics Basic theories Basic Ethical theories help us in two ways: 1. For situations where right vs wrong is very clear (like stealing is wrong), the theories help us explain why one action is right and why the other is wrong. 2. For situations where right or wrong is not very obvious (like lying about whereabouts of a person may either be right or wrong) they should guide us to discover what is the right thing to do. (Glenn C. Graber) Principles of Health Care Ethics (Tools of Bioethics) The principle of respect for autonomy The principle of nonmaleficence The principle of beneficence The principle of justice Principle of Autonomy Means that the patient has the capacity to act intentionally, with understanding, and without controlling influences that would mitigate against a free and voluntary act. This principle is the basis for the practice of "informed consent” and emphasizes the need for the competence and, voluntariness to consent or withdraw. Principle of Nonmaleficence Requires not intentionally creating a needless harm or injury to the patient, either through acts of commission or omission or imposing a careless or unreasonable risk of harm upon him. This principle is the basis for Standard of Care and reaffirms the need for competence. It also emphasizes risks and benefits. Nonmaleficence is expected of all physicians all of the time. It is a constant duty. He applies it to all patients who seek him. Thru this principle, the definitions of “negligence”, “malpractice”, “physician’s error” and “medical mistakes” are based. Principle of Beneficence - Duty to be of a benefit to the patient, to take positive steps to prevent, and to remove harm from him. - Duties that are self-evident and widely accepted as the proper goals of medicine, Applied both to individual patients, and to the good of society as a whole. This principle may be the underlying principle for the Prioritization of health care benefits

Principle of Justice Justice in health care is usually defined as a form of fairness, or as Aristotle once said, "giving to each that which is his due." This principle underlies Allocation and distribution Resources, and the concept of the Right to Health Care.

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Justice in health care can involve: distribution of burden availability and use of benefits compensation of subjects prioritization in use of funds Distribution of health services take different forms: to each person an equal share to each person according to need to each person according to effort to each person according to contribution to each person according to merit to each person according to free-market exchanges Questions/ Dilemmas/ Issues -

The Right to Health Care : Is it both a Legal and a Moral right? Ethical issues … Is it ethical to require people to assist others in meeting their health care needs? Is it ethical to expect (entitlement to) health services because one needs them?

Usually, moral values such as mutual respect, honesty, trustworthiness, compassion, and a commitment to pursue shared goals, make a clinical encounter between physician and patient morally unproblematic. In summary Clinical ethics then, and for that matter, ethical health care, relies upon the conviction that, even when perplexity is great and emotions run high, physicians, patients, and policy makers can work constructively to identify, analyze and resolve many of the ethical problems that arise in health care by using the tools described.

“There is no special ingredient in becoming special.” --- Jack Black as Po, in Kung Fu Panda “I have not come this far only to quit.” --- Maan Galang, PLMCM 2010 forums

However, beneficence is widely seen as a matter of choice for the physician. He can choose who should benefit from his services; whom to take into his care. By limiting himself to a subspecialty, for example, he limits his patients to that specialty.

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