AETCOM module 2.6
- 1. AETCOM MODULE 2.6 DR. ANKITA BIST ASSISTANT PROFESSOR DEPARTMENT OF PHARMACOLOGY
- 2. OVERVIEW • Medical ethics is founded on a set of core principles that are based on respect to patients as individuals. • The core ethical principles of medicine are autonomy, beneficence, nonmaleficence, and justice. • Ethical dilemmas arise when respecting one of these principles becomes impossible without compromising another. • Ethical responsibilities usually align with legal precedence, but the two systems remain distinct.
- 3. PRINCIPLES Autonomy • Provide sufficient information but honor the patient's choices to accept or decline care. Beneficence • Advocate for the patient and act in their best interest. Nonmaleficence • Avoid causing injury or suffering to the patient. Justice • Treat patients fairly and equitably.
- 4. OBLIGATION TO TREAT • A physician is legally obligated to treat a patient when failing to provide treatment would immediately endanger the patient's life. • The patient or their surrogate must be notified and have the ability (e.g., time, money) to establish care with another physician. • The physician is also obligated to facilitate the transfer of care.
- 5. DECISION-MAKING CAPACITY AND LEGAL COMPETENCE • Decision-making capacity: the psychological and/or legal ability to process information, make decisions, communicate a choice, and understand the consequences of a decision. • Components: Choice, Understanding, Appreciation, Reasoning • Legal competence: the legal assessment of a patient's ability to freely make conscious decisions • Assessed by a court of law; (with input from the patient's family and physicians as needed)
- 6. • MacArthur Competence Assessment Tool-Treatment (Mac CAT-T) Scale assesses patient’s competence in terms of: understanding the information, reasoning the risks/benefits of their choice, consequences of their choice and expression of their choice
- 7. SURROGATE DECISION-MAKING • “alternate decision maker” • Another person makes treatment decisions for the patient because they lack decision-making capacity and/or competence • The surrogate may be appointed by the patient (e.g., medical power of attorney), legally appointed (e.g., court-ordered guardian), or next of kin (if no Advance Healthcare Directive exists).
- 8. HIERARCHY OF SURROGATE DECISION- MAKING • Advance healthcare directive: Living will Durable medical power of attorney (health care proxy) Oral advance directive • Next of kin: Spouse Adult child Other family member/ intimate associate
- 9. MEDICAL DECISION-MAKING IN PAEDIATRICS • In India, ‘majority’ is achieved at an age of 18 years and considered a legal age for giving a valid consent for treatment. • A child below 12 years (minor) cannot give consent. • A child between 12-18 years can give consent only for medical examination but not for any procedure. • The consent for medical procedures or treatments of minors is given by the patient's surrogates (i.e., parents or caretakers). • In case of emergency, a person in charge of the child like principal or school teacher can consent for medical treatment (loco parentis) • For children who are orphans or unknown or street children, the court is appointed as a guardian.
- 10. When a patient lacks decision-making capacity, the physician has an ethical responsibility to: 1.Identify an appropriate surrogate to make decisions on the patient’s behalf: 2.Recognize that the patient’s surrogate is entitled to the same respect as the patient. 3.Provide advice, guidance, and support to the surrogate. 4.Assist the surrogate to make decisions in keeping with the standard of substituted judgment, basing decisions on: The patient’s preferences (if any) as expressed in an advance directive or as documented in the medical record. The patient’s views about life and how it should be lived. The patient’s attitudes toward sickness, suffering, and certain medical procedures.
- 11. 5. Assist the surrogate to make decisions in keeping with the best interest standard if patient’s preferences and values are not known and cannot reasonably be inferred., based on: The pain and suffering associated with the intervention The degree of and potential for benefit Impairments that may result from the intervention Quality of life as experienced by the patient 6. Consult an ethics committee or other institutional resource when: a. No surrogate available or disagreement about who is the appropriate surrogate. b. The physician judges that the surrogate’s decision: Is not what the patient would have decided had the patient’s preferences are known Could not reasonably be judged to be in the patient’s best interest Primarily serves the interests of the surrogate/ other third party
- 12. CASE SCENARIO 1 Parents refuse life-saving treatment for their child. • Emergency treatment: Provide life-saving treatment. • Nonemergency essential treatment: Get a court order. CASE: (Conjoined Twins- Surgical Separation 2000) • The court had to consider the ethical implication of separating twins (Mary and Jodie). • Mary was the parasitic twin. She was dependent on Jodie for her blood supply. • Without Jodie, Mary would be unable to survive. • Jodie had a 94% survival rate and would be able to live a normal life if separated. • If Jodie was not separated from Mary, she would eventually die.
- 13. • The conjoined twins were too young to be able to express a view. • The parents refused consent to separate the twins as their religious views preferred to leave the decision in the hands of God. • The application of ‘best interests’ was the most appropriate way of resolving the dilemma. It was in Jodie’s best interests to be separated, in order to allow Jodie to have a chance at living a normal life. • Separation was not in Mary’s ‘best interests’ but a balance was required and the court held in favor of Jodie’s potential life.
- 14. CASE SCENARIO 2 a. A pregnant 15-year-old female wants to keep her baby against her parents' will. • Pregnant individuals have the right to decide to carry their infants to term, and to chose to keep the baby or put it up for adoption. • Provide practical information about all options. Accept and support the patient's decision. Encourage good communication between the patient and her parents to evaluate the options and arrive at an agreement. b. A pregnant 15-year-old wants to abort. • Needs consent from legal guardian
- 15. CASE SCENARIO 3 A father and 13-year-old son are found unconscious with internal bleeding after a car accident; the father is found to have a religious preferences card, which states that he declines blood transfusions because of religious beliefs. • Find a surrogate asap • Only if required as a life saving measure, ensure transfusion to the son but not to the father.
- 16. CASE SCENARIO 4 • A regular patient at your clinic 78-year-old Mrs A. who was living all alone in an apartment as her son stays in U.S. She has hypertension which is reasonably controlled on medications. Four months ago, she spent some time talking about her sister who recently died following metastatic breast cancer. “My sister suffered a lot, Doctor - they put a tube down her throat to breathe. Even when her heart stopped they kept thumping her chest - it was awful. If I ever fall sick I don't want to go through all this. Promise me, doctor, that you won’t do all of this to me- I don't want to depend on a machine to live”. One day she was brought to the Emergency room with fever and shortness of breath. She is somewhat drowsy, intubated and restrained. She points out at the ET and makes a pleading gesture to remove it. Her son waiting with her, was very distressed at his mother’s health and wants “everything” possible done for her. You ask him if she had ever indicated what she wanted to be done if she were to require hospitalization and intubation. He states she never discussed such matters.
- 18. 52-year-old man collapses in the street complaining of severe acute pain in his right abdomen. A surgeon happens to be passing and examines the man, suspecting that he is on the brink of rupturing his appendix. The surgeon decides the best course of action is to remove the appendix in situ, using his trusty pen-knife. CASE SCENARIO 5
- 19. • From a beneficence perspective, a successful removal of the appendix in situ would certainly improve the patient’s life. • But from a non-maleficence perspective: The environment is unlikely to be sterile and so the risk of infection is extremely high. Second, the surgeon has no other clinical staff available or surgical equipment meaning that the chances of a successful operation are already lower than in normal circumstances. Unless there isn’t a hospital around for miles this is an incredibly disproportionate intervention. • Before leaping to action, we need to consider the implications and risks of intervening.
- 20. THANK YOU