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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
A practical, insightful guide to the moral and ethical standards of healthcare Succeeding in the healthcare field means more than just making a diagnosis and writing a prescription. Healthcare professionals are responsible for convincing patients and their family members of the best course of action and treatments to follow, while knowing how to make the right moral and ethical choices, and so much more. Unlike daunting and expensive texts, Medical Ethics For Dummies offers an accessible and affordable course supplement for anyone studying medical or biomedical ethics. * Follows typical medical and biomedical ethics courses * Covers real ethical dilemmas doctors, nurses and other healthcare workers may face * Includes moral issues surrounding stem cell research, genetic engineering, euthanasia, and more Packed with helpful information, Medical Ethics For Dummies arms aspiring medical professionals with the philosophical and practical foundation for advancing in a field where critical ethical and moral decisions need to be rapidly and convincingly made.
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Seitenzahl: 674
Veröffentlichungsjahr: 2010
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Medical Ethics For Dummies®
Table of Contents
Introduction
About This Book
Conventions Used in This Book
What You’re Not to Read
Foolish Assumptions
How This Book Is Organized
Part I: Medical Ethics, or Doing the Right Thing
Part II: A Patient’s Right to Request, Receive, and Refuse Care
Part III: Ethics at the Beginning and End of Life
Part IV: Advancing Medical Knowledge with Ethical Clinical Research
Part V: The Part of Tens
Icons Used in This Book
Where to Go from Here
Part I: Medical Ethics, or Doing the Right Thing
Chapter 1: What Are Medical Ethics?
Defining Medical Ethics
What are ethics?
The four principles of medical ethics
Differences between ethics and legality
Reconciling medical ethics and patient care
Turning to ethical guideposts and guidelines
Looking at the Common Medical Ethics Issues
Privacy and confidentiality concerns
Reproduction and beginning-of-life issues
End-of-life issues
Access to care
Moving Medicine Forward: The Ethics of Research
Chapter 2: Morality in Medicine
Distinguishing among Ethics, Morality, and Law
Looking at the Hippocratic Oath and Its Modern Descendents
Noting why the Oath was updated
Taking a new oath at graduation
Understanding humanitarian goals: The Declaration of Geneva
Rules for Engagement: Today’s Codes of Medical Ethics
American Medical Association Code of Ethics
American Nursing Association Code of Ethics
Bedside Manners: Ethics inside the Hospital
Understanding the hospital ethics panel
Patient bill of rights
Emergency room ethics
Bioethics as a Field of Study
Chapter 3: The Provider-Patient Relationship
Protecting Patient Privacy
Understanding confidentiality
Balancing privacy with public good
Confidentiality in research
Clear and Ethical Communications
Communicating with the patient
Informed consent
Understanding Full Disclosure: Telling the Patient What Matters
Decoding conflicts of interest
Deciding who has access to medical information
Choosing not to disclose information to a patient
Understanding Appropriate Referrals
Considering second opinions
Discovering the need for specialist referrals
Choosing Whom to Serve
Refusing to treat a patient
Ending a doctor-patient relationship
Giving medical advice to non-patients
Patient Rights and Obligations
Patient autonomy: Patient as decision-maker
Encouraging honesty
Balancing treatment and cost
Chapter 4: Outside the Examining Room: Running an Ethical Practice
Propriety in the Paperwork: Medical Records
Complying with the Health Insurance Portability and Accountability Act (HIPAA)
Training staff to handle records
Preventing identity theft
Releasing medical records
Safeguarding anonymity
Modern Managed Care and Today’s Office Practice
Ethical concerns of managed care
Working with midlevel providers
Prescribing good care while still getting paid
Third-Party Issues
Dealing with insurance companies and HMOs
Perks and freebies
Targeted advertising and ethics
Chapter 5: Learning from Mistakes: Disclosing Medical Errors
Types of Medical Errors and Ways to Prevent Them
Understanding diagnostic errors
Understanding treatment errors
Medication errors
Communication errors
Administrative errors
Lab errors
Equipment failures
Admitting Your Mistakes
Understanding truth telling
Disclosing an error to a patient
Balancing ethics with legal protection
Telling a higher-up that you’ve made an error
When Colleagues Don’t Disclose: Your Ethical Obligations
Healthcare Provider Impairment
Knowing the warning signs of impairment
Addressing a colleague’s impairment
Testifying before a medical board
How Reporting Errors Helps Medicine as a Whole
Creating a no-blame system for reporting errors
Understanding how to reduce errors
Part II: A Patient’s Right to Request, Receive, and Refuse Care
Chapter 6: The Ethical Challenges in Distributing Basic Healthcare
Ethics of Healthcare Distribution
Exploring Healthcare Rationing
How services are rationed
The ethics of rationing
Looking at Healthcare in the United States
The current system and its ethical challenges
The reformed system and potential ethical speed bumps
Examining universal healthcare
Chapter 7: When Spirituality and Cultural Beliefs Affect Care
Accommodating Religious Beliefs
Religions that limit or ban medical care
Discussing religion and understanding objections
Offering alternatives to care
Respecting Cultural Diversity
Attitudes and beliefs that affect care
Communicating with non-English-speaking patients
Discussing cultural beliefs
When the Patient Refuses Treatment
Determining competency
Making sure the patient understands
Validating concerns and assuaging fears
Accepting refusals
Chapter 8: Parental Guidance and Responsibilities
Acknowledging Parental Rights to Choose or Refuse Care
Responsibilities of a parent
Weighing parental choice against a child’s best interest
Caring for a child when parents disagree with you
Knowing when and how to treat impaired infants
Vaccination: The Evidence and the Ethics
Understanding vaccination as a public health issue
Considering risk-benefit analysis
Understanding full disclosure
Addressing parent opposition to vaccines
Child Endangerment: The Healthcare Provider’s Role
Discovering signs of abuse and neglect
Reporting abuse and working with Child Protective Services
Confidentiality, Care, and the Adolescent Patient
Understanding adolescent patients’ rights
Balancing privacy and patients’ rights
Talking to teens about informed consent
Mature minors and emancipated minors
Part III: Ethics at the Beginning and End of Life
Chapter 9: Two Lives, One Patient: Pregnancy Rights and Issues
Medical Intervention: Rights of the Mother versus Rights of the Fetus
Setting forth rights with the Fourteenth Amendment
Understanding self-determination
Balancing treatments for a woman and fetus
The role of technology
Considering a Father’s Rights
Birth Control
Educating your patient about birth control
Balancing your beliefs about birth control with a patient’s rights
Understanding religious ethics and birth control
Fetal Abuse
Maternal drug abuse or neglect: Crimes against the fetus
Detecting fetal abuse: Ethical and legal obligations
Limiting maternal freedom for fetal well-being
Seeing into the Future: Prenatal and Genetic Testing
Understanding the ethical use of prenatal testing
Understanding tests and accuracy issues
Genetic counseling and sharing results with parents
Chapter 10: When Science Supersedes Sex: Reproductive Technology and Surrogacy
In Vitro Fertilization
Understanding acceptable versus unacceptable harm
Pre-implantation genetic diagnosis: Choosing which embryos to implant
Multiple pregnancy reduction: When IVF works too well
Decoding embryo storage and destruction
Artificial Insemination
Understanding safe, anonymous, and consensual sperm donation
Sex selection: Is it ever ethical?
Surrogacy: Carrying Someone Else’s Child
Paying for pregnancy: The ethics of commercial surrogacy
Considering the emotional and physical health of the surrogate
Looking at the contract and surrogate responsibilities
Understanding rights of the child
The doctor’s responsibilities
Sterilization: Preventing Reproduction
Voluntary sterilization as birth control
The ethics of involuntary birth control
Understanding eugenics: Social engineering
Chapter 11: Walking a Fine Line: Examining the Ethics of Abortion
When Does Personhood Begin?
What, and who, is a person?
Applying ethical principles to personhood
Looking at Each Side’s Point of View
Understanding the pro-life stance
Understanding the pro-choice stance
Therapeutic Abortion: To Protect Maternal Health and Life
Reasons for therapeutic abortion
Informing the patient
Counseling for the family
When a patient refuses medical advice
Abortion Due to Fetal Defect
Reasons for abortion because of fetal defect
Weighing the ethics of selective abortion
Voluntary Abortion
Legal definition and limitations
A less invasive option: RU-486
Roe v. Wade: Legal Status of Abortion and Ethical Implications
Looking at changes on the state level
Accurate medical counseling
The Religious Divide
Toward Common Ground
Chapter 12: Determining Death: Not an Event, but a Process
Defining Death
Using heart and lung function to define death
Adding brain function to the definition of death
Examining Brain Death
A quick look at how the brain works
Looking at the types of brain death
Current standards of brain death
Declaring a patient brain dead
Understanding Cases That Defined Brain Death
Karen Ann Quinlan
Nancy Cruzan
Withdrawing Life-Sustaining Treatment
Weighing the benefits of further treatment
Counseling the family
Examining Euthanasia and Physician-Assisted Suicide
Relieving suffering with mercy-killing
Understanding the history of physician-assisted suicide
When a doctor aids in death
Chapter 13: Death with Dignity: The Right to Appropriate End-of-Life Care
Roadmaps for the End of Life
Understanding advance directives
Looking at living wills
Looking at Durable Power of Attorney for Health Care
Do Not Resuscitate and Do Not Intubate orders
Physician’s Order for Life-Sustaining Treatment (POLST)
Of Sound Mind: Establishing Mental Capacity
Understanding informed consent and a patient’s ability to give it
Assessing decision-making capacity
Substitute decision-makers: When a patient is declared incompetent
Relief of Pain and Suffering
Understanding palliative care
Walking a fine line: The double-effect rule
Easing pain with terminal sedation
Organ Donation and Allocation for Transplants
Legality of organ donation
Sustaining life for organ harvesting
Looking at living donation
The financial inequities of transplant eligibility
Compensation for donation: The ethical challenges
Xenotransplantation, or animal to human transplant
Part IV: Advancing Medical Knowledge with Ethical Clinical Research
Chapter 14: Toward Trials without Error: The Evolution of Ethics in Clinical Research
An Introduction to Medical Research
Moving from lab experiments to research on humans
Understanding the importance of informed consent in clinical trials
Turning Points in Medical Research in America
The Tuskegee Syphilis Study: The ethics of withholding treatment
The establishment of the Office for Human Research Protections and IRBs
Guiding Principles of Ethical Studies
The Nuremberg Code: New research standards in the wake of World War II
The Declaration of Helsinki: A global roadmap for ethical clinical research
Good Clinical Practice Guidelines: Replacing the Declaration of Helsinki
The Belmont Report: Best ethical practices in U.S. research
Chapter 15: Beyond Guinea Pigs: Anatomy of an Ethical Clinical Trial
Elements of a Valid Trial: Leveling the Playing Field Ethically
Collective clinical equipoise: Asking whether a trial is needed
Understanding basic trial design
Choosing ethical controls
Preventing bias with blind studies and randomization
Minimizing any risk of harm
The Institutional Review Board: Ethical Gatekeepers of Clinical Research
Looking at the role of the IRB
Evaluating and green-lighting a clinical trial
Recruiting Study Participants
Deciding to ask patients to participate
Laying out all the risks and benefits with informed consent
Full disclosure: Explaining financial and institutional conflicts of interest
Ending a Trial Early
Remembering obligations to patients
Looking at implications for research
Publicizing preliminary results
Chapter 16: Research in Special Populations
Animal Research
Understanding why animals are used
Ethical treatment of research animals
Psychiatric Research and Consent
Assessing decision-making ability in psychiatric patients
Protecting the patient: Risk versus benefit
Pregnancy and Pediatrics
Understanding research with pregnant women
Why risk may outweigh the benefits
Research on children: Surrogate consent
Chapter 17: It’s All in the Genes: The Ethics of Stem Cell and Genetic Research
Understanding Stem Cell Research
Who will benefit? The case for stem cell research
The ethical debate over embryonic stem cell lines
Focusing on adult stem cells
Genetic Testing: Looking for Problems in DNA
Knowing what we can and can’t change
Weighing the risks and benefits
Offering emotional counseling for patients
Genome Sequencing: Mapping DNA
Gene patents: Deciding who owns what
Looking at ethical problems with patents
Deciding who can use the human genome
Gene Therapy: Changing the Code
Weighing the risks and benefits of gene therapy
Designer genes: Going beyond therapy
Cloning: Making Copies
Cloning as a reproductive option
Growing tissues with therapeutic cloning
Part V: The Part of Tens
Chapter 18: Ten Ethical Issues to Address with Your Patients
Confidentiality in the Patient Visit
Informed Consent
Integration of Religious and Cultural Beliefs into Patient Care
The Ethics of Clinical Research
Help for the Uninsured
Screening for Genetic Diseases
Ethical Dilemmas in Infertility
Minimize Suffering in Terminal Conditions
The Living Will Discussion
Honor the Patient-Provider Relationship
Chapter 19: Ten High-Profile Medical Ethics Cases
Terri Schiavo: The Right to Die
Daniel Hauser: A Child’s Right to Refuse Lifesaving Treatment
Angela Carder: Maternal versus Fetal Rights
Sister Margaret Mary McBride: Religion in Conflict with Medicine
Baby Manji: An Unclear Identity
Louise Brown: The First Test Tube Baby
Jesse Gelsinger: The Risks of Gene Therapy
Nadya Suleman: Too Much Fertility
Glen Mills: Autonomy versus Protecting Society
Baby Jane Doe: Treatment of Impaired Babies
Chapter 20: Almost Ten Ethical Issues for the Future
Cloning
Designer Babies and Future Elites
Rationing of Medical Care
Who Owns Your Genes?
The Doctor Is Online
Pandemic Influenza Outbreak
Future Clinical Trials
Artificial Wombs
The Global Spread of AIDS
End User License Agreement
Medical Ethics For Dummies®
by Jane Runzheimer, MD, and Linda Johnson Larsen
Medical Ethics For Dummies®
Published byWiley Publishing, Inc.111 River St.Hoboken, NJ 07030-5774www.wiley.com
Copyright © 2011 by Wiley Publishing, Inc., Indianapolis, Indiana
Published simultaneously in Canada
No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Sections 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the Publisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600. Requests to the Publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, (201) 748-6011, fax (201) 748-6008, or online at http://www.wiley.com/go/permissions.
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Library of Congress Control Number: 2010939506
ISBN: 978-0-470-87856-9
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About the Authors
Jane Runzheimer, MD, is a family physician who has been practicing primary care medicine for ten years. Her practice at Allina Medical Clinic in Northfield, Minnesota, includes pregnancy care, pediatrics, adult medicine, and geriatrics. She has a bachelor of science degree in molecular biology from the University of Wisconsin–Madison and is a graduate of the University of Minnesota Medical School. She is a member of the American Academy of Family Physicians and the Alpha Omega Alpha Medical Honor Society.
She has served on the Ethics Committee of Methodist Hospital in St. Louis Park, Minnesota, and Northfield Hospital. She has a special interest in medical ethics, especially in the areas of race and end-of-life care. She has also worked with the Indian Health Service in Zuni, New Mexico, and the Pine Ridge Indian Reservation in South Dakota.
Linda Johnson Larsen is an author and journalist who has written 24 books, many about food and nutrition. She earned a bachelor of arts degree in biology from St. Olaf College and a bachelor of science degree with high distinction in food science and nutrition from the University of Minnesota after she realized she didn’t want to go to medical school after all.
She has been a patient advocate for her husband and several family members. She has spent thousands of hours in hospital and doctor’s waiting rooms, learning the questions to ask when someone is sick, studying how doctors and nurses work together, and researching hospital standards. Linda understands that someone must be the voice for patients in the hospital. She has always been a student of ethics, and even made several life decisions (such as honoring a commitment to a college roommate when a semester studying abroad beckoned) depending on ethical issues such as nonmaleficence.
Linda is the Busy Cooks Guide for About.com and writes about food, recipes, and nutrition. Her books with an emphasis on health include recipes for Detox Diet For Dummies, Knack Low-Salt Cooking, The Everything No Trans Fat Cookbook, and The Everything Low-Cholesterol Cookbook.
Dedication
From Jane: First, I dedicate this book to my husband, Mark, the greatest gift in my life. I also dedicate this book to our three wonderful children — Jessica, Luke, and Marie Labenski. You four are deeply loved. I also would like to honor my parents, Kitty and Lee Runzheimer. They are two of the greatest examples of love, compassion for others, and ethical behavior that a person could ever have. And I can’t forget my little brother, Kurt, who has been my best friend from the very beginning. Thank you all for the love and support you have given me. Finally, I dedicate this book back to God in gratitude for the many gifts He has given me — my loving family and friends, a profession that is my passion, my own (usually) good health, and the opportunity to spread a little light into places of darkness. Thank you, God, for your many gifts!
From Linda: I dedicate this book first and foremost to my husband, Doug. Throughout the last 29 years, we’ve had many ups and downs with medical issues and had the good fortune to be treated by excellent doctors and nurses. Through it all, he’s been by my side and is my biggest cheerleader and confidant. I’d also like to dedicate the book to my parents, Duane and Marlene Johnson, for their support and encouragement. They always told me I could do anything I put my mind to!
Authors’ Acknowledgments
From Jane: I would like to thank Linda Larsen for inviting me to work on this project with her. She has been an excellent coauthor — a gifted writer, a patient partner, and a great friend. I would also like to thank three of my fellow physicians — my husband, Dr. Mark Labenski, and my dear friends Dr. Amy Ripley and Dr. Laurel Gamm — for their professional input and their personal support.
I would like to thank all of my co-workers at Allina for putting up with a doctor who was more underslept than usual — I couldn’t work with a better group of people. I send a special thanks to Linda Franek, LPN, my nurse of ten years, who is my dedicated friend and partner in our practice. I would also like to acknowledge Pastor Timothy McDermott and Lois Lindbloom for their spiritual input and support. And I would like to thank the two doctors who keep me healthy — Dr. Marty Freeman and Dr. Gretchen Ehresmann.
I should also say a special thanks to the man who first inspired my love of writing — my high school English teacher Roger Mahn. And also those professors who fueled my interest in medical ethics — Dr. Wayne Becker and Dr. Norm Fost (University of Wisconsin) and Dr. Arthur Caplan (University of Minnesota).
Finally, I would be remiss if I didn’t mention my most important teachers and supporters — my many patients. Thank you all for the things that you have taught me, all the times that you have encouraged me, all the times you have forgiven me when I have failed you, and all the times we have worked together for a successful outcome.
From Linda: I’d like to thank my co-author, Jane, first of all, for being such a wonderful friend and guide while working on this book. We made a great team, and I’m grateful that we share the same sense of humor!
I’d also like to thank the biology department at St. Olaf College for giving me such a strong foundation in science, and for helping me realize I didn’t want to become a doctor!
Thanks to our agent, Barb Doyen. She had such confidence in my ability to write this book and encouraged me every step of the way. Thanks to our wonderful editors for their support, suggestions, and guidance.
Special thanks to Amy Adams and Meg Schneider for their assistance and excellent logical reasoning skills. And thanks to my friends, especially my Facebook friends, and my faithful family for their support and love as I poured myself into this project.
Publisher’s Acknowledgments
We’re proud of this book; please send us your comments at http://dummies.custhelp.com. For other comments, please contact our Customer Care Department within the U.S. at 877-762-2974, outside the U.S. at 317-572-3993, or fax 317-572-4002.
Some of the people who helped bring this book to market include the following:
Acquisitions, Editorial, and Media Development
Project Editor: Victoria M. Adang
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Composition Services
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Introduction
While I (co-author Linda) was writing this book, my husband was admitted to the hospital and had to undergo a surgical procedure. Because I have studied medical ethics, it was interesting to see how the nurses, doctors, and other staff worked with us and each other, and how many of the issues in this book were addressed.
We had a very positive experience. Everyone was kind and helpful, and many of the topics I had researched were covered without a single glitch, down to asking about advance directives and telling us about the patient’s bill of rights. But not every hospital or clinic visit is so smooth. Everyone who practices medicine takes a course or two on medical ethics, but applying what you’ve learned to real-life experiences takes effort. You gain knowledge from day-to-day experiences, and you learn from stories of other patients and providers. That’s what Medical Ethics For Dummies is about.
For healthcare providers, Jane and I have provided many examples of real-life cases that require wrestling with ethical and philosophical problems. These examples cover many of the aspects you’ll encounter as you build your practice. From the ethics of prenatal care, through family practice, medical research, and dealing with the last stages of life, the principles of medical ethics are examined and applied.
We don’t always draw conclusions from the examples. Sometimes an issue can raise more questions than answers, and some of these issues are so personal they must be answered on a case-by-case basis.
About This Book
The practice of medicine is an art and a science. The art comes from dealing with human beings, who can be fragile and unpredictable when they are sick and need your help. The science comes from years of research and study. Medical ethics puts the art and science together in practical applications to tricky problems.
This book is arranged in a practical format. First, we examine the basics of medical ethics, its principles, and some controversies. Then we move on to putting morality in medicine. We look at the provider-patient relationship and how you can run a good, ethical practice. Everyone makes mistakes, but it’s possible to learn from medical errors and design your practice so they are caught and fixed before they become serious problems or affect patients.
Then we follow patients through their lives, from prenatal care and dealing with the ethical issues of pregnancy, abortion, and reproductive technology, to treating children and working with parents. Then the discussion turns to death, both understanding when life ends and the ethics of end-of-life care. Finally, standards for medical research and the ethics of clinical trials using human beings are covered.
The great thing about Medical Ethics For Dummies is that providers and patients can both learn something relevant to their lives. Everyone is a patient at some point in their life, so understanding the philosophical side of medicine can only make the process smoother. And the more providers understand about the ethics of their profession, the more satisfying their work lives will be.
Conventions Used in This Book
The following conventions are used throughout the text to make things consistent and easy to understand:
All Web addresses appear in monofont.
Some new terms appear in italic and are closely followed by an easy-to-understand definition. We also italicize words that are often used in the medical field.
Bold is used to highlight keywords in bulleted lists.
Co-author Jane has gleaned many stories relating to the ethics of practicing medicine from her practice and years of experience; we’ve placed those in sidebars throughout the text and marked them with an “A Note From the Doctor” icon. They are written in her voice and explain the issues she’s faced in her work as a family practice physician and as a member of hospital medical ethics boards. Chapter 18, on ethical issues to address with your patients, is also written in her voice.
Because patients are both male and female, we’ve tried to alternate using male and female pronouns throughout the book — except of course in the chapters on pregnancy! Names and genders of the cases in the book have been changed, and actual information, although medically accurate, has been tweaked to protect privacy.
What You’re Not to Read
We’ve written this book so you can find information easily and understand what you find. Each chapter covers one area of medicine and gives you the ethical basics you’ll need to practice. But if you don’t read every word, that’s okay. Some text is set off from the main information, and it’s interesting and relevant, but it’s also stuff you can live without.
Text in sidebars: Sidebars are the shaded boxes that give detailed examples or add interesting information that will help enhance your understanding of medical ethics.
The copyright and publisher’s acknowledgments pages: Unless you want to read legal jargon or are interested about all the people who put the book together (and they are important!), that’s not the essential meat of the book.
Foolish Assumptions
This is what we’ve assumed about you because you’re reading this book:
You’re a physician or medical student who wants to know more about medical ethics, either to enhance your practice or before you take licensing board exams.
You’re a nursing student who is curious about medical ethics. Nurses have their own code of medical ethics, which you’ve probably studied.
You’re in the medical field or a community member of a hospital ethics committee and have questions about ethical issues, or you need a refresher course on topics you may have studied in school.
You’re not in the medical field, but you want to know more about medical ethics from a patient’s point of view. This knowledge will help make you a better patient because you can more actively participate in your healthcare needs and decisions. We’ve tried to avoid using much medical jargon in this book so anyone can understand it. An interest in the topic is all you really need to learn more.
How This Book Is Organized
This book is divided into five parts. Each part deals with a certain aspect of medicine and discusses the relevant ethical issues. You don’t have to read straight through the book; you can pick a chapter of interest and read that to find out all you need to know about that issue.
Part I: Medical Ethics, or Doing the Right Thing
Medical ethics is based on essential principles. Those principles of autonomy, beneficence, nonmaleficence, and justice can be applied to difficult ethical situations. That’s not as complicated as it sounds! When you decide which principle or principles apply, you can use them in a medical situation to reach an ethical decision on some pretty knotty subjects. You find out about codes of medical ethics and the importance of the doctor-patient relationship, especially the importance of confidentiality and informed consent. In this part, we also discuss how to set up an ethical medical practice and how to prevent medical mistakes, as well as learn from them.
Part II: A Patient’s Right to Request, Receive, and Refuse Care
Should everyone have access to healthcare? If so, how are we going to make sure it’s distributed fairly? We try to answer those questions and address the issues of religious and cultural differences. Finally, we include information about parental responsibilities and rights and the privacy rights of minor patients.
Part III: Ethics at the Beginning and End of Life
Personhood is the focus of this section. When does an embryo become a person? What are the ethical issues surrounding abortion? What about genetic testing and counseling for pregnant women? And because reproductive technology has exploded over the past years, we look at the ethics of in vitro fertilization (IVF), embryo storage, surrogacy, and sterilization. And at the other end of life, when does life end? What are the ethical standards regarding brain death? How can we help patients die with dignity and minimize suffering without violating ethical standards? We also look at some landmark ethical cases on the right to die and discuss physician-assisted suicide.
Part IV: Advancing Medical Knowledge with Ethical Clinical Research
Clinical research is the cornerstone of medicine. Just think how much the average lifespan has increased over the last 100 years. Much of that is due to modern medicine! Clinical research has given us more effective treatments for diseases, has found cures for some, discovered ways to diagnose problems earlier, and offers hope for the future. But there have been some dark times in medical research. Those need to be studied to avoid problems in the future. We look at the basics of ethical research trials, including the issue of informed consent and truth telling. We also take a look at some of the most controversial research projects: stem cell and genetic research.
Part V: The Part of Tens
Finally, we address some ethical issues you should talk about with your patients, look at some high profile medical ethics cases that set the current ethical standards (and even changed some laws), and try to gaze into a crystal ball at future ethics issues.
Icons Used in This Book
To make this book easier to read and simpler to use, we include some icons that can help you find and fathom key ideas and information.
We use this icon to highlight Jane’s thoughts on the ethics of practicing medicine or to draw your attention to real-life situations she has encountered.
Whenever you see this icon, you know that the information that follows is so important that it’s worth reading twice. Or three times!
This icon appears whenever an idea or information can help you in your medical practice or in your work with other providers.
When you see this icon, it’s highlighting information that’s important or that could be dangerous to you or your patient if not heeded.
Where to Go from Here
This book is organized so you can go wherever you want to find complete information. Want to know more about the ethical issues of abortion? Head to Chapter 11. If you’re interested in the history of medical research and clinical trials, Chapter 14 is for you. If you want to know about the ethics of treating children and parental responsibilities, read Chapter 8. You can use the table of contents to find the broad categories of subjects, or use the index to look up specific information.
If you’re not sure where to start, read Part I. It gives you all the basic information you need to understand the ethics of medicine and will tell you where to get the details.
Part I
Medical Ethics, or Doing the Right Thing
In this part . . .
Medical ethics, also called bioethics, is the underpinning of any medical practice. To understand medical ethics, you need to look at the historical context and guideposts that have been developed over the years. “Doing the right thing” sounds simple, but can be difficult in practice. We define the four main principles of medical ethics, take a look at the basics of running an ethical practice, examine the doctor-patient relationship, and discover what to do when mistakes are made.
Chapter 1
What Are Medical Ethics?
In This Chapter
Defining medical ethics
Looking at common controversies
Moving medicine forward in research
Do the right thing. It sounds so easy, but it isn’t. Every time a story is written about any medical issue, whether it’s abortion, end-of-life care, or multiple births, everyone has an opinion about what’s right and what’s wrong. We’re bombarded with two or more opposing viewpoints, and each one sound reasonable. But which one is right?
And that’s medical ethics in a nutshell. What’s the right thing to do? How do we structure clinics, hospitals, and government so the most people benefit and patients are treated with respect and compassion? What should you, as the provider, do in certain situations?
There are guidelines and principles in place to help us make decisions, but sometimes those come into direct conflict with each other. When that happens, we need to use logical reasoning skills, ethical theories, and some tools of philosophy to balance and weigh our options. Even after all of that is done, there are still questions. Medical ethics gets into the gray areas of life. As you look at these issues in more depth, you realize there aren’t many that are truly black and white.
In this chapter, we define medical ethics, look at the differences between ethical and legal behaviors, and explain the difference between patient rights and provider responsibilities. We need to understand the guidelines and guideposts to follow while treating patients in all stages of life. We look at some of the common and hot-button controversies and take a peek at the ethics of medical research, which is on the forefront of medicine.
Defining Medical Ethics
Healthcare providers have always been respected and even revered. As societies were formed, ethical principles were developed by physicians and scholars from all walks of life. From Hippocrates to Muhammad ibn Zakariya ar-Razi to Thomas Aquinas, physicians and theologians have crafted guidelines to aid providers in their quest to help patients.
As a result, the American Medical Association has written a Code of Medical Ethics that covers most situations healthcare providers face in their careers. The Code is made up of guidelines and opinions written by ethical scholars and physicians. Whenever you have a question about an ethical issue, the Code will provide a good basis for your decisions. (See Chapter 2 for more on the AMA Code.)
In this section, we define the four principles of medical ethics. We also look at the differences between ethics and the law, and how you should reconcile patient care with ethical standards. One of the most important facts in medical ethics is that they are not static. Medical ethics have changed over the years and will continue to evolve as medicine advances.
What are ethics?
Ethics and morality mean the same thing to many people, and they are similar. Morals are used to describe personal character, whereas ethics defines behavior in different situations. Morality refers to personal character, beliefs, and behavior; ethics is about the reflection on morality and deciding how to act as a person or a professional. An ethical person and a moral person are usually one and the same. We use medical ethics to refer to those guidelines and behaviors that we expect a medical professional with moral integrity to exhibit.
Ethics has developed over the centuries as a code of conduct, especially for professionals. Healthcare providers have so much knowledge about the human body, so much potential power over patients, and the ability to change and save lives. Because of these factors, the ethical bar is set very high, and providers have moral obligations to their patients.
The field of medical ethics is really about reflection on how to behave as a medical professional as well as the morality of particular medical interventions. Medical ethics are simply some key ethical principles applied to the practice of medicine. These principles are the bedrock of good clinical practice, and they are autonomy, nonmaleficence, beneficence, and justice. But they often come in conflict with each other as they are applied to a case. By using these principles in each individual case, it can be easier to make difficult decisions with your patients as you guide them through their care.
The four principles of medical ethics
The four major principles of medical ethics are
Autonomy: This principle is focused on the patient’s independence or liberty. A competent adult has the right to make decisions about what happens to his body. The person must be capable of rational thought and not be manipulated or coerced into any decision. An adult can refuse medical care or treatment or accept treatment when his provider suggests it. That person then lives with the consequences of his decision.
Beneficence: This principle states that a physician must act in the best interest of the patient. Providers are required to promote their patient’s health and well-being. Most doctors agree that healing is the main purpose of modern medicine. Beneficence means providers must help their patients.
Nonmaleficence: First, do no harm. Physicians must not harm a patient through carelessness, malice, vengeance, or dislike, or even through treatments intended to help the patient. This principle is balanced with beneficence in that any risks of a treatment or procedure to a patient must be outweighed by benefit. Some treatments always carry a risk of harm. But when the treatment is very risky, the benefit must be great, or the risk of not performing the procedure must be great.
Double effect is an offshoot of nonmaleficence. A treatment that is normally used to help someone may have an unintended negative effect. For instance, a vaccine used to prevent disease can, in rare cases, actually cause the infection it is intended to prevent. This principle provides specific guidance when determining when unintended effects are justified and when they are not.
Justice: Justice refers to fairness with respect to the distribution of medical resources. This principle draws upon ethics, the law, and public policy. Who should receive scarce medical resources, and how should we distribute them in order to realize the best outcomes? Making the system as a whole more fair is one of the goals of justice.
There are two other values of medical ethics: truthfulness (or honesty) and dignity. Although these are important qualities, they are more standards of conduct, not overarching ethical principles.
These ethical principles all have merit, but they are not absolute and they are often in conflict. You will also see some tools of philosophy applied to some of the difficult ethical situations addressed in the upcoming chapters. Deontology states that some actions are, in and of themselves, good or bad, no matter if the end result is good. Universality is the concept that what is right or wrong for a person is right or wrong for all people in all places and at all times. Consequentialism holds that the consequences of any action determine whether that action is just or right. And utilitarianism holds that the worth of any action is determined by the amount of good it produces.
Even with all of these principles and tools at our disposal, medical ethics can be complicated and messy. There will be times in your practice where you and your patient will simply not be able to decide on one course of action or agree about a treatment. Sometimes, all we can do is try to think clearly about what is ethical, then decide on a path, act, and hope for the best.
Differences between ethics and legality
What is ethical is not necessarily legal, and vice versa. For instance, doctors have a fiduciary and ethical duty to their patents to do no harm, tell the truth, and treat patients with respect. The law does not demand that patients receive respect or compassion; it simply demands good medicine applied according to current standards. Some have said that good ethics begins where the law ends. In fact, ethical obligations often exceed legal standards.
The law is expressed in our society through court rulings and legislation. A statute sets a conduct standard that must be met, and a court ruling is binding on all relevant parties. Ethics, on the other hand, are guidelines. And breaches of ethics are usually not legally enforceable, although providers can be sanctioned by different medical institutions or boards if a serious breach occurs. The law does have some bearing on medical ethics in several different areas. For instance, laws, legal opinions, and court rulings affect
Informed consent: A consent form is a legal document, which states that the patient has been informed about his condition and treatments, and that he understands and agrees to them.
Advance directives: Directions for end-of-life care or care when the patient is incapacitated are legally binding. Although the patient doesn’t need a lawyer to create an advance directive, it should be notarized or witnessed.
Abortion and birth control: Countries and states have different laws regarding access to abortion and birth control. Doctors and providers must follow these laws depending on where they live.
Euthanasia: Two states in the United States (Oregon and Washington) and some countries allow physician-assisted suicide. Those laws state specifically what providers are and aren’t allowed to do for a patient.
Privacy and confidentiality: In the United States, confidentiality laws and regulations are strictly enforced to protect the privacy of the patient at all times.
Access to medical care: State-sponsored medical care, including Medicare and Medicaid, are laws that provide access to people who usually couldn’t afford the care. Universal healthcare is provided in most countries around the world.
Medical ethics standards do have an effect upon the law. Many laws are devised and written based on the ethical codes of doctors and nurses. It is important that you, as a provider, know the laws in your state as well as understand the ethics guidelines that apply in different situations.
Reconciling medical ethics and patient care
If you are in the medical profession, you do your best to become the kind of provider who is trusted by your patients. You want your patients to know that you have their best interests at heart, and you want to build relationships with your patients so you can give them the best care possible.
Medical ethics provide guidelines to becoming a better provider. Ethics can help you communicate better, be a better partner to your fellow doctors and nurses, reduce risk of errors, and increase job satisfaction. When you embrace ethics as simply doing the right thing, there will be few conflicts between medical ethics and good patient care.
In many cases, it may help to put yourself in your patient’s shoes (or hospital slippers). What would you want if you were the patient? Would you want your doctor to be compassionate and caring? Would you want test results delivered to you quickly? Treating patients with a sense of courtesy comes first.
The Golden Rule applies in medical ethics. If you treat your patients as you would want to be treated, or as you would want someone to treat a cherished family member, you will provide good medical care.
Turning to ethical guideposts and guidelines
If you have questions about a medical ethics issue, by all means turn to this book! But there are other sources for information, such as the Declaration of Geneva, an updated version of the Hippocratic Oath, or the AMA Code of Medical Ethics. If you work for a healthcare organization, your employer may have a code of ethics as well.
It’s a good idea to read over an ethics code every now and then, not just when you have questions about issues. These codes aren’t perfect or even enforceable, but taking the time to learn their principles and following the basic rules will help you enjoy your practice more, will result in more satisfying patient relationships, and will help make you a more effective provider.
Looking at the Common Medical Ethics Issues
Medical ethics can be divided into five main areas of discussion: individual rights or privacy; beginning-of-life issues; end-of-life issues; access to healthcare; and ethics in research are the main overarching areas that can generate the most need for medical ethics guidelines.
In this section, we look at each of the first four of these areas of ethics and talk a bit about how the four ethical principles can clash and intersect as people make decisions about their lives and providers make decisions about how to best help their patients. All four ethical principles apply to situations in these areas of ethics, and how a dilemma is resolved depends on which ethical principles you follow.
Privacy and confidentiality concerns
Privacy and confidentiality go hand in hand with the principle of autonomy. In fact, because privacy upholds all four medical principles, it can be considered the cornerstone of your practice. Patient autonomy rules this issue because competent, informed patients can legally and ethically make all decisions about their care. It can be frustrating when a patient refuses treatment you know will help, but respecting his decisions, whether those decisions are made on personal, religious, or cultural grounds, is paramount.
Complying with federal regulations and putting safeguards in place in your office and clinic are important. It’s also important to train your staff about privacy and confidentiality, as we discuss in Chapter 3. Running an ethical practice means respecting patient privacy at all times.
If a patient doesn’t trust that you will keep their information private, he will be less likely to confide in you about matters that may be important in making the correct diagnosis.
Patient confidentiality demonstrates all of the medical ethics principles. Confidentiality is crucial to respecting autonomy because patients need to know that their decisions about their health and any diagnoses are being kept in a personal space. Nonmaleficence is important because if that information falls into the wrong hands, the patient can be hurt. Doing the best for your patient, or beneficence, means honoring the trust he places in you. And justice demands that confidential information be kept private because when others can learn information about intimate matters, patients can feel violated.
In Chapter 4, we take a detailed look at how to manage paperwork, deal with managed care situations, and handle sharing information with third parties, particularly insurance companies. But complying with these standards is the bare minimum of keeping patient information confidential. It’s important that you pay attention to what you are discussing with others and where, and what you communicate through the written and spoken word.
Most information about a patient, including test results, diagnoses, treatments, and vital statistics, can be shared only with others when the patient has given express permission for that release. That permission, when at all possible, should be in the written form.
When you have a system in place to comply with HIPAA (the Health Information Portability and Accountability Act), honoring confidentiality becomes second nature. Learning to not discuss patient information with anyone except other providers who are involved in the case or whom you are consulting is important. Practice it until it becomes second nature.
It’s important to remember that in medical ethics, the law really is the lowest common denominator. Ethics goes above and beyond the law, from what is legal to what is right. So complying with the law is important, but to be the best healthcare provider, go beyond the law and add compassion, respect, and honesty to your practice. And speaking of honesty, medical errors do occur, and the best practice is to report them to your patient. We look at the best ways of disclosing medical errors in Chapter 5.
Reproduction and beginning-of-life issues
Reproduction includes access to birth control, abortion, the right of a woman to choose or refuse care, the rights of the fetus, reproductive technologies, and access to care. Autonomy often comes into conflict with the other principles in reproductive issues simply because these matters are so personal.
For instance, a pregnant woman is allowed to refuse healthcare for her and her fetus up until the moment of birth. Respecting the woman’s autonomy means that she is allowed to decide for herself what happens to her body, even when pregnant. In Chapters 9 and 11 we look at how to weigh the rights of a mother versus the rights of her fetus and pro-choice and pro-life stances on abortion. The definition of personhood also is explored as it relates to the rights of the fetus.
Access to birth control becomes an issue when minors request it. Because the law has decided that mature minors can have access to prescribed birth control, how do we respect a minor’s privacy and autonomy while not interfering with the parent-child relationship? In Chapter 8, we take a look at adolescent patient’s rights, emancipated minors, mature minors, and how to balance privacy with your obligations to your patient and her parents.
Finally, assisted reproduction can raise many ethical issues. In Chapter 10, we look at the ethics of artificial insemination, in vitro fertilization, surrogacy, and sterilization. How do we balance risk and harm to the mother and fetus? Who should receive genetic screening, and how do you prepare your patient for the results? What are your responsibilities toward your patient as you try to provide the best care?
End-of-life issues
As at the beginning of life, the end of life raises many difficult ethical issues. With the advent of medical technology that is capable of supporting life far beyond what had once been possible, we need to understand anew when life ends. In Chapter 12, death is defined, and the rights of dying patients are discussed by looking at some landmark ethics cases. The physician’s role in end-of-life cases is discussed, including the ethics of physician-assisted suicide.
We then look at honoring a patient’s wishes at the time of death. Healthcare directives, or living wills, are addressed in Chapter 13 as vehicles for patient autonomy. How can we help patients die with dignity and as little suffering as possible? The rule of double effect (see the earlier section, “The four principles of medical ethics”) is pertinent in this issue. Giving a patient drugs with the intent to make them comfortable can hasten death. Is that an ethical move?
Euthanasia and terminal sedation are hot-button topics. Who decides when it’s someone’s time to die? When it becomes obvious that life is ending, how much help should we offer someone who is suffering? One of medical science’s advances is the ability to help relieve suffering. That’s one of the greatest opportunities for beneficence. When someone is at the end of life, however, balancing beneficence and nonmaleficence can become tricky.
Access to care
In the United States, universal healthcare has been in the news. Passionate supporters of this concept and equally passionate opponents have made their voices heard. But what’s the reality of the situation? And what does medical ethics have to say about access to care? The principle of justice takes center stage with this topic.
Congress passed, and President Obama signed into law, the Health Care Reform Act of 2009. Because this act will take years to implement, there are still millions of Americans who are uninsured and underinsured, and no real guarantee that provisions of the act will ever be put into place. Thousands of Americans die every year because they don’t have access to medical care, and thousands more go bankrupt because of the prohibitive cost of medicine.
The principle of justice is most applicable to this issue. As we discuss in Chapter 6, providing the basic minimum of care to the most people possible, while not reducing the standard of care enjoyed by others, is the balancing act. This fulfills a utilitarian approach to ethics by maximizing benefit to the greatest number of people. As a provider, you can help your patients by volunteering at free clinics, by prescribing generic drugs and less invasive and expensive procedures first, and by encouraging people to live healthy lifestyles. Respecting patient autonomy, guarding against harm (including financial harm), trying to do the best for your patient, and treating all patients equally is challenging but necessary in the current healthcare climate.
In Chapter 7, we look at integrating your patient’s spiritual and cultural beliefs into their care as a way of enhancing treatment as well.
Moving Medicine Forward: The Ethics of Research
Medical research has brought great advances in the 20th and 21st centuries. The life span for the average American has increased from 49 years at the beginning of the 20th century to 77 years at the beginning of the 21st century.
But with this progress has come some dark days. We look at the Tuskegee syphilis study and the abuses of medical research during the Holocaust. Patients have been abused, hurt, and killed in the name of medical research before standards were put into place, as documented in Chapter 14. Even now, some researchers fail to follow guidelines and end up harming patients.
For example, in July 2010, media sources revealed that the drug manufacturer SmithKline Beecham hid results that showed Avandia, their successful diabetes medication, was harmful to the heart. Patients in the clinical trial had serious heart issues, including a significant risk of increased myocardial infarction, that weren’t recorded in the tally of adverse events. The FDA is now deciding whether the drug should be withdrawn from the market. Clearly, if SmithKline Beecham knew about adverse side effects from this drug, they should have been made public. If true, this was a clear violation of nonmaleficence.
In Chapter 15, we look at the important components in an ethical clinical trial. This is vital information, whether you are a researcher or a caregiver of patients in the trials. In Chapter 16, we look at research in some special populations, such as animals, children, and psychiatric patients. Special care needs to be given to protect research subjects who cannot give full informed consent. And finally in Chapter 17, we look at the ethics of stem cell research and the controversies around genetic testing and cloning.
Chapter 2
Morality in Medicine
In This Chapter
Reviewing the Hippocratic Oath and modern descendants
Understanding today’s code of medical ethics
Developing bedside manners: Ethics inside the hospital
Examining bioethics as a field of study
Life in today’s society is complicated, and there aren’t many professions as complicated or challenging as medicine. Furthermore, because doctors and healthcare providers have been so highly educated and the decisions they make may mean the difference between life and death, they’re held to a higher standard of behavior and conduct. And because patients are so vulnerable when they’re sick, the conduct of providers must be of the highest moral quality.
Doctors and healthcare professionals are usually regarded as upright and moral. But doctors, like anyone else, have the potential to be unethical. Throughout history, codes of ethics have been developed to help guide phy-sicians. So where did morality in medicine come from? Who decides what is ethical and what isn’t? And what about moral absolutes? Is there a time when lying to a patient or helping someone die is ethically acceptable?
In this chapter, we look at medical ethics and morality in medicine, including the Hippocratic Oath and how it has evolved. Humanitarian goals, culminating in the Declaration of Geneva, are also examined.
We also look at the American Medical Association and the American Nursing Association’s Codes of Ethics and what you should know about them. Ethical behavior in the hospital is examined, and then we look at the influence of religion on ethical judgment. Finally, if you want to learn more about bioethics, we name some good places to get more information.
We have to decide how personal morals can affect clinical judgment, and when a conflict of interest is unethical. Doctors study life as a biological function, but the emotional, spiritual, and psychological parts of human beings must be considered as well. When we treat the whole person, morality and ethics become paramount.
Distinguishing among Ethics, Morality, and Law
Applying the principles of medical ethics and the theories of morality help healthcare providers decide what course of action to take. Basically, ethics is all about asking the question, “What is the right thing to do?”
What is morality? Most people define it as choosing the right beliefs or behavior in a difficult situation. Ethics is then reflecting on those moral standards and acting upon them. Ethics sets moral standards for behavior in many professions. With the four principles of medical ethics (see Chapter 1), providers often must weigh and balance one against another. When these principles seem to contradict, deciding which one has more moral weight, based on moral arguments, is the task of medical ethics.
At first, many scholars thought that ethics belonged solely to the study of religion or philosophy, but as medicine advanced, ethics became part of the practice of medicine through interdisciplinary studies.
Although many laws are derived from ethical or moral precepts, ethics and morality are not the same as the law. For instance:
Some laws uphold ethical standards. For example, it’s illegal for a doctor to have a sexual relationship with a young patient. And that behavior is highly unethical.
Some ethical standards are stricter than the law. For instance, in Chapter 3 we discuss the case of the doctor who posted a sign on his door stating that anyone who voted for President Obama should seek care elsewhere. Although it was legal for this doctor to state this, the action wasn’t ethical.
Sometimes ethics partially conflict with laws. Some physicians are ethically opposed to abortions and will not perform them. The law in many states restricts abortion in the second and third trimesters. However, abortions are legal in the first trimester, and doctors are ethically required to tell this to their patients, even if they are morally opposed to abortion.
And some laws are directly opposed to ethical standards. For instance, lethal injection is, in many countries, used as a means of capital punishment. But the AMA Code of Medical Ethics states that participating in this activity is a violation of ethical standards.
Some have said that good ethics take over where legal sanctions end. These ethical standards are not enforceable by law, but act as approved guidelines for healthcare provider behavior.
