Ethics

7


Ethics





Objectives


Upon completion of this chapter, the reader will be able to:


• Discuss the most commonly cited principles of ethical decision making in medical care.


• Understand how to systematically elucidate and resolve ethical dilemmas.


• Discuss the requirements of informed consent and the criteria for decisional capacity.


• Discuss the role and use of different types of advance directives, including do-not-resuscitate (DNR) orders.


• Understand the use of the term futility as it applies to medical decision making.


• Discuss ethical concerns regarding assisted suicide and what’s known as the double effect.


• Discuss the unique issues involving provision of food and fluid.


The rapid advancements in medical technology, the growing population of the elderly, and the increasing awareness of the legal and moral issues confronting the elderly, their families, and their caregivers have resulted in the need for a methodology to evaluate and resolve moral conflicts that may confront clinicians who care for older patients.


Ethics is the field that systematically studies morality, which is defined as the rightness and wrongness of human acts. Medical ethics is the discipline that studies morality in health care, generally using a process that attempts to recognize and seek solutions to moral questions or dilemmas that arise in the care and treatment of patients. As a branch of moral philosophy, medical ethics is responsive to shifts in philosophical opinion and fashion. It is also a field that is a fusion of theory and practice.1


Moral dilemmas arise when the rights and wishes of patients conflict with the obligations of clinicians or when there are competing obligations among clinicians. These rights and obligations may be informed by philosophic, cultural, religious, or personal principles, beliefs, and values. In geriatric medicine, rights and obligations are often influenced and complicated by factors such as limited life expectancy, cognitive impairment, impaired decision-making capacity, insufficient social and economic resources, and the complexity of multiple concomitant medical problems and functional disorders.2


Over the past 20 years, there has been a growing awareness of the need to institute clinical ethics as a required discipline in medical training and in health care organizations. Ethics courses are becoming more common in medical schools, and ethics committees and similar venues for the resolution of ethical conflicts have become a required and expected presence in hospitals, nursing homes (NHs), and other health care organizations. The rise of medical consumerism has resulted in a population of patients and caregivers who are increasingly well-informed about their rights and choices in the health care market. As a result, it is vital that clinicians develop a shared language of ethical decision making.


This chapter introduces the basic principles of ethical decision making and examines common ethical issues encountered in the care of older patients.



CASE 1   Alice Oliver (Part 1)


Mrs. Alice Oliver is an 83-year-old woman, an active swimmer and gardener, who suffered a right-sided stroke with mild left hemiparesis and dysphagia. During hospitalization, her motor deficits were improving but the dysphagia persisted. A swallow evaluation indicated that she was able to tolerate a chopped or pureed diet with nectar-thick liquids, but she experienced asymptomatic aspiration with thin liquids. The speech therapist recommended thickening all liquids, and you enter this order on the chart. Mrs. Oliver, however, refuses thickened liquids, insisting that she would rather take her chances with thin liquids. The nurses and the dietician tell you they do not want to provide her with thin liquids; they believe that by doing so, they will be contributing to the risk they were trying to ameliorate.


You are confronted with an ethical dilemma. On one hand, you think the patient should have the right to take risks and eat what she wants. On the other hand, you can sympathize with the other health care professionals’ discomfort in abetting risky behavior. Medical ethics provides a means for articulating and analyzing such dilemmas.





Principles of medical ethics


Traditional principles of medical ethics derived largely from the works of Greek philosophers such as Hippocrates3 and Pythagorus.4 During the second half of the twentieth century, increasing pressure on the medical establishment from technological change, cultural upheaval, and the increasing complexity of medical care and the issues it raised resulted in the need to more explicitly frame the principles of medical ethics.


Although there are a number of alternative theories of medical ethics—such as the virtue-based theories favored by the Greek philosophers, the ethics of caring,5 and casuistry6—there remain four prima facie principles that are most often cited as the bedrock of clinical ethics. These are autonomy, beneficence, nonmaleficence, and justice.7



Autonomy


The principle of autonomy refers to the duty to respect a patient’s right to self-determination. This has been legally enshrined in the judicial ruling of Schloendorff v. Society of New York Hospital (NY 1914), in which Justice Cardozo found that, “Every human being of adult years and of sound mind has a right to determine what shall be done with his body.”8


Traditionally, clinicians have assumed a strongly authoritarian and paternalistic role in the medical decision-making process. With the increase in consumerism and the availability of medical information, patients have been more likely to assert their autonomy. Health care providers have been increasingly recognizing autonomy as a fundamental ethical principle.


Integral to the principle of autonomy is the right to receive sufficient factual information to allow self-determination. This is the basis of informed consent, established in the Nuremberg code, which states, “The voluntary consent of the human subject is absolutely essential.”9 In Nathanson v. Kline (KS 1960), a case that centered on the failure to inform a patient of potential surgical risks, the ruling found that, “It follows that each man is considered to be master of his own body, and he may, if he be of sound mind, prohibit the performance of life-saving surgery or other medical treatment.”10


In addition to establishing the right of an autonomous patient to refuse treatment, these rulings also introduce the “of sound mind” concept, which is indicative of a patient’s capacity to understand what has been explained, appreciate the situation and its consequences, rationally manipulate information, and communicate choices.11 Decision-making capacity is a critical requirement for providing informed consent and, therefore, for exercising autonomy.


Effective clinician–patient communication is an integral part of providing informed consent throughout the process of reaching an autonomous decision. The clinician has a duty to tell the truth and provide fact-based, objective information to the patient. Such discussions must be free of personal, subjective biases. The information must be fair and lawful and must not be swayed by any financial or personal gain. This does not preclude the clinician from providing advice as to what would be the clinician’s own preference, but the clinician should avoid labeling that choice as the “right” decision and assure the patient of support, regardless of the patient’s own decision.


Truth-telling is an essential component of the exercise of autonomy. The recognition that there is an obligation to provide truthful information to patients about potentially life-threatening conditions is a relatively recent phenomenon. A 1961 survey of physicians in the United States reported that 90% would not reveal a diagnosis of cancer to their patients.12 A 1979 survey reported that 97% of physicians would reveal a diagnosis of cancer to their patients.13 A recent survey of hospitalized patients reported that a large majority would prefer to be told of a diagnosis of cancer or Alzheimer’s disease. Among those who were unsure or who did not want to be told, a majority would want to be told if it was essential to treatment. Preferences did not differ by age.14


Age is not, by itself, an obstacle to the full exercise of autonomy. In one study, even very old hospitalized patients were able to express their health values, underscoring the need to elicit such choices directly from the patient, unless that patient lacks decision-making capacity.15




Nonmaleficence


The principle of nonmaleficence states that throughout the physician–patient relationship, the physician shall “at the least, do no harm.” It is incumbent upon all clinicians to determine the goals of the intervention and to weigh these goals against the potential risk of an adverse outcome. Factors such as advanced age, concurrent disease states, comorbidities, and expected prognosis must be considered in the equation. When available, the clinician may use formal algorithms to assess risk. For instance, preoperative cardiac risk stratification can help the clinician determine the risk of an adverse cardiac event from surgery. A short life expectancy may suggest that a particular screening test or procedure is not likely to have its expected benefit. In essence, the duty of nonmaleficence is balanced against the duty of beneficence when weighing risks and benefits.



Justice


Justice refers to the duty to treat patients fairly. Justice can be viewed along two dimensions: access and allocation.16 Access refers to whether those who are entitled to health care resources can obtain them. Allocation refers to the determination of how resources are distributed. The distribution of rights and responsibilities among the members of a society in a manner governed by consistent moral norms is often referred to as distributive justice.


The principle of justice can apply to either the macroenvironment, such as the decisions made to ration health care within Oregon’s Medicaid program,17 or the microenvironment, such as decisions made to allocate money and other resources within a hospital, nursing home, or office practice.


In a hospital or nursing home, conflicts involving the principle of justice may revolve around the use of scarce, expensive, or labor-intensive medical interventions in frail, elderly patients with limited life expectancies. On a national scale, justice may be the central principle in determining whether Medicare should cover a particular procedure or in determining who should have control over allocation decisions in managed care organizations.18



Other principles


In addition to the principles outlined in the previous sections, there are other ethical principles that are common in geriatrics, particularly in communal settings such as assisted-living facilities or nursing homes, in which elderly residents not only obtain medical care but consider the facility their home. The principle of community, which refers to the duty to balance individual need with communal need, takes on great importance in such settings. Not only is personal autonomy important, but also individual dignity, a closely related but distinct value, is greatly valued. Also closely related to autonomy, the principle of authenticity refers to the ability to choose a lifestyle consistent with one’s own values, beliefs, and habits.19 These ethical principles largely underlie the advocacy of culture change in the nursing home industry. The culture change movement has as its goals to provide residents more homelike environments and choice over their lives, and to provide staff members the authority and empowerment to facilitate those choices.20,21



In Western society, the principle of autonomy has come to dominate other ethical principles, but this may not be true of all cultures.




CASE 1   Alice Oliver (Part 2)


The case of Mrs. Oliver represents a classic conflict between the duty to respect the patient’s autonomy and the duty to do good (beneficence) and avoid harm (nonmaleficence). Mrs. Oliver is unable to exercise her autonomy without the cooperation of the care team in providing her food, but the team feels that supplying her choice of diet would violate the duty to avoid harm. Having identified the ethical principles that are at odds with each other, you must now systematically evaluate alternatives for resolution.





Structure for deliberating ethical dilemmas


There are several models for systematically evaluating and analyzing dilemmas in medical ethics. One of the most commonly used models is the “four topics” model devised by Jonsen et al.22 This is a case-based approach that allows an organized review of the facts and issues in a given case, according to four topics: medical indications, patient preferences, quality of life, and contextual features (Figure 7-1).



Each topic represents a systematic means of organizing the questions related to the corresponding ethical principles. Under the topic “medical indications” are questions that determine how the facts of the case determine what is beneficence and nonmaleficence. The topic “patient preferences” contains questions that establish the patient’s autonomy and how that autonomy fits into the ethical problem at hand. “Quality of life” contains questions that further elucidate what is considered beneficence and what is considered nonmaleficence, according to the patient’s own values. “Contextual features” contains grouped questions that tease out other influences on the case and incorporate principles such as loyalty and fairness.


Once the facts of the case are organized, it is important to identify the ethical dilemma(s), if any. Only when the ethical questions are framed is it possible to formulate potential solutions. Frequently, ethical dilemmas have more than one morally permissible alternative. If the ethics consultant or ethics committee has been asked to participate, it may be their role to outline these alternatives. Nonetheless, it generally falls to the health care team and patient to determine which alternative will be followed.



An ethical conflict may have more than one morally acceptable solution.



What appears at first to be an ethical dilemma may ultimately emerge as an interpersonal dispute among family members or between staff and family members.23 In geriatrics, patients may have several family members, usually children, who may disagree with each other or with the health care team over decisions, large and small, sometimes making medical management time-consuming and difficult. In these cases, typical ethical deliberation may not always be useful or sufficient. Alternate techniques such as mediation,24 negotiation,25 or a combination of these and other methods of conflict resolution may be necessary.



It is sometimes difficult to differentiate an ethical dilemma from an interpersonal conflict, and one may accompany the other.




CASE 1   Alice Oliver (Part 3)


Mrs. Oliver’s nutrition may be viewed in a dual manner. Because nutrition is considered basic to life and comfort, the team has an obligation defined by the principle of beneficence to provide it. There is, however, a therapeutic component as well, because the food must be provided in a form and texture suitable to Mrs. Oliver’s swallowing disorder. You tell the team that although Mrs. Oliver is refusing the recommended therapeutic form of the nutrition, they are still fulfilling the duty of beneficence and respecting her autonomy by providing her thin liquids, although the risk may be greater. In other words, the duties of autonomy and beneficence outweigh the duty of nonmaleficence. So long as Mrs. Oliver understands the increased risk she is assuming, it is ethically permissible to provide her with thin liquids. It is your responsibility, in conjunction with the care team, to establish that Mrs. Oliver has adequate information to make this decision.





Informed consent


Informed consent is the foundation for the exercise of autonomy. It has become increasingly central to both the ethical and legal regulation of American medicine and the clinician–patient relationship since the concept was first used in 1957.26 Informed consent is more than simply the required signing of permission forms before surgery or other medical procedures. In representing the means by which the principles of autonomy, beneficence, and nonmaleficence are balanced and incorporated into medical decision making,27 informed consent requires disclosure and comprehension of information as well as voluntary and competent decision making28 (Box 7-1).



BOX 7-1


THE ELEMENTS OF INFORMED CONSENT






From Karlawish JHT. Getting competent at assessing competency. Presented at the 2003 Annual Meeting of the American Geriatrics Society.




Disclosure


The requirement for disclosure is not an obligation for the clinician to impart everything about a proposed intervention to the patient. Some states measure the adequacy of disclosure according to the standard determined by what a reasonable clinician would disclose, whereas others measure adequacy by what information a reasonable patient would need to make the decision.29 Although this may appear at first glance to be vague, “reasonable” generally means that disclosure should provide information about the goals of the procedure, the probability of success, and the most probable adverse effects. In addition, disclosure should include information about alternative options, including foregoing of any procedure.


Disclosure should allow the patient to weigh not only the risks and benefits of the proposed intervention but also the comparative risks and comparative benefits of alternatives, including the status quo or doing nothing. The information should be provided in a form the patient can understand, in terms of both the language itself and educational level.



Voluntariness


When patients are sick, they are often vulnerable as well. There may be conflicting values, not only among the patient’s own values but also among the patient’s, family’s, and other caregivers’ values. It is important, therefore, that the clinician ascertain that the decision is not coerced, that it truly represents the free will of the patient.


Simply asking patients whether they feel they have a choice or asking how much time they will need to make a choice may ensure voluntariness. Sometimes family members and friends may need to be excluded from the discussion to allow patients to freely express themselves. Overt threats from family are an obvious impediment to the free expression of choice, but subtle coercion or abuse may also occur.


The clinician may also exert undue pressure on the patient, interfering with the patient’s perceived ability to express his or her free will. A patient may be afraid of disappointing the clinician or, worse, of being abandoned by the clinician if he or she does not consent. In some instances, perception by the patient of abandonment may not mean the complete exit of the clinician from the clinician–patient relationship but the fear that the clinician may not be fully committed to all the patient’s needs should the patient choose to pursue a course contrary to the clinician’s recommendation.30 Therefore, part of the disclosure process should include information regarding the management of the patient and an assurance of support should he or she refuse the proposed intervention.



Capacity


Although disclosure of information and voluntariness are necessary for informed consent, the patient must also be able to use the information meaningfully to render an informed decision. The ability to cognitively process the provided information appropriately and render a decision is generally referred to as decision-making capacity.


Most authors tend to use the term competence as a legal term, referring to the individual’s soundness of mind to make most routine decisions. When a court rules that an individual is incompetent, that individual is determined to lack sufficient cognitive function to make most routine decisions. This is usually accompanied by the appointment of a guardian and results in limitations in the individual’s exercise of basic rights. The term capacity is used clinically on a case-by-case basis to denote the capability to render a specific decision. A patient may have the capacity to make one decision but not another. In everyday practice the distinctions between these terms often break down, leading to the use of the terms capacity and competence interchangeably.


In geriatric medicine, the prevalence of cognitive impairment owing to dementia or delirium raises difficult questions about the patient’s capacity to participate in the process of informed consent. It is important to distinguish between cognitive impairment and impaired decision-making capacity. The presence of cognitive impairment does not necessarily rule out the ability to render all medical decisions, nor is an abnormal Folstein mini-mental state score,31 by itself, an indication of incapacity.32


The determination of capacity should ideally be made on a case-by-case basis as part of the process of obtaining informed consent. A patient, who, because of dementia, is unable to participate in rendering a decision about a lower extremity vascular procedure, may nevertheless be able to clearly express a decision about resuscitation. Thus the inability to provide informed consent for one intervention should not necessarily imply a presumption of incapacity for other interventions. Likewise, the presence of mental illness, such as depression, should not lead to the conclusion that the patient cannot participate in decision making,33 although there is evidence that the judgment of acutely ill adults may be sufficiently impaired in many cases to interfere with decision making.34 This underscores the importance of using a systematic assessment of decision making specific to the decision at hand.



The presence of dementia does not, by itself, indicate that the patient lacks decision-making capacity.



The set of standards that has evolved for assessing decision-making capacity includes the following components: (1) understanding of information that is disclosed in the informed consent process, (2) appreciation of the information for one’s own circumstances, (3) reasoning with the information, and (4) expressing a choice35,36 (Box 7-2).



BOX 7-2


MODEL QUESTIONS FOR ASSESSING CAPACITY







Adapted from Ganzini L, Volicer L, Nelson WA, et al. Ten myths about decision-making capacity. J Am Med Dir Assoc 2004;5:263-67. Also from Appelbaum PS, Grisso T, unpublished.


Understanding represents the ability to comprehend the information provided and to be able to restate it in terms that make this evident. Thus it is helpful to ask the patient to repeat, in his or her own words, the information the clinician has provided, so it is clear that the patient fully comprehends the information.


Appreciation represents the ability to recognize that the information applies to oneself. For instance, a patient may clearly articulate information about a proposed procedure, but if the patient then asserts the procedure is not needed because of an erroneous belief that he or she does not have the condition that indicates the procedure, the patient’s appreciation would be questionable.


Reasoning involves the ability to use and apply logic to information. This refers to the patient’s ability to infer the consequences of a choice and to weigh the respective merits of various choices. The ability to consider the risks and benefits of a procedure or to compare the risks of two or more procedures is an example of reasoning.

Related posts:

Billing and coding Hospital care Hearing impairment Financing and organization of health care Assessment Dizziness

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Jun 8, 2016 | Posted by in GERIATRICS | Comments Off on Ethics

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