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An Introduction to Medical Ethics Christopher DeMella, Pharm.D. PGY2 Academic Pharmacy Resident VCU School of Pharmacy Spring Semester, 2016 Objectives • Define “medical ethics” • Summarize the 4 primary ethical principles • Illustrate Kohlberg’s theory of ethical development Medical Ethics • Ethics o From the Greek ethos, meaning “character” o Defines what is good for the individual and for society and establishes the nature of obligations that people owe to themselves and one another • Medical Ethics o The standard of behavior used to guide medical practitioners in relationships with patients, health professionals, and society o “Trying to do the right thing while achieving the best possible outcome for every patient.” – Medical Ethics for Dummies Principles of Medical Ethics • Beneficence • Non-maleficence • Autonomy • Justice Beneficence • Promoting what is best for the patient • Requires that health care providers: o o o o o Develop and maintain skills and knowledge Continually update training (CEs) Consider individual circumstances of each patient Strive for net benefit Acknowledge the patient’s wishes (autonomy) Non-maleficence • Do no harm • Do the benefits outweigh the risks? • Principle of double effect o A single action may have a good and a bad effect o In order to determine if the action is permissible, consider: • The nature of the act must be good or neutral, it cannot be intrinsically wrong • The agent intends the good effect and not the bad either as a means to the good or as an end itself • The good effect must outweigh the evil that is permitted Autonomy • Recognizes the rights of individuals to make their own decisions o Free from both controlling interference by others and from limitations • Basis for informed consent and advanced directives o Disclosure of medically relevant information • Exceptions to autonomy o o o o Certain disabilities Mental status Maturity Incapacity Justice • Describes how people are treated when interests compete • Persons who have similar circumstances and conditions should be treated alike • Considerations when evaluating justice: o Fair distribution of scarce resources (distributive justice) o Respect for people’s rights (rights based justice) o Respect for morally acceptable laws (legal justice) Kohlberg’s Theory of Ethical Development • Three distinct levels of moral reasoning, each with two sub-stages • People can only pass through the stages in order, with each new stage replacing the reasoning typical of the previous stage • Not everyone achieves all the stages Level 1: Pre-Conventional Morality • Authority is outside the individual and reasoning is based on the physical consequences of actions • Stage 1: Obedience and Punishment Orientation o The individual behaves in order to avoid being punished o If a person is punished, they must have done wrong • Stage 2: Individualism and Exchange o The individual recognizes that there is not always just one right view o Different individuals have different viewpoints Level 2: Conventional Morality • Moral standards of role models become internalized • Stage 3: Good Interpersonal Relationships o The individual is good in order to be seen as a good person o Answers and behaviors are related to the approval of others • Stage 4: Maintaining the Social Order o The individual becomes aware of the rules of society so decisions are based on obeying rules in order to uphold the law and avoid guilt Level 3: Post-Conventional Morality • Individual judgment is based on self-chosen principles, and moral reasoning is based on individual rights and justice • Stage 5: Social Contract and Individual Rights o The individual becomes aware that while rules/laws might exist for the good of the greatest number, there are times when they will work against the individual (Heinz’s dilemma) • Stage 6: Universal Principles o The individual has developed their own set of moral guidelines which may or may not fit the law (human rights, justice, equality) o The individual is prepared to defend these principles, even if it goes against the rest of society Comprehension Assessment • Which of the following patients would be fully capable of making an autonomous decision? A. A patient with bipolar schizophrenia who is demonstrating aggravated behavior and is refusing his monthly haloperidol injection A. A patient with dementia and a DVT who is refusing to take warfarin in the nursing home A. A patient diagnosed with stage IV lung cancer who is refusing potentially life-saving chemotherapy A. A drug addict who requires inpatient IV antibiotics for treatment of an infection but is attempting to leave AMA due to their addiction