Download Ethics and Clinical Harm Reduction

Ethics and Clinical Harm
Reduction
Frederick Rotgers, PsyD, ABPP
Associate Professor of Psychology
Philadelphia College of Osteopathic
Medicine
Overview
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Framework for discussion
Current trends in bioethics
Ethical basis for clinical harm reduction
Objections to clinical harm reduction
Discussion
Framework for Discussion
Veatch, 2003
Metaethics
Normative Ethics
Rules and Rights (Codes of Ethics)
Cases (Casuistry)
Cases (Casuistry)
• Two people disagree on how to handle a
case
• Each cites cases to support a particular
course of action
• Reliance on “paradigm” cases=casuistry
Rules and Rights (Codes of Ethics)
• Grounded in moral system
• Rights claims, e.g. “patient should always
give consent to a treatment.”
• Question of how rigidly rules apply
– Antinomianism—no rules/rights ever apply
– Legalism—Specific rules/rights for every
situation
Normative Ethics
• Three Questions
– Action theory: “what principles make actions morally
right?”
• Beneficence
• Non-maleficence
– Value theory: “What kinds of consequences are good
or valuable?”
– Virtue theory: “What kind of character traits are
morally praiseworthy?”
• Benevolence
• Respect
Metaethics
• Meaning and justification
of ethical terms
• How people know which
principle or virtues are the
“correct” ones
• How we can know we
have the “right” answer
• Religious Answers
– Divine will
– Divine Law
• Secular Answers
– Universal
• Natural law
• Hypothetical contract
– Relativist
• One’s culture
• One’s Personal
preferences
• Actual Social contract
Current Trends in Bioethics
• Deciding what constitutes “benefit” and
“harm”
• Shift from Conservative to Liberal values
• Traditional Hippocratean Approach
– Physician/clinician decides what is best using
own best judgment—paternalistic
– Focus either on limited “health” or broader
“well-being”
– Benificence/Nonmaleficence
Current Trends in Bioethics
• Shift in focus from physician/clinician to
patient
– Autonomy
– Personal choice
– Rights
• To refuse beneficial treatment
• To choose treatment other than that recommended
by a particular clinician
• To place a higher value on aspects of well-being
other than health
Current Trends in Bioethics
• Balancing Benefits and Harms
– Bentham: arithmetic summing--utilitarianism
– Comparing ratio of benefits to harms
– “Primum non nocere”
• Who should do the balancing?
Current Trends in Bioethics
• Deontological (duty-based) models emphasize
“respect for persons”
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Respect for autonomy
Fidelity to promises
Veracity
Avoidance of killing (but not always—e.g. legal
euthanasia)
• Duty based: formal obligation to act in certain
way towards others regardless of the
consequences
Ethical Basis for Clinical Harm
Reduction
• Follows from the most universal
deontological ethics
– Emphasis on personal choice and autonomy
– Fidelity—loyalty to the patient
• Sometimes produces dilemmas: loyalty to patient
sometimes does not produce best outcomes
– Veracity—informed consent
Objections to Clinical Harm
Reduction
• Over-borne will
– Being addicted itself reduces personal autonomy
– Raises questions about the nature of addiction—is
addictive behavior voluntary or involuntary?
• Competency
– Being addicted renders one incapable of making
certain decisions
– “Cynthia’s Dilemma: Consenting to Prescription
Heroin” Charland, 2002
• Social obligation
– Responsibility to family members of addict and
society at large
Discussion
• What should be the basis for clinical
decision-making and clinician
recommendations?
– Subjective
– Religious
– Objective research
• How do we factor in the interests of both
the individual and society?