MLI: Ch. 11 Ethical and Bioethical Issues in Medicine – Flashcards

The study of healthcare ethics is an applied ethics, which means that it is more than just a study of theory. Students need to understand the role of ethics in the practice of their medical discipline. A critical-thinking approach to ethics requires the student to look for a solution that includes fairness to patients, respect for society, and a concern for the future implications of the decision. This must be a decision in which the dignity of the individual is always respected. This chapter includes a brief history of ethics, codes of ethics, and a discussion of ethics committees. Bioethical issues such as transplant rationing, biomedical research, and conflicts of interest are included. Three models for examining ethical dilemmas are included in Chapter 1.

to assert or declare without proof.

—to find fault with, criticize, or condemn. • Physicians accused of unethical behavior can be issued a warning or censure by the AMA.

—threadlike structures within the nucleus (center) of a cell that transmit genetic information.

—a group of identical matching cells that come from a single common cell.

—research subjects who receive no treatment.

—a research design in which neither the experimenter nor the patient knows who is getting the research treatment.

—the administration of a lethal agent by another person to a patient for the purpose of relieving intolerable and incurable suffering.

—the act of forcing out.

—list of genes that are responsible for disease.

—the replacement of a defective or malfunctioning gene.

—a science that describes the biological influence that parents have on their offspring.

—remove organs or embryos.

—the complete set of genes within the 23 pairs of human chromosomes.

—a research program funded by the federal government to "map" and sequence the total number of genes with the 23 pairs, or 46 chromosomes.

—a hospital or university board of members who oversee any human research in that facility.

—federal law that forbids the sale of organs in interstate commerce.

—research conducted that will not directly benefit the research subject.

—after death.

—the act of taking away or recalling, such as taking away a license to practice medicine.

—a method of determining the allocation of organs by giving them to people who will benefit the most.

—master cells in the body that can generate specialized cells.

—a form of medical research that might directly benefit the research subject.

—the legal entity in the United States responsible for allocating organs for transplantation.

abortion allocation of scarce health resources determination of death euthanasia: active and passive fetal tissue research genetic counseling harvesting of embryos HIV, AIDS, and ARC in-vitro fertilization organ donation and transplantation quality-of-life issues random clinical trials stem cell research sterilization surrogate parenthood withdrawing treatment withholding lifesaving treatment

An ethical model, such as the seven-step model, can help when confronted with an ethical dilemma, to problem solve instead of following a gut reaction. Furthermore, it requires that one examine all the facts and look at alternative solutions before coming to a conclusion.

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New information is coming out about stem cell research almost weekly. These master body cells can generate specialized cells that can grow into any cells or tissue in the body. It is believed that the use of stem cells will eventually allow the body to heal itself from diseases such as Parkinson's, diabetes, stroke, and Alzheimer's.

The ethical concerns for this issue are wide-ranging but include determining who receives a scarce organ, the expense of a transplant, and the sale of organs.

These codes were developed as a direct response to atrocities that occurred during wartime, especially in response to the medical experimentation in Nazi concentration camps during World War II. These codes express concern for the human subject in medical experimentation.

• Healthcare ethics, bioethics and medical law are intertwined. • Ethics (a branch of philosophy) in healthcare are applied ethics. • Ethics requires critical-thinking approach that examines important considerations such as fairness for all consumers, the impact on society, and future implications of the decision. • The dignity of the individual, whether it is the patient, employee,or physician must always be of paramount concern when discussing ethics and bioethics. • Bioethics concerns ethical issues discussed in the context of advanced medical technology. • An illegal act is almost always unethical. However, an unethical act may not be illegal.

• The Hippocratic Oath reminds students of the importance of their profession, the need to teach others, and the obligation to never knowingly harm a patient or divulge a confidence. • The same principles are found in the AMA's code of ethics.

• According to the AMA, ethical behavior refers to moral principles or practices, the customs of the medical profession, and matters of medical policy. • Physicians accused of unethical behavior can be issued a warning or censure by the AMA. • The AMA Board of Examiners may recommend the expulsion or suspension of a physician from the AMA, but it does not have authority to bring legal action against a physician. • The AMA is required to report to the state licensing board or governmental agency if someone alleges that a physician has committed a criminal act. • Violation and conviction may result in a fine, imprisonment, or revocation of the physician's license. • Serious cases of fraud require the loss of a physician's license.

• People's behavior must match their set of values. • Codes of Ethics or statements of intent are developed by professional organizations to summarize the the principles of behavior they expect of their practitioners. • The Nuremberg Code was developed in response to a wartime medical ethic atrocities; it outlines the basic ethical principles that must be followed when conducting medical research • The first AMA Code of Ethics was developed in 1847. Since then the AMA has taken a leadership role in setting such standards. • Know the code of ethics that relates to your professional practice. Many healthcare professionals keep a framed copy near their place of work to remind them of this responsibility.

The AMA Principles of Medical Ethics discuss • Human dignity • Honesty • Responsibility to society • Confidentiality • The need for continued study • Patient autonomy • Responsibility of the physician to improve the community • Responsibility to the patient • Access to medical care Every healthcare professional who interacts with patients (even medical receptionists) must be familiar with the Principles of the AMA.

• The Council on Ethical and Judicial Affairs of the AMA is compromised of nine members who interpret the Principles of Medical Ethics. Issues include: • Abuse • Accepting patients • Allocations of health resources • Confidential care of minors • Euthanasia • Fee splitting • Financial incentives for organ donation • Gene therapy • Ghost surgery • HIV testing • Mandatory parental consent to abortion • Physician-assisted suicide • Quality of life • Withholding or withdrawing life-prolonging treatment

ANA - American Nurses Association AAMA - American Association of Medical Assistants ADA - American Dietetic Association AHIMA - American health Information Management Association ASMT - American Society for Medical Technology ASRT - American Society of Radiologic Technologitst

The American Nurses Association (ANA) has developed a code for nurses.

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New bioethical issues arise almost daily due to advances in medical technology.

In the United States people may voluntarily donate their organs and tissues to others. They can indicate this desire in their advance directive or on their driver's license (in some states). • The most commonly donated are corneas, heart, kidneys, skin, bone marrow, blood, liver, and lungs. The long bones of the body (tibia, fibula, femur, humerus, radius, and ulna) can also be transplanted. • Some organs and tissues can be donated by a living person, such as, blood, bone marrow, and kidneys. • A U.S. law prohibits the sale of organs. Payment to cover the medical cost for the donor is allowed. • UNOS contains a database relating to every organ donation and transplant in the U.S. since 1986. • UNOS uses a formula that gives half the weight to considerations of medical untility or need and half to considerations of justice. • An estimated 400,000 people are waiting for transplant in the U.S. • There are 106,000 people listed on the UNOS waiting list (many are for kidneys) • Severe shortages of organs leaves patients to take desperate measures to find organs on their own

• Transplant rationing is one of the most discussed bioethic issues • One issue is the extreme expense involved for the procedure and continued immune suppression therapy • The criteria for rationing are controversial. • The United States and Great Britain are committed to the donation model for organs; organs may be harvested only with the consent of the donor or the donor's surrogate representative. • All U.S. states have adopted the Uniform Anatomical Gift Act, permits competent adults to either allow or forbid the posthumous use of their organs though some type of written document, including a donor card. • The social utility method of allocation determines the allocation of organs based on who will benefit the most through careful matching and estimated survival rate. • Another approach is the justice method, which gives everyone an equal change at the available organs. • Other methods include seniority (first come, first serve) basis and the lottery method. Both of these methods cause concern because they may result in a person in lesser need receiving an organ first. The lottery method may result in a patient with little chance of recovery, receiving a scarce organ. • Other selection criteria, such as age, social status, projected ability to give back to the community raise concerns that this is not a just system for all persons. • A combination approach using medical suitability first and then seniority basis second is the most often used method. • National Organ Transplant Law of 1984 forbids the sale of organs and addresses the matter of finding donor organs close to recipients locations. • Financial incentives for cadavers is generally frowned upon • Medicare has been expanded to fully fund kidney transplants and most insurance will cover heart transplants. • Lessons learned from the Oregon case are: - Medical resources are limited in all states - The need for acute care, such as for transplants, is more visible than preventative care, such as prenatal care - New medical discoveries and treatments, with their enormous costs, are likely targets for cost containment rather than older, more basic medical treatments. - For new treatments to be funded, they must replace older, ineffective treatments

Table 11.3

• Healthcare professionals may have personal, religious, or ethical reasons for not wishing to be involved in a particular procedure. • The preference should be stated before hiring takes place. • If the healthcare providers reasons jeopardize the health and safety of the patient it may be necessary for them to resign. • The ethics of the employer must be in agreement with the ethics of the healthcare professional.

• Aims of healthcare include: - the relief of pain and suffering - the restoration of body functions and health - the prevention of disability and death • Human experimentation is considered necessary for medical progress to occur • Medical research carries some degree of risk and patients must be willing, informed participants, especially in nontherapeutic research • The justification for all research is that the benefits must outweigh the risks. • This utilitarian (benefit/cost) approach is considered a good model for research. • Increasing knowledge is not considered justification for risking human life • Medical researches must abide by the code of ethics established by their professional organizations • HHS implements government standards for research. They require all institutions that receive federal research funds to establish an Institutional Review Board (IRB) to oversee any human research.

• Informed consent is necessary in therapeutic research • Patients must be informed about the risks and they type of research design that is used. Such as: - Control group - Randomized study in which the subjects is assigned at random to either the control or experimental treatment group - Placebo group in which an inactive substance or an alternative type of treatment is given

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• Ethics becomes a concern when research results prove that the type of treatment subjects have been receiving has actually harmed patients. • Research can help determine the which course of treatment is best • Physicians are responsible for explaining the risks involved in a research project, however, other healthcare professionals have a duty to covey information the patient tells them to the doctor.

• A conflict of interest can arise in research if the researcher's interests are put above the patients'. As when a researchers falsifies data so they continue to receive funding. • Physicians should not engage in drug trials for drugs made by companies that they own stock in. •

at the National Institute of Health Clinical Center

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• Many ethicsists believe that control groups are unethical because that group cannot benefit form the experimental drug • Race based control groups create another ethical dilemma because people of a certain race may not receive treatment • However, race based control groups are necessary when researching a condition that only affects that particular race

Considered to be an objective means of gathering test data because it eliminates bias, an ethical question still arises. Is the process of informed consent adequate when the patient does not know if they are receiving treatment or not.

The goal of the Human Genome Project is to provide a map of where each gene is located on the 23 pairs, or 46 chromosomes.

The ability to alter the basic structure of life to correct a malfunction is the goal of genetic engineering. Moral and ethical concerns are raised by critics who say that manipulation the human genetic code is akin to playing God.

• Researches claim that a major reason for developing cloning in animals is to permit the study of genetic development and genetic diseases. • Arguments against human cloning is the effect it might have on human dignity.If we control the creation of human beings, then we can eliminate the creation of imperfect human beings. • Three more oppositions to cloning are: - health risks from mutated genes - emotional risks - the risk of abusing technology • Also,since therapeutic cloning destroys a 4-d-ay-old embryo, many anti-abortionists are against it.

A needed gene is spliced onto the DNA of a body of cells to control the production of a particular substance. • This could cure some diseases but there are unanswered questions such as: - Should gene therapy be used to create healthier fetuses? - Should companies develop tests to predict mental illness? - Could gene therapies, designed to save lives, end up being a way to choose the traits we want our children to have?

• Stem cells can be used to treat Parkinson's disease, Alzheimer's, disease, stroke, and diabetes. • The controversy revolves around the moral implications of using human embryos to obtain stem cells. • Embryos are grown in the lab, in-vitro fertilization left overs and from abortions. • Congress has banned all federal funding of stem cell research • The FDA has little jurisdiction over embryonic research • States have widely opposing views • The ban on stem cell research was lifted in 2009 • Research using stem cells from sources other than embryos is less controversial. • Some fear there are dangers of starting a practice that is ethically questionable

Somatic cells that are genetically reprogrammed to differentiate differently

►Occurs when employees publicly report a potentially dangerous situation in their organization to authorities who can take corrective action. The employee must: • Exhaust all other channels for correcting the situation within the organization • Have documented evidence that would convince an impartial and reasonable observer. • Have a good reason to believe that by "blowing the whistle" and going public the necessary changes will be made to prevent harm and injury. ► Anonymous complaints can be made to reulatory agencies like the EPA or OSHA. ►The Occupational Safety and Health Act of 1970, the Solid Waste Disposal Act and the FDA prohibits retaliation against an employee who files a complaint with them. Federal workers are protected from losing their jobs. ►Whisteblowing is used as a last resort when all other methods for warning about a dangerous situation have failed.

• An estimated 50 million Americans are without healthcare • Illness has been linked to 50 percent of all personal bankruptcies in the U.S. Often the person starts out owning a home and having health insurance, but once they get sick and can no longer work, they lose their health insurance and then their homes. With out a law to protect them, they may be denied new insurance because of their preexisting condition. • Physicians no longer provide as much free care as they used to. • Medical office personnel must treat all patients with the same consideration for the patient's dignity no matter what their ability to pay. • Another cause of rising medical cost is the physicians need to practice defensive medicine to avoid potential lawsuits. • Rationing of medical resources to keep costs down but often makes patients unhappy

The House passed H.R. 3590 on March 21, 2010 and was approved by the Senate on December 24, 2009. Major components include: • A provision that allows individuals who already have healthcare coverage to retain their coverage if desired • A provision also applies to employers who currently offer coverage. • Patients who are not eligible under Medicare and Medicaid will be required to maintain minimum coverage beginning after 2013. There will be a fine for failing to retain coverage. • A tax credit and reduced cost sharing, on a sliding scale, for qualified individuals. • An expansion of Medicaid • The act does not require employers to provide healthcare coverage, However, if they do not, they may be liable for an additional tax. • Hospitals would be required to conduct periodic community health needs assessments.

predicting (without justification) that one step in a process will lead unavoidably to a second, generally undesirable step

Organs are given to patients who would benefit the most

All patients have an equal chance of receiving an organ.

Measures the medical need and medical benefit to determine organ allocation.