Consent and Assent
The doctrine of informed consent, which requires that patients with capacity be given the relevant diagnostic and prognostic information and then retain the right to grant or withhold consent for any treatment, is derived from this ethics principle.
What is autonomy?
These are the four core principles of modern biomedical ethics
Respect for autonomy, beneficence, nonmaleficence, and justice
An implicit or explicit promise by the physician to not divulge a patient’s personal information without his or her permission
What is confidentiality?
According to the AMA Code of Ethics, what is the correct way to handle medical error?
Disclose medical errors if they have occurred in the patient’s care
A chief medical officer (CMO) discovers that a physician at the hospital is receiving compensation for recommending a medical device to his patients. The CMO informs the physician about the institution’s conflict of interest policies. Of the following, the BEST next step for the CMO is to
A. Require creation of a consulting agreement that stipulates that the physician must disclose the financial arrangement to his patients
B. Require creation of a document that discloses the financial relationship between the physician and the company to his employer
C. Require the physician and his staff to perform remedial training on the institution’s relevant policies
D. Terminate the physician from practice immediately for unethical behavior
A- Require creation of a consulting agreement that stipulates that the physician must disclose the financial arrangement to his patients.
- Receiving compensation for recommending a medical device to patients is a COI because medical judgment could be influenced by secondary financial gain.
- The Institute of Medicine in 2009 defined conflict of interest as “a set of circumstances that create a risk that professional judgment or actions regarding a primary interest will be unduly influenced by a secondary interest.”
- Examples of conflict of interest include acceptance of gifts from industry (eg, meals and drug samples), writing for or promoting an industrial product, and financial interest in a medical product that the physician prescribes, uses, or recommends.
A developmentally appropriate child’s willingness or preference to participate in a proposed therapy, procedure, or research OR recognizes the child’s developing ability to participate in the decision-making process
What is assent?
This historical event inspired the creation of the Universal Declaration of Human Rights by the United Nations in 1948?
The Holocaust
Confidentiality in the care of an adolescent patients involves which one of the central principles of biomedical ethics?
Respect for autonomy
*Roughly* define what an apology law is
A law intended to encourage formal acknowledgment of a medical error while simultaneously insulating such statements from use in subsequent malpractice litigation
A 9-year-old girl with history of prematurity at 23 weeks, HIE with spastic quadriplegia and chronic respiratory failure requiring trach/vent is admitted to the hospital after feeding intolerance requiring IV hydration and medications. She is now at her baseline- she is awake, in no distress, does not interact with no spontaneous respiratory effort. She does not interact with her environment, has severe spasticity, and minimal response to painful stimulation except for increased tone posturing. She has been requiring hospitalization more frequently for minor illnesses and does not return to her prior baseline after each hospitalization. On day of discharge, parents ask to discuss end-of-life options. The girl’s parents believe their daughter is suffering and ask about end-of-life options, specifically withdrawal of support or limitation of curative medical care in the event of another acute illness requiring in-patient hospital care.
Of the following, the BEST next option to offer this girl’s family is referral to a(n)
A. Inpatient social worker for approval to continue elective inpatient admission for planned withdrawal of technological support
B. Institutional ethics committee for review of ethics of withdrawal
C. Local hospice for palliative care and establishment of advance directives
D. Regional organ procurement organization
C. Local hospice for palliative care and establishment of advance directives
- Although she appears to be in a persistent vegetative state, she does not meet the clinical criteria for brain death; her decorticate posturing suggests intact brainstem reflexes, and thus determination of brain death cannot be made.
- Given that the girl’s parents perceive her to be suffering and wish to limit life prolonging interventions, the best option is to refer the girl and her family to hospice and palliative care and establish advance directives including a do not attempt resuscitation order and limitation of care.
- Pediatric euthanasia is currently illegal in the United States. However, withdrawal of life-sustaining technological support may take place under the direction of experts in end-of-life care, specifically those with hospice or palliative care training. The active withdrawal of life-sustaining technology can be done ethically when caregiver goals are clearly established and made in the best interest of the child. This action is ethically comparable to not initiating the same therapy in children who have underlying life-limiting illnesses.
- Finally, although withdrawal of technological support could be facilitated by an elective inpatient admission, engagement with hospice or palliative care clinicians would be preferred prior to this
The term use to describe parents or other surrogate decision makers allowing for diagnostic procedures and medical treatment for their children
What is informed permission?
Statutory support for access to confidential care for reproductive health in adolescents is ethically based in the concern about limiting transmission of sexually transmitted disease and unwanted pregnancy, not a belief that adolescents should be making independent decisions about sexual and reproductive health. This example supports which ethical framework?
Public health ethics
The legal obligation to report abuse
What is mandated reporting?
Any adverse condition in a patient that is the result of a treatment error by a physician, health care professional, or member of the medical team.
What is iatrogenesis?
There are four elements of disclosure to discuss when obtaining informed consent. List all four.
•Indications
•Benefits
•Risks
•Alternatives
Having the ability to understand a proposed therapy or procedure, to understand its risks, benefits and alternatives, and to be able to then arrive at a decision based on consideration of these factors in light of one’s values and life plans.
What is capacity?
Give a common example of communitarian ethics related to prenatal screening
HIV screening, syphilis screening in pregnancy (limiting the spread of communicable diseases)
Name three situations we are required to report as physician mandated reporters?
Abuse, neglect, harassment, or discrimination
Patients that have been harmed deserve an apology. For such an apology to be ethically significant, it needs to be (fill in the blank)
1. Be ______ about its content, recognizing what went wrong and how it happened
2. Express the ______ that it caused in all involved and the regrets that followed
3. Include any _______ that can be offered, making sure the patient does not experience abandonment of care.
1. Clear (or synonym)
2. (Heartfelt) sorrow (or synonym)
3. Amends or repair (or synonym)
In difficult ethical situations, a useful guideline for all pediatricians, has been provided by the AAP Committee on Bioethics: “All children are entitled to effective medical treatment that is likely to prevent _______, or _________, or ______.” Fill in at least 2 blanks.
All children are entitled to effective medical treatment that is likely to prevent serious harm, or suffering, or death.”
Describe one way pediatricians can help foster a practice of obtaining assent from a child?
1. Helping the child achieve a developmentally appropriate awareness of the condition
2. Telling the child what to expect with tests and treatment
3. Assessing the child’s understanding of the situation
4. Soliciting an expression of the child’s willingness to accept the proposed care.
*Roughly* define communitarian ethics
Placing a value on the health of the community that can override autonomy
Name four reasons to break confidentiality for an adolescent patient?
1&2. Suspected physical or sexual abuse
3&4. Suspected risk of suicide or homicide
5. Public health laws require reporting certain diseases, e.g., Chlamydia, gonorrhea, TB, HIV
A patient’s right to know about iatrogenic events trumps the doctor’s self- interest and any desire for discretion and privacy. Name one ethical principles which supports this statement?
What is autonomy, respect, truth-telling
The term to describe when deciding on behalf of an incompetent patient, decisions are ideally based on the patient’s previously expressed wishes or what the surrogate decision maker believes the patient would have wanted.
What is substituted judgment?