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Flashcards in Clinical EthicsQuestions Deck (10)
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1
Q

Pros and Cons of Accreditation (pro-CECA, Smith, Con, Bishop Engelhardt)

A

Pro:

  1. CECA Report to the Board of Directors ASBH - Only 5% individuals performing CEC completed fellowship or graduate degree program
  2. Smith: We need training programs, credentialing by hospitals, a code of ethics, and a certification.
  3. Quality control, Easier to regulate and control, Establish a market, Bare minimum standard

Con:

  1. Bishop, Fanning, Bliton: we claim that CEC is a kind of moral inquiry irreducible to the procedural models; pluralism of practice and the heterogeneity of backgrounds of providers strengthen CEC and the idea of the credentialed ethics expert closes rather than opens space for moral deliberation.
  2. Engelhardt: Credentialing will likely increase chance that pts, their families, and physicians will be mislead by the description of ethics consultants as ethics those of offering normative ethical guidance
  3. Lack sufficient consensus, No accurate measures of testing knowledge, Cost
2
Q

Pros and Cons of Ethics Expert

A

Con:
Scofield: Not a profession, not moral experts, not ethical, there cannot be expert ethicists, they are power hungry
Pro:
1. Fletcher: not moral expertise, but educator and mediator, ethics expert has knowledge and skills sets
2. Jonsen: “expert opinion” is shaped by reflective encounter with many similar cases and by dialogue with peers
3. Lilje: CEC not a policemen but consultants that do not claim objectivity to moral truth, but try to educate
4. Ross: CEC are outsiders not power hungry
5. Agich: CEC are an authority no in authority; they have epistemic and competence authority
6. Rasmussen: CEC give non-normatively binding recommendations, not singular moral truth, ethics expert vs. Moral expert

3
Q

What are the ways in which they render better recommendations than laypeople
Rassmussen:

A
  1. CECs better able to identify clearly wrong answers than laypeople
  2. reason from a given moral premise to its implications, based on context
  3. they are better than laypeople at identifying the full range of moral values and stakeholders involved in a situation
  4. they may be better than laypeople at creative solutions to clinical dilemmas
4
Q

Describe 4 models of how to do ethical analysis in CEC.

A
  1. Jonsen: ethical work up’ which is modeled after what many physicians are trained to do in a ‘clinical work up’:
    4 Elements to analyze:
  2. Medical indications
  3. Patient preferences
  4. Quality of life
  5. Contextual features (social, economic, legal, administrative)
  6. Dubois “A framework for Analyzing Ethics cases”
    SFNO:
    Stakeholders: Who has a stake in the decisions being made, that is, who will be significantly affected by the decision made?
    Facts: What factual issues might generate disagreement? What facts are relevant to a solution?
    Norms What ethical principals, norms, or values are at stake? Which do you think are relevant, and which might appear to conflict or generate disagreement?
    Options: What actions or policies deserve serious consideration? If the ethical ideal is not possible what compromise solutions are most attractive?
  7. VA Mode:
    Steps: CASES
    1. Clarify: type consult, information, expectations, ethics question
    2. Assemble Relevant Information: types info needed, sources, summarize
    3. Synthesize the Information: meeting? Ethical analysis, id decision maker, facilitate moral deliberation
    4. Explain Synthesis: to participants, provide additional resources, document
    5. Support the consultation process: follow up, evaluate, adjust process, id underlying systems issues
  8. Miller: general moral principles are unsuitable for practical text, adopts method John Dewey
    Steps:
    1. Recognition of a problematic situation prompts empirical inquiry to explain the causes of the problem by observation or diagnostic testing
    2. Hypothetical ideas for resolving
    3. Plan of action
    4. Observed results evaluated
5
Q

What are the problems with cultural competency training and what are some solutions?

A
  1. Kleinman, Benson: Problem: No one can define this term precisely enough to operationalize it in clinical training and best practices.
    Solution: We should instead train physicians in Ethnography
  2. Gregg, Saha: Problem: mismatch between motivation behind design of cross-cultural education programs and the motivation behind their current application creates problems
    Solution: Cross-cultural curricula in medical setting needs to stress 5 central concepts:
    1. Culture matters in health care
    2. Cultural competence is not a panacea for health disparities
    3. Culture, race, and ethnicity are distinct concepts
    4. Culture is mutable and multiply
    5. Finally, context is critical
6
Q

Name the alternative models of autonomy:

A
  1. Quill, Brody-Enhanced Autonomy: encourages pts and physicians to actively exchange ideas, explicitly negotiate differences, and share power and influence to serve the pt’s best interests (vs. Independent choice model)
    1. Sulmasy-Natural law autonomy: against pure autonomist justification - human beings do not define their well-being for themselves by the mere act of choosing, not the case that any and all interference in the free choice of a patient is a transgression against the good
    2. Kuczewski - interpretive model: I am advocating that we view the development of pt autonomy as the goal of the process of informed consent rather than as something given or in need of restoration (do this through family)
    3. Lantos-Persuasive - Most treatment decisions are through shared decision making and uses the standard of care (positive right and duty on behalf of the physician
7
Q

Name the alternative models of surrogate decision-making

A
  1. Brock-we rarely acknowledge the family unit in opposition to individual autonomy; most of us use our families to make decisions
    1. Berger, et al - Making surrogates decisions is far more complex, dynamic, and nuanced than is generally understood. Norms for surrogacy should fully account for a robust range of pts concerns and interests in order to improve the quality of surrogates’ decision making. Sometimes we need to overturn the hierarchy of known wishes, sub. Judgment, best interest ex. Horrible pain, son coming home from Iraq)
    2. Post et al - narrative-relational model:Physicians can only help a proxy or surrogate make wise decisions if they have a better understanding of the substitute decision-maker’s ethical responsibilities.
    3. Dresser, Robertson-Alternative approach ask whether treatment actually serves incompetent pt’s existing interests. It doesn’t matter what the old self said, we are too behold to past requests, as quality of life changes people change with it.
    4. Emmanuel: community control regarding the care of incompetent pts
8
Q

Name the Alternative models of pediatric care

A
  1. AAP -emphasizes that physicians and parents should give great weight to clearly expressed views of child patients regarding LSMT, regardless of the legal particulars
    1. Weir, Peters: advanced directives ought to be used by adolescents to address problem of disputes with parents
    2. Ross: There are morally relevant differences between competent children and adults which justify different treatment with respect to autonomy. A competent child’s short term autonomy can be morally overridden to promote life time autonomy
9
Q

What are baby doe laws and why do some find them ineffective?

A

Baby Does Law (1984) The Baby Doe Law mandates that states receiving federal money for child abuse programs develop procedures to report medical neglect, which the law defines as the withholding of treatment unless a baby is irreversibly comatose or the treatment is “virtually futile” in terms of the newborn’s survival. Assessments of a child’s quality of life are not valid reasons for withholding medical care.
Coppleman: argued that words ‘futile’ ‘virtually futile’ ‘appropriate’ ‘inhumane,’ and ‘reasonable medical judgment’ are taken out of context by the Committee on Bioethics and the AAP leadership supporting the Baby Doe rules. he Baby Doe rules are incompatible with other AAP recommendations about using the best interest standard for decision-making for children and about compassionate and individualized end-of-life care

10
Q

Describe the debates about futility:

A
  1. Schneiderman et al. - a futile action is one that cannot achieve the goal of the action, no matter how often repeated. In our proposal of futility, we treat quantitative (Last 100 cases past like cases) and qualitative (Any treatment that merely preserves permanent unconsciousness or that fails to end total dependence on intensive medical care should be regarded as non-beneficial and, therefore, futile ) aspects as independent thresholds, as minimal cutoff levels, either of which frees the physician from the obligation to offer treatment. medical profession has articulated appropriate general goals; treatments that cannot succeed in achieving medicine’s goals are futile
  2. Brody: ‘futility cases’ are those in which it is reasonably certain that a given intervention ‘will not work’ when applied for the purpose of attaining clinical goal
  3. Trotter: 1. Goal, 2. Action aims at achieving goal 3. Virtual certainty action will fail; the real debates about goals and virtual certainty
  4. Hardwig- futility problems are helped by spiritual care to families which goes beyond other solutions which involve unilateral decisions made by physicians and hospital futility policies