Ethics Flashcards

Question

End of life: | What do doctors legally have a duty to do if they want to place a DNACPR on medical notes?

Answer 1

Doctors now have a legal duty to (usually) consult with and inform patients if they want to place a DNACPR order on medical notes, the Court of Appeal in England ruled e.g the case of Mrs. Tracey with lung cancer who was involved in RTA- then was put on DNACPR It is inappropriate (and therefore not a requirement of article 8 ) to involve the patient in the process if the clinician considers that to do so is likely to cause her to suffer physical or psychological harm- but must be sufficient! The Ruling - breach of article 8 procedural obligation to involve Tracey before first notice completed- grant a declaration against trust that it violated Tracey;s article 8 right to respect for private life in failing to involve her in the process which led to the first notice.. Since a DNACPR decision is one which will potentially deprive the patient of life saving treatment, there should be a presumption in favour of patient involvement. There needs to be convincing reason not to involve patient

Answer 2

· Competent patients can issue advanced decisions giving directives as to which treatment they do not wish to get if they become incompetent at a later state · An advanced statement can include a statement to the effect that resuscitation should NOT be attempted This decision is LEGALLY binding (subject to some caveats)

Answer 3

· When incompetent, physicians must decide whether to issue a DNACPR order on the basis of best interest · Questions: Can it ever be in a patient's best interest not be resuscitated? Is this is the same as saying that it is the patients' best interest to die?

Answer 4

Recent case of incapacity 1. In order to make a fully informed decision, where it is both practicable and appropriate they must discuss the patients' situation and the decision with those close to patient (subject to any confidentiality restrictions expressed if, and when the patient has capacity) 2. Where both practicable and appropriate, they should delay contacting those close to patient to do this. Of note, in the recent judgement it was stated by the judge that 'a telephone call at 3:00am may be less than convenient or desirable that a meeting in working hours, but that is not the same as whether it is practicable'

Answer 5

Primary benefit: is chance of extending life however survival rates are low CPR: also invasive and includes the following risks: • Rib/sternal fractures • Hepatic and splenic ruptures • Prolonged ITU care (including ventilation and dialysis)n • Brain damage following hypoxia • Traumatic death

Answer 6

If a DNACPR order are to be used the following points must be adhered to: • Effective recording of DNACPR decision in a form that is recognized by all those involved in giving care • Effective communication and explanation of DNACPR decisions (where appropriate) with the patient • Effective communication and explanation of DNACPR decisions (where appropriate and with due respect for confidentiality) w/ patient's family, friends etc • Effective communication of DNACPR decisions b/w healthcare workers and organizations involved with the patient Practical problems: ○ Awareness and understanding of guidelines is poor ○ Many DNACPR orders are made w/o adequate communication to patients (or family) ○ Health professionals are often unaware that DNACPR orders apply to CPR only ○ Discussions relating to DNACPR orders are often not adequately documents in notes ○ Senior health care professionals should be making decision regarding DNACPR but not always available when decision must be made There are various polices on this in each hospital!

Answer 7

• Oral or written statement made by a competent individual about how they would like to be treated in the future, if they happen to fall ill and are no longer competent to make decisions about their health care • Advanced decisions= advanced statements= advanced directives= living wills • Why are they advocated and why are they opposed? ○ + Extend patient autonomy ○ + improve patient welfare b/c patient will be less anxious about the possibility of unwanted treatments - What healthy ppl think they will want when they are ill is not what they want when they are ill - Not specific enough - People may change their mind but not communicate - Problems of personal identity Legality of them: ○ Mental health capacity act 2005: advanced decisions are legally binding and must be respected (subject to important caveats) ○ Failure to adhere to patients wishes as expressed in a valid advanced decision may lead to a charge of assault or battery

Answer 8

Lasting power of attorney: capability to make decisions as the patient would, it is assumed they would understand the patient’s wishes. If the last power of attorney starts to make decisions which do not appear to be in the patient interest then a legal investigation and challenge would be justified (e.g. they are eager to withdraw potentially beneficial treatment in the chance of getting inheritance, sometimes things can seem wrong and should be explored)

Answer 9

* Before losing capacity if the individual annuls the advanced directive * There is the evidence that the patient has changed his mind regarding the advanced directive * The advanced directive does not refer specifically to the situation at hand * There are reasonable grounds for thinking that circumstances now exist, where the patient did not anticipate, and which would have affected the patients decisions had he anticipated them * The patient has created a lasting power of attorney since the advanced directive was written

Answer 10

· Continued to be poorly understood by medical professional (only 49% of GPs knew directives had a legal force if porperly drafted) · Policies exist in increasing numbers of trusts, but are people aware of them · Polices are meaningless without sufficient training on advanced directives for all staff

Answer 11

Historical cases of research that has been carried out with little ethics e.g Nazi's research, willbowbrook hepatitis experiments (60's- in children in care given hepatitis), Pavlov's conditioning experiments Lead to introduction of rules and regulations Argument now is that there are too many rules and this makes research harder to carry out

Answer 12

Numerberg code (1947)/Declaration of Helsinki (1964)/GMC guidelines that apply to research Even though we had these declarations/codes we still had this Self regulation of the professionals were not good

Answer 13

Legislation: ○ DPA (data protection act) 2018/HTA (human tissue act) 2004/ MCA-mental capacity act (need consent) 2005 ○ Medicine for human use (Clinical trails) regulations 2004 Research is regulated in Criminal law and common law ○ Cannot administer 'noxious substance' unless this part of the 'properly approved research' with proper consent Negligence law in relation to consent is applied to research

Answer 14

· Scientific validity ○ Is the research question important? ○ Is the research relevant? ○ Is the methodology appropriate? ○ Why is conducting research that is not scientifically valid (and which cannot be published) unethical It Exposes people to risk for no good reason It Involves spending resources that could have been used elsewhere

Answer 15

MUST BE VOLUNTARY, INFORMED, CAPACITY TO BE VALID Must be voluntary and informed by someone with capacity (not required if data anonymised) Note that this is more stringent than in clinical practice a signed consent form is NOT sufficient Threats to voluntariness: - When payment is made to participate - Those with a terminal illness i.e may feel grateful or sense of duty, fear or rejection/withdrawal of care, a misconception perception that participation may be bringing therapeutic treatment - Healthcare students - Incentive issues- should research pay money? Giving up their time, would get participants, but it may mean that patients are more likely to do a test without reading the consent- should you only pay expenses or more than expenses? (expenses- is not really controversial), may give disproportional population

Answer 16

MUST BE VOLUNTARY, INFORMED, CAPACITY TO BE VALID Must be voluntary and informed by someone with capacity (not required if data anonymised) Note that this is more stringent than in clinical practice a signed consent form is NOT sufficient Threats to informed: - Perhaps information overload (more than is given to patients) - Needs to be in a form that participants will understand - Difficult to explain some concepts like randomisation - May also not understand the burden

Answer 17

MUST BE VOLUNTARY, INFORMED, CAPACITY TO BE VALID Must be voluntary and informed by someone with capacity (not required if data anonymised) Note that this is more stringent than in clinical practice a signed consent form is NOT sufficient Threats to capacity: - Is research in the best interest of the patient and if not how can we justify it? i.e regulations have meant that it is really difficult to do research on people like AD, or mental health individuals so most research is on healthy young people - If there is no capacity MHU (CT) regulations require (2004) That consent must be obtained from a 'legal representative' (e.g an adult close relative' That research must be likely to benefit the patient or other people who suffer from the same condition That efforts are made to gain consent and that any sign of dissent should be taken seriously - Consent vs. assent Consent is legally valid- legally valid Assent is an agreement but no legal force If you have participants who do not have legal capacity - they may get consent, but if lack assent then there is ? Of whether should do it E.g Alzheimer's patient got consent but got distressed and lacked assent- therefore doing the research was unethical

Answer 18

Participants have a legal right to have their confidentiality protected by researchers The data protection act 1998: requires all data (especially all sensitive data) be adequately protected

Answer 19

In general in research the benefit must be assessed to outweigh the risk even if the patient has agreed to participate. but how much risk is acceptable is debatable Benefits are usually public Risks are usually to the individuals

Answer 20

For research to take place there needs to be genuine uncertainty that the treatment will have a positive effect But sometimes we are not after this we may want to examine this e.g more tolerable treatment Trials are often stopped once benefit is found as equipoise is no longer met.

Answer 21

If a treatment is available can a placebo ever be justified. | They are accepted when there is no empirical treatment or the treatment given does not have therapeutic effects

Answer 22

Given the vast majority of us benefit from medical research, do we have a moral duty to volunteer for research? If we fail to do so are we not guilty of free-riding on other peoples altruism? If we do not should be have lower priority when it comes to getting a treatment? Principle of reciprocity

Answer 23

· National research ethics service (NRES) part of the NHS health research authority (HRA)- triages research proposals. All proposals needing review are examined by a REC · RECs: research ethic committees ○ Are local (LREC) or multi centre (MREC) ○ Have 12-18 members (membership must be balanced and include lay people) Offer ethical review but do not give legal advice

Answer 24

· Encapsulates a whole range of issues including: ○ Pressure of publish or perish culture- Various retracted papers ○ Biased trails and biased publications ○ Potentially problematic pharmaceutical involvement and perverse incentives Should we have journals for non significant results? Should we have biased trails?

Answer 25

· All drugs licensed for use in Britain's have been tested on animals · The number of experiments has been declining (70s-90s) but is now increasing again · 100 million animals used worldwide · 52% in medicine or veterinary research, 24% for fundamental scientific research · Rodents eg. Rats are most commonly used 84% Research with great apes, gorillas, chimps, orangutans and bonobos were banned in 1998 · If it is morally unacceptable to perform certain research on humans, why is it acceptable to perform the same research on animals? -Moral status and superiority? Consent What is the criterion which distinguishes animals from humans? Is this criterion a morally valid one?

Answer 26

· Replacement: non animal methods to be used where possible · Reduction: the number of animals used should be kept to a minimum Refinement: smallest amount of pain and distress should be caused to animals and should be caused only for justifiable purpose

Answer 27

· The animals (scientific procedures) act 1986: · Regulates the use of all 'protected' laboratory animals where research procedures might cause: pain, suffering, distress, or lasting harm · Provides a special protection for primates, cats, dogs, horses · Requires that there be an ethics committee in institutions Uk has the tightest system of regulation in world- house of lords select committee (2002) Under the 1986 act: still legal for animal in lab to be unnaturally caged for entire life, poisoned, deprived of food, water, or sleep, applied with skin and eye irritants, subjected to psychological stress, deliberately infected with diseases such as cancers and AIDs, brain damaged, paralysed, surgically mutilated, irradiated, burned, gasses, force fed, electrocuted, killed

Answer 28

92% are diagnosed this still means that 1/12 in the UK do not known they are have the virus 98% of those with HIV in UK are on treatment 97% of those are treatment are virally suppressed- cannot pass the virus on · 90% of people accessing HIV care have acquire it through sexual transmission % of people accessing HIV care who acquired HIV through heterosexual sex is roughly the same as the proportion of people who acquired HIV through sex between men AGE- Cohort is growing older therefore going to have more health condition- prone to things like oestoporosis, cancers therefore be proactive to take care of health AE in the St Georges- picked up when doing blood tests- this is OPT OUT U= U undetectable undetectable

Answer 29

``` · Reasons/benefits · Identify/quantify risks · Seroconversion period · Capacity to deal with result · Expectation of results · Support networks · How/when results given ```

Answer 30

Health advisors: used to be contact tracing then counselling PARTNER NOTIFICATION, counselling and sexual health information If they tell you they can't- you give the health advisor permission they will tell them · Very rare to break confidentiality If working as GP patient not on treatment, viral is high- wife comes to service, and do not condoms and not told them- may have duty of care If the person were only patient- would try and work with them to get them to tell - Legal cases - explain treatment - Most people will notify - Partner on PREP or them on treatment is way to prevent Some patients do not want their GP involvement- they must be informed that the GP may get information online • Other specialities if referred may see it and accidentally write to their GP Address why you do not want them to find out? - maybe try to say something like why do you not want to tell? What would you tell a friend?

Answer 31

* If a court requests the information. * In some cases, if the police request the information. * If a doctor believes that someone with HIV is putting the life of another person in danger, the doctor may have the right to disclose information to the person in danger. This can only be as a last resort, and after telling the person with HIV that confidentiality will be broken.

Answer 32

PrEP- taken on daily basis would not get HIV - and have unprotected sex Often taken privately online Long waiting list Large increase of syphilis and gonorrhoea Now may be injectable given once a month Non adherence is strong: stigma, mental health problems, community issues

Answer 33

Transition groups are hard - legal right to remain, under psychiatry, homeless, mental health issues, learning difficulties ALL HIV treatment is free CHEM SEX is becoming more prevalent

Answer 34

Repeated negative test/investigations Low risk sexual history Convert/guilt inducing sexual activity High levels of anxiety/obsessive behaviour

Answer 35

Possibility that positive Talk about protecting baby Stigma Relationship Window periods Act fast V important she starts rx IF positive Explain the fears - and tell her about confidentiality If she was tested- would not have to tell husband immediately If she does not want to be test- special case study -if there were other issues - we are worried we have to discuss with safe guarding and legal team Work with individual to tell them how to disclose Always think about domestic abuse

Answer 36

· Fear of rejection · Fear of being judged- sexually acquired/vertical- therefore disclosing mother's status · Fear of being ostracised by friends/community/family · Personality type- a person who has in the past kept personal issues private · Lack of acceptance of one's own HIV status · Fear of loss of control of own private information · Concern confidentiality may be breached · Stigma- undesirable difference that undermines a personal identify- internalised Explain how it is manageable and live normal life Talking about HIV: is a process, can improve relationships with family, partners, peers, healthcare professionals, less secrecy, not living in fear- taking control, increased aherence, better mental and physical health NOT TELLING- may feel safer but it is potentially more damaging: social and physical isolation, risk of transmission, poor adherence, stress, anxiety

Answer 37

``` Giving HIV+ result: · Be prepared · Give immediately · Allow space · Do not make assumptions · Clarify understanding · Avoid information overload · Assess self harm risk · Arrange follow up support ``` WHAT will reaction be? - SHOCK, anger, fear, denial, guilt, fatalism, relief, acceptance, grief Loss of: control/independence, productivity/parenthood, health/life, relationships/libido, identity/meanings, hopes/dreams They may think they can never have sex again, or never have children- it is about addressing this fear

Answer 38

1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance

Answer 39

* Other conditions can be passed on - should have regular screen * Is he on regular medication? If his viral load is undetectable * GAY MEN: have higher risk of mental health risk - consider his mental health and emotional issues Ongoing counselling: risk reduction, partner notification, social/legal issues, relationships, treatment, acceptance

Answer 40

Utility – poor, sick people have a greater need for healthcare and therefore should have more access Rights - Everyone has the right to basic health care and so there is a duty to provide this Justice – The wealthy of the world harm the poor and therefore have a duty to provide healthcare to rectify this harm

Answer 41

80%- restrictions on people accessing medicines- essential medicines 20% 35% and 0.5% 82 and 41- even in the UK- dorset 82 and glasgow in 70s- social determinants of health 90% The same number as in the whole of california 2%

Answer 42

Do we have a duty to help or it is a case of charity? If something is a duty is not options- legally and morally In providing health we have a duty - e.g refugee, migrant healthcare Who are we exactly? US VS. THEM - reflects a power dynamic- sometimes good intentions lead to bad outcome

Answer 43

* 10% of the world expenditure on health is devoted to the problems that primarily effect 90% of the world. * Most people die of diseases for which we already have treatment – they just do not have access to this treatment * Most new drugs are aimed at those that need medications the least

Answer 44

' everyone has the right to a standard of living adequate for the health and wellbeing of himself and of his family, including food, clothing, housing and medical care, and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age, or the other lack of livelihood in circumstances beyond his control'

Answer 45

This is pogge's challenge: If you cause harm to someone you have a greater duty to rectify the harm which was caused. The global economic system harms the poor (e.g via unjust trade tariffs and internal subsidies) and therefore 'we' have an obligation to provide compensation - that is how he extends that example even if was it an accident

Answer 46

• The WHO defines essential medicines as those that satisfy the priority health needs of the population • The list of essential drugs is updated every 2 years 375 medicines - each country has their own one * 69% have access to affordable essential drugs * 1.9 billion lack access to essential drugs * There are complications e.g poverty and social factors to get these

Answer 47

• Bio tech, pharmaceutical, and medical devices, companies are the major players on the global markets. This is partly because in the developed world- about 10% of GDP is spent on healthcare (other countries spend only 2%)- Many of these companies have now merged over the last few decades to create giant multi national companies (big pharma) e.g Johnson and Johnson

Answer 48

* A patent is a set of exclusive rights granted by a state to an investor for a limited period to time * TRIPS (Trade related aspects of intellectual property rights) agreement (applies to drugs after 1989) gives a 20 year protection- this is increasing the 10/90 gap Patents prevents rival companies from producing generic companies- this encourages research/development investment and helps to maximise profits. This also means that important drugs cannot be made cheaply for years. - so even though they are invented people cannot afford them

Answer 49

* Do pharmaceutical companies have a special responsibility? Should they ensure that profits reach the people that need them * Do they have an ethical obligation to increase R&D spending on 'neglected diseases'? ``` Arguments for - they have a lot of money and resource - Their whole aim is to treat disease Against - They do their ‘bit’ already - What about other organisations that also cause damage e.g oil companies ```

Answer 50

Bio-pharm companies are in competition with each other. It would be financial suicide for a company to concentrate on poor world diseases unless its competitors were to do the same. Thus some kind of general agreement is needed. * Encourage biopharm companies to make voluntary agreements to increase availability of drugs * Use taxation to encourage a change * Use legislation to force bio-pharm to research and produce different kinds of drugs * Use government market force to bargain with companies * Poggee's solution (health impact fund)

Answer 51

• Do we have a duty to change the balance or is it a matter of charity? • If we have a duty, what is the basis of the obligation (utilitarianism or rights or justice?)- justify the premises- THIS IS IMPORTANT FOR EXAM Do the bio-pharmaceutical companies have a special duty?- this is currently absent

Ethics Flashcards

(75 cards)