Philosophy 2

Question 1

supports autonomy (ADC) (autonomy is the abcs)

Answer 1

Determining the patient’s ability to understand the issues, consider the consequences of different options, and communicate these thoughts to professionals is necessary

Question 2

personhood (babies to comatose are persons)

Answer 2

newborns, cognitive impairment, comatose, children

Question 3

Competence (in legal terms) (your dad)

Answer 3

Competence is a legal presumption that a person who has reached the age of majority has the requisite cognition and judgment to negotiate legal tasks, such as entering into a contract, making a will, or standing for trial.

Question 4

decisional capacity (in medicine)

Answer 4

clinical context it is customary to refer to the patient’s decisional capacity, a clinical determination of the ability to make decisions about treatment or health care

Question 5

Elements of Decisional Capacity (DPT BRD) decision to dip bird - this is basically informed consent

Answer 5

Decisional capacity refers to the patient’s ability to perform a set of cognitive tasks, including • • • • • understanding and pro­cessing information about diagnosis, prognosis, and treatment options; weighing the relative benefits, burdens, and risks of the therapeutic options; applying a set of values to the analysis; arriving at a decision that is consistent over time;

Question 6

Capacity can be seen as an index of a person’s…

Answer 6

ability to exercise autonomy by making decisions that reflect personal preferences, values, and judgments at a given time.

Question 7

Having capacity enables but does not obligate patients to…

Answer 7

to act in­de­pen­dently. Despite our good intentions, we cannot force people who are unwilling to exercise their capacity for self-­ determination to do so.

Question 8

delegated autonomy - assisted autonomy

Answer 8

These patients often entrust to others the authority to make decisions on their behalf

Question 9

Capacity is not global, but…

Answer 9

decision-­ specific, referring to the ability to make par­tic­u­lar decisions. ie - can decide what to have for lunch, but not specifics about surgery

Question 10

Just as capacity is not global in its application to all decisions, it is not always…

Answer 10

constant. Elderly patients and sundowning.

Question 11

The fact is, we only question the capacity of people who

Answer 11

not agree with us.

Question 12

mini mental status exam (MMSE) - pros and cons

Answer 12

good for “orientation of the subject to person, place, and time, attention span, immediate recall, short-­ term and long-­ term memory, ability to perform simple calculations, and language skills” (Lo 2000, pp. 84– 85), it is less helpful in assessing an individual’s ability to grasp situations, weigh alternatives, and appreciate consequences— the skills required for capable decision making

Question 13

Three standards are customarily invoked in attempting to make decisions as the patient would have made them (p (prior) is)

Answer 13

prior explicit articulation, substituted judgement - inferring, best interest

Question 14

most problematic decision making standard (hardest for the substitute)

Answer 14

substituted judgement most problematic because, as commonly formulated, it requires the intellectually convoluted task of imagining what the now-­incapacitated patient would choose if she were ­ magically capable and in possession of all the relevant clinical facts.

Question 15

how to use decision making standard (decisions must be authentic bc life is cohesive) AND what is it called

Answer 15

Apply Authenticity, which expresses the value of having one’s life be a coherent narrative, and surrogate decisions guided by this value seek to maintain the coherence of the patient’s life through the decisions that are made on her behalf, rather than to honor her hypothetical choices

Question 16

advanced directives (disease is advancing) use by whom?

Answer 16

used for the formerly capacitated, ie dementia

Question 17

2 types of advanced directives (instructions for the appointment)

Answer 17

instruction ­directives, also known as living wills, and appointment directives, also known as health care proxies or powers of attorney for health care.

Question 18

hybrid advance directive, Five Wishes (5 hybrids decide my treatment, comfort, treat me, and loved ones)

Answer 18

provides the opportunity to communicate decisions about (1) the person I want to make care decisions for me when I can’t; (2) the kind of medical treatment I want or don’t want; (3) how comfortable I want to be; (4) how I want people to treat me; and (5) what I want my loved ones to know.

Question 19

Without the patient’s explicit instructions in an advance directive, health care decisions made by surrogates have traditionally been based on the remaining two decision- (BS - is this judgement in the best interest?)

Answer 19

making standards— either ­substituted judgment (when the patient’s wishes can be inferred) or the best interest standard

Question 20

EDMM - steps (FEPACCD) EDMM is fee packed

Answer 20

1) gather the facts
2) determine the ethical issues
3) state the principles which have a Bearing on the Case
4) List the Alternatives
5) Compare the Alternatives with the Principles
6) Consider the Consequences
7) Make a Decision
8) glossary

Question 21

EDMM - ethical issues compete

Answer 21

“Ethical issues are stated in terms of legitimate competing interests or goods. These competing interests are
what actually create an ethical dilemma. The issues should be presented in an X versus Y format in order to
reflect the competing interest in a particular dilemma”

Question 22

EDMM - state the principles

Answer 22

In bullet point fashion, list the ethical principles involved in the case. Such principles include things like:
professional codes of conduct, constitutional principles, legal principles, commonly accepted cultural
principles, natural law principles, or religious principles. The principles should be listed in order of their
ethical weight in the given case, e.g. P1, P2, P3, P4

Question 23

EDMM - Consider the Consequences

Answer 23

“Both positive and negative consequences should be considered. They should be informally weighted since
some positive consequences are more beneficial than others, and some negative consequences are more
detrimental than others” (Rae, p. 106). You might list the alternatives with their consequences in the order of
informal weight, e.g. A2→ C2 weightier than A3→C3

Question 24

EDMM - make a decision

Answer 24

“Deliberation cannot continue indefinitely. At some point, you must make a decision. Realize, too, that
ethical dilemmas often have no easy and painless solutions. Frequently, the decision that is made is one that
involves the least number of problems of negative consequences, not one that is devoid of them” (

Question 25

principles of autonomy (RI DC) autonomy is redic (think about signing paper at doc office)

Answer 25

1) Informed Consent 2) Disclosure of Medical Information 3) Confidentiality 4) Right to Refuse Treatment

Question 26

Four Main principles in medical ethics (the big ones - AJNB)

Answer 26

1) Autonomy (self-law/self-determination) 2) Justice (fairness/make-right; “doing and pursuing the good”) 3) Nonmaleficence (do no harm/not harming) 4) Beneficence (benefitng)

Question 27

2 components of informed consent (doctor do job and patient understood)

Answer 27

1) doctor's disclosure of medical information to the patient 2) competent patient

Question 28

informed consent - doctor's disclosure (DPAR BR) what you didn't get for your mom - (disclosure is a dapper bro)

Answer 28

diagnosis, prognosis, available and alternative treatments, and the risks, benefits, and consequences of having or refusing treatment.

Question 29

informed consent - competent patient (was I competent)

Answer 29

A patient who understands the nature of his or her condition and the consequences of accepting or refusing an intervention for it. If a patient thinks or believes that the burdens of treatment will outweigh the benefits of treatment, then the patients autonomy must be respected. If the level of risks to the patient for refusing treatment is high, then a greater level of competence is required by the patient

Question 30

Competence vs. Risk vs. | Invasiveness of the Procedure

Answer 30

``` Some would argue that only a minimal degree of competence would be necessary for the patient’s doctor to be obligated to respect and not override the patient’s decision ```

Question 31

2 ways surrogates act (surrogate in your shoes or theirs)

Answer 31

1) They make decisions about treatment as the patient would have made them if they were competent. 2) They can decide on a course of action that they believe to be in the patient’s best interest.

Question 32

informative model (information is basic)

Answer 32

The physician is obligated to provide all the available medical facts. On the basis of personal values, the patient then determines which treatments they will accept or refuse.

Question 33

interpretive model

Answer 33

In addition to the medical facts, the physician also provides the patient with information about the nature of their condition and the risks and benefits of different interventions.

Question 34

deliberative model (deliberately tell me what to do)

Answer 34

The physician is engaged in not only presenting medical information to the patient, but also in recommending treatment in line with the patient’s health-related values and preferences. (Non-coercive)

Question 35

disclosure of medical information - This obligation is grounded in both..

Answer 35

deontological and consequentialist reasons

Question 36

arguments to support confidentiality (Kant and Mill)

Answer 36

1) It is deontological (there is a duty) and involves respect for the patient’s autonomy and privacy. It is an extension of the patient’s right to privacy. 2) It is consequentalist (bad outcome), e.g., if physicians violate confidentiality by divulging information about their patients to third parties, then patients might lose trust

Question 37

research/experimentation

Answer 37

Practices aimed at the advancement of scientific knowledge

Question 38

therapy

Answer 38

Practices aimed at maintaining or restoring wellness of subject

Question 39

therapeutic research

Answer 39

: Research which “offers the prospect of direct medical benefit” to the research participant

Question 40

Utilitarian justification for research

Answer 40

``` Social benefits of advanced knowledge applied to therapeutic practice; controlled research methods enhance efficacy of therapies, reducing overall suffering over time, thus justifying pains endured by research participants. ```

Question 41

justification for research (pay the research forward)

Answer 41

Duty Duty to participate in research professed via appeals to fairness: “paying back” or “paying forward”; just distribution of burdens/ benefits of medical advancement

Question 42

Protection model v. access model: Protection model

Answer 42

Safeguard participant from undue risks, faulty experimental | design, uninformed/under-informed consent.

Question 43

access model

Answer 43

Ensure participant has access to experimental trials that might provide therapeutic benefit; ensure representative access to such trials, particularly to traditionally underrepresented groups.

Question 44

Informed consent requirement - voluntary

Answer 44

``` 1. Nuremberg Code (1946) and Declaration of Helsinki (1964): Two of the more than thirty statements of human-participant research ethics promulgated since World War II. 2. Informed consent is the central issue ```

Question 45

Voluntary informed consent as a central issue

Answer 45

``` Duties of trust, loyalty, veracity in practioner-patient interactions. 1. Sometimes viewed as a safeguard against act-utilitarian impulse to use bodies/pains/sufferings of the few to benefit the many. ```

Question 46

Voluntary informed consent as a central issue - cont

Answer 46

``` 2. Thus, respect for persons entails informed-consent requirement: i) Each has a right to decide for herself, whether to consent; ii) Consent is autonomous if and only if it is fully informed. 3. Proxy consent for incompetent participants: Helsinki code, Articles 24-26. ```

Question 47

two principles and 3 more

Answer 47

1. Voluntary Informed Consent 2. Ratio of Benefits Later 3. Distinction between therapeutic research (benefit patient) and nontherapeutic (generate scientific knowledge; not to benefit patient) 4. Institutional Mechanisms to ensure ethical principles (Inst. Review Boards). 5. Provision for Proxy consent by family member

Question 48

fernald state school (no ferns grow)

Answer 48

low does of raditation

Question 49

willowbrooke (willow will never get it)

Answer 49

hepatitis

Question 50

san quentin

Answer 50

testosterone

Question 51

statesville (don't have it in our state)

Answer 51

malaria

Question 52

holmsburg (hopefully not in our home)

Answer 52

dioxin - carcenogen

Question 53

guatalmala

Answer 53

radiation

Question 54

marshall islands

Answer 54

radiation

Question 55

ethical dilemmas - randomized trial

Answer 55

1. Patient may or may not receive potentially-preferable treatment; thus, conflicting obligations of Researcher qua Physician (ensure patient benefit) Vs. 2. Researcher qua Scientist (ensure viability of experimental control group).

Question 56

ethical dilemma - con't

Answer 56

``` Others argue against the assumption of ethical equipoise (balance of interest) between MD as researcher and MD as care-giver; different roles have different ethical obligations; model of “researcher-as- caregiver” yields an overly paternalistic relationship between researcher and participant. ```

Question 57

equipoise (equipoise is not biased)

Answer 57

A researcher is in equipoise when he or she does not know whether one treatment is more effective than another.

Question 58

A research community is in equipoise when

Answer 58

there is genuine disagreement within the community about the comparative merits of the experimental and control arms of the trial.

Question 59

design of clinical trials - the phases

Answer 59

1) Phase I: Test the toxicity. 2) Phase II: Test the dosing. 3) Phase III: Test for effectiveness and side-effects. 4) Phase IV: Once FDA approved, collect more information and continue to test for side-effects.

Question 60

Phase I and II are....(AND main moral obligation)

Answer 60

nontherapeutic 1. Main moral obligation: i) Protect subjects from harm.

Question 61

Phase III and IV may be (AND main moral obligation) (is nara risky?)

Answer 61

therapeutic 2. Main moral obligation: i) Ensure that there is an appropriate risk- benefit analysis. • Ideally there is a randomized controlled clinical trial (double-blind).

Question 62

3 ethical requirements to protect human participants (informed risk and distribution)

Answer 62

1. Voluntary Informed Consent 2. Appropriate Risk-Benefit Ratio 3. Fair Distribution of Risks between different groups

Question 63

singer is a...

Answer 63

utilitarianist

Question 64

cohen

Answer 64

animals cannot have rights because they are not moral

Question 65

for children, there should never be...

Answer 65

more than a minimal risk

Question 66

Pellegrino and Thomasma

Answer 66

argue that the patient autonomy model does not give sufficient attention to the impact of disease on the patient’s capacity for autonomy.