Case-Based Medical Ethics in Practice
Preface by the authors
Foreword
Chapter 1: A brief introduction to medical ethics in Internal Medicine
- Definitions of ethics and medical ethics
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- Why is medical ethics important? (teaching competency in ethics, teaching professionalism)
- Evolution of medical ethics and its importance/role in modern medicine (from paternalism to informed consent)
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- Who determines ethical guidelines for medicine?
- Difference/similarities between ethics and law
- Purpose of the book (i.e. to stimulate thought and discussion, not cover all details of all ethical principles)
Chapter 2: The underlying principles of ethical patient care
- Beneficence - a practitioner should act in the best interest of the patient. (Salus aegroti suprema lex.)
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- Non-maleficence - first, do no harm (Primum non nocere).
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- Autonomy - the patient has the right to refuse or choose their treatment (Voluntas aegroti suprema lex.)
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- Justice - concerns the distribution of scarce health resources, and the decision of who gets what treatment.
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- Dignity - the patient (and the person treating the patient) have the right to dignity.
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- Veracity - the patient should not be lied to, and deserves to know the whole truth about his/her illness and treatment.
Chapter 3: Putting ethics into practice - realities, limitations, and roadblocks
- Practitioners and personal belief systems
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- Cultural competency and practice of ethical care
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- Statement about pharmaceutical company influence on education and practice
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- Medical oaths - Are they valid for medicine today? Are they fulfilled by practitioners?
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- The Patient Bill of Rights
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- Federal, state, local, and institutional regulations - how they intertwine and affect each other
Chapter 4: Advanced Directives, Living Wills, and the Health Care Power of Attorney (HCPOA)
Chapter 5: Case-based ethical dilemmas
- How the reader should approach these cases
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- Where to find more information if needed
Case 1
- Topic: Consent in the mentally ill or otherwise unfit (and 'in between' situations: delirium, psychiatric decompensation)
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- Subtopic: When does forcing an incompetent patient to undergo treatment limit their right to dignity and the principle of 'do-no-harm'?
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 2
- Topic: When the HCPOA neglects their responsibility, or has other personal interests/potential gains
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 3
- Topic: When the patient/their family bullies practitioners into unnecessary diagnostics/therapeutics
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* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 4
- Topic: When an estranged family member or spouse suddenly appears to make decisions
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 5
- Topic: How to deal with an inpatient behaving badly (psych consults, behavioral contracts, room restriction etc.)
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- Outbursts
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- Substance abuse
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- Illegal activity (e.g. drug-dealing)
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- Known criminal warrants
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- Inappropriate actions or remarks
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- Admitted for ulterior motives (secondary psychologic gains, homelessness, etc.)
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 6
- Topic: When DSS consults are needed
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- Child abuse/neglect
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- Elder abuse/neglect
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- Spousal abuse
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 7
- Topic: When a patient has 'burned all bridges' and no discharge planning is possible
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- No nursing home or rehab center will accept the patient
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- No home health services will accept the patient
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 8
- Topic: Can a practitioner refuse to admit a patient? To see a patient in the office (e.g. administrative discharge)?
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 9
- Topic: When a patient makes 'bad' decisions (e.g. will accept some therapies and not others, such as some blood products but not others, some procedures but not others, DNI but not DNR, etc.)
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- Does a practitioner follow the patient's wishes? Do they refuse to treat?
- Subtopic: When a patient is guided by incomplete, or misinformation (e.g. from the internet)
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 10
- Topic: When a patient's same-sex partner has no legal rights and is excluded by a family
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 11
- Topic: When a patient has a contagious disease (e.g. HIV) and their partner is not aware
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- Subtopic: When a partner/family does not have all the information needed to make decisions for a patient (e.g. when to disclose diagnoses such as HIV-positivity, substance abuse, suicidality)
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- Subtopic: When confidential information is inadvertently leaked to those who 'don't need to know'
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- Subtopic: What diseases are 'reportable'?
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- Subtopic: Do patients avoid testing for confidentiality fears?
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 12
- Topic: When a family will not accept a terminal prognosis (i.e. futile 'full codes')
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- Should a family be present during the code?
- Subtopic: When a patient themselves is unrealistic about prognosis
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- Subtopic: When is a patient 'terminal'? (i.e. definition of brain death)
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- Subtopic: When is it appropriate to change the focus of care to comfort/hospice?
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- How do a practitioner's personal beliefs affect this guidance?
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- The concept of dignity/therapeutic death v. Euthanasia
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 13
- Topic: When there is no one to make decisions for a patient (e.g. John/Jane Doe in ICU, wards of the state)
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 14
- Topic: When a mistake has been made by a practitioner (what/how to/how much to disclose)
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- Mistake by primary practitioner; mistake by other/outside practitioner
- Subtopic: Caring for a patient after a poor outcome or mistake (i.e. how is care affected)
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- Subtopic: When a patient makes a reference to a grievance or verbally disparages another practitioner
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 15
- Topic: When what a patient needs cannot be obtained (e.g. financial/insurance limitations)
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- Tests/procedures (e.g. colonoscopy in an uninsured/pre-Medicare patient aged 50 to 64 years old)
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- Treatments
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- A different medical team (I want a new doctor), especially when no others will take your difficult patient
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 16
- Topic: When next-of-kin (NOK) disagree with each other
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- Subtopic: Which of the NOK has 'seniority'? Are legal definitions for NOK equivalent to ethically 'best' choices?
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 17
- Topic: When a toxicology screen is ordered without patient consent and comes back positive
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- Subtopic: When tests are ordered 'in emergency situations' without patient consent (e.g. HIV tests)
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- Subtopic: When a practitioner is potentially exposed to infectious agents (e.g. via a needlestick) and a patient is refusing further testing
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 18
- Topic: When a patient 'signs out against medical advice'
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- Practitioner obligations
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- How can competence be quickly assessed and assured?
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- What about a patient with contagious disease (e.g. TB)? Can they be allowed to leave?
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 19
- Topic: When a patient requests a clinical interaction be recorded
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 20
- Topic: When a family member requests patient information not be shared with the patient, or with other persons
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 21
- Topic: When a patient requests to not be seen by a (specific, or any) medical resident or student
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 22
- Topic: When a patient requires or demands large amounts of time from a practitioner
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 23
- Topic: How to prescribe medications to someone who has attempted suicide (e.g. with pills)
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- Subtopic: How to accurately assess and document safety in a depressed patient
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 24
- Topic: When a colleague demonstrates suspicious behavior
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- Memory problems
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- Substance abuse
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- Outbursts
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- Inappropriate relationships with or behavior toward patients, coworkers, etc.
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- Dishonesty
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 25
- Topic: When a language translator is not available (or only a family member/hospital employee is)
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 26
- Topic: When a patient is repeatedly readmitted to the hospital due to non-adherence (e.g. with therapy, diet, etc.)
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- Where does a patient's responsibility for their own care and well-being begin?
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- The 'cry wolf' syndrome
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- Should a procedure be repeated if a patient's behavior may have caused failure of the first one?
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 27
- Topic: When lawyers or law enforcement want to know patient information (HIPAA/confidentiality and the law)
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- Blood alcohol level or toxicology testing
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- Rape exam results
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- Hidden drug stores (e.g. body cavities)
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- When should access to a crime victim be allowed? To a suspected perpetrator?
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- What right to privacy do prisoners have with regard to history, physical exam?
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- Can/should discharge plans be shared with prisoners?
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 28
- Topic: When a patient requests disability certification, handicap plates, etc. - or when they request renewal of a revoked driver's license (e.g. can a practitioner-patient relationship be maintained when a patient doesn't get what they want?)
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 29
- Topic: How much resources should be spent on a single patient's case? (i.e. public health cost v. value of human life)
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- Subtopic: When do you stop looking for answers to a patient's 'mystery problem'?
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- Subtopic: When if ever do you call a case futile based on cost/public burden of care?
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- Subtopic: What resources need to be made available at a hospital for 'rare' situations or patients?
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- MRI for the morbidly obese
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- Male Pap smear equipment
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 30
- Topic: How much information must a practitioner share with a patient?
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- Explanation of logic for decisions/opinion/treatment plan, explanation of test results
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- Explanation of all potential side-effects
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- How much information is needed for 'informed consent'?
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 31
- Topic: How to deal with a patient seeing two or more practitioners (same specialty, overlapping meds, etc.)
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 32
- Topic: How to manage chronic pain (e.g. are 'pain contracts' ethical?; how is pain objectively assessed?)
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 33
- Topic: At what age, if any, do you stop health maintenance disease screening?
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- Subtopic: At what age, if any, to you stop invasive procedures? Placing pacemakers?
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 34
- Topic: When can a practitioner withhold therapy from a patient based on their behavior?
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- Examples: HAART therapy for HIV, HepC treatment, anti-coagulation
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- Behavior: Non-adherence to therapy, substance use/abuse, continued tobacco use/abuse
- Subtopic: When does a patient qualify for a transplant? Is 6 months sobriety appropriate?
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 35
- Topic: When a Jehovah's witness needs a blood transfusion
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- Are blood substitutes allowed?
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- Should surgery/organ transplantation be withheld if transfusion will not be allowed by the patient?
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Case 36
- Topic: How far does screening go?
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- Breast cancer genes, hypercoaguability work-up in family members of a patient with a new diagnosis
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- Will this lead to insurance decisions re: 'pre-existing conditions'?
* Narrative of clinical scenario with specific example of ethical dilemma
* Questions for thought/discussion
* Explanations of underlying ethical and legal principles
Comprehensive Exam
Suggested reading and internet resources
Glossary of terms
Index