Notes from 01/24/11 lecture

From Iusmicm

• started here on 01/24/11 at 1PM.

Contents 1 Medical ethics 1.1 Case 1: 48yo F 1.2 Ages of medicine 1.3 4 box method 1.4 Confidentiality 1.5 Moral theories 1.6 Kidder's dilemma paradigms 1.7 Standards for decision making for incompetent patients 1.8 Kruzann family case 1.9 PSDA

Medical ethics

• All the hospitals have adult and peds ethics boards.

Case 1: 48yo F

• Advance directive law is specific state to state, so it is important to know how the laws work in the state where you are practicing.

Ages of medicine

• The age of the physician:
  • 400 BC to 1960
• The age of the patient:
  • 1960 to Oct 1 1983
    • DRG = disease related groupings
    • These categorize payment
    • An attempt to reign in healthcare costs
    • Blue Cross Blue Shield also started in 1960
• The age of the payor

4 box method

• Also called georgetown mantra = 4 box method
• A two by two
• First box is the medical indications and beneficence
  • This is what the dr. brings to the table.
• Second box: Patient preference and autonomy
  • This is what we want to get from the patient (through their rational decision making)
  • Diff between capacity and competence: competence is a legal term (only a judge or lawyer can call someone competent through assessment by a psychiatrist or psychologist).
  • Out of autonomy comes informed consent:
    • Must disclose risks, benefits, costs, outcomes, other options.
    • Must ascertain that they have the capacity to decide.
    • Must be sure it is voluntary.
      • People who may not make it straight forward voluntary: third party payors, healthcare providers, researchers, family members
• Third box: Quality of life and burdens / benefits
  • Murky area because it is hard to determine what level of quality of life is worth living for.
  • Burdens and benefits are patient focused, not about money or the healthcare or anything else.
• Fourth box: socioeconomic factors and justice

Confidentiality

• The exceptions are harm to self or others.
  • Not just an allowance but a perogative (duty to report).

Moral theories

Kidder's dilemma paradigms

• Reporter for Christian Science Monitor found that people in extroidinary situations were deciding between four major decisions:
  • "How Good People Make Tough Choices"
  • Justice vs. Mercy
  • Truth vs. Loyalty
  • Individual vs. Community
  • Short term vs. Long Term

Standards for decision making for incompetent patients

• There are three types of standards against which decisions can be made for a pt.
• Subjective standard
• Substituted judgement
  • Asking someone who knows the pt to make a decision for the pt.
• Objective standard - "Best interests"

Kruzann family case

• Supreme court determined:
  • Nutrition and fluids are therapy that can be denied.
  • States decide how things work.

PSDA

• Patient self-determination act

• stopped here on 01/24/11 on 2PM.