1.

THE APPLICATION OF THE LEVEL OF THE MORAL DISCOURSE ACCORDING TO

VEATCHS CHART . ((VEATCHS LEVEL OF MORAL DISCOURSE) CHAPTER A MAP OF THE
TERRAIN IN BLACKBOARD
1. Respond to the sense that something is wrong.
2. Gather information
3. Identify the ethical conflict/ moral diagnosis using the four principles or additional ones (i.e.
is it a problem of
specification or balancing?)
4. Seek and Plan a resolution
5. Work with OTHERS to choose a course of action
2. DECISION MAKING- AUTONOMY, SURROGATE, PROXYWHO DECIDES?

How to determine whether a patient has decision-making capacity?

- Any physician can make this determination, psychiatrist is not needed.
- General impression of capacity from clinical encounter. Talk and Ask the patient....get to know him!
- Do a Mini Mental State Exam (MMSE). To assess orientation of person/place/time, attention span,
memory..ect.
-Careful, this test is not specifically to assess patients understanding of present situation.
-Does not evaluate several cognitive functions (e.g., judgment, reasoning) that are relevant to
capacity.
-Does not assesses delusions.
- Use (ACE) specific capacity assessment tools:
To evaluate patients ability of evaluates ability to understand information and appreciate the
consequences of his/her decision.
(probe 7 relevant areas)
i. Ability to understand medical problem
ii. Ability to understand proposed treatment

iii. Ability to understand alternatives (if any)

iv. Ability to understand option of refusing treatment
v. Ability to appreciate reasonably foreseeable consequences of accepting proposed treatment
vi. Ability to appreciate reasonably foreseeable consequences of refusing proposed treatment
vii. Ability to make decisions not substantially based on delusions or depression
i. Comprises:
1. Information: People should be given the right amount of information during research
projects and/or during any medical intervention. This information should include: research
procedure, purposes, risks and anticipated benefits, alternative procedures (therapy) and the
opportunity for the person to step out of the research at any moment. Other criteria has been
proposed such as how the selection is done and who is in charge of the project. It is important
that the patients or subjects know about the risks/benefits of the procedures and their
participation must be completely voluntary. Information should never be withheld in exchange
of a person's cooperation in research. Never should their lives be at risk for the sake of the
study as they should always receive truthful information.
2. Comprehension: The manner and context in which information is conveyed is as important
as the information itself. For example, presenting information in a disorganized and rapid
fashion, allowing too little time for consideration or curtailing opportunities for questioning, all
may adversely affect a subjects ability to make an informed choice. Because the subjects
ability to understand is a function of intelligence, rationality, maturity and language, it is
necessary to adapt the presentation of the information to the subjects capacity. Special
provision may be made when comprehension is severely limited. Each one of subjects that
one might consider as incompetent should be considered on its own terms.
3. Voluntariness- Element of informed consent which requires conditions free of coercion and
undue influence. Coercion occurs when a threat is made by a person to another to force the
other to comply. On the other hand, undue influence occurs from an offer of excessive or
improper reward in order to achieve compliance. These unjustifiable pressures usually occur
when people in authority urge a course of action for a subject. In this case, undue influence
could result from manipulating a person's choice by, for example, threatening to remove
benefits that are otherwise entitled to the person being manipulated.
ii. The risks, benefits and harms of the proposed intervention, including doing nothing, should be
known (information), and understood (comprehension) by the patient for adequate decisionmaking. The information should be offered to the COMPETENT patient or surrogate, free of
internal and external pressures (voluntariness), which refers to being without coercion, undue
influence, unjustified fears, false beliefs, etc.)
3. THE CLINICAL APPLICATION OF THE PRINCIPLES OF AUTONOMY, BENEFICENCE, NON
MALEFICENCE.
1. Autonomy- Self-governance, freedom of interference and limitations by others is necessary for
informed, comprehended, and voluntary decision making.
i. Autonomy conditions:
1. Liberty ! independence from influences or coercion
ii. Agency ! subjects capacity for intentional action.
Capacity is determined by a physician.

Competence is determined in a court of law.

iii. Autonomy moral rules:
1. Tell the truth (veracity)
2. Respect the privacy of others (privacy)
3. Protect confidential information (confidentiality)
4. Obtain consent for interventions with patients (respect for autonomy)
5. Help others make important decisions (beneficence)
iv. Overriding autonomy:
1. When there is a hazard to public health (tb)
2. Scarcity of funding or resources
3. Valid justification
4. Non-autonomous person (justified for protection/paternalism)
v. Incapacity (incompetence)its the inability to:
1. Communicate or express a choice
2. Understand the situation and its consequences
3. Understand relevant information
4. Give reasons for the decision
5. Reason risks and benefits
6. Reach a reasonable decision
2. Beneficence- benefits of patients health care. For example, in a terminal Cancer patient even
though days are almost counted is crucial to make everything necessary to make his days more
easily by often a good pain managing and support. This will benefit the patient emotionally.
3. Non-malfeasance- This fundamental principle refers to do no harm. In other words, in any
circumstances one should not injure or provoke damage to patients. However, often in medical
practice patients are exposes risks of been affected, for example in some kind of procedure (surgery,
ect.). We should learn, inform and make arrangements to prevent possible damage. For example a
patient with a family history of Gouty comes to your office asking you for treatment because he is
afraid and concern of developing the condition. He does not have any symptom and just a slightly
elevated ammonia appeared in hes urine. Even though diet and exercises can be used to control and
prevent the condition, patients demands treatment. In this case treating patient for Gout can put him
in danger because of the unnecessary medicines that can cause him side effects and other health
complications that can harm him. Patient should not be treated for and undiagnosed condition.
4. Justice- Refers to the sense of fairness in reading patients treatment. Based on the norms of
social cooperation was equitable, fair and appropriate service should be offered to people. However,
this principle is influenced by implications of health programs and insurance. For example, two
patients arrived to the emergency room, one with a severe bleeding and the other with common cold
symptoms. The one with the severe bleeding does not have health insurance will the other has health
cover. Both patients should be treaded no matter if he/she has or has not health insurance, but the
one with more detrimental health status should be priority.
4. NORMATIVE ETHICS- CONFLICT BETWEEN PRINCIPLES
Normative Ethics: attempt to answer specific moral questions concerning what people should do or
believe. The word "normative" refers to guidelines or norms and is often used interchangeably with
the word "prescriptive." Normative ethical theories are Kantian ethics, Virtue ethics, Utilitarian ethics,
and so on.
http://faculty.stedwards.edu/ursery/norm.htm

from BB article: suuuper resumido !!!

normative ethics
- used to resolve problems when rules and rights cannot resolve the matter, por tanto este se
considera a third level of the moral discourse
o four levels of the moral discourse
" cases
" rules and rights
" normative ethics
" metaethics
a. Utilitarism
i. Creed which accepts the foundation of morals, utility or the Greatest happiness principle,
which holds that actions are right in proportion as they tend to promote happiness, wrong as
they tend to produce the reverse of happiness.
ii. The principle of utility
1. Ex. In pandemics, whom to treat preferably
b. Kantianism
i. Morality is grounded in REASON
ii. The moral worth of individuals actions depends exclusively on the moral acceptability of the
rule (an objective maxim) on which the person acts.
iii. The rule provides a moral reason that justifies the action; moral obligation depends on an
objective rule determining the individuals will.
iv. Kants categorical imperative
1. I ought never to act except in such a way, that I can also will that my maxim becomes a universal
law
2. One must act to treat every person as an end, and never as a means only.
c. Principlism
i. Respect for autonomy
1. Respect for persons
ii. Beneficence & non-maleficence
1. Alleviate suffering
2. Do not cause harm
iii. Justice
1. Equals treated as equals
2. Anti-discrimination
3. Fair distribution of resources
d. Virtue Ethics:
i. By Pellegrinoemphasis on character
1. Fidelity to trust
2. Suppression of self-interest
3. Honesty
4. Compassion
ii. Moral relativism
1. Claims that there are no universal principles or norms
( tomado del repaso q envio jimmy)

-Examples of Virtues or Values:

Autonomy: the duty to maximize the individual's right to make his or her own decisions.
Beneficence: the duty to do good both individually and for all.
Confidentiality: the duty to respect privacy of information and action.
Equality: the duty to view all people as moral equals.
Finality: the duty to take action that may override the demands of law, religion, and social customs.
Justice: the duty to treat all fairly, distributing the risks and benefits equally.
Nonmaleficence: the duty to cause no harm, both individually and for all.
Understanding/Tolerance: the duty to understand and to accept other viewpoints if reason dictates
doing so is warranted.
Publicity: the duty to take actions based on ethical standards that must be known and recognized by
all who are involved.
Respect for persons: the duty to honor others, their rights, and their responsibilities. Showing
respect others implies that we do not treat them as a mere means to our end.
Universality: the duty to take actions that hold for everyone, regardless of time, place, or people
involved. This concept is similar to the Categorical Imperative.
Veracity: the duty to tell the truth.

5. PARADIGMATIC CASES- WHAT THEY ESTABLISHED IN MEDICAL PRACTICE. BE ABLE TO

RECOGNIZE A WHEN A PARADIGM CASE WAS USED.
a. Cruzan Bouvia: Has to do with incompetent patient refusing life-sustaining tx through a surrogate,
failure to set a precedent for a "right to die" and clear and convincing evidence of the patient's wishes.
i. It was the case of a woman who was in a vegetative state for 8 years after a car accident,
and the parents wanted
to disconnect all the machines to let her die in peace.
ii. The court ruled to their favor and Nancy Cruzan was disconnected and died 12 days later (in
1990).

b. Schoendorff: conflicting principles are medical beneficiende and autonomy.

Every human being of adult years and sound mind has a right to determine what shall be done
with his own body; and a surgeon who performs an operation without his patient's consent commits
an assault for which he is liable in damages, except in cases of emergency where the patient is
unconscious, and where it is necessary to operate before consent can be obtained
c. Bowman: Has to do with the Clinical Criteria for Brain Death, the definition of death and who
defines death.
d. Baby Doe: The Baby Doe Rules represent the first attempt by the US government to directly
intervene in treatment options for neonates born with severe congenital defects. Treatment for
severely impaired infants garnered national attention in April 1982 when Baby Doe was born
with Down syndrome and an abnormal connection of the trachea and esophagus. The baby required
immediate surgery to correct the defect. However, the parents, with the advice of their physician,
chose to withhold surgery and medical care because the child would still be severely retarded.
Officials at the hospital had the Indiana Juvenile Courts appoint a guardian to determine whether or
not to perform the surgery. The court finally ruled in favor of the parents and upheld their right to an
informed medical decision. The infant, by then known nationally as Baby Doe, died five days later of
dehydration and pneumonia. The Indiana Supreme Court refused to hear the case. Baby Doe died
shortly after the refusal, which prevented an appeal to the US Supreme Court.
e. Baby Houle: Maine Medical Center v. Houle was the first legal challenge to parental
decisions related to medical treatment for newborns with anomalies. In 1974, the Supreme Court of
the state of Maine ruled that parents did not have the right to withhold lifesaving treatment and that
doing so constituted neglect. The ruling included two other important points. First, a guardian cannot
withhold consent for lifesaving medical measures. Second, the ruling affirmed that children with
physical or mental impairments have the same right to life as other children.
f. Quinlan: Has to do with surrogate decision-making, removal of life sustaining interventions to an
incompetent patient and chronic persistent vegetative state.
Defines the proxy or substitute during the decision making as a person authorized in the
decision making process for patients with decreased autonomy. There are three general standard
models
i. Substitute judgment
1. The premise is that the patient has no capacity (non autonomous) to make a
decision. The
judgment is deferred to another agent
presumed to know the, now incompetent patient, well.
2 The substitute should make a mental analysis of the situation as the patient would,
were she/he
competent, in order to reflect the patient values
(what the patient would be doing in these
circumstances).
ii. Pure autonomy model
1. It is based in the fact that a previously autonomous person has expressed his/her
values or preferences,
although not necessarily through a living will or
anticipated instructions. The previously autonomous
judgment is accepted.
iii. Patients best interest model
1. In this case the substitute is based in the best interest, the best benefit for the patient
according to
alternatives (pain, suffering, loss of function, and quality of
life). In minors the parents should
watch for the best interest of their
children (Jehovahs Witnesses)
2. The order of importance should be: pure autonomy, substitute judgment, and best

interest. Pure
trumps best interests.

autonomy trumps substitute judgment, which in turn

6. DISCLOSURE OF INFORMATION, INFORM CONSENT, VIRTUES IN MEDICINE..

INFORMED CONSENT (IC)
Definition: is an extension of the autonomy principle where the physician share
decision making with patients.
Two clinical applications:
! Obtaining patient consent for medical intervention or research, focused on legal
requirements for disclosure.
! Mutual decision-making between physician and patient, exchange of information,
education and asses of patient goals and values.
! Requisites for IC:
Competence/Capacity
Disclosure and advice
Understanding
Voluntariness
Consent (agree or disagree)
Exceptions to IC

7. PRINCIPLE OF DOUBLE EFFECT. WHERE IT APPLIES?

- The doctrine (or principle) of double effect is often invoked to explain the permissibility of an action
that causes a serious harm, such as the death of a human being, as a side effect of promoting some
good end. It is claimed that sometimes it is permissible to cause such a harm as a side effect (or
double effect) of bringing about a good result even though it would not be permissible to cause such
a harm as a means to bringing about the same good end.
**A doctor who believes abortion is always morally wrong may still remove the uterus or fallopian
tubes of a pregnant woman, knowing the procedure will cause the death of the embryo or fetus, in
cases in which the woman is certain to die without the procedure (examples cited include
aggressive uterine cancer and ectopic pregnancy). In these cases, the intended effect is to save the
woman's life, not to terminate the pregnancy, and the effect of not performing the procedure would
result in the greater evil of the death of both the mother and the fetus.
8. PRINCIPLE OF UNCERTAINTY.
uncertainty principle, which allows one to mathematically derive the parameters that influence
the balance between the two competing goals.
9. EMTALA Law: Emergency Medical Treatment and Active Labor Act
- EMTALA is not to be treated as a malpractice statute.
- The Act does not require a covered Hospital to provide a uniform minimum level of care to
each patient seeking
emergency care and does not provide a course of action
against a treating hospital (or doctor) for
misdiagnosis or improper medical
treatment generated by State Malpractice Law.
- The hospital must be a participating Hospital (defined as a hospital that has entered into a
Medicaid provider
agreement under 42 U.S.C. 1395 cc.
- Said hospital must have an emergency department (or subcontractor) to provide an

appropriate medical
screening to any individual who presents himself or herself
to the emergency room and request and
examination for a medical condition.
Elements of a course of action against the participating hospital:
- The hospital must be a participating hospital, covered by EMTALA, that operates an
emergency department.
- The patient has arrived at the facility seeking treatment.
- The hospital did not provide the patient an appropriate screening in order to determine if she
or he had an
emergency condition.
SCREENING General Rules applicable to Hospital:
- A Hospital fulfills its statutory duty to screen patients in its emergency rooms if it provides for
a screening
examination reasonably calculated to identify critical medical
conditions that may be afflicting
symptomatic patients... (thus a refusal to
follow regular screening procedures (National Standards)
in a particular
instance contravenes the Statute.
- A Hospital fulfills the appropriate medical screening requirement when it conforms in its
treatment of a
particular patient to its Standard Screening Procedures. By the
same token any departure from the
Standard Screening procedure constitutes
inappropriate screening in violation of the Emergency
Act (EMTALA).
- The failure to appropriately screen by itself is sufficient to cause liability as long as other
elements of the cause
of action are met.
- Hospitals are expected to employ ancillary services routinely available in the emergency
department in order to
identify such conditions.
Substantive and Procedural Components to Screening under EMTALA:
- First, a Hospital fulfills its statutory duty to screen patients in its emergency room if it
provides for a screening
examination calculated to identify critical medical
conditions that may be afflicting symptomatic
patients.
- Second, the second prong of the test to determine whether Federal Jurisdiction is proper
under EMTALA is
whether the duty to stabilize the patient before transfer / discharge
is complied with.
Transfer and Discharge for Patients with Emergency Medical Conditions:
- Within such terms, the hospital must provide either,
- within the staff and facilities available at the hospital, for such further medical
examination and such
treatment as may be required to stabilize the medical
condition, or;
- for transfer of the individual to another medical facility in accordance with subsection
(c).
- "Once the hospital makes the determination that the patient is suffering from an emergency
condition, the
hospital must provide reasonable treatment to stabilize the patients
emergency situation before discharging or
transferring him or her"
Duty to STABILIZE:
- In determining whether a patient has been stabilized, the fact finder must consider whether
the medical treatment and subsequent release were reasonable[,] in view of the circumstances that
existed at the time the
hospital discharged or transferred the individual.
- A hospital violates its duty to stabilize under EMTALA when it fails to stabilize a patient before
transferring or
discharging him or her.
- A hospital's duty is "to provide such medical treatment of the condition as may be necessary

to assure, within a reasonable medical probability, that no material deterioration of the condition is
likely to result from or occur."
- "The duty to stabilize is therefore greater than the duty to
screen".
Doctors Liability under EMTALA:
- The court harbors no doubt that there is no cause of action against physicians under
EMTALA.
- Although the First Circuit Court of Appeals has yet to resolve this the controversy, it
must be noted that
other sister circuits have uniformly decided the issue
handily rejecting a cause of action against
physicians under EMTALA.

10. JUSTICE CONFERENCE: CO-PAYMENT, DEDUCTIBLE, ETC

You pay copays when you see the doctor. Coinsurance is how you and your insurance
company split up your care. Maximum out-of-pocket is the largest amount you will pay for treatment in
one year. Lifetime Maximum is the total amount your insurance company will ever pay for your care
over the course of your life. And deductibles are the portion you must pay before your insurance pays
its share.
Premium: The amount the policy-holder pays to the health plan each month to purchase
health coverage.
Deductible: The amount that the policy-holder must pay out-of-pocket before the health plan
pays its share.
ej Here's an example. Gary has a health plan with a $1500 deductible. If Gary only has
a few little things
go wrong during the year that cost less than $1500 total, he's going
to pay the full amount to treat them.
However, if Gary has a catastrophic injury or
serious illness that requires a lot of medical care to get
better, he'll pay his $1500
deductible and then his health insurance takes over to pay most if not all of his
additional costs. It's a way for Gary to shoulder some of the responsibility for his health, while
still
affording him protection from huge medical expenses.
Copayment: The amount that the policy-holder must pay out-of-pocket before the health plan
pays for a
particular visit or service.
ej. Let's say Gary goes to the doctor with a case of mono. His doctor charges a $25
copay, and when Gary
fills his prescription, he pays a $5 copay to the pharmacy. His outof-pocket costs are $30, and his
insurance company will reimburse the pharmacy and
the doctor for the difference between the copay and
the cost of treatment.
Coinsurance: Instead of paying a fixed amount up front (a copayment), the policy-holder must
pay a percentage
of the total cost. For example, the member may have to pay 20% of
the cost of the surgery, while the plan
pays the other 80%. Because there is no upper
limit on coinsurance, the policy-holder can end up owing
very little, or a significant
amount, depending on the actual costs of the services they obtain.
ej. Co-insurance is the way you and your health insurer share the costs of your care.
For example, if Gary
is injured, and he's met his deductible for the year, his health

plan will pay 80% of the cost of the rest of

remaining 20%.

his bills, leaving him responsible for the

Exclusions: Not all services are covered. The policy-holder is generally expected to pay the
full cost of noncovered services out of their own pocket.
Coverage limits: Some health plans only pay for health care up to a certain dollar amount.
The policy-holder may
be expected to pay any charges in excess of the health plans
maximum payment for a specific service. In
addition, some plans have annual or
lifetime coverage maximums. In these cases, the health plan will stop
payment when they
reach the benefit maximum, and the policy-holder must pay all remaining costs.
Capitation: An amount paid by an insurer to a health care provider, for which the provider
agrees to treat all
members of the insurer.
- IPA: Independent Practice Association
- HMO: Healthcare Management Organizations
- ACO: Accountable Care Organization