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LAURA GUIDRY-GRIMES, PHD

ASSISTANT PROFESSOR OF MEDICAL HUMANITIES AND BIOETHICS


CLINICAL ETHICIST, UAMS/ACH
What Is Ethics?

 Ethics is the formal, systematic study of what counts as the


good, who we ought to be, what types of duties we have,
and how we should judge right from wrong action.

 Ethicists provide reasons for choosing one course of action over


others.
 More than merely feeling something to be desirable,
preferable
 Can be independent of legal considerations and
other norms
Ethical Investigation

 What moral interests do the involved parties have?


 Examples: avoiding pain/suffering, quality of life, autonomy, social
bonding, meaningful experiences, spirituality/religion

 What moral obligations do the involved parties have?


 Examples: caring for those who cannot care for themselves,
protecting from coercion/exploitation/abuse, prudent truth-telling,
supporting each other as agents, acknowledging and trying to
remedy moral errors

 Which actions are ethically permissible, impermissible, and preferable?


Complex Ethical Terrain

 Obligations can be weak or strong, general or role-specific


 Prima facie obligation: what we should do as a matter of
“default,” but can be overridden by other ethical considerations
What Is Bioethics?

 Ethical investigation into healthcare,


biomedical sciences, and medical
technology

 Research ethics + clinical ethics +


public health ethics
 Can also include animal ethics +
environmental ethics
Four Key Questions

1. What is the ethical question?


 Requires moral imagination and moral sensitivity

2. What are the relevant facts?

3. Who/what could be affected by the way the question


gets resolved?

4. What are the relevant ethical considerations?


Exploring Bioethics, NIH
Image from http://www.voicesinbioethics.net
Case of Ms. Nicholson

 43 yo woman with diagnosis of paranoid schizophrenia

 Lives with her sister, Sandra, who has been surreptitiously


putting Ms. N’s psych meds in her food

 Sandra called cops when Ms. N started walking in the middle


of their residential street  Ms. N ran from the cops and locked
herself in a public elevator  72-hour involuntary psych hold
Case of Ms. Nicholson

 Ms. N refuses all psychiatric treatments – “I’ve been doing


fine for a while now without any drugs!”
 No self-harming behavior observed

 Multi-disciplinary team convened to discuss whether to


involuntarily treat Ms. N with consent from surrogate, Sandra

 What are some ethical concerns in this case?


Some Ethical Principles for
Nursing Practice

 AUTONOMY Guide Posts for


Ethical Reasoning
 BENEFICENCE / NON-MALEFICENCE

 FIDELITY

 VERACITY

 JUSTICE
Autonomy

 “to be one’s own person, to be directed by considerations,


desires, conditions, and characteristics that are not simply
imposed externally upon one, but are part of what can
somehow be considered one’s authentic self” (Christman)

 Ethically, why does autonomy matter?


 Respecting individual as an individual
 Enhances the value of achieving goals
 Individual generally understands their own interests best
 Benefits of pluralist society vs. homogenous one
Autonomy

 “Respect involves respectful action, not merely a respect


attitude. It requires more than noninterference in others’
personal affairs. It includes, in some contexts, building up or
maintaining others’ capacities” (Beauchamp & Childress)

 Closely tied to a number of healthcare rights, such as:


 Informed consent
 Privacy/confidentiality
 Capacitated patient being allowed to refuse any intervention
Autonomy

 But couldn’t respecting someone’s autonomy lead to harms to


the individual or others?

 YES, respecting autonomy can lead to morally relevant harms,


but remember:
 under certain conditions, people have the moral right to make bad
decisions for themselves and
 this principle should be counterbalanced by other ethical
principles
Autonomy - Capacity

 Capacity as clinical determination (appx. check for autonomy)


 Separate from competence (legal designation)

 4 components of capacity:
 Communicating a stable choice
 Understanding relevant information
SPECTRUM
 Reasoning through the proposed treatment in
relation to alternatives
 Appreciating the situation and consequences
Autonomy - Capacity

More risk to individual:


Higher standard for capacity
More certainty of capacity determination req’d

Less risk to individual:


Lower standard for capacity
Less certainty of capacity determination req’d
Buchanan & Brock, Deciding for Others
Autonomy - Capacity

 Challenges for capacity assessments with patients who have


psychiatric conditions:
 Unintelligible or unstable expressed choices?
 Unclear understanding? Delusional beliefs?
 Inability to form/convey a justification?
 Inability to grasp consequences? Unstable values?

 No blanket statements about capacity are warranted!


 Studies show that patients with schizophrenia are less
compromised when educational efforts are made (Misra & Ganzini)
Autonomy

 Types of hospital admission


 voluntary, non-voluntary, involuntary
 emergency, long-term
 inpatient, outpatient

 Grounds for involuntary commitment:


Narrow: imminent threat to life
 for patient’s own good Broad: likely deterioration, self-negligence
 for the good of others
Case of Ms. Nicholson

 Does the patient have autonomy interests?


 Past, present, future
 How would a capacity assessment affect your answer?

 Is it ethically problematic that the sister has been secretly


giving Ms. N psych meds?
 Should someone on the healthcare team raise this as an
ethical issue?
Beneficence
Non-Maleficence

 Beneficence: advocating for the patient’s interests;


to promote net benefit over net harm for the patient
 Associated with kindness, charity

 Non-maleficence: preventing unnecessary harms

 Both tied to the fundamental aims of medicine


 To heal, to contribute to patient well-being, to protect against
pain and anguish
Beneficence
Non-Maleficence

 Medical paternalism: When


healthcare professionals override or
interfere with a patient’s preferences
for the sake of avoiding harm or
securing benefit
 Examples of when this is unjustified?
Examples when it can be justified?
Beneficence
Non-Maleficence
 What about physical, chemical, and environmental restraints?

 American Psychiatric Nurses Association:


 Pts deserve safe, humane, respectful care
 Only used to ensure safety of pt or others
 Restraints should never be used for convenience or punishment
 Ensure maximum freedom, least restrictive means, minimum time
 Establish proper training, safeguards, oversight

APNA Position on the Use of Seclusion and Restraint, 2014


Case of Ms. Nicholson

 Could giving Ms. N a depot shot against her will


be beneficent?

 If it turned out that the medical team needed to


physically restrain her and force treatment, would
those actions violate the principle of non-
maleficence?

 Could medical paternalism be justified in this


case? What would you want to know first?
Fidelity

 Loyalty, advocacy, and dedication to patients


 Includes keeping promises and a caring commitment
 Helping patient participate in care to the full extent possible

 Important to demonstrate in patient care and


organizationally

 Are there limits to fidelity?


ANA, “Ethical Principles and Theories”
Fidelity

 Tarasoff v. Board of Regents of the University of California


(1976)
 “The protective privilege ends where the public peril begins”

 AR Code § 20-45-202 (2014) : healthcare providers


protected if they try to warn law enforcement of pt’s threats
to commit violent act
Case of Ms. Nicholson

 Ms. N asks her nurse to promise her that she will


not receive any drugs against her will. How should
the nurse respond, given the principle of fidelity?

 Ms. N curses loudly at one of the nurses who tries


to defend the doctors, and the nurse requests to
be removed from the patient’s care team. Is this a
violation of fidelity?
Veracity

 “willingness to dig for truth in a rational, methodical, and


diligent way and having the ability to place emphasis on
resolve and action” (Nursing Ethics, 2nd ed.)
 Foundation of therapeutic alliance

 Should not intentionally and maliciously deceive patients


 Problems of informational manipulation, critical omissions,
shading the truth
Case of Ms. Nicholson

 Sandra asks the healthcare team to treat Ms. N


involuntarily, but she also requests that they not
disclose to the patient that Sandra provided the
consent or that Sandra has been putting medicine
in Ms. N’s food without her knowledge. How
should the team respond to this request?
Justice

 Several meanings of justice:


 Equals should be treated equally

 Fair distribution of limited resources

 Prevent exploitation

 Respect perspectives and needs of


historically vulnerable populations
Justice

 Tied to a number of healthcare concerns:


 Wise use of technology, blood, organs, beds, staff, and
other resources

 Not discriminating against patients because of their


social group

 Tackling stigma against patients due to psychiatric


conditions, obesity, inability to pay
Case of Ms. Nicholson

 On the involuntary admission form, the police


documented that Ms. N ran from them, which
they considered evidence of self-harmful
behavior. When asked about this, Ms. N says
that the police would not have tried to throw her
in “this prison” if she had a different skin color.
How should the healthcare team respond to
their patient’s perspective on this sensitive
issue?
An Ethically Fraught Past

 1840s – Dorothea Dix lobbies for better living conditions 


federal government eventually builds state hospitals

 Early 1900s – commitment laws

 1900-1955 – dramatic increase in population of long-term


patients in state hospitals
 over 558,000 patients in state hospitals by 1955
 underfunded and understaffed
 experimental procedures, limited medications
Out of the Shadows by F. Torrey
An Ethically Fraught Past

 Deinstitutionalization
 92% who would have been in state
hospitals in 1955 were not living there by
1994

 Move toward community-based


treatment instead of asylum-based living

 Involuntary hospitalization only allowed


in cases of imminent harm

 Correlated with successful antipsychotic


medications
Out of the Shadows by F. Torrey
Ethically Fraught Situation
Continues

 Current issues:
 inadequate mental health coverage from insurance
 few community resources
 homelessness, vulnerability to violence
 disproportionately imprisoned
 millions untreated
 revolving door: many go from streets to emergency to
streets and back again
Out of the Shadows by F. Torrey
Take an Ethical Look

 Ethically,
what are some problematic features of
how patients with psychiatric disabilities have
been treated at different stages of U.S. history?

 What ethically reasonable steps might you suggest for


addressing the current situation?
EACH TABLE:

Debate DIVIDE INTO


TEAM MICHAEL AND
TEAM TABITHA