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CASE WESTERN RESERVE UNIVERSITY MEDICAL SCHOOL

SEMINAR FOR ANESTHESIOLOGY ASSISTANT STUDENTS


14 APRIL 2017

Laura Guidry-Grimes, PhD(c)


Center for Ethics @ MWHC
Clinical Ethicist
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OUTLINE

 Professionalism and Character Development

 Ethics of the Informed Consent Process

 Moral Distress
 Concepts Activity

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CONSIDER THE FOLLOWING

• You work under an anesthesiologist who


routinely takes home anesthesia
medications, and during a procedure he
nods off. You worry that he is abusing the
medications, and now he is not properly
monitoring the pt.

• After this procedure, you confront the


anesthesiologist, and he tells you that you
are overstepping, and he has no problem.

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PROFESSION OF MEDICINE
VAN NORMAN & JACKSON

• “The medical profession expects privileges


and special considerations above and
beyond those normally afforded by society.
In return, society expects a greater sense of
responsibility and a higher standard of
behavior for physicians [and other medical
professionals] than that of the general
public.”

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PROFESSION OF MEDICINE
EDMUND PELLEGRINO

• Act of professing -- “promise, commitment


and dedication to an ideal”
– Entering moral community, what distinguishes
medical professionals from “body technicians”
– Everyday acceptance of pt care – implicit or explicit
promise, asking for trust

• Ends of medicine: provide competent help


for the patient’s best interests
– “curing when possible, caring always, relieving
suffering, and cultivating health”

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PROFESSION OF MEDICINE
EDMUND PELLEGRINO

• Moral virtues are intrinsic to medicine


because they are necessary to achieve the
ends of medicine.
– Fidelity to trust, benevolence, intellectual
honesty, courage, compassion, truthfulness

– Development of practical wisdom (phronesis) with


experience and careful reflection

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384-322 BCE
CHARACTER DEVELOPMENT
ARISTOTLE

• Virtue - “to feel [passions] at the right times, with


reference to the right objects, towards the right
people, with the right motive, and in the right way”
(NE 1106b20)

• Focus on character
– Forming the right habits (ethos) for the right reasons
– Examine particulars of a specific case (avoid giving
generalized prescriptions)

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CHARACTER DEVELOPMENT
ARISTOTLE

• How do we achieve virtue?


– Moral perception: identify and understand morally
salient features of situation; know own failings,
inclinations, biases

– Imagination: can envision self in various moral


scenarios and dilemmas

– Reasoning: contemplation, rational reflection

– Disposition: cultivate proper emotions and attitudes


toward moral issues

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CASE FOR ANALYSIS
BASED ON A CASE PRESENTED BY SADOVNIKOFF

• Ms. X is an 80 year-old woman scheduled for


a AAA repair. When speaking with her in the
preoperative holding area, you find that she
seems confused about the procedure and
even as to where she is. The nurse asks if
you’re ready to go to the OR, and you
recognize that she signed the surgical and
anesthesia consent. The surgeon and
anesthesiologist have the OR booked, and
they are ready to take Ms. X in for the repair
she needs.

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BEGINNING THOUGHTS

• Why does informed consent matter,


ethically?

• What are some of the challenges of receiving


truly informed consent?

• How does a medical professional’s approach


to informed consent reflect on his/her
professionalism?

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MEANINGS OF ‘INFORMED C ONSENT’
• Legally and institutionally valid
consent
– Based on social rules, avoiding legal
liability
– “Blunt” determination – not as fine-grained
or individualized

• Autonomous authorization
– More than mere assent
– Does not have to be perfect to have moral
force

• Care covenant

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FORMS OF I NFLUENCE ( INTENTIONAL OR NOT )

• Coercion
– Credible threat + subject responds as if threatened

• Persuasion
– Remonstration, appeal to reason

• Manipulation
– Informational: framing or interpreting information in a way
that suits the interests of the manipulator
– “an anesthesiologist may manipulate a patient by not
offering general anesthesia for an operation because of a
desire to minimize OR time or a desire to gain experience
with regional anesthesia” (ASA, “Syllabus on Ethics”)
SURROGATE D ECISION MAKING STANDARDS
• Substituted Judgment
– Formerly capacitated patients with eligible surrogate
who has sufficient knowledge of what the patient would
want in these circumstances

• Pure/Precedent Autonomy
– Formerly capacitated patients: “whether or not a formal
advance directive exists, caretakers should accept prior
autonomous judgments” (Beauchamp & Childress)

• Best Interests
– Never capacitated or insufficiently known wishes;
choose option with the highest net benefit and lowest net
harms/risks for this particular individual
D ISCUSSION G ROUPS
• Problem-solve the following scenarios with the aims of
securing informed consent/refusal and establishing a
trusting physician-patient relationship.
– Idiosyncratic religious belief
• e.g., refusing treatment based on religious conviction that
others in that religious community do not share
– False belief / therapeutic misconception
• e.g., believing negative side effects of anesthesia “never
happen”
– Over-optimism
• e.g., conviction in a miracle, hopefulness that does not match
the odds
– Inconsistent beliefs
• e.g., patient claims to value living but refuses only available
life-saving procedure
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WHAT IS MORAL D ISTRESS ?
 When you are in a morally charged situation,
believe you know what ought to be done, but
you are constrained from doing it
 Perceived or actual powerlessness

 Problem of moral residue, feeling compromised

 Threat to moral integrity – “the sense of wholeness and


self-worth that comes from having clearly defined values
that are congruent with one’s actions and perceptions”
(Epstein & Delgado)

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C ONSTRAINTS ON THE MORAL A GENT
 Role obligations & competence
(e.g., nurse, not physician)
 Laws, policies, codes
 Power hierarchy
 Realities of time
 Limited resources, staff
 LOS pressures
 Others?

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Sources & Contributing Factors
• abusive pt/family
Case-level • demands for inappropriate tx
• poor communication
• misunderstanding of EOL options

Unit-level • hostile climate


• high turnover
• rescue mentality
• not enough staff

Institution-level

• lack of safe reporting mechanisms


• unclear or problematic policies
• insufficient training

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Crescendo Effect

• After repeated MD, level of moral residue builds


– Insufficient preventive ethics and resolutions
– Increasing sense of powerlessness, isolation

Job
dissatisfaction

Burnout Alienation

Physical and
psychological Moral
effects insensitivity

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C OPING WITH AND PREVENTING MD
 AACN Guide:
 Ask: become aware MD is present
 Affirm: make a commitment to address MD
 Assess: identify sources of MD and make action plan
 Act: implement strategies to preserve integrity

 Moral distress programming


 Discussions, workshops, educational sessions

 Ethics involvement
 Consultation, follow up, education
 Organizational ethics and review of policies/practices

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