Académique Documents
Professionnel Documents
Culture Documents
Moral Distress
Concepts Activity
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CONSIDER THE FOLLOWING
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PROFESSION OF MEDICINE
VAN NORMAN & JACKSON
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PROFESSION OF MEDICINE
EDMUND PELLEGRINO
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PROFESSION OF MEDICINE
EDMUND PELLEGRINO
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384-322 BCE
CHARACTER DEVELOPMENT
ARISTOTLE
• 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
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CASE FOR ANALYSIS
BASED ON A CASE PRESENTED BY SADOVNIKOFF
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BEGINNING THOUGHTS
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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
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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
Institution-level
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Crescendo Effect
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
Ethics involvement
Consultation, follow up, education
Organizational ethics and review of policies/practices
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