Topics on exams
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- Bu səhifədəki naviqasiya:
- Clinton issued formal apology in 1997
- Had given oral consent ot experiment, but not told they wouyld be injected with cancer
- Showed that OC were effective: 10 preg. In placebo group. Abortion not legally available Most subjects were RC
- IMPORTANT Legal definition of minor
- Truthful disclosure
- Stages of life According to Erickson Erickson theory deals with the ego
- Trust vs Mistrust
- Ego Identity vs Role confusion
- Generativity vs self absorption
- MATERNAL DRUG ABUSE AND EFFECT SMOKING------- LOW BIRTH WIEFHT AND WITHDRAWL AT BIRTH
- FETAL ALCOHOL SYNDROME---- LEADING KNOWN CAUSE OF MENTAL RETARDATION(DOWN SYNDROME IS SECOND)
HEW Final Report in 1972 • Concluded that the 40-year longitudinal study was ethically unjustified – Failed to obtain informed consent – However, they did not expose the egregious fact of
The Tuskegee Syphilis Study 11
• High prevalence of Hep B (almost 100%) • Subjects injected with Hep B to assess antibody
• Patients kept in special quarters and supervised • Hep B vaccine developed successfully.
Medical Ethics Truthful Disclosure Medical Ethics Truthful Disclosure • “Being honest with the patient” • Supported by moral principles: Fidelity & Autonomy • Need truthful facts
• Omitting a fact (success rate=10%) or distorting information • Therefore are DECEPTIVE • Deception= to lie or omission of info • “therapeutic privilege” – If harm of disclosure outweighs harm of nondisclosure. • Trend: Now is Absolute Honesty • If you “mess up” - you inform the pt’/family • Disclosure of medical mistakes: • “If it can’t be fixed,why break it more?” Reasons against Disclosure • 1)Legal- fear against Law suit • 2)Causes unnecessary distress • 3)Decreased competency as viewed by colleagues hence getting less referrals (i.e. poor/unsuccessful post-op result) • 4)Decrease in trust from patients Reasons for Disclosure 1)Respect for autonomy- Allows patient to: *Decide whether they want to continue seeing this Dr *Remedy the mistake *Opportunity to sue *Honesty in physician/patient relationship 2)Legal risk of not disclosing *Fear of patient finding out 3) Obligation to make changes to prevent recurrence of mistakes. • Eg. Phenol & LA ankle block. • Phenol injected instead of local anaesthetic • BK amputation • Doctor reads cartridge,shown by nurse • Label better • Common practice= check name,dose,dates • USA- 44,000-98,000 deaths per year 2ndary to medical mistakes Use of placebos • A substance that is administered as a drug but has no medicinal content, either given to a patient for its reassuring or used in a clinical trial of a real drug. Use of placebos • Psychological or biological effect? 1) Pain + placebo: decrease in pain= 1st effect • Do endogenous opiates(endorphins) decrease pain? • How to test? Give opiate antagonists. So: • 2) Pain + opiate antag^ + placebo: No change in pain Is it ethical to do this? To have not told patient you are not giving them real drug in this pain trial. Types of placebo 1)Therapeutic 2) Diagnostic tool 3) Clinical research Types of placebo
• Pure- sugar pill. Very few • Impure- Most common Is a drug & will have an action but not for pt’s symptoms Problems: Deceiving them & therefore violating informed consent & violating fidelity (pt expects you to be honest) Justification for therapeutic placebo
• Patient insists on prescription • Alternative is toxic • High placebo response Types of placebo cont... 2) Diagnostic tool • Aids diagnosis • eg. Pseudoseizures: • attack resembles epileptic seizure but has purely psychological causes. Lacks EEG changes of epilepsy. Sometimes stopped just by act of will. • give patient placebo to control “seizure”. • Helps rule out “fake” seizures • 3) Clinical research • Require informed consent eg. placebos used in drug trials • Continued monitoring needed Truthful Disclosure- Unethical Cases
• Stanley Milgram’s study on Obedience • 1961-1962 • Subjects= teachers • Experiment to implement punishment using shock. • Wrong answers then shock • Caused significant distress to subjects
“Don’t Tell Mother” Withholding Information from a Patient The Case
• Lillian 84 y.o. • Developed dysphagia • Not concerned by sx (mild,”eats too fast”) • Son concerned. Persuades medical eval^ • Workup: reveals mediastinal mass impinging on esophagus • Biopsy recommended • If Ca- need immediate surgery(incl. Laryngectomy & tracheostomy)to avoid obstruction • Radiotherapy & chemotherapy produce palliation but not cure expected • Even with rx obstruction likely but later date
• Otherwise appears healthy. Severe hearing loss
• Time & patience for explanations. Alert, orientated & appears mentally intact. • Apartment next to son & family • Transport dependent on them • Able to make decisions(daily living) • Not asked many specific questions about current situation (Dr’s relief) • Son tells Dr not to tell mother diagnosis b/c will not tolerate news nor disfiguring operation • Son reports hx of pt’s depression & takes appearance as top priority • Son argues her sx are mild & have not progressed significantly over 2 years • Tumor unusual & no radical rx need perhaps
• Even if it is malignant son states, mother is 84yrs & may die of an unrelated cause so this invasive plan of care is not appropriate. 1)How valid is the son’s argument that the progress of his mother’s tumor eliminates the need for an invasive care plan? Progress of tumor has been slower than expected; her sx have not progressed & no loss of weight. Incidence of cancer increases with age & only a few specific malignancies are more aggressive in older individuals. Majority in the elderly population are less aggressive, non-metastatic & less often the cause of death. • Any apparent reduction in cancer aggressiveness may represent vulnerability to higher prevalence of CVS or cerebrovascular dz. • Controversy over prognosis of CA among very old in general remains unresolved. • In any case, it is not possible to predict the course of Lillian’s tumor. Ethical & Legal Considerations • 2) Should Lillian be told her diagnosis? • Physician’s primary obligation is to the patient-Lillian. • The principle of truthful disclosure/selfdetermination requires the physician to disclose to patient all reasonable information relevant to her condition and treatment options so can make individually appropriate decision. • Info included upset Lillian but sensitive approach to deliver news. • Information upsetting is not justification to withhold from pt. • Physician in this case take time to communicate if hearing impairment is a barrier. Written explanations effective or son assist in disclosure in the doctor’s office.
• News not be delivered quickly. Gradual process adopt & inform in a way emotionally tolerated. • Only way to confirm if Lillian wants shielding from distressing info is to hear her own thoughts thro dialogue. • Statistics- Most people want to hear details of their situation, even if info is burdensome or devastating. • Physicians should directly inquire to particular preferences of individual pt’s rather than presume. • Lillian has right to decide whether wants treatment. Can only decide if informed of dx. • Important to know if palliative approach or more aggressive cure-orientated approaches to her condition required 2)Could a decision be made to withhold info from Lillian based on her son’s warning about her emotional state? • There are limited situations where justified. • Physician may be excused from disclosing info to pt where sufficient evidence that pt is not psychiatrically or emotionally equipped to consider the info or that disclosure of info itself would pose serious & immediate harm to pt. • Eg. by inducing some physiologic response such as a MI or prompting suicidal behaviour • Known as therapeutic exception to informed consent process. • In this limited scenario: benefit to be achieved by disclosure is outweighed by the harm induced from the disclosure itself. • In this case: son believes info could harm Lillian, perhaps causing deep depression. Given the apparent closeness of his relationship with mother, cannot lightly dismiss his concerns. 10 • However, important to further explore Lillian’s psychiatric hx, values & current state of mind before concluding that son was right. • Even if therapeutic exception utilized here, physician is not relieved of the obligation to continually attempt to involve the pt in decision process & prepare her for problems that may arise. 3)Can it be concluded that Lillian has delegated her decision-making authority to her son? • Clearly, son heavily involved in medical decisions(started diagnostic path) • The fact that a pt would rely on her son for advice & support is natural & even justifiable in view of their close relationship. • Not clear though is if Lillian wishes son to take her place in decision making. • If she wishes, then has right to make delegation of authority. • She could execute a health care power of attorney or proxy, formalizing her decision to have her son make medical decisions on her behalf. Authority usually activated once decisional capacity lost. • The pattern in this case certainly suggests Lillian;s son be authorized decision maker. • Delegation of decisional authority clearly established by physician. Not presumed. • If pt has decisional capacity then physician has no right to discuss pt’s medical care with others unless the pt gives permission for this (info is confidential) • Physician ask directly whether she wants son to be involved in the decision process & to what extent, & whether she wants all or part of info about her condition disclosed to him. • In this case: No conclusion of delegation authority to son. Finally…. 11 • The information he has conveyed could well be highly pertinent; furthermore, excluding him outright would alienate him & might disrupt a therapeutic relationship between physician & patient. LOW YIELD: for those aiming for 100% IMPORTANT Legal definition of minor- In most states, any person under 18 years of age. All minors must be under the care of a competent adult (parent or guardian) unless they are "emancipated"--in the military, married or living independently with court permission. Property left to a minor must be handled by an adult until the minor becomes an adult under the laws of the state where he or she lives. Emancipated minor- married, or in military, or have children, or independent- make their own decision.
Truthful disclosure- TUSEGEE CASE: Low yield Justification for therapeutic placebo- Placebos can be physical (e.g., a manipulation), pharmacological (e.g., a pill) or psychological (e.g., a conversation). Double-blind and placebo-controlled trials have sometimes been the source of anxiety on the part of the public or of prospective participants, usually because an element of deception seems to be involved, or because patients who are allocated to the control group (which might, e.g., not receive a new treatment) may seem to be at an unfair disadvantage. Anxiety on both of these counts is quite understandable if certain conditions fail to be met when the trial is proposed. The scientific justification for the use of placebo preparations is set out above. Their use is ethical if patients give consent in advance. However, there is "little evidence in general" that placebos had powerful clinical effects. The authors state "outside the setting of clinical trials, there is no justification for the use of placebos."
• Jehovah witness 11 y.o. girl • Trauma patient- child unconscious • Needs surgery & blood transfusion • Mother refuses transfusion b/c of religion. • Even if child will die, mother refuses rx • Court rules- BEST INTEREST • Therefore rx^ed the patient Termination of Treatment • Federal Law- Child Abuse Amendments of 1984 • Includes regulations to ensure appropriate medical therapy for disabled infants • Mandates life supporting/saving medical treatment(LSMT) • Exceptions= permanent unconsciousness, futile rx imposing excessive burdens AMA’s position on seriously ill infants • LSMT may be withheld if pain overrides comfort or no experience of emotion due to brain damage. • Law & ethics state, if suffering & no joy then “plug” can be pulled. Research with Children • FDA Modernization Act: • Pediatric drug trials are mandated on all drugs which are approved for adults before they can be routinely used for children. • Federal regulations: • Parental consent always • Childs consent usually ( but if refuses then not in trial)
A man was injured when his car was rear-ended by another car. The other car was being driven by a person diagnosed with epilepsy. The Case, continued The patient diagnosed with epilepsy had a seizure right before the collision, causing him to lose control of his automobile and crash into the car ahead of him. 15 The Case, continued The man in the first car sued the patient and received a settlement award of $100,000. The Suit
After this settlement, the man also sued the patient’s physician. This suit claimed negligence by failing to warn the patient not to drive while under the influence of an anti-seizure medication (Dilantin with phenobarbital). The Court • The trial court dismissed the case. • On appeal the court affirmed the dismissal order. • The case was dismissed based on proximate cause. What Do You Think? • What does proximate cause mean? • Who/what caused the accident? • Was the physician directly responsible for the accident? Summary • There was no evidence that the accident had been proximately caused by the physician’s failure to warn the patient about taking the anti-seizure medication. • Contrary, evidence suggested the accident was proximately caused by the patient’s seizure. Werner v. Varner, Stafford & Seaman, P.A., 659 So. 2d 1308 (Fla. Dist. Ct. of App., Sept. 6, 1995).
Stage 2: Toddler - 2 to 3yrs
Stage 3: Pre school stage : 5 to 6
Stage 4: School age - 7 to 12
Stage 5: Adolescent stage – 12 to 18yrs
Stage 6: Young adult – 20’s
Stage 7: Middle Adulthood - 20 to 50’s
Don’t bother with 8th stage PREGNANCY, Growth & Development PREGNANCY
Teenage pregnancy About 1 million teenage become pregnant each year
15-19 Teenage pregnancy CONSEQUENCES FOR MOTHER: LEADING CAUSE OF SCHOOL DROPOUT HIGH RISK OF OBSTETRIC COMPLICATIONS
NEONATAL DEATH AND PREMATURITY LOWER LEVEL OF INTELLECTUAL FUNCTIONING PROBLEMS OF SINGLE PARENT FAMILY ( DELINQUENCY, SUICIDE)
CESAREAN BIRTH
MATERNAL DRUG ABUSE AND EFFECT
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