APPLIED CLINICAL

ETHICS
SHEREEN DAWKINS, MA (HEALTH LAW & ETHICS)
APPLIED CLINICAL ETHICS

 Definition
 Four quadrants of clinical ethics
 Contraceptives & Minors
 Conscientious objection
 The right to refuse
 The patient, physician, the pharmacist
 Cases – Physician assisted dying, the principle of double effect
 Palliative and end of life care
 Drug Shortages- expired drugs/counterfeit
Definition

 Clinical ethics is a practical discipline that provides a structured approach to assist

physicians in identifying, analyzing and resolving ethical issues in clinical medicine

Source: Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, 4th Edition by Albert R. Jonsen, Mark Siegler, and William J.
Winslade (1998) at https://depts.washington.edu/bioethx/tools/ceintro.html
Quadrants of clinical ethics
Medical indications

 What is the nature of the client’s disease, its history, its associated diagnosis and prognosis?
 What treatments, intervention, services, and resources are available?
 What are the success probabilities of the various available treatments, interventions, and
resources?
 What are the various ways “success” might be understood?

Source: The case Managers’ ethical decision-making at

https://www.cmbodyofknowledge.com/content/case-manager%E2%80%99s-ethical-decision-
making
Client’s preferences

 Clients who are judgmentally and cognitively able have the autonomous right to make medically unwise
decisions (e.g., refuse a treatment or service).
 As a healthcare professional you are obligated to accommodate the client’s preferences to which he/she
is reasonably entitled.
 In instances in which someone else is making decisions for the client (e.g., a member of the client’s
support system or a designated healthcare proxy), you must be careful that the decision maker is legally
authorized to do so.
 Know who can consent for individuals who are cognitively impaired, and you should be thoroughly
informed about them.

Source: The case Managers’ ethical decision-making at https://www.cmbodyofknowledge.com/content/case-

manager%E2%80%99s-ethical-decision-making
Client’s preference

 Religion
 Culture

 Source: The case Managers’ ethical decision-making at

https://www.cmbodyofknowledge.com/content/case-manager%E2%80%99s-ethical-decision-
making
Quality of life

 What is an acceptable quality of life

 Economic Calculations – QALY – Quality adjusted life year
 A measure of the state of health of a person or group in which the benefits, in terms of
length of life, are adjusted to reflect the quality of life. One QALY is equal to 1 year of
life in perfect health.
 QALYs are calculated by estimating the years of life remaining for a patient following a
particular treatment or intervention and weighting each year with a quality-of-life score
(on a 0 to 1 scale). It is often measured in terms of the person’s ability to carry out the
activities of daily life, and freedom from pain and mental disturbance.
Quality adjusted life year
Contextual features

 Have you examined relevant legal issues or spiritual or cultural factors that might
influence whatever values are relevant in the client’s situation?
 eg health insurance
 Support
 Surrogate decision maker
 Laws

 Source: The case Managers’ ethical decision-making at https://www.cmbodyofknowledge.com/content/case-manager%E2%80%99s-ethical-

decision-making
Terri schiavo ‘s

 https://www.youtube.com/watch?v=O-rQ3tIabvM
END OF LIFE ISSUES

 Palliative Care
 Doctrine of Double effect
 Euthanasia
 Physician Assisted Dying
END OF LIFE ISSUES

 Terminal illness - an advanced stage of a disease with an unfavorable prognosis and no known cure.
Mosby's Medical Dictionary, 9th edition. © 2009, Elsevier

 Palliative care is an approach that improves the quality of life of patients and their families facing the
problem associated with life-threatening illness, through the prevention and relief of suffering by
means of early identification and impeccable assessment and treatment of pain and other problems,
physical, psychosocial and spiritual (Source: WHO http://www.who.int/cancer/palliative/definition/en/)

 Euthanasia is generally defined as the act of killing an incurably ill person out of concern and
compassion for that person's suffering. It is sometimes called mercy killing, but many advocates of
euthanasia define
 Mercy - the ending of another person's life without his or her request.
Doctrine of double effect

 Medications used in palliative care may have the side effect of hastening death even
though the intent of the practitioner is to achieve relief of symptoms and not euthanasia.
KEVORKIAN – DR DEATH

 https://www.bing.com/videos/search?
q=kervokian&&view=detail&mid=06FA7A1870DC61C9C24806FA7A1870DC61C9C24
8&&FORM=VRDGAR
PHYSICIAN ASSISTED DYING

 Oregon's DWDA permits a terminally ill patient to request a prescription for a self-administered
lethal dose of medication to end his or her life.
 The patient must be at least 18 years of age,
 a legal resident of Oregon,
 capable of making and communicating health care decisions, and
 diagnosed with a terminal illness that will lead to death within six months.
 The patient must make two oral requests to a physician for a lethal medication dose, at least 15
days apart, and
 provide a written request to an attending physician, the person with the primary responsibility for
the patient's care and treatment of the terminal illness; the request must be signed before two
witnesses.
PHYSICIAN ASSISTED DYING

 The attending physician must refer the patient to a consulting physician to confirm the
diagnosis and prognosis and
 determine whether the person is capable of making health care decisions.
 If either physician suspects the patient may be suffering from a psychiatric or
psychological disorder that could impair judgment, the individual must be referred for a
mental health evaluation.
 The psychiatrist or psychologist should evaluate the patient for mental disorders,
including depression and delirium, and decision-making abilities.
PHYSICIAN ASSISTED DYING

 the prescribing physician must notify the patient of alternatives to suicide, including comfort care,
hospice care, and pain management.
 The physician must also recommend that the patient notify his or her next of kin. Also, the patient may
rescind the expressed desire for a lethal medication dose at any time, and the physician must explicitly
offer an opportunity to rescind upon the second oral request.
 A physician is permitted to dispense the medication directly to patients provided he or she is registered
as a dispensing practitioner with the Oregon Medical Board and maintains a current Drug Enforcement
Administration certificate.
 Physicians issuing prescriptions to be dispensed at a pharmacy must notify the pharmacist in advance.
 The physician must either deliver the written prescription personally or mail it to the pharmacist.
 Once the prescription is filled, it may be obtained by the physician, the patient, or an agent of the patient
(e.g., family member
PHYSICIAN ASSISTED DYING

 Oral medication counseling must be offered to the patient or patient's agent and provided in
person, whenever practical, and in a private area; the pharmacist can offer to provide
counseling over the telephone

 Records must be kept and submitted to authorities

 Source: Physician-assisted Suicide, Ongoing Challenges for Pharmacists,Jennifer Fass and Andrea Fass
Am J Health Syst Pharm. 2011;68(9):846-849. https://www.medscape.com/viewarticle/742070_5
Contraceptives & Minors

 In 1982 Mrs Victoria Gillick took her local health authority (West Norfolk and Wisbech Area Health Authority) and the
Department of Health and Social Security to court in an attempt to stop doctors from giving contraceptive advice or treatment to
under 16-year-olds without parental consent.

 The case went to the High Court in 1984 where Mr Justice Woolf dismissed Mrs Gillick’s claims. The Court of Appeal reversed
this decision, but in 1985 it went to the House of Lords and the Law Lords (Lord Scarman, Lord Fraser and Lord Bridge) ruled
in favour of the original judgment delivered by Mr Justice Woolf:

 "...whether or not a child is capable of giving the necessary consent will depend on the child’s maturity and understanding and
the nature of the consent required. The child must be capable of making a reasonable assessment of the advantages and
disadvantages of the treatment proposed, so the consent, if given, can be properly and fairly described as true consent." (Gillick
v West Norfolk, 1984)

Source: British and Irish Legal Information Institute. Gillick v West Norfolk & Wisbech Area Health Authority, UKHL 7 (17 October
1985) obtained at
FRASER’S GUIDELINES

 The Fraser guidelines refer to the guidelines set out by Lord Fraser in his judgment of the Gillick case in the House
of Lords (1985), which apply specifically to contraceptive advice. Lord Fraser stated that a doctor (health
professional) could proceed to give advice and treatment:

 "provided he is satisfied in the following criteria:

 that the girl (although under the age of 16 years of age) will understand his advice;
 that he cannot persuade her to inform her parents or to allow him to inform the parents that she is seeking contraceptive
advice;
 that she is very likely to continue having sexual intercourse with or without contraceptive treatment;
 that unless she receives contraceptive advice or treatment her physical or mental health or both are likely to suffer;
 that her best interests require him to give her contraceptive advice, treatment or both without the parental consent." (Gillick
v West Norfolk, 1985)
Duty to report - not refuse?

 Duty to report – Child Care & Protection Act, 2004

 Sexual Offences Act 2009
The right to refuse

 Conscientious objection
 Conscientious objection in health care is the refusal to perform a legal role or
responsibility because of moral or other personal beliefs.

 refers to the desire or intent to refuse, or to the actual refusal of, a course of action
requested by a patient or expected by the ordinary standard of care.

 Conscience clauses” in law describe the right of physicians and other health care
providers to refuse to provide services such as abortions and emergency contraceptives
CONSCIENTIOUS OBJECTION

 On July 6, 2002, a University of Wisconsin-Stout student, went to the K-Mart in

Menomonie, Wisconsin, to fill her prescription for oral contraceptives, birth control pills.
The only pharmacist on duty, Neil Noesen, asked if she intended to use the prescription for
contraception. When she replied in the affirmative, Noesen, a Roman Catholic, refused to
fill the prescription, explaining that to do so would be against his religious beliefs. She
thought that he was kidding.
 But Noesen was very serious. As a devout Catholic, he had concluded that he could not
dispense contraceptives. He also refused to transfer the prescription or tell her how or where
she could get the prescription filled, all of which, he explained later, would, in his view,
constitute participating in wrongful behavior. Significantly, prior to employment at K-Mart,
Noesen had informed the district manager that he would not dispense contraceptives;
however, he did not mention that he would refuse to refer or to transfer prescriptions.
CONSCIENTIOUS OBJECTION

 The woman filed a complaint with the Wisconsin Department of Regulation and
Licensing's Pharmacy Examining Board. The found that the ordinary standard of care
"requires that a pharmacist who exercises a conscientious objection to dispensing of a
prescription must ensure that there is an alternative mechanism for the patient to receive
his or her medication, including informing the patient of their options to obtain their
prescription." Further, he found that Noesen's conduct constituted "a danger to the health,
welfare, or safety of a patient and was practiced in a manner which substantially departs
from the standard of care ordinarily exercised by a pharmacist and which harmed or could
have harmed a patient.“
 His ruling also limited Noesen's license, requiring him to notify any pharmacy where he
worked of any practices he would refuse to perform and how he would ensure patient
access to prescriptions that he declined to fill.1
THE RIGHT TO REFUSE

 The right to refuse does not include a right to obstruct—the patient must be informed
about the intent to refuse and alternative courses of action; otherwise it becomes a
troubling imposition of personal beliefs on patients, notably, female patients.
 Source: https://www.scu.edu/ethics/focus-areas/bioethics/resources/conscientious-refusal/