Medical Ethics and

Leadership
Communication
Resource Allocation
 Resource Allocation
Toy, Eugene C.; Toy, Eugene C.; Raine, Susan P.; Raine, Susan P.; Cochrane, Thomas I.; Cochrane, Thomas I.. Case
Files Medical Ethics and Professionalism (p. 49). McGraw-Hill Education. Kindle Edition.

• A 32-year-old man with an artificial aortic valve is admitted into the hospital with acute
shortness of breath. He is found to have aortic valve insufficiency and a large vegetation
of the aortic valve. Physical examination reveals fresh track marks on his arms, and
urinalysis shows opiates. The patient admits to using intravenous (IV) heroin.
• The patient is treated with IV antibiotics and is medically stabilized; however, the extent
of the aortic valve damage is such that surgical replacement of the aortic valve is
indicated.
• The cardiovascular surgical team is refusing to take the patient to surgery due to
continued IV drug use and cites resource allocation and medical futility as reasons to
deny surgery.
 Case Study cont’d
• What are the ethical issues involved with this patient?
• Does the cardiovascular surgical team have ethical standing to refuse
surgery?
 Case Study Summary
• A 32-year-old man with an artificial aortic valve is complaining of
shortness of breath. He is found to have aortic valve insufficiency and a
large vegetation of the aortic valve and needs surgical valve replacement.
The patient admits to using IV heroin. The cardiovascular surgical team is
refusing to take the patient to surgery due to continued IV drug use.
 Learning Objectives
1. Describe the ethical principles in health care resource allocation.
2. Describe the role of the physician in resource allocation and advocating
for patients
3. List the criteria used in deciding the equitable and appropriate allocation
of scarce resources.
 The presenting patient....
• Clinical Information
• He is experiencing shortness of breath due to aortic valve insufficiency
• He needs an artificial aortic valve replacement

• Social Information
• IV drug user
• Non committed to caring for previous artificial valve
 The real dilemma...

BEST INTEREST VS FRUSTRATED DOCTORS

 Basic Ethical
Principles
• Beneficence
• Maleficence
• Justice
 Ethical Issues

• Resource allocation
• Medical futility
• Physician advocacy
 Resource Allocation
• The constellation of decisions and actions that prioritize health care needs.
 Medical
Futility
• A judgment that further
medical treatment of a
patient would not have
useful or successful
results.
Argument to refuse surgery:
• The patient will likely continue IV drug use
that will result in future complications and
failure of the new artificial aortic valve.

• The artificial aortic valve and surgeon’s time

could be utilized for other patients who do not
participate in behaviors known to negatively
affect the outcomes of the procedure.
 • Cure of disease

The • Maintenance or improvement of quality of

life through relief of symptoms, pain, and
general suffering
goals of
• Promotion of health and prevention of
medicine disease
are as
follows: • Prevention of untimely death
 • Improvement of functional status or
maintenance of compromised status

The • Education and counseling of patients

general regarding their condition and
goals of prognosis

medicine
• Avoidance of harm to the patient in
are as the course of care
follows:
• Providing relief and support near time
of death
An old medical maxim sums up the goals of
medicine concisely:

“Cure sometimes, relieve

often, comfort always.”
Health care resources
are limited
• Health care facilities
• Hospital beds
• Supplies
• Organs
• Personnel
 There is also a limit
to:
• Operating room time
• Turn around time for investigations
• The number of tests that can be
performed in a given day
So who determines who receives these limited
resources?
So who determines who receives these limited
resources?
 According to The Principles of Medical
Ethics of the American Medical Association
(AMA),
• “A physician shall be dedicated to providing competent medical
service with compassion and respect for human dignity.”
•
• Beneficence: A physician also has a duty to do all he or she can for the
benefit of the individual patient
• Advocacy: A physician also has a societal duty to speak on behalf of
patients regarding the allocation of health care resources.
 Decisions should be based on appropriate
criteria relating to medical need
• Likelihood of benefit
• Urgency of need
• Change in quality
• Duration of benefit
• The amount of resources required for successful treatment
 Decisions should be based on appropriate
criteria relating to medical need (Q1)
• These criteria prioritize patients who are assessed to have a greater
likelihood of benefiting from treatment
• Should treatment be provided where the benefit is minimal?

• The purpose of this resource allocation system is to maximize the use of

limited resources to provide maximum benefit to society
 Decisions should be based on appropriate
criteria relating to medical need (Q1)
• Define Resource Allocation
• In the present case, how is the surgery team using these criteria to
argue?
 Decisions regarding should be based on
appropriate criteria relating to medical need
• In the present case, the surgery team is using these criteria to argue that
another patient who does not use IV drugs would benefit more from the
time and money spent on an artificial aortic valve replacement by being
able to utilize it for more years.
 Decisions should be based on appropriate
criteria relating to medical need (Q2)
• The surgery team believes another artificial aortic valve replacement in
this patient is “futile” because he will continue to use IV drugs and will
get another infection that will require another valve in the future.

• Define Futility of Care

• Can the surgical team accurately predict this likelihood?
 Predicting and defining outcomes
• The patient in this case will likely benefit from a new
artificial aortic valve even if it is for a shorter period of
time than a patient who does not use IV drugs.

• There are also other nonmedical factors that contribute

to a patient’s likelihood of benefit, such as
• Compliance
• Finances
Pause........
• Many of these non medical factors are
not permanent and can be overcome.
• Consider the nonmedical factors or
behaviours that directly affect the
patient’s likelihood of benefit

This Photo by Unknown Author is licensed under CC BY-NC-ND

 Quality of Life (Q3)
• Defining quality of life and quantifying improvement are difficult tasks.
• The AMA defines quality of life in terms of functional status.
• Although functional status can be objectively assessed by physicians, the
attitude toward a certain functional level is patient dependent.
• A disability may make life not worth living for some patients, whereas others may
view it as acceptable.
 Quality of Life (Q3)
• Define Quality of Life
• Define QALY
• In this case, how will the patient’s functional status, and thus quality
of life change?
 Quality of Life (Q3)
• Patient’s Quality of life is likely to improve with a new heart valve
 Urgency of Need
• This criteria applies when the scarcity of the resources changes.
• E.g. Pandemic
• When resources are especially scarce, priority should be given to the
sickest patients until the scarcity situation improves.
 Urgency of Need
• How can this criteria can be applied to the present case?
• The surgery team’s operating room time and staff
• The patient appears to be stable and can be medically sustained for a period of time.
• However, these criteria should not be used to deny current patients treatment
because others with more urgent need may present themselves.
• The question in this case refers to whether the patient should receive the
treatment at all; it is not addressing the timing of the treatment.
 Amount of resources required
• When resources are exceptionally scarce
• May be allocated to those who will require less of the resource
• This maximizes the number of patients who could benefit from the resource
• Including human resource

• These criteria do not apply to this particular case.

 Additional Criteria for allocating scarce
resources: True or False
1. Ability to pay
2. Contribution of the patient to society
3. Perceived obstacles to treatment
4. Contribution of the patient to his or her own medical condition
5. Past use of resource
ALL FALSE: ALL INAPPROPRIATE AND UNETHICAL
 CONCLUSION
• The surgery’s team has an underlying bias toward the patient using IV
drugs
• The perceptions about those who use IV drugs and their contribution to
society should not affect the team’s decision-making.
• In addition, efforts to address the patient’s obstacles to successful
treatment (eg, a drug rehabilitation program) have not been approached.
•
 CONCLUSION
• Based on the appropriate medical criteria, this patient should undergo the
artificial aortic valve replacement surgery.
• The surgery should not be denied to the patient based on his past, current,
or future IV drug use.
• Instead, the team should help the patient stop his drug use to prevent
future infections and complications.
 COVID- 19
WHO GETS THE FIRST VACCINE ?
 The Law

To resolve To establish and

To maintain those
To promote civil disputes without define standards
standards and
order resorting to use of of acceptable
punish ‘offences’
force behaviour

To provide rules To provide fair

To do justice and
enabling trade recompense for
put right wrongs
and business injury
 Medical Law

Majority of cases are civil law

Majority of remainder criminal
law
 Legal terms
Claimant
• The injured party or the person accusing the defendant of negligence

Defendant
• The person or authority accused of negligence

Malpractice
• Occurs when a patient is harmed by a medical professional who fails to
competently perform his or her medical duties
 Civil Law Cases

• Majority Medical Negligence:

• A duty of care
• Breach of duty of care
• The breach caused injury/harm: Causation
 Duty of Care
• A duty of care must have been established. It must be shown by the that
the defendant owed the claimant a duty of care.
 Breach of Duty of Care
• There must be a standard of care that could be expected from
the defendant
• The standard of reasonable care
• The level of care expected from a doctor in similar capacity
• The standard of care doctors are expected to reach was asserted by
Bolam v. Friern Hospital Management Committee [1957].
 The Standard of Care- Bolam Test
• The standard of care was set as that of ‘the ordinary skilled man
exercising and professing to have that special skill’.
• Applicable to all aspects of treatment, diagnosis, the disclosure of
information or risks to patients.
• This standard was possibly modified in Bolitho v. City and Hackney
Health Authority [1998], where it held that a court must find the medical
opinion to be ‘reasonable’ and ‘responsible’
 Causation

• The claimant must then show that that

breach of the duty of care caused the
damage they claim to have suffered
• The ‘but for’ test.
• The claimant must demonstrate that but for
the defendant’s negligence, he would not
have suffered the harm in respect of which
he seeks damages.
 Barnett v. Chelsea and Kensington HMC
[1969]
• A casualty officer refused to attend three night watchmen who were
vomiting after drinking tea.
• One later died from arsenic poisoning.
• A claim filed by the spouse. Though there was a breach of duty, the claim
failed because, even if he had received treatment, the man would have
died anyway and there was therefore no causation.
Damages
 Gross Negligence- Criminal Law
• Infrequent
• The most severe form of negligence in a medical malpractice claim.
• The law defines gross negligence as a “reckless disregard for the safety
of others.”
 Gross Negligence- Criminal Law
• Gross negligence is a step beyond simple mistakes or lack of reasonable
care.
• It is an error so egregious as to appear to violate a patient’s rights
consciously or intentionally.
• A physician may be guilty of gross negligence if he or she demonstrates a
lack of regard to patient health and safety during treatment or care.
• Or takes a deliberate action the physician knows – or reasonably should
know – will cause patient harm.
 Examples of gross negligence
• Operating on a patient while drunk or intoxicated
• Ignoring a patient in an emergency room out of discrimination
• Intentionally causing harm to a patient
• Knowingly executing an operation that the hospital does not allow the
surgeon to perform
• Operating on the wrong patient or body part
 The medical student and the law
• If you undertake a task which you know – or ought to know – that you are not
qualified or sufficiently experienced to perform, you may be guilty of negligence.
• If a patient were to suffer harm as a result of your exercising less than reasonable
care, you might be held personally liable/legally responsible.
• You could in theory be sued, but in practice the patient would sue the supervising
practitioner or the Hospital
• It is unlikely that the hospital authority would refuse to assist a student with any
defence that might be necessary, or to meet damages if awarded.
 The medical student and the law
• The level of responsibility which had been delegated to the student by the
supervisor must be held to be reasonable in regard to the student’s
experience and level of attainment.
• If you had been given a task to perform for which you were not
sufficiently skilled, a court would probably conclude that you were not to
blame for having performed it badly.
• But never forget to be true to yourself first anforemost (Ethics)
Poor Communication + Medication Error
• DUTY OF CARE

• BREACH OF DUTY OF CARE

• INJURY/DAMAGE CAUSED
 Medical Errors + Law
• Medical errors may qualify as malpractice if the patient can prove that a
reasonable physician would have properly evaluated the situation or
performed the operation based on his or her medical education and
training.
Know your limits + Act quickly
• DUTY OF CARE

• BREACH OF DUTY OF CARE

• INJURY/DAMAGE CAUSED