Grand Rounds (week 8): Scarlett on Ethics

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Ethics

Dr Scarlett begins with offering some historical perspective, including the advent of dialysis meaning that we have an additional technology for keeping people alive. In medicine ethics applies to research, health policy, and the duties, behavior and decisions of the physician. Some approaches to ethics include virtue, deontological, teleological (utilitarianism), principalism (autonomy, non-maleficence, beneficence, and justice), and the ethics of care. A virtuous doctor does not cheat on his taxes. The deontology approach has to do with fulfillment of duties, like calling the patient back. Teleology has to do with allocation of resources. Principalism is the main ethics topic found in medical textbooks. There are four basic principles to apply. Automomy of the patient means that they may make their own decisions, and have a right to good and thorough information. Nonmaleficence is doing no harm, beneficience is doing good by the patient, and justice has to do with treating everyone with respect and equality. The ethics of care is a newer practice that is less intellectual and more compassionate, but requires attention to boundaries.

Ethical dilemmas however do occur. Dr Scarlet recommends this approach. First name and clarify the problem, and research the situation and options. Get help, and analyze. Deliberate and reflect on the choice. Make a decision on whether or not to act, and take responsibility for that choice and action/nonaction.

The Albert Jonsen Model offers the 4 box method from his book on Clinical Ethics. The boxes, left to right and top to bottom, are: medical indications, patient preferences, quality of life and contextual features. The exercise involves filling in the boxes with this info: Medical Indications (including patient hx, dx, prog, condition acuteness, goals of tx, alternatives, ways the pt can be helped and harm can be avoided), Patient Preferences (expressed, information/consent, pt right to chose), Quality of Life (prospects of reutrn to normal life, bias at play?, plans for comfort and palliative care--this box less active in ND practice), and Contextual Features (family, provider, financial/economic, religious and cultural factors, legal implications).

She offers a case for us to work on, using this model. A second case is offered in which a 15 year old female is pregnant and wishes her pregnancy to be kept secret from her family and community. The conflict in the case is between the child's confidentiality and the family's need to know in order to care for her appropriately. Dr Scarlett makes the point that in dilemmas the wrong course of action is easy to see, but the options for right action are harder to clarify.

Some other principles that may be at play include holism, role of environment, commmunity, naturalism, relationism, spriitualism. A CAM interpretation of the principles of ethics may be found here: R Nash Alt Ther 1999 5(5): 92-95. The naturopathic interpretation is somewhat different from the conventional one. The conventional model is much more lenient about the use of potentially harmful treatments. Dr Scarlett suggests that naturopaths may be taking "do no harm" to a whole new level. Another article, by DE Guinn (in Alt Ther Health Med 2001 7(6):68-72) emphasizes the doctor patient relationship and the patient's culture and spiritual orientation.

Finally she points out that we each have individual values or principles that bring ethical challenges and obligations. Naturopaths further have the tenets of naturopathic medicine that we attempt to hold to. Some areas that are frequently problematic are conflicts with other practitioners, noncompliant patients, patients not wanting to follow recommendations, conflicts between minors and parents, the influence of the peer group, and the difference between what is illegal and what is simply bad form.

Shepoints out that new social media requires a conscious effort to create a professional image. Background checks now routinely include a scan of what's on the web about you.

If you do break the law your license could be revoked, or a new license refused by OBNM http://www.oregon.gov/OBNM/. See ORS 685.111. Since I am probably going to practice in a state where there is no license for naturopaths, I am studying carefully on the question of to what degree I will be able to practice.

She brings up a few challenging situations including "firing" a patient. Firing a patient is "at will" in Oregon, but laws vary so check in your jurisdiction. The convention is that you must give 30 days notice in writing, and keep a record in the chart. Usually people offer a general referral, as in back to a primary care physician they have seen before. There's an article in the New York Times called "Should a Doctor Fire a Patient? Sometimes its Good Medicine" by richard A Friedman, MD, published 9/27/05. Here's the link: http://www.nytimes.com/2005/09/27/health/27comm.html.

Apologizing to a patient is also a troublesome area. Reasons why someone might apologize: competence errors like missing something, procedural errors like botching a procedure. Usually docs express no intention of making the mistake again. The Oregon there are apology laws which allow the physician to apologize without admitting guilt. These do not exist everywhere.
Resources: See Annals of Internal Medicine 2008 149(11):811-815, and there is the statute: ORS 677.082 on the Expression of regret or apology by license. The final message that she offers is that we should "be human with folks", and they are more likely to forgive and return for more of what you have to offer.

Here's an acronym for dealing with an upset patient: BLAST: Believe, listen, apologize, satisfy, thank. My question based on this is what do you do when the patient cannot be satisfied?

Two statues that bear on the Duty to Report: ORS 685.220 and 222. 220 is about the obligation to report suspected violation of the law by a practitioner. 222 is about reporting when there is a suspicion that any licensed practitioner has engaged in illegal or prohibited conduct as defined by 676.150.

Conflict of interest concerns include: self dealing, accepting benefits, using confidential information, and influence peddling. There is a concern with using information gained in a medical setting for your own benefit. Getting "kick-backs" is also suspect.

Ethics applies at all times, regardless of situation. Patients are vulnerable and the doctor is in service to their needs. It is important to consider what is in the patient's best interest. Ethical practice is a considerably responsibility and requires a strong commitment on the part of the practitioner.