Evidence-Based Medical Ethics:

Inhaltsverzeichnis

Case-Based Medical Ethics in Practice
Preface by the authors
Foreword
Chapter 1: A brief introduction to medical ethics in Internal Medicine
Definitions of ethics and medical ethics
Why is medical ethics important? (teaching competency in ethics, teaching professionalism)
Evolution of medical ethics and its importance/role in modern medicine (from paternalism to informed consent)
Who determines ethical guidelines for medicine?
Difference/similarities between ethics and law
Purpose of the book (i.e. to stimulate thought and discussion, not cover all details of all ethical principles)
Chapter 2: The underlying principles of ethical patient care
Beneficence - a practitioner should act in the best interest of the patient. (Salus aegroti suprema lex.)
Non-maleficence - "first, do no harm" (Primum non nocere).
Autonomy - the patient has the right to refuse or choose their treatment (Voluntas aegroti suprema lex.)
Justice - concerns the distribution of scarce health resources, and the decision of who gets what treatment.
Dignity - the patient (and the person treating the patient) have the right to dignity.
Veracity - the patient should not be lied to, and deserves to know the whole truth about his/her illness and treatment.
Chapter 3: Putting ethics into practice - realities, limitations, and roadblocks
Practitioners and personal belief systems
Cultural competency and practice of ethical care
Statement about pharmaceutical company influence on education and practice
Medical oaths - Are they valid for medicine today? Are they fulfilled by practitioners?
The Patient Bill of Rights
Federal, state, local, and institutional regulations - how they intertwine and affect each other
Chapter 4: Advanced Directives, Living Wills, and the Health Care Power of Attorney (HCPOA)
Chapter 5: Case-based ethical dilemmas
How the reader should approach these cases
Where to find more information if needed

Case 1
Topic: Consent in the mentally ill or otherwise unfit (and 'in between' situations: delirium, psychiatric decompensation)
Subtopic: When does forcing an incompetent patient to undergo treatment limit their right to dignity and the principle of 'do-no-harm'?
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 2
Topic: When the HCPOA neglects their responsibility, or has other personal interests/potential gains
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 3
Topic: When the patient/their family bullies practitioners into unnecessary diagnostics/therapeutics
"C.Y.A." medicine
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 4
Topic: When an estranged family member or spouse suddenly appears to make decisions
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 5
Topic: How to deal with an inpatient behaving badly (psych consults, behavioral contracts, room restriction etc.)
Outbursts
Substance abuse
Illegal activity (e.g. drug-dealing)
Known criminal warrants
Inappropriate actions or remarks
Admitted for ulterior motives (secondary psychologic gains, homelessness, etc.)
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 6
Topic: When DSS consults are needed
Child abuse/neglect
Elder abuse/neglect
Spousal abuse
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 7
Topic: When a patient has 'burned all bridges' and no discharge planning is possible
No nursing home or rehab center will accept the patient
No home health services will accept the patient
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 8
Topic: Can a practitioner refuse to admit a patient? To see a patient in the office (e.g. administrative discharge)?
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 9
Topic: When a patient makes 'bad' decisions (e.g. will accept some therapies and not others, such as some blood products but not others, some procedures but not others, DNI but not DNR, etc.)
Does a practitioner follow the patient's wishes? Do they refuse to treat?
Subtopic: When a patient is guided by incomplete, or misinformation (e.g. from the internet)
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles


Case 10
Topic: When a patient's same-sex partner has no legal rights and is excluded by a family
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 11
Topic: When a patient has a contagious disease (e.g. HIV) and their partner is not aware
Subtopic: When a partner/family does not have all the information needed to make decisions for a patient (e.g. when to disclose diagnoses such as HIV-positivity, substance abuse, suicidality)
Subtopic: When confidential information is inadvertently leaked to those who 'don't need to know'
Subtopic: What diseases are 'reportable'?
Subtopic: Do patients avoid testing for confidentiality fears?
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 12
Topic: When a family will not accept a terminal prognosis (i.e. futile 'full codes')
Should a family be present during the code?
Subtopic: When a patient themselves is unrealistic about prognosis
Subtopic: When is a patient 'terminal'? (i.e. definition of brain death)
Subtopic: When is it appropriate to change the focus of care to comfort/hospice?
How do a practitioner's personal beliefs affect this guidance?
The concept of dignity/therapeutic death v. Euthanasia
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 13
Topic: When there is no one to make decisions for a patient (e.g. John/Jane Doe in ICU, wards of the state)
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 14
Topic: When a mistake has been made by a practitioner (what/how to/how much to disclose)
Mistake by primary practitioner; mistake by other/outside practitioner
Subtopic: Caring for a patient after a poor outcome or mistake (i.e. how is care affected)
Subtopic: When a patient makes a reference to a grievance or verbally disparages another practitioner
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 15
Topic: When what a patient needs cannot be obtained (e.g. financial/insurance limitations)
Tests/procedures (e.g. colonoscopy in an uninsured/pre-Medicare patient aged 50 to 64 years old)
Treatments
A different medical team ("I want a new doctor"), especially when no others will take your "difficult" patient
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 16
Topic: When next-of-kin (NOK) disagree with each other
Subtopic: Which of the NOK has 'seniority'? Are legal definitions for NOK equivalent to ethically 'best' choices?
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 17
Topic: When a toxicology screen is ordered without patient consent and comes back positive
Subtopic: When tests are ordered 'in emergency situations' without patient consent (e.g. HIV tests)
Subtopic: When a practitioner is potentially exposed to infectious agents (e.g. via a needlestick) and a patient is refusing further testing
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 18
Topic: When a patient 'signs out against medical advice'
Practitioner obligations
How can competence be quickly assessed and assured?
What about a patient with contagious disease (e.g. TB)? Can they be allowed to leave?
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 19
Topic: When a patient requests a clinical interaction be recorded
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 20
Topic: When a family member requests patient information not be shared with the patient, or with other persons
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 21
Topic: When a patient requests to not be seen by a (specific, or any) medical resident or student
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 22
Topic: When a patient requires or demands large amounts of time from a practitioner
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 23
Topic: How to prescribe medications to someone who has attempted suicide (e.g. with pills)
Subtopic: How to accurately assess and document safety in a depressed patient
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 24
Topic: When a colleague demonstrates suspicious behavior
Memory problems
Substance abuse
Outbursts
Inappropriate relationships with or behavior toward patients, coworkers, etc.
Dishonesty
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 25
Topic: When a language translator is not available (or only a family member/hospital employee is)
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 26
Topic: When a patient is repeatedly readmitted to the hospital due to non-adherence (e.g. with therapy, diet, etc.)
Where does a patient's responsibility for their own care and well-being begin?
The 'cry wolf' syndrome
Should a procedure be repeated if a patient's behavior may have caused failure of the first one?
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 27
Topic: When lawyers or law enforcement want to know patient information (HIPAA/confidentiality and the law)
Blood alcohol level or toxicology testing
Rape exam results
Hidden drug stores (e.g. body cavities)
When should access to a crime victim be allowed? To a suspected perpetrator?
What right to privacy do prisoners have with regard to history, physical exam?
Can/should discharge plans be shared with prisoners?
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 28
Topic: When a patient requests disability certification, handicap plates, etc. - or when they request renewal of a revoked driver's license (e.g. can a practitioner-patient relationship be maintained when a patient doesn't get what they want?)
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 29
Topic: How much resources should be spent on a single patient's case? (i.e. public health cost v. value of human life)
Subtopic: When do you stop looking for answers to a patient's 'mystery problem'?
Subtopic: When if ever do you call a case futile based on cost/public burden of care?
Subtopic: What resources need to be made available at a hospital for 'rare' situations or patients?
MRI for the morbidly obese
Male Pap smear equipment
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 30
Topic: How much information must a practitioner share with a patient?
Explanation of logic for decisions/opinion/treatment plan, explanation of test results
Explanation of all potential side-effects
How much information is needed for 'informed consent'?
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 31
Topic: How to deal with a patient seeing two or more practitioners (same specialty, overlapping meds, etc.)
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 32
Topic: How to manage chronic pain (e.g. are 'pain contracts' ethical?; how is pain objectively assessed?)
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 33
Topic: At what age, if any, do you stop health maintenance disease screening?
Subtopic: At what age, if any, to you stop invasive procedures? Placing pacemakers?
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 34
Topic: When can a practitioner withhold therapy from a patient based on their behavior?
Examples: HAART therapy for HIV, HepC treatment, anti-coagulation
Behavior: Non-adherence to therapy, substance use/abuse, continued tobacco use/abuse
Subtopic: When does a patient qualify for a transplant? Is 6 months sobriety appropriate?
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 35
Topic: When a Jehovah's witness needs a blood transfusion
Are blood substitutes allowed?
Should surgery/organ transplantation be withheld if transfusion will not be allowed by the patient?
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles
Case 36
Topic: How far does screening go?
Breast cancer genes, hypercoaguability work-up in family members of a patient with a new diagnosis
Will this lead to insurance decisions re: 'pre-existing conditions'?
. Narrative of clinical scenario with specific example of ethical dilemma
. Questions for thought/discussion
. Explanations of underlying ethical and legal principles

Comprehensive Exam
Suggested reading and internet resources
Glossary of terms
Index

Leseprobe

Jetzt reinlesen: Leseprobe (pdf)

Pressestimmen

From the reviews:

"Fictional case records that encapsulate many of the problems encountered frequently by comprehensive therapists become the basis for this nice, inexpensive, little manual. ... It becomes an easy reading monograph that can be appropriately sampled as time permits and will spare time when similar cases are encountered in clinical practice." (William H Wehrmacher, Comprehensive Therapy, December, 2008)

"This is the newest addition to case-based clinical ethics books. ... the purpose of this book is `to provide a method for the reader to learn how to systematically manage dilemmas seen in the everyday practice of medicine.' The authors ... have several audiences in mind for the book: medical students and residents, nursing students, undergraduate and graduate medical ethics courses, as well as clinicians." (Michele K. Langowski, Doody's Review Service, November, 2008)

"Synder and Gauthier have taken a very interesting, and surprisingly seductive, approach to teaching medical ethics. ... the book would be a valuable addition to many bookshelves." (Ruth Wilkinson, Public Health Ethics, January, 2009)

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