Law326 Modules (4-11)

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Module 4 – Introduction to Ethics Ethics – what and why? What is ethics ? - The study or evaluation of human conduct in the light of moral principles (can be viewed as the standard of conduct that an individual has constructed for themselves) Why discuss ethics? - Healthcare professions that are concerned with curing illness, relieving suffering, and caring for people are ethical professions. - The existence of illness necessitates a relationship of dependence on a healthcare professional who is obligated to act in the patient's best interest in a way that respects the patient's unique experience of illness. - Ethical does NOT mean complying with the law Paternalism - It is an issue at the basis of many ethical debates - It occurs when a health care professional takes it upon themselves to limit/restrict/construe the information provided to a patient. - In certain situations, they do so without the patient’s consent. Major Ethical theories - Two dominant trends: Consequentialist ethics: Utilitarianism is the most well-known - Focuses on the consequences of actions - The duty is right if the consequences are right - Utilitarianism is the most well-known form of consequentialist ethics. - One should act in order to maximize the greatest good or happiness for the greatest # of people. - Critics of this ethical theory often focus on what they consider the hedonistic quality of equating utility with pleasure Deontological ethics : Denotes from the Greek word duty - a duty which one thinks should be universally applied to all is mandatory regardless of the consequences. - It does not direct us to assess details of people or situations - They hold despite consequences (you cannot hurt another in self-defence) - Everyone gets the same treatment no matter the expectations for the outcome Right- based ethics - A legal right to access your publicly funded health system is granted to all Canadians under the Canada Health Act, R.S.C 1985 - The rights-based ethical theory reflects our intuition that we have certain things as a matter of right, and this cannot be violated. Negative rights – correlate with duties to refrain from doing something (privacy rights, secure against unreasonable search or seizure) Positive rights – correlate with duties to help in some manner (healthcare professions are bound to help someone who claims a right to healthcare. (right to housing) Legal rights – justified by legal principles and/or rules, moral rights by moral rules Violation of rights – unjustified action against a right Infringement of rights – a justified action which overrides a right
Medical ethical principles 4 medical ethical principles… 1) Autonomy o This stands for political self-governance in the city-state. o Respect for personal autonomy equates with personal self-governance or personal control o Example: patients are generally encouraged to be involved as much as possible in their care 2) Beneficence o The obligation to do good connects to utilitarian theory o Act to prevent harm to do good 3) Non-maleficence o The duty to do no harm o Do no harm o Ex: I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. There is a fiduciary (legal or ethical relationship of trust) relationship between healthcare professionals and the patient that demands beneficent acts. 4) Justice o Concepts of fairness, desert (punishment and redistribution), and entitlement (distribution) o Fair, due, or owed Distributive justice: the proper distribution of social benefits & burdens, refers to primary social goods Formal equality: alike cases should be treated alike Case law – look at the cases from various ethical perspectives (4 principles) Rodriquez v. British Columbia [1993] 3 S.C.R 519 - The SCC upheld the prohibition on assisted suicide - They ruled it was constitutional and justified for the protection of vulnerable individuals who might be influenced to end their lives in moments of weakness - The majority opinion held that the blanket prohibition was necessary to protect life and prevent its depreciation by allowing it to be taken - Section 7 of the Canadian Charter of Rights and Freedoms and any potential breach was justified under Sec1 of the charter - The decision established that while competent individuals have the right to refuse treatment and thereby choose death, they do not have the right to obtain assistance from others to end their life Policy aims under consequentialist ethics theory - The BCCOA emphasized the ethical distinction between palliative care and physician-assisted suicide. There is a fine line between the two that should only be crossed by the courts. - The court highlighted the medical profession's position that the intent behind administering drugs for pain relief differs from setting up a system for patients to end their lives. Until Parliament addresses this ethical dilemma after consulting with medical professionals and other stakeholders, the court believed it should not overstep the Charter and concluded that physician-assisted suicide should be allowed. Winnipeg Child and Family v. G - A pregnant woman addicted to glue sniffing, with 3 previous children becoming permanently disabled due to her addiction, was ordered into custody for treatment until the birth of her child. - The COA overturned the decision, stating that the existing law did not support such an order and the issue was best addressed by the legislature rather than the courts.
- The SCC dismissed the further appeal, stating the unborn child was not considered a person with rights as it had no existence apart from the mother at that stage. R. v. Latimer - Saskatchewan farmer killed his daughter, 12-year-old Tracy, who suffered from severe cerebral palsy, was quadriplegic and had the mental development of a four-month-old, only able to communicate by facial expressions, laughing and crying. - It was not so much whether it was a crime but whether the court's responsibility was to enforce a statutory sentence of life imprisonment without possibility of parole for 10 years. B . (R). v. Children’s Aid Society of Metro Toronto - Jehovah’s Witness's parent's child needed a blood transfusion, but the parents refused to present consent. There was a temporary wardship order that allowed CAS to consent to treatment. - Reached the SCC majority rules the parent’s liberty interest was infringed under section 7 of the Charter, it was justified by principles of fundamental justice o Parents have a protected sphere of decision-making for their children; their ability to deviate from medical recommendations in the child’s best interests is limited. Discussion #4 1. Consider whether overriding refusals of treatment by patients (e.g. Jehovah’s Witness patient’s refusal, on religious grounds, of a blood transfusion) constitutes a) a violation of a right or b) an infringement of a right. c) Consider an opposing argument: whether or not this action would constitute medical paternalism. Make sure you have included your opinion with support on all 3 of these (violation of a right, infringement of a right or paternalism. (See "Rights Based Ethics" for help distinguishing violations and infringement). The issue presented of overriding refusals of treatment by patients, more specifically in the case involving the Jehovah's Witness religious objection to refusing blood transactions, is a very complex ethical dilemma. It is essential to balance respecting the right to self-determination and ensuring one's health and safety. Looking at the realm of medical ethics, a violation of rights signifies that there is a disregard for a fundamental ethical principle or a legal right. Regarding this case, there could be a consideration of a violation of a patient's right to autonomy, primarily since it's based on religious beliefs and reasoned from the fact that a healthcare provider was to ignore a patient's refusal of treatment against their will. Autonomy is a cornerstone of medical ethics, acknowledging patients' authority to make decisions regarding their bodies, even if these choices diverge from medical recommendations. Further on, infringement of a right occurs when there is a valid reason to restrict someone's rights in specific situations. Referring to the Jehovah's Witnesses' decline in blood transfusions; a healthcare provider may argue that administering one can be crucial to saving a patient's life. Refusing treatment can be seen as an attempt to undermine a patient's autonomy; overriding it can be deemed justifiable as there may be concerns for a patient's well-being. Medical paternalism involves healthcare professionals making decisions for patients without informed consent, perceiving it to be in the patient's best interests. Disregarding a patient's rejection of treatment could also amount to medical paternalism if carried out without their consent and against their wishes. Whether overriding refusals of treatment by patients constitutes a violation of a right, an infringement, or a right to paternalism depends on the situation's particulars and the patient's capacity for decision-making. As previously stated, patient autonomy and the right to self-determination are the cornerstone of medical ethics; however, this principle must be weighed against one obligation toward the patient's well-being. Therefore, any decision that is made to override
treatment should be made very carefully, not only involving ethical committees but also adhering to legal and ethical guidelines. 2. Consider the Winnipeg Child and Family case. Relying on the ethical theories and principles discussed within this module as a framework for your answer discuss the ethical concerns raised in this case. (See module page “Winnipeg Child and Family v. G.”) Autonomy: The breach of confidentiality in this case directly violates G.'s autonomy. Autonomy, in the medical context, refers to a patient's right to self-determination and decision-making regarding their own healthcare. In this case, G. was not given the opportunity to make informed decisions about the disclosure of her information. Respecting autonomy means involving patients as much as possible in decisions about their care, which was not done in this situation. Beneficence: The principle of beneficence requires healthcare professionals to act in the best interest of their patients and to prevent harm. However, in this case, the social worker's actions did not align with beneficence. By disclosing G.'s sensitive information without her consent, the social worker potentially caused harm by exposing her to judgment and stigma. Additionally, the disclosure did not serve G.'s best interests but rather prioritized the interests of the organization. Non-maleficence: Non-maleficence emphasizes the obligation to avoid causing harm to patients. The breach of confidentiality in this case directly violates the principle of non-maleficence. By disclosing G.'s information without her consent, the social worker breached the trust and confidentiality that are essential for the therapeutic relationship. This action not only caused potential harm to G. but also undermined the integrity of the social work profession. Justice: Justice in the medical context involves concepts of fairness and proper distribution of resources and benefits. While the breach of confidentiality in this case may not directly relate to distributive justice, it does raise concerns about fairness and the proper treatment of individuals. G. was not treated fairly or respectfully when her confidential information was disclosed without her consent, highlighting a failure of justice in this situation. In summary, the Winnipeg Child and Family case can be analyzed through the lens of the four medical ethical principles, highlighting the ethical concerns raised by the breach of confidentiality and the importance of upholding principles such as autonomy, beneficence, non-maleficence, and justice in healthcare practice. Part B: *For each of the following situations, consider its ethical implications and incorporate two ethical theories from the module, noting any additional information you might need in order to resolve the situation if you think that is necessary. 1. A patient requests treatment that the healthcare professional considers futile or non-beneficial. Looking at this situation from a utilitarian perspective, the action of providing furtile or non-beneficials treatment can be evaluated on the basis of its consequences. As we learned, utilitarianism seeks to maximized overall well-being or happiness for the greatest number of people. A healthcare profession in this situation may consider the potential suffering that furtile treat could cause or the allocation of resources that could be better used for patients who could benefit from them. utiliitarism might support that withholding treatment in certain case where its deemed furtile or non-beneficial to avoid the
unnecessary hard and continue to maximize wellbeing. Additionally, deontological ethics tends to prioritize principles and duties regardless of outcomes. In this situation healthcare professionals might weigh might weigh beneficence (doing good) and non-maleficence (avoiding harm). One could argue that futile treatment contradicts beneficence, lacking benefit and risking harm breaching non-maleficence by exposing the patient to unnecessary risks. Hoever, obtaiing more details about a patietns medical status, prognosis, and care goals is a very critical part for informed decision-making. Consulting with colleagues, ethics committess or even involving the pateints and family can help to aid in a thoughtful resolution. 2. Do Not Resuscitate (DNR) Order is written without the agreement of the patient or substitute decision maker. Writing a DNR order without the patient's agreement or a substitute decision-maker can be justified if it prevents suffering and preserves resources for others. However, utilitarianism prioritizes overall well- being, respecting the patient's wishes, and avoids vain interventions. When emphasizing patient autonomy, deontological ethics requires involving patients or their substitutes in care decisions; writing a DNR order without consent risks the violation of autonomy and self-determination. Proving why obtaining informed consent would remain a priority despite potential utilitarian drawbacks. To solve this kind of issue, it is vital that the healthcare profession acquire more details on the patient’s wishes, values and care goals, which is why Consulting the patient or their substitute, alongside considering advance directives and legal obligations, is crucial for ethical resolution. A patient expresses a wish to die and requests medication. Granting a patient's request for end-of-life medication might align with utilitarianism if it can reduce overall suffering and promote well-being for the patient. If a patient's suffering is intolerable and their quality of life is severely diminished, euthanasia or assisted suicide could be justified to alleviate their pain. Similarly, prioritizing autonomy and beneficence, deontological ethics would be goosing a healthcare profession to consider the patients right to make decisions about their life. They must not forget to uphold their duty to do good and prevent harm therefore exploring alternatives like palliative care and ensuring comprehensive support services may be necessary. Additionally gathering certain details about the patients medical conation and reasoning for their request is crucial because if a helacaree profession is able to understand their values, beliefs and care goals they can make decisions to align with their wishes. Module 5 – Regulation of the health professions in Ontario Regulation - Legislation limiting the practice of certain jobs to those with specific training, education, and credentials and governing the practice of these jobs to protect public safety as we as to ensure that work is done ethically. o A tool that allows governments and other policymakers to establish norms to which health professionals must adhere (scope of practice and standards of practice) Self-regulation - Self-regulation is the regulation by the profession of its own members - Provides greater expertise and technical knowledge of practice than independent agencies. o Peer pressure can help to ensure colleagues feel the pressure to adhere to standards and rules set by their profession. o Administrative costs are internalized by the profession rather than passed on to taxpayers. o There should be flexibility with rules adjusted to meet the public's changing expectations. - Contemplates ethical standards of conduct that extend beyond the law and raise the standard of behaviour
Criticisms of self-regulation - Failure by the various self-regulating organization to ensure profession competence of the profession to protect patients - There is a perception that self-regulatory standards are weak, their enforcement ineffective and that punishment is secret and mild. Types and theories of self-regulations Types of self-regulation Input regulation - focuses on who may be admitted to membership into a profession through licensure and is though of as being proactive. o Licensure will follow a school component (university followed by a further regulated college education component, including one or more exams) Output regulation - Focuses on performance by those in the profession (civil liability, monitoring and discipline of health professionals, external assessment) Theories of self-regulation - Regulation of health professionals if often said to be subjected to analysis between “public” & “private” theories Public interest theory - Regulation is developed to further the “public interest” (public interest is dependent on those who exercise power in society and provide for its definition or lack thereof) - Criticism is compounded by doubts regarding expertise, objectiveness, efficiency, and competency of regulators Private interest theory - They were developed to address the demands of private interests (health professionals themselves and perhaps others with influence). - They rely on the assumption that individuals act to advance their self-interest and do so rationally o Ex: in Ontario dentists have tried to prevent dental hygienists from forming independent practice Serving public interests - The legislative intent for regulation of health professionals is primarily based on serving the public interest, including (protection from harm, quality of care, accountability, equity and equality) Regulation of Health professions - The Regulated Health Professions Act of 1991 came into force on December 31, 1993. It enabled legislation for the self-regulation of health professions in Ontario - Key purpose: protect the public interest and provide the public with assurances of appropriate and quality healthcare services - Consists of main act and 2 schedules o Schedule 1: a list of 26 self-regulated and governing health professions o Schedule 2: health professions procedural code, which applied to all of the health professions and profession-specific acts and regulations Regulated health professions statute law amendment act - Sets the framework to expand scopes of practice for 15 names health professions set out in it. - 5 separate new acts have received royal assent and have been or will be proclaimed after transitional matters have been resolved - Duty: protect the public, making sure healthcare professionals are safe, ethical, and competent
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