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Ethics in Radiation Sciences: Improving our Ethical Fitness

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Title: Ethics in Radiation Sciences: Improving our Ethical Fitness


1
Ethics in Radiation Sciences Improving our
Ethical Fitness
  • Rosanna Macri, Ethicist
  • Member, Joint Centre for Bioethics, University of
    Toronto
  • Adjunct Lecturer, University of Toronto,
    Department of
  • Radiation Oncology

May 28 30, 2015, Montréal, Québec
2
Disclosure Statement No Conflict of Interest
I do not have an affiliation, financial or
otherwise, with a pharmaceutical company, medical
device or communications organization. I have no
conflicts of interest to disclose ( i.e. no
industry funding received or other commercial
relationships). I have no financial relationship
or advisory role with pharmaceutical or
device-making companies, or CME provider.
May 28 30, 2015, Montréal, Québec
3
Objectives
  • Review the history of ethics in Radiation
    Sciences
  • Explore a few common ethical issues in Radiation
    Sciences
  • Resource Allocation VIP Treatment
  • Consent Capacity SDM
  • Privacy Confidentiality
  • Review ethics skills Strategies to improve
    ethical fitness
  • Introduce a tool to help work through ethics
    issues

4
Did you know
  • Human radiation experiments (1944-1974)
  • Almost 4000 experiments sponsored by US gov.
  • The ringworm affair
  • Children treated for scalp ringworm
  • Pregnant women and babies
  • Pregnant women and babies were given radioactive
    iodine to better understand its uptake by the
    thyroid gland
  • Vitamin drinks - 829 pregnant mothers in
    Tennessee contained radioactive iron to
    determining how fast the radioisotope crossed
    into the placenta
  • Mentally disabled children
  • Fed oatmeal containing radioactive calcium and
    other radioisotopes, in order to track "how
    nutrients were digested
  • Told they were joining a science club

5
Ethics Issues Can Cause Moral Distress
  • Have you ever encountered a situation in which
    you felt you had no choice but to do something
    that
  • You believed was morally wrong?
  • Or violated your professional integrity?
  • Or was contrary to your code of ethics?

6
How did you feel?
7
Common Ethics Issues
  • Resource Allocation VIP Treatment
  • Consent Capacity SDM
  • Privacy Confidentiality

8
Resource Allocation
9
(No Transcript)
10
VIP Treatment
11
CAMRT Code of Ethics
  • Fairness, accountability and integrity
  • Prioritize the use of resources according to need
  • Utilize and distribute resources over which they
    have control in a fair and responsible manner
  • Advocate for working environments that support
    safe, competent and ethical practice
  • Contribute to interdisciplinary collaboration
  • Participate in collaborative problem solving

12
Consent, Capacity SDM
Mr. T is an 85 year old man. He has recently been
admitted to a palliative care unit. Due to Mr.
Ts diagnosis of metastatic prostate cancer, two
months ago he was given a prognosis of 3-6
months. Over the past couple of months Mr. T has
been taking pain medication however upon
admittance to the palliative care unit the family
has asked for the pain medication to be
discontinued for religious reasons and also
because they feel that the meds may be hastening
Mr. Ts death. The doctor has ordered an x-ray
for a suspected hip fracture. Mr. T is now in the
x-ray suite on a stretcher. He continues to groan
and ask for pain medication. You are unable to
transfer him.
13
Consent and Capacity Quick Review
  • Consent Informed decision-making involves has 3
    components
  • Disclosure the provision of all relevant
    information and the comprehension of this
    information by the patient
  • Capacity- the patients ability to understand
    information and appreciate potential consequences
    of their decision
  • Voluntariness- the patients right to come to a
    decision freely (without force, coercion or
    manipulation)

14
Quick Review Continued
  • Bad decisions ? incapacity
  • Capacity is decision specific
  • No such thing as global incapacity
  • Capacity is PRESUMED for ALL patient until proven
    otherwise
  • Observe your environment
  • Capacity is time specific (i.e. Capacity may
    fluctuate)
  • Include the right players
  • Mind all barriers in communication

15
The Players in the CC Game
  • Who delivers the information?
  • the member of the health care team offering the
    treatment
  • Thats YOU
  • Who decides?
  • The patient if capable
  • The substitute decision maker (HCCA)
  • How should that decision be made?
  • Prior expressed capable wishes
  • Best interests

16
CAMRT Code of Ethics
  • Patient respect and dignity
  • Assist patients and families to make informed
    decisions regarding care
  • Facilitate the patients free and informed
    choices
  • Provide the patient with an accurate description
    of all procedures and associated risks in a
    truthful and comprehensible manner
  • Answer patient questions fully and honestly
    within the limits of their knowledge and
    authority/ responsibility
  • Participate in the formal consent process by
    ensuring patient willingness to participate in
    the procedure
  • Respect the patients right to refuse or withdraw
    from treatment

17
Privacy Confidentiality
  • Whatsoever I shall see or hear in the course of
    my professionif it be what should not be
    published abroad, I will never divulge, holding
    such things to be holy secrets.
  • (Hippocratic Oath)

18
Definition
  • Privacy persons right to control access to
    their personal information
  • Confidentiality the duty of every health care
    practitioner to respect and maintain this patient
    privacy
  • Privacy itself is the foundation of a persons
    dignity and autonomy
  • Confidentiality is a basic tenet of the
    therapeutic relationship
  • Ethics Theory Virtue Theory

19
Former Toronto Mayor
20
CAMRT Code of Ethics
  • Patient respect and dignity
  • Take steps to ensure the physical privacy of the
    patient
  • Maintain the confidentiality of information
    provided by or about the patient, as well as
    anything contained in the patients record,
    except as part of standard therapeutic
    information sharing within the health care team,
    or where required by law

21
What is Bioethics?
  • Bioethics involves critical
  • reflection on moral/ethical
  • issues arising in the areas of
  • health care and research
  • toward
  • deciding what we should do
  • What decisions are morally right or acceptable
  • explaining why we should do it
  • Justifying our decision in moral terms
  • describing how we should do it
  • The method or manner of our response

  • (Dr. Barb Secker)

22
Guides to Our Practice
  • Our Principles
  • Organizational Values
  • Professional codes of Practice
  • The Law

23
Strategies to Work Through Ethical Issues
  • Ethics education (i.e. issues techniques)
  • Ethically fitness
  • Can lead to prevention
  • Ethics debriefing
  • Ethics consultations

24
Ethics Education Ethical Fitness
  • Rushworth Kidder president and founder of the
    Institute for Global Ethics in the USA
  • Similar to physical fitness
  • we are not born with it, rather, it is
  • reached by giving a little effort each
  • day, and it needs to be maintained
  • Must be mentally engaged thinking,
  • reasoning, grappling with difficult
  • situations or their potential, as well as a
    commitment to
  • finding better ways to reach good outcomes
  • Take time for ethical reflection in practice

25
Ethics Education Ethics Skills
Frank Wagner, Toronto Central CCAC
  • Sensitivity attunement to know when an issue is
    an ethical issue
  • Critical reflection
  • Practical reasoning
  • Problem solving

26
Ethics Skills
1. Sensitivity Attunement
We need to be aware and be sensitive to
recognizing when an issue is an ethical issue.
27
What is an Ethical Issue?
Could
Should
Any situation where we Encounter conflicting
values, beliefs goals, or difficult
alternatives Have conflicting obligations or
responsibilities Are concerned that rights are
being violated or persons not being respected
Are concerned with fairness justice Are
unsure about what we should do or why we should
do it
28
Ethics Skills
  1. Critical Reflection

Give careful consideration
To question assumptions, both our own and others
29
Ethics Skills
  1. Critical Reflection Continued..
  • Why is critical reflection important?
  • Initial reactions are often knee-jerk emotional
    responses.
  • Initial reactions do not take other perspectives
    into account.
  • We naturally jump to conclusions.

30
Ethics Skills
  1. Critical Reflection Continued..
  • Levels of a Moral Response
  • The expressive level (unanalyzed expressions or
    feeling that, by themselves, dont provide
    reasons or justification)
  • The pre-reflective level (appeal to law,
    religious tenets, social values, codes of ethics,
    etc. accepted uncritically)
  • The reflective level (reasoned ethical
    argument/defense using ethical principles,
    values, rules, virtues, etc., i.e., justification
    provided)
  • (Thomas J and Waluchow W, 1998)

31
Ethics Skills
  • Practical reasoning
  • the ability to reach a well-supported answer to a
    well-defined question (Stanford Encyclopedia of
    Philosophy)
  • Problem solving
  • the ability to apply practical reasoning and
    critical reflection to the problem at hand.

32
The Role of an Ethics Debriefing
  • Definition
  • Group-based reflective practice exercise
  • The role of the ethicist
  • Facilitation create the space and rules
  • Focus on individuals needs not team needs
  • Listen, stabilize, inform, normalize and recover
  • Reflect on ethical issues discuss where values
    clash introduce ethics language where
    appropriate
  • Provide follow-up as agreed by the group

33
The Role of Ethics Consultation
  • Definition
  • A process by which a trained ethicist responds to
    a request for assistance around an ethically
    challenging situation
  • Purpose
  • To identify and promote reflection on ethical
    issues, principles/values, and relevant policies
    and law
  • To promote fair decision-making

34
The Case of Mrs. V
  • Ms. V is an 88-year-old Russian woman who lives
    alone with her elderly dog. She does not speak
    English well.
  • Ms. V was recently diagnosed with advanced lung
    cancer.
  • Her son has asked the doctor not to tell his
    mother that she has cancer. He states that she
    has never wanted to know that type of health care
    information and that the knowledge of the
    diagnosis would cause more harm than good.
  • You are asked to provide treatment.
  • In broken English you believe the patient is
    asking what type of treatment she is receiving
    and why.

35
The IDEA Tool for Ethical Decision-Making
  • Step-by-step tool
  • Considers facts, emotions, ethical principles,
    alternatives consequences, outcome evaluation
  • Forum for open non-threatening discussion

36
STEP 1 IDENTIFY THE KEY QUESTION FACTS
  • Clinical indications
  • Clients current health status history,
    diagnosis, prognosis?
  • Type of problem acute, chronic, critical,
    emergent, reversible?
  • Goals of treatment/ intervention?
  • Probabilities of success?
  • Plans in case of therapeutic failure?
  • Benefit of treatment/ intervention to client?
  • Harm to be avoided?
  •  
  • Relevant Facts
  • Describe the relevant facts of the case/issue.
  • What are the main problems or areas of
    concern/tension?
  • Who are the individuals involved, and who else
    needs to be involved?
  • What statutes, regulations, policies, standards,
    etc. are relevant?
  • Contextual features
  • Family issues influencing decisions re.
    treatment/ intervention?
  • Any relevant religious or cultural factors
  • Any health practitioner issues influencing
    decisions, e.g., judgments about quality of life?
  • Any organizational issues influencing decisions,
    e.g., financial/economic factors, teaching or
    research?
  • Any legal implications of decisions regarding
    treatment/ intervention?
  • Any limits on confidentiality?
  • Any conflict of interest on the part of the
    providers or the organization?
  • Client preferences
  • Client's assessment of quality of life with and
    without treatment/ intervention?
  • Clients preferences re. treatment/ intervention?
  • Clients decision voluntary and informed?
  • Substitute decision-maker if client not capable
    of making decision?
  • SDM understands role?
  • Client expressed prior wishes (oral, (written, or
    other means)?
  • Client willing or ability to cooperate? If not,
    why not?
  • Clients right to choose respected to extent
    possible in ethics and law?
  •  

Jonsen, Albert, Siegler, Mark and Winslade,
William. Clinical Ethics A Practical Approach to
Ethical Decisions in Clinical Medicine, 5th ed.
McGraw-Hill Medical 2002.
37
STEP 2 DETERMINE THE ETHICAL PRINCIPLES IN
CONFLICT
38
STEP 3 EXPLORE OPTIONS
39
STEP 4 ACT ON YOUR DECISION AND EVALUATE
1. Develop an action plan (Note the actual plan
should be documented in the chart) Given all the
information that you have, choose the best option
available. Develop an action plan. Present
your suggested alternative and action plan to the
client and those involved in such a way that it
allows them to accept the plan. Re-examine the
alternatives if other factors come to light, if
the situation changes, or if an agreement cannot
be reached. Determine when to evaluate the
plan. Document and communicate the plan
2. Evaluate the plan What was the outcome of
the plan? Are changes necessary? Document the
evaluation.
3. Self-evaluate your decision How do you feel
about the decision and the outcome? What would
you do differently next time? What would you do
the same? What have you learned about yourself?
What have you learned about this
decision-making process?
40
Questions/Comments
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