Ethics

Question 1

What do we mean when we talk about ethics?

Answer 1

• Study, elaboration and discussion of standards for the right action: “What is the right thing to do?”
• And analysis of the source of these judgements.
• Why? Is the most important question. It is important to be able to articulate why something is right or wrong.

Question 2

According to J-P Ricoeur, what is the aim of ethics?

Answer 2

The good life with and for others, in just institutions.

Question 3

What is the difference between personal and professional ethics?

Answer 3

There are certain expectations of physiotherapists as professionals that must be upheld. So while one may hold personal beliefs about what is right or wrong, in a regulated profession such as PT there are certain ethical standards that must be upheld. Such as not being friends with a patient on Facebook.

Question 4

Who is involved in ethical aspects of healthcare?

Answer 4

It is the responsibility of all HCPs to uphold ethical practice
Clinical and Research Ethics Committees
Clinical Ethics Consultants are available in hospitals to help with challenging cases.
Patients, Families.

Question 5

What are some examples of vocabulary that suggests that an ethical issue is at play?

Answer 5

• Confidentiality
• Autonomy
• Right or wrong
• Vulnerability
• Obligations
• Promoting Well-Being
• Professional Boundaries
• Conflict of Interest: A conflict of interest is something else (other factor) that is influencing your primary obligation to your patient (such as financial interest or personal gains).
• Trust
• Best Interest
• Avoid Harm
• Judgement
• Just or unjust

Question 6

Recall: Rehabilitation as a health care strategy

What is distinctive about rehab ethics?

Answer 6

Rehabilitation is the health strategy that aims to enable people with health conditions experiencing or likely to experience disability to achieve and maintain optimal functioning in interaction with the environment.

What is distinct: Team work, goal setting(what is important to pt), participatory approach (work with the pt, not for the pt), contexts of care (home care-you are a guest in their home), risks (#1 issue in rehab ethics, driving, discharge), focus on individual in society (function, occupation), discontinuities and personal identity (ppl responding to a new acquired disability, new identity).

Question 7

What are the most common ethical issues that OTs and PTs encounter in clinical practice?

Answer 7

1. Reimbursement pressure.
2. Conflicts over goal setting.
3. Pt and family refusal of treatment.
4. Justifying knowledge where evidence lacks.
5. Distress at not being able to act effectively on behalf of the patient.
6. Issues associated w/ interdisciplinary work.

More:

• Pt vs PT autonomy
• Risk taking behaviour of pt
• Challenging behaviour of pt
• Resource use and prioritization; allocation scare resources
• Informed consent
• Confidentiality
• Autonomy and preferences
• System and Institutional Issues
• End of life plans and decisions
• Insurance issues
• Conflicting goals
• Decision making capacity
• Discharge planning

Question 8

What are 4 key considerations for Julie’s case and with ethical decision?

Answer 8

• Capacity
• Consent
• Confidentiality
• Managing Risk

Question 9

What are the elements of capacity?

What does a competency assessment evaluate?

Answer 9

• Not all or nothing: Someone can remain competent in making decisions in 1 area of their life (financial) but not another area of their life (health care).
• Different domains of competency
• Clinical and Legal Concepts
• Assumption of competency: In clinical care we assume that everyone is competent.
• Sliding scale

Evaluate whether the individual understands:

• The condition for which treatment is propose
• Nature and purpose of treatment
• Risks involved in treatment
• Risks in forgoing treatment
• Whether or not individual;s ability to consent is affect by his/her condition.

Question 10

1. What is the legal context for informed consent in QC?

2. What are the components of informed consent?

Answer 10

1. Everyone is entitled to the integrity of his person.
   - Except in cases permitted by law, no one may interfere w/ his person w/ out his free and enlightened consent.
   - No person may be made to undergo care of any nature (such as treatment) except w/ his consent.
   - Ppl can refuse care.
2. What would a reasonable person need to know to make a decision?
   - Information
   - Voluntariness
   - Comprehension
   - Implicit (Ie when a patient just brings you a doctors note it is assumed they are agreeing to being seen by PT) and explicit consent
   - Written consent in certain circumstance.

Question 11

What is the duty of confidentiality?

What is it based on?

Answer 11

The right to have health information kept private.

2. Everyone has the right to respect for their privacy.
   - Confidentiality is a duty owed to the patient.
   - Confidentiality is based on the trust nature of the HCP-pt relationship.

Question 12

What are exceptions to confidentiality?

Answer 12

-Expressed Waiver: when a pt gives you permission to discuss their information w/ someone else.

Duties to disclose: Public health (certain diseases), child abuse, births and deaths, driving (permitted but not required in QC), court of law, duty to warn third party (to make a judgement use: clarity, seriousness, immanence)- like w/ suicide the law requires you to take action if you can answer these 3 questions and the person is a danger to themselves or others.

Question 13

Managing Risk:

What types of risks must a PT manage?

Answer 13

Risks to the public: Driving, return home at risk of starting a fire.

Risk to self: Dysphagia (aspiration), D/C to unsafe location, not following precautions or contraindications

Risk to family, friends of pt.

Question 14

Why is it important to assess risk?

What are the components of risk assessment?

Answer 14

Risk is subjective: what seems rational to one person may seem risky to another. everyone has different perceptions that influence their view of risk.

Risk Localization: What is the risk?
Risk Estimation: How likely is it?
Risk Evaluation: How significant are the consequences?
Risk Management: Harm reduction, make it less likely or less severe.
ex: Find a friend for Julie to go home w/

Question 15

At what level can resource allocation happen?

Answer 15

Macro: Health care system (money for paediatric hospital vs LTC)

Meso: Hospital, regional health authority (allocation between programs in a hospital)

Micro: Bedside decision-making, decision among pts (How to allocate time between pts. Management of PT wait list)

Question 16

What are the 3 broad ways of viewing resource allocation?

Answer 16

1. EBM: Focuses on effective and appropriate use of resources; decisions based on research.
   What has the strongest evidence?
2. Economics: Focuses on efficacy at a population level.
   what is more cost effective?
3. Ethics: Focuses on fairness/justice, fair processes.
   What is most just?

Question 17

What is a needs based assessment?

Answer 17

View that things should be based on need, how do we define need? What does it mean to need something more then someone else?
Defining individual need for a service (like pulmonary rehab program) based on:
-Poor initial state of health (the least well off)
-Most likely to have the greatest health benefit
-Most likely to make functional gain

Question 18

What supports and resources can guide ethics in clinical practice?

Answer 18

-Code of Ethics (OEQ, OPPQ, Hospital, CAOT, CPA)
As a professional you promise to be accountable to upholding this code of ethics. Although code of ethics is general and does not have a solution for everything.

• Principles of Medical Ethics
• Moral Role Models
• Evaluation of Likely consequences
• Law
• Ethical Frameworks

Question 19

What are the fundamental principles of medical ethics?

Answer 19

Autonomy 
Beneficence (doing good)
Non-maleficence (avoiding harm) 
Justice 
(Fidelity, veracity)

Question 20

What are the different types of autonomy?

Answer 20

1. Functional Autonomy: Functional independence, capacity for self-care, freedom from handicaps
2. Decisional Autonomy: Capacity to make and enact choices that align with your goals, plans and responsibilities, to “self-govern”

• Respect for persons (preferences, choices, priorities)
• Protection of those who are vulnerable
• Negative duty: non-interference -Others should not interfere on your decisions.
• Able to act in a way that is consistent with your personal integrity (wha is important to the individual).

Critical Question: Have we respected and promoted the autonomy of the patient or duly appointed surrogates?

Its not just about respecting decisional autonomy, its also about promoting it so encouraging people to be involved in making decision related to their own well-being. (Consider why decision is important, the outcomes of different decisions)

Question 21

What is Beneficence?

Non-maleficence?

Answer 21

• Maximizing benefits
• Promoting health, dignity and welfare of pt and family
• First do no harm
• Seek to avoid or at least minimize negative outcomes.

Key Question: How can benefits be optimized for pt and family while minimizing the likelihood of harm for pt, family, caregivers and society.

Question 22

What is the Justice principle?

Answer 22

• Impartiality and equity
• Attentive to the possibilities of injustices of institutional structures/policies.

Key Question: Are we treating others fairly? Do we have fair procedures? Are we producing just outcomes?

Question 23

What is the principle of fidelity or veracity?

Answer 23

• Keeping promises (Fidelity)
• Truth-telling (Veracity)
• Loyalty (Fidelity)

Are we being faithful to institutional and professional roles? Are we living up to the trust relationships we have with others?

Question 24

What is the most important thing clinicians identified when dealing with ethical situations?

Answer 24

Team work

Question 25

What are the 5 components needed for a multidisciplinary team to be effective at addressing challenging ethical issues?

Answer 25

1. Develop a common moral language for discussing moral issues. (moral values like non-maleficence) 2. Team members must have cognitive and practical training in articulating their feelings about issues rationally. (I think we should, because) 3. Value clarification exercises are needed. (What are my own ethical commitments or values?) 4. Team must have common experiences upon which to base workable moral policies. 5. Team must develop a moral decision-making method for all to use.

Question 26

What are the 3 special tests to determine if an ethical issues is at play?

Answer 26

1. Icky feeling test: Are you feeling uncomfortable, unsettled, ill at ease? (IF you are worried about your colleague or boss hearing about it or if you need to convince yourself or rationalize choices, maybe there is a problem) 2. Your momma test: Would you feel comfortable explaining your actions and reasons for them to your mom? If not, maybe there's a problem. 3. Front Page test: Would you feel comfortable if your actions and rationale were printed on the front page of tomorrow's Gazette? If not, maybe there is a problem. Tests are there to help identify if ethical issue exists, not to help make a decision.

Question 27

What is the active engagement model?

Answer 27

1) Listen Actively 2) Think Reflexively 3) Reason Critically

Question 28

What ethical analysis model is being used in this class?

Answer 28

PCEAM-R Patient-Centered Care Ethics Analysis Model for Rehabilitation - This is a model for being comprehensive with ethical issues. - This model is tailored to rehab - And it is uses clinical reasoning to be structured like how we think as clinicians.

Question 29

What are the categories of the PCEAM-R and the relevant question for each?

Answer 29

1. Identify the ethical issue(s) - What is at stake and for whom? 2. Collect information - What do we need to know to be able to evaluate the situation? 3. Review and analyze - Do we need to reformulate the issue and what can help us better understand it? 4. Identify and weigh options - What are our options and what rationales support them? 5. Make decisions - -What is the best option and how should we implement it? 6. Evaluate and follow-up - What was the outcome and how can we learn from it? Not necessarily trying to make the right decision, trying to make the best decision given the circumstances.

Question 30

How is the model tailored to rehabilitation?

Answer 30

The prompts/questions are guided to rehab context especial in section 2 collection of information based on the ICF model. (activity and participation, environmental factors). Entire Ethical care analysis model is grounded in patient-cantered care theory consistent with rehab practices.

Question 31

In terms of the exam what do we have to do for Step 1 and Step 2.

Answer 31

Step 1: Identify the ethical issue: 1) Succinctly identify what is at stake (the core ethical issue/problem) 2) Identify the most important ethical principles or values implicated by the case (and explain why they are relevant). Identify any principles/values that appear to be in tension or opposition. Step 2: Collect Info -Not on Exam

Question 32

In terms of the exam what do we have to do for Step 3

Answer 32

3: Review and Analyze 1) Identify 3 elements of the OPPQ Code of Ethics that you think are most relevant to the case. 2) Explain WHY these sections of the Code are relevant to the case and 3) HOW they inform your understanding of the ethical issue

Question 33

In terms of the exam what do we have to do for Step4

Answer 33

Step 4: Identify and Weigh Options: What are three options in this situation and what ethical rationales support and oppose them. - Describe option - Ethical arguments for the option - Ethical arguments against option

Question 34

In terms of the exam what do we have to do for Step 5

Answer 34

Step 5: Make a decision - Identify the best option and explain why it is the best under the circumstances - Explain the steps that you would take to implement the decision - Explain how you would follow-up and evaluate the decision and its implementation

Question 35

What are the 5 take away points from the lecture?

Answer 35

1. Ethics is important part of everyday practice 2. It is something you should think about 3. It is something you should take about 4. You have reference points and resource people to help orient your response to ethically challenging situations that you encounter in clinical practice.