An approach as to how a doctor ought to respond to a patient who chooses lethal alternative medicine over effective evidence based medicine

Gruner,John1,

1 Monash Centre for Human Bioethics, Menzies Building, 20 Chancellors Walk, Monash University VIC 3800, Australia.

As a doctor, I have cared for patients who choose futile care over effective care, and die. Just as doctors ought to assist patients attain substantial understanding, so doctors ought to attempt to guide patients from unwise choices due to implicit biases, including cultural bias. A patient may counter that they have a right to believe what they want and make health choices as they want.  However I debate that patients always have a right to health care when their desire for this is based on false beliefs. Many core aspects of healthcare are unique goal-orientated activities, unlike consumer transactions or cultural activity.  Tolerance has limits, and in health care, society ought to allow for a reasonable amount of pluralism. In a liberal pluralistic society, we agree to abide by moral principles that others may not reasonably reject. Where a patient chooses lethal alternative medicine, despite protestations from health carers and family that such a path is futile, if the patient agrees to be part of a community of co-deliberators, the patient ought to engage in dialogue with expert health carers. Evidence based medicine (E.B.M.) embraces dialogical consensus as a means by which outlying beliefs may be debated by society as being reasonable or unreasonable. Dogmatic belief that restricts a patient’s freedom of choice and leads to a patient’s death, not only is antithetical to a longitudinal notion of patient autonomy, as it kills the patient, but such dogma precludes co-deliberation. If a patient seeks care of an E.B.M. carer, the patient may not reasonably reject that a carer will seek to dissuade the patient from lethal implausible health beliefs. A patient who considers that their beliefs are immutable and refuses any co-deliberation, should respect that a doctor has a professional obligation to care, and in such circumstances the patient ought to listen to the doctor


Biography

Dr John Gruner has been a G.P in the Dandenong Ranges near Melbourne since 1995. He has had long term interests in the ethical interface of complimentary medicine and  evidence based medicine. In 1996 after a one year acupuncture course he commenced  a Master of bioethics course that he completed in 1999 with a publication examining informed consent in complimentary medicine. More recently he  has resumed research in the same  area, looking at fallibism, hope,trust and  cultural relativity in complimentary medicine.

What if the brain in a vat has a body?: Medical ethics and human beings

Rebacca Y X Tock1

1 Department of Philosophy, Macquarie University, NSW 2109, Sydney Australia Email: rebacca.tock@gmail.com

Alistair Campbell claims, “the body is of central concern to most people’s understanding of the moral issues raised by modern biomedicine and modern medical practice. Yet, strangely, it is either devalued or largely ignored in much contemporary writing about the ethical aspects of these disciplines”[1]. This paper takes up the challenge to understand this claim and explore the normative significance of the body in medical ethics. Outlining the effect of the conventional dualist paradigm in medicine, I will suggest that the traditional ‘brain in a vat’ model of medical decision-making ignores a fundamental fact of human beings, that they are embodied and therefore medical morality should attend to the lived experience of illness.

Accepting the framework of medical ethics provided by Beauchamp and Childress[2], I will suggest that the rational decision maker that is the normative subject of the medical encounter is an unnecessarily idealised representation of the patient. Although this representation is challenged by feminist critiques of autonomy[3], others suggest that even this critique lacks a full consideration of the limits that biology place on autonomy[4]. By suggesting a phenomenological approach to the body in medical ethics, the gap between the ethicists, patients, and practitioners may start to close.

[1] Alastair V. Campbell, The Body in Bioethics (London ; New York: Routledge, 2009). 2.
[2] Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 7th ed. (New York: Oxford University Press, 2013).
[3] Catriona Mackenzie, “Conceptions of Autonomy and Conceptions of the Body,” in Feminist Bioethics : At the Centre, on the Margins, ed. Jackie Leach Scully, Laurel Baldwin-Ragaven, and Petya Fitzpatrick (Baltimore: Johns Hopkins University Press, 2010).
[4] Jonathan Beever and Nicolae Morar, “The Porosity of Autonomy: Social and Biological Constitution of the Patient in Biomedicine,” The American Journal of Bioethics 16, no. 2 (2016).


Biography

Rebacca is a PhD candidate at Macquarie University undertaking research into the theoretical role of the body in medical ethics. Her research interests lie primarily in the field of applied ethics and healthcare.

Procedures and processes: General Practitioners’ and Practice Nurses’ experiences of ethical dilemmas within primary care

Kate Robins-Browne1, Nancy Sturman2, Kelsey Hegarty3, Christopher Dowrick4, Victoria Palmer5

1 Department of General Practice, Melbourne Medical School, The University of Melbourne, 200 Berkeley St, Carlton, Vic, 3053, k.robinsbrowne@unimelb.edu.au
2 University of Queensland Medical School; 288 Herston Road, Herston, Qld, 4006
3 Department of General Practice, University of Melbourne, 200 Berkeley St, Carlton, Vic, 3053
4 University of Liverpool, Institute of Psychology, Liverpool; United Kingdom; L69 3BX
5 Department of General Practice, University of Melbourne, 200 Berkeley St, Carlton, Vic, 3053

A significant proportion of healthcare takes place in the primary care setting, but the clinical ethics literature is heavily weighted towards problems that occur in the inpatient (secondary care) settings.  Inpatient problems may be more time critical and garner more attention, but primary care presents its own ethical dilemmas and challenges which to date have received only minimal attention in the published literature.  Primary healthcare professionals (PHPs) experience ethical tensions within their relationship with the patient, the family, other healthcare professionals, and the health service system and attendant regulations.  There is currently no formal mechanism whereby a PHP can seek support regarding an ethical problem.  Furthermore, while it is recognised that primary care ethics is different to hospital ethics, there is relatively little research regarding PHPs’ experience of these problem or the supports they use to address them.  To address this gap we conducted 6 focus groups with Victorian GPs (3 groups) and primary care practice nurses (PNs) (3 groups) as part of a study to explore clinical ethics support services (CESS) for primary care.  The focus groups were audio-recorded and a note taker documented the group processes and interactions.  The data for each group was integrated into a single document and analysed thematically.  We found that GPs and PNs tended to recount different ethical problems.  GPs commonly described difficulties in maintaining the doctor-patient relationship, particularly in situations where there was conflict within the relationship, and were concerned with the blurring of the boundaries of the relationship; they had a greater focus on process.  By contrast, PNs were more likely to identify tensions within their working relationships, in particular with the GPs; they had a greater focus on procedures.  The two groups also utilised different supports to resolve their concerns.  Both groups thought a primary care CESS would be useful.


Biography

Kate Robins-Browne is a general practitioner with an interest in clinical ethics.  Her PhD was focused on decision making when the patient’s ability to participate is impaired.  This drew her attention to the difficulties healthcare providers encounter when they face ethical dilemmas and the lack of formal support structures, particularly for primary healthcare providers.

Is there an acceptable and feasible model for providing clinical ethics support in the primary care setting?

Kate Robins-Browne1, Nancy Sturman2, Kelsey Hegarty3, Christopher Dowrick4, Victoria Palmer5

1 Department of General Practice, Melbourne Medical School, The University of Melbourne, 200 Berkeley St, Carlton, Vic, 3053, k.robinsbrowne@unimelb.edu.au
2 University of Queensland Medical School; 288 Herston Road, Herston, Qld, 4006
3 Department of General Practice, University of Melbourne, 200 Berkeley St, Carlton, Vic, 3053
4 University of Liverpool, Institute of Psychology, Liverpool; United Kingdom; L69 3BX
5 Department of General Practice, University of Melbourne, 200 Berkeley St, Carlton, Vic, 3053

High quality healthcare provision is an intrinsically ethical activity, the ethical nature of which often goes unnoticed until a problem arises.  Clinical ethics support services (CESSs) can assist to address these ethical problems and dilemmas that arise in healthcare.  A CESS can take a variety of forms, including an individual ethicist (ethics consultant) integrated within a care setting or acting as an external consultant, or, an ethics team/committee also integrated or external to a health care organisation. Current CESSs are largely designed for the hospital setting and there is no existing CESS for primary care services.  Yet, primary care presents its own ethical complexities which are often quite different to those that occur within the hospital setting; the very factors that are seen as protective, such as the ongoing relationship between primary healthcare professionals and their patients, can become a source of ethical tension.  A hospital based CESS cannot be directly translated to the primary care setting, as a primary care CESS needs accommodate the smaller nature of general practices and be responsive to the kinds of dilemmas that emerge in the primary care setting.  To develop a CESS model for primary care we needed to know what ethical problems general practitioners (GPs) and primary care practice nurses (PNs) encounter, how they currently address these, and their perception of the acceptability and feasibility of CESS models.  In this paper we present findings from 6 focus groups conducted with GPs (3) and PNs (3).  The focus groups aimed to identify the ethical concerns of these professionals and their responses to five existing CESS models. We outline the challenges and opportunities for individuals and systems that participants identified for each model, and consider whether it would be possible to develop a CESS for primary care.


Biography

Kate Robins-Browne is a general practitioner with an interest in clinical ethics.  Her PhD explored decision making when the patient’s ability to participate is compromised.  This drew her attention to the difficulties clinicians face when they encounter ethical dilemmas and the lack of formal ethics support for healthcare providers.

Developing an empirically-informed virtue ethics policy approach to medical practice

Justin Oakley1

1 Centre for Human Bioethics, Monash University, Victoria 3800. justin.oakley@monash.edu

Several philosophers have recently developed accounts of virtue ethics which are more empirically-informed than previous versions of this approach. In doing so, they have argued for a comprehensive conception of virtuous character-traits, whereby practically intelligent virtues include an awareness of situational and environmental factors which conduce to or inhibit virtuous behavior. However, these accounts have so far had only a limited impact on virtue ethics approaches to medical ethics, and on policy applications of medical virtue ethics.

In this presentation I argue that policymakers should design institutional environments which help raise medical practitioners’ awareness of when such situational ‘conducers’ or ‘inhibitors’ are likely to assist or derail medical role virtues from hitting their targets. I also argue that policymakers can feasibly support doctors developing and maintaining role virtues such as medical beneficence by designing institutional environments which minimize the impact of these situational ‘inhibitors’ on the therapeutic relationship between doctors and patients.


Biography

Justin Oakley is Associate Professor at Monash University Centre for Human Bioethics. He is author of Morality and the Emotions (Routledge, 1993), and Virtue Ethics and Professional Roles (with Dean Cocking) (Cambridge University Press, 2001), and editor of Informed Consent and Clinician Accountability: The ethics of report cards on surgeon performance (with Steve Clarke) (Cambridge University Press, 2007), and Bioethics (Ashgate, 2009). He is currently working on a project on policy applications of virtue ethics in medical practice, and a project on genetic parenthood and the regulation of assisted reproduction. Justin is also co-editor of the journal Monash Bioethics Review.

Creating a positive learning environment: An anti-bullying initiative

Lynley Anderson1, Althea Blakey2, Kelby Smith-Han3, Tim Wilkinson4, Liz Berryman5

1 Bioethics Centre, University of Otago, PO Box 56 Dunedin, lynley.anderson@otago.ac.nz
2 Bioethics Centre, University of Otago, PO Box 56 Dunedin, althea.blakey@otago.ac.nz
3 Anatomy Department, University of Otago, PO Box 56, Dunedin, kelby.smith-han@otago.ac.nz
4 Programme Director, Otago Medical School, University of Otago, PO Box 46, Dunedin, tim.wilkinson@otago.ac.nz
5 Medical student, Otago Medical School, University of Otago, PO Box 46, Dunedin, berel235@student.otago.ac.nz

Health professional students commonly describe mixed experiences in their interactions with staff within busy clinical areas. These experiences, both positive and negative, are well-described within the literature both internationally and nationally.1 Recent local media reports from the NZMSA and the Royal Australasian College of Surgeons attest to the fact that not all students fare well during their training.2,3 These reports reveal that the toll on students can actually be significant and long lasting: from doubts about career choice, failure to learn, stress and mental health issues, to a  fostering of the persistent negative behaviours themselves to go on and affect the next generation of students.4,5 With the support of the Division of Health Sciences, Dunedin School of Medicine, University of Otago, and the School of Nursing, Otago Polytechnic the CAPLE team is piloting a set of interventions within a clinical department with the aim of improving the working environment for all.

This project is informed by two literature reviews. the first identified the nature and prevalence of the problem; the second explored the success or otherwise of the interventions that have been tried. The CAPLE project pilot now takes a deliberate new approach and the engages actively with staff through participatory action research.6 Researchers from the CAPLE project work closely alongside these staff, providing interventions that have been selected and determined by those receiving the intervention. Pre and post ‘climate’-testing provides data to determine the success of the pilot by measuring how the working environment ‘feels’ for all staff. In this workshop we aim to discuss the reasoning for the current project design, seek critique about this methodology and to introduce some of the topics we taught during the study. Thus, the workshop will contain input from participants. Following testing of the CAPLE programme this year, we hope to expand the project in 2017 by exploring what would work in other clinical areas.

References

  1. Wilkinson, T. J., Gill, D. J., Fitzjohn, J., Palmer, C. L., & Mulder, R. T. (2006). The impact on students of adverse experiences during medical school. Medical teacher, 28(2), 129-135.
  2. NZMSA (2015). Final results for NZMSA Survey: Release to TV One, Auckland, New Zealand.
  3. Royal Australasian College of Surgeons, About Respect: Addressing bullying and harassment http://www.surgeons.org/about-respect/ [Accessed 17 June 2016]
  4. Nielsen, M. B., Tangen, T., Idsoe, T., Matthiesen, S. B., & Magerøy, N. (2015). Post-traumatic stress disorder as a consequence of bullying at work and at school. A literature review and meta-analysis. Aggression and violent behavior, 21, 17-24.
  5. Gullander, M., Hogh, A., Hansen, Å. M., Persson, R., Rugulies, R., Kolstad, H. A. & Bonde, J. P. (2014). Exposure to workplace bullying and risk of depression. Journal of Occupational and Environmental Medicine, 56(12), 1258-1265.
  6. Herr, K., & Anderson, G. L. (2014). The action research dissertation: A guide for students and faculty. Sage Publications.

Biography

A/P Lynley Anderson: clinical experience in physiotherapy, policy making, codes of conduct, ethics and professional development teaching.

Althea Blakey: clinical experience in radiation oncology, PhD developing thinking and values in medical education.

Kelby Smith-Han: clinical experience in mental health and psychology, PhD in medical education.

“The angel intern would do all of it”: Junior doctors, ethics and role conflict

Rosalind McDougall1,2

1 Melbourne School of Population and Global Health, University of Melbourne VIC 3010, rmcdo@unimelb.edu.au
2 Children’s Bioethics Centre, Royal Children’s Hospital, Melbourne

Medical internship has long been the subject of sociological study. However, ethical analysis of this crucial intersection between medical school and professional practice has been very limited.  To date there has been little systematic philosophical work that focuses specifically on junior doctors.  Instead, in ethical discussions, interns and residents tend to be included either with medical students or with their more senior colleagues.

In this paper, I argue that interns and residents differ from both medical students and more experienced doctors in ethically important ways.  Their working context requires them to play multiple roles simultaneously, including doctor, subjugate team member, learner, and hospital employee.  The demands of these multiple roles create a set of ethical challenges for junior doctors that is unique to their professional stage.  Further, the potentially conflicting demands of these multiple roles limit the ways in which junior doctors can act in response to the ethical difficulties that they encounter.

On the basis of in-depth qualitative interviews with fourteen Melbourne-based junior doctors and a review of research findings about junior doctors across various disciplines, I develop a typology of the kinds of ethical challenges associated with internship and residency.  These include being involved in treatment perceived as futile, seniors discouraging disclosure of errors, and reporting unrostered hours.

I also develop and use a role-based framework as a way of analysing the ethical challenges faced by interns and residents.  I argue that this role-based framework both reflects and engages with junior doctors’ specific position of agency and thus captures a fuller range of moral considerations than do other possible modes of analysis.


Biography

Dr Rosalind McDougall is a Research Fellow in Ethics at the Melbourne School of Population and Global Health at the University of Melbourne, and at the Children’s Bioethics Centre at the Royal Children’s Hospital, Melbourne.  She studied at the University of Melbourne and the University of Oxford, and has published widely in clinical ethics and reproductive ethics.  Her research interests include paediatric clinical ethics, parenthood, and the ethical challenges faced by junior doctors.

Arguing for a value of place in bioethics

Fiona McDonald1,2, Christy Simpson2,1,

1 Australian Centre for Health Law Research, Queensland University of Technology, C Block, Gardens Point Campus, GPO Box 2434 Brisbane Queensland 4001
2 Department of Bioethics, Dalhousie University 5849 University Avenue, Room C-315, CRC Bldg, PO Box 15000 Halifax, NS  B3H 4R2, Canada

We argue in this presentation for a value of place in health ethics.  That is to say we argue that ethicists should acknowledge that people may feel connected to and identify with a particular place. When we use the term place we are referring to: geography; an emotional connection to land, a particular location or a feature of a landscape; a sense of belonging associated with that place; and a sense of identity arising from that place. This identification with place has implications epistemologically and in terms of a person’s standpoint – what we know is fundamentally influenced by where we come from. We believe place ought to be considered a specific value to give it the necessary weight in ethical deliberations in health care settings at the micro, meso and macro levels of service delivery.  We argue that the value of place is particularly relevant for rural residents as it may influence their health care choices, impact on access to health care, and their experience of receiving care.


Biography

Dr Fiona McDonald is a Senior Lecturer at the Australian Centre for Health Law Research at the Queensland University of Technology and an Adjunct Associate Professor at the Department of Bioethics, Dalhousie University, Canada. She is a co-editor of Health Law In Australia (Thomson 2014), Health Workforce Governance (Ashgate 2012) and a co-author of Ethics, Law and Health Care (Palgrave 2014). Interested in regulation and healthcare, her research interests currently focus on the governance of health systems, including health professionals, health facilities and health technologies, and rural bioethics.

Recording devices in clinical consultation. The good, the not so good and the ugly. Do we have policies that are fit for purpose?

Dr Alastair Macdonald1

1CCDHB- Wellington Hospital

In recent years the sophistication and utility of mobile phones has been remarkable as has their ubiquity. These developments have enabled patients/family or their whanau, to covertly and easily record clinical encounters.

If health care professionals discover that their conversation is being covertly recorded, it is not surprising that a common reaction is one of consternation and even anger. The implicit sense of trust and privacy embodied in the consultation process are betrayed by such actions. Health professionals can therefore rightly view the use of this technology in a very negative fashion.

Whilst these issues remain very important, this negative view has to be integrated with a more enlightened perspective view that the use of recording devices actually has the potential to significantly improve the consultation process. There is good evidence that information recall by patients, the ability to confer with family / whanau members and decisional regret are all positively influenced by the ability to replay the recording. Not a surprise given that patient-centred care is at the heart of a successful consultation process!

Traditionally clinical ethics committees identify three areas of involvement, individual case consultation, education and policy development. However policy development by ethics committees is conspicuous by its absence in the literature and in practice.

This presentation outlines the processes involved in the development of a policy which addresses the issue of the use of recording devices in the consultation process. The justification for this includes the inevitable increasing use of these devices in the future. In addition there needs to be recognition that the appropriate use of this technology has the potential to benefit the patient /family and whanau experience. It follows that any policies that are developed in the future need to recognise these realities.


Biography

I am a retired renal physician.  I have been involved in the promotion of clinical ethics to the extent that I believe that “Clinical ethics is everyone’s business”. The sustainability of our health services is a reasonable prospect  if it is based upon robust,  ethical decision making at an individual level in the context of the broader concept of stewardship of these valuable resources.  If neither of these concepts is developed to their full potential then we have no one to blame but ourselves if our “health” future turns out to be bleak!

Conflicts and con-fusions confounding compassionate care: A compassion café account of the experiences of critical care nurses

Jennifer (Jenny) Jones1, Professor Amanda Henderson2, Assoc Professor Marion Mitchell3, Petra Strube4, Dr Sarah Winch5

1 Clinical Ethics Coordinator, Metro South Clinical Ethics Service, Metro South Health
2 Griffith University, Brisbane
3 Griffith University, Brisbane and Princess Alexandra Hospital, Brisbane
4 Princess Alexandra Hospital, Brisbane
5 University of Queensland, Brisbane

Due to the social and complex nature of ethics, Peter Isaacs and David Massey contend that a more appropriate question to that which is usually asked (“What ought one to do?”) when faced with an ethical dilemma is ‘“How ought we respond?” where the “we” is inclusive of all significant stakeholders, and the outcome proposed might evoke or demand a complex range of practical responses’ (1994, p.2). The question of “how ought we respond?” is vitally important in all healthcare settings. In complex critical care units such as intensive care, the diverse patient groups, the range of health disciplines, and the demanding priorities when delivering high acuity care can create difficulties for the individual nurse to maintain shared understandings, values, emotions and behaviours. Intensive care nurses are required to deliver care in situations that confound their feelings and belief systems.

This presentation draws on research conducted within the framework of a Compassion Café (Winch et al. 2014) in which the participants were members of the nursing staff of the Intensive Care Unit (ICU) of a large metropolitan hospital in Australia. Through the creation of a safe space, these ICU nurses reflected upon and spoke of the competing tensions associated with notions of how they “ought” and how they “wanted” to respond. This presentation seeks to build upon shared understandings of nurses’ ability to respond compassionately to their patients, their patients’ families, their colleagues and themselves.


Biography

Dr Jenny Jones is the Clinical Ethics Coordinator, Metro South Hospital and Health, Brisbane. She is also an Academic Title Holder, School of Medicine, Griffith University, Gold Coast. Jenny began her working career as a hospital trained registered nurse before moving into education and completing a PhD in Applied Ethics. She is passionate about compassionate rather than procedural driven care. Jenny is married, with 3 adult children and 1 delightful 5 year old grand daughter!

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About the Association

The Australasian Association of Bioethics and Health Law (AABHL) was formed in 2009.

It encourages open discussion and debate on a range of bioethical issues, providing a place where people can ask difficult questions about ideas and practices associated with health and illness, biomedical research and human values.

The AABHL seeks to foster a distinctive Australasian voice in bioethics, and provide opportunities for international engagement through its membership, journal and conferences.

Members come from all the contributing humanities, social science and science disciplines that make up contemporary bioethics.

Many members have cross-disciplinary interests and all seek to broaden the dialogues in which all members of the wider community ultimately have an interest.

The AABHL is a supportive, creative and challenging community that provides a rich source of continuing academic refreshment and renewal.

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