Presented at Providence Family Medicine Residency Spokane once in 2010 and again in 2012

1. Ethics and the
Family Medicine Resident
From the beginning of life to the end and everything in between

2. Ethics and the Family
Medicine Resident
•BriefHistory of Bioethics as a field
•Framework for Ethics
•Tools and Processes for Decision
Making
•Review of topics in Bioethics
•Case examples
•Small Group Exercise

3. Frameworks for Ethics
Principle Based Framework for
Ethical Decision Making
Beauchamp & Childress:
 Autonomy
 Beneficence
 Non-maleficence
 Justice

4. Frameworks for Ethics
Values & Virtues Based Framework for
Ethical Decision Making
 Nel Noddings: Ethics of caring
 John Rawls: Veil of ignorance
 Martha Nussbaum: Capabilities approach
 Reciprocity
 Religious Directives for decision making are often based on
the values held highest within that community

5. Frameworks for Ethics
Cultural and Religious Norms
 Social Contracts, Laws
 Professional Codes of Ethic
 Religious Traditions & Scriptures
 Personal experiences

6. Framework for Ethics
Causistry
 Case – based approach to ethical decision making
 Most common way for Hospital ethics committees to
work through cases and consultations
 Potter‟s Boxes
Facts Values
Principles Loyalties

7. Framework for Ethics
 Deontology
 Duties
 Ex: Immanuel Kant‟s Categorical Imperative
 Teleology
 Consequences
 Ex: John Stuart Mill, “Greatest Good for the
Greatest Number”- Utilitarianism
 Both: Worth of persons
Stanford Encyclopedia of Philosophy
plato.stanford.edu

8. • Autonomy • Reciprocity
• Beneficence • Honesty
• Nonmaleficence • Integrity
• Justice • Worth of persons
Principles Values
Cases
Cultural Teleology
and vs.
Religious Deontology
• Traditions • Categorical
• Beliefs Imperative
• Experiences • Utilitarianism
• Social Contracts & • Worth of Persons
Laws

9. Principles Values
Decision
Making
Cultural Teleology
and vs.
Religious Deontology

10. Topics
 Consent  Institutional Ethics
 Capacity  Conflicts of Interest in
education and in patient care
 Disclosure
 Just distribution of scarce
 Voluntariness/Autonomy resources
 Truth Telling  Infectious disease ethics
 Confidentiality  Transplantation ethics
 Surrogate decision making  Differences in Cultural
Norms
 Genetics
 Research & IRBs

11. Topics
 Before birth  End of Life  Every Age In-between
 Personhood  Advanced Directives  Allocation of Scarce
 Contraception  Futility Resources
 Donation and storing of  Brain Death vs. Cardiac  Money/Insurance
Eggs and sperm Death  Access to care
 Care of Embryos  Organ Donation  Urban vs. Rural
 Mother vs. Fetus  Physician Assisted  Organ
 Assisted reproduction Death Transplantation
 Population issues  Palliative Sedation  Infectious Disease –
 Withoding HIV & STIs
 Genetic Screening and
Counseling vs.Withdrawaling  Elective Procedures
 Prenatal Screening  Artificial Hydration and  Psychiatric Care
Nutrition  Opioid Prescribing
 Sex Selection
 Ventilation  Research & trials
 Cloning
 Surrogate Decision  Informed consent
 Eugenics making
 Blood transfusions

12. Famous Landmark Cases
 Baby M- anencephaly
 Helga Wanglie- When families disagree
 Terri Shiavo, Nancy Cruzan- Withdrawling vs.
Witholding Life Support: Artificial Nutrition and
Hydration & Ventilator
 Tuskeegee Syphillis Study

13. Local Cases
 Mr. K
 21 yo near drowning in 2009, with brain damage and
recurrent sepsis. Mr. K was an exchange student from
Ghana, planning to study and play soccer at Whitworth
 Mr. C
 Conscientious objection of Medtronic technologist to
turn off dual ICD and Pacer in a gentleman who has
chosen to allow natural death
 Ms. N
 Bipolar clinic patient in active mania who refuses to go to
SMH for Psychiatric evaluation. Due to her insurance, this
is currently her only option for Psychiatric care.

14. Things we encounter in
FMS Daily
In the Clinic
 Opioid prescribing
 Care of the Difficult patient
 Reproductive topics:
 Contraception- daily OCPs and emergency contraception
 IUDs, Tubals, Vasectomies
 Discussing Advanced Directives & POLST forms
 What to Do When Families Disagree
In the hospital:
 Withholding and Withdrawaling life support

15. The Role of Conscience in
Medical Decisions
Daniel Sulmasy, OFM, MD, PhD
University of Chicago
 Does conscience ever clash with professional duties? What do we
mean by terms such as „conscience‟ and „conscientious objection‟?
How should one approach a request from a patient that conflicts with
one‟s individual conscience? Exploring how medical professionals can
strive to preserve their moral integrity while also respecting and
serving patients with whom they might have deep moral
disagreements.