May 28 – 30, 2015, Montréal, Québec

Ethics in Radiation Sciences: Improving our Ethical Fitness

Rosanna Macri, EthicistMember, Joint Centre for Bioethics, University of TorontoAdjunct Lecturer, University of Toronto, Department of Radiation Oncology

Disclosure Statement: No Conflict of Interest

May 28 – 30, 2015, Montréal, Québec

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.

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

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 it’s 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”

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?

How did you feel?

Common Ethics Issues

Resource Allocation & VIP Treatment Consent & Capacity & SDM Privacy & Confidentiality

Resource Allocation

VIP Treatment

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

Consent, Capacity & SDMMr. T is an 85 year old man. He has recently been admitted to a palliative care unit. Due to Mr. T’s 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. T’s 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.

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 patientCapacity- the patient’s ability to understand information and appreciate potential consequences of their decisionVoluntariness- the patient’s right to come to a decision freely (without force, coercion or manipulation)

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

The Players in the C&C Game

Who delivers the information? the member of the health care team offering the

treatment That’s YOU

Who decides? The patient if capable The substitute decision maker (HCCA)

How should that decision be made? Prior expressed capable wishes Best interests

CAMRT Code of Ethics Patient respect and dignity

Assist patients and families to make informed decisions regarding care

Facilitate the patient’s 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 patient’s right to refuse or withdraw from treatment

Privacy & Confidentiality

“Whatsoever I shall see or hear in the course of my profession…if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets.”

(Hippocratic Oath)

Definition

• Privacy = person’s 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 person’s dignity and autonomy

• Confidentiality is a basic tenet of the therapeutic relationship

• Ethics Theory = Virtue Theory

Former Toronto Mayor

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 patient’s record, except as part of standard therapeutic information sharing within the health care team, or where required by law

What is Bioethics?

Bioethics involves critical reflection on moral/ethical issues arising in the areas of health care and researchtoward:

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)

Guides to Our Practice

•Our Principles

•Organizational Values

•Professional codes of Practice

•The Law

Strategies to Work Through Ethical Issues

Ethics education (i.e. issues & techniques) “Ethically fitness” Can lead to prevention

Ethics debriefing Ethics consultations

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

Ethics Education: Ethics Skills

1. Sensitivity & attunement to know when an issue is an ethical issue

2. Critical reflection

3. Practical reasoning

4. Problem solving

Frank Wagner, Toronto Central CCAC

1. Sensitivity & Attunement

We need to be aware and be sensitive to recognizing when an issue is an ethical issue.

Ethics Skills

What is an Ethical Issue?

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

Could Should

2. Critical Reflection

To question assumptions, both our own and others

Give careful consideration

Ethics Skills

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.

2. Critical Reflection Continued…..

Ethics Skills

Levels of a Moral ResponseThe expressive level (unanalyzed expressions or feeling that,

by themselves, don’t 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)

2. Critical Reflection Continued…..

Ethics Skills

3. Practical reasoning

• the ability to reach a well-supported answer to a well-defined question (Stanford Encyclopedia of Philosophy)

4. Problem solving

• the ability to apply practical reasoning and critical reflection to the problem at hand.

Ethics Skills

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 individual’s 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

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

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.

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.

• Step-by-step tool• Considers facts, emotions, ethical principles,

alternatives & consequences, & outcome evaluation • Forum for open & non-threatening discussion

The IDEA Tool for Ethical Decision-Making

STEP 1: IDENTIFY THE KEY QUESTION & FACTS

Jonsen, Albert, Siegler, Mark and Winslade, William. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, 5th ed. McGraw-Hill Medical: 2002.

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?

Clinical indications:•Client’s 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? 

Client preferences: •Client's assessment of quality of life with and without treatment/ intervention?•Client’s preferences re. treatment/ intervention?•Client’s 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? •Client’s right to choose respected to extent possible in ethics and law? 

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?

STEP 2: DETERMINE THE ETHICAL PRINCIPLES IN CONFLICT

STEP 3: EXPLORE OPTIONS

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 decisionHow 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?

STEP 4: ACT ON YOUR DECISION AND EVALUATE

Questions/Comments