Randy M. Rosenberg, MD FAAN FACP

Clinical Assistant Professor of Neurology

Temple University School of Medicine

Moral Principles

What is good and bad

What is right and wrong

Based on value system

Ethical norms are not universal – depends on the sub culture of the society

Ethics is not the same as feelings Ethics is not religion Ethics is not following the law Ethics is not following culturally

accepted norms Ethics is not science To be ethically correct does not

imply a painless outcome.

Saving of life and promotion of health above all

else.

Make every effort to keep the patient as comfortable as possible and preserve life when possible or feasible.

Respect the patient’s choices when all options have been discussed.

Treat all patients equally.

Principles and Duties of Physicians are the Central Elements of

Bioethics

Provide for all individuals to the best of your ability.

Maintain competent level of skill.

Stay informed and up-to-date.

Primum Non Nocere !

3 criteria for judging ethical dilemmas:

1. Obligations – rights, rules, oaths.

2. Ideals – goals, concept of excellence, fairness, loyalty, forgiveness, peace.

3. Consequences – may be beneficial or harmful effects that result from the action and the people involved. Can be physical, emotional, obvious, or hidden.

Several parts of the oath have been revised over the years

“To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him…”

“Nor will I give a woman a pessary to procure abortion;”

“I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in his art.”

AUTONOMY

BENEFICENCE

NON MALEFICENCE

JUSTICE

The right to participate in and decide on a course of action without undue influence.

Self-Determination: which is the freedom to act independently. Individual actions are directed toward goals that are exclusively one’s own.

Actions or inactions are for the good of the patient.

Maximize possible benefits

Provide paliation

Direct benefit to subject

Overall benefits to society

Guard that actions or inactions do not result in harm

Physicians must refrain from providing harmful or ineffective treatments or acting with malice toward patients.

Possible benefits outweighs potential harm

Taking action when harmful consequence are identified

Admitting wrong (“apologies”) ?

Fair distribution of benefits

Equal shares

Equal individual need

Equal individual effort

Equal societal contribution

Equal merit

Key Elements of the Standard Approach and the Presumptive Approach to Counseling Potential

Organ Donors.

Death is implicit. The challenge is to make death explicit

Death is a biological phenomenon

Death is a term applied to living organisms

Death is irreversible

Death is univocal among higher animal species

Dog=man

Death is an event and not a process

Physicians should be able to determine death with accuracy and reproducibility

Greek physicians held that the heart was the seat of life, the first organ to live and the first organ to die

Neither respiration nor brain function was essential for life

Hippocrates held that the brain was the source of reason, sensation and motion

Can be regarded as the father of brain death. Hebrew law had provided that breathing

and not heartbeat was the essence of life

Argued that a decapitated person was immediately dead, despite movement of some muscles

Muscle movements after decapitation were not indicative of central control

THEREFORE BELIEVED THAT THE CENTRAL CONTROLLING

MECHANISMS OF LOCOMOTION (BRAIN FUNCTION) WERE AS ESSENTIAL TO LIFE AS WAS

BREATHING

Suddenly the brain became important and death was no long just the irreversible cessation of cardiopulmonary function

Provides comprehensive basis for determining death in all

situations and recommended for all states.

Adopted by all except New Jersey and New York (modifications)

Clinicians in all but those two states can terminate ventilation without

consent of family

Based on a 10 year effort to unify medical and legal opinion

that began with the Kansas laws on brain death (1970)

Proposes the legal standard but not the mechanisms for

determination of death or time of death.

Death is defined as “irreversible cessation of circulatory and

respiratory functions” or “irreversible cessation of all

functions of the entire brain, including the brain stem.”

Underwent tonsillectomy for OSA in December 9, 2013

Post op bleeding followed by cardiac arrest

Declared brain dead on December 12, 2013

Hospital believes it has followed letter of California law on brain death

Family believes the Jahi is still alive and she has been transferred to facility to be treated as a brain injured patient rather than brain dead.

A parent’s love of their child is not a controversy but efforts made to protect that child complicate the ethical dilemmas.

How far can parent seek to protect the safeguards of their child’s interest?

Can life support be given to a patient who is dead? Where does the physician’s ethical responsibility

begin when asked to provide treatment with no appreciable benefit?

The principal of autonomy means that patients or their surrogates can decline treatment. By the same token is the inverse true ie can family demand treatment options not endorsed by physicians, law or insurance companies?

How long is it appropriate to give life support to a brain dead patient to permit the family to accept a painful reality?

On November 26, 2013, Erick Muñoz found his 33-year-old wife Marlise unconscious in their family home

Workup revealed pulmonary emboli as cause of CP failure. Also found to be 14 weeks pregnant

Declared brain dead on November 28, 2013 Marlise, a paramedic like her husband, had previously

told him that in case of brain death, she would not want to be kept alive artificially

Hospital acknowledged that the patient was legally dead (consistent with Texas law) on November 28, 2013

Texas law prohibits discontinuation of life support on a pregnant woman.

Erick Muñoz petitioned for Marlise to be removed from all life-sustaining measures once

brain death had been declared consistent with the wishes of the patient.

The hospital refused, citing a Texas law which required that lifesaving measures be

maintained if a female patient was pregnant--even if there was written documentation

that this was against the wishes of the patient or the next of kin.

While Marlise had been declared dead, the condition of her fetus was unknown. In

January 2014, Erick Muñoz's attorneys argued that the fetus had suffered from anoxia

and was suspected to be non-viable. The fetus' lower extremities were deformed to the

extent that the gender couldn't be determined and there was evidence of hydrocephalus

On January 24, 2014, Judge R. H. Wallace Jr. ruled that the hospital must disconnect

Munoz's life support by January 27, 2014

How can the decision be viewed if it is not a ruling against the constitutionality of Texas

law?

Where does this leave future patients?

Marlise Muñoz was disconnected from life support at 11:30 AM on January 26, 2014.

By 2012, 37 states had pregnancy consideration in their advance directive statutes. In assessing them, the Center placed the statutes into five major categories: 1. The law states that pregnancy at any stage automatically invalidates

the advance directive; 2. The law contains pregnancy restrictions similar to those in the model

Uniform Rights of the Terminally Ill Act (1989) Basis of legality of “living will” Withholding of life sustaining treatment continues in case of most pregnancy

unless there is severe fetal anomaly.

3. The law uses a viability standard to determine enforceability of the declaration; or

4. The law is silent with regard to pregnancy. 5. Patient may have specific written instructions regarding end of life

care if she is pregnant.

Pennsylvania law Act 169, that addresses living wills and health-care decision-making, requires that a pregnant patient be kept on life support "unless, with a reasonable degree of medical certainty, the fetus cannot develop to live birth."

How can state mandated “life support” be given to a patient who is legally dead?

State appears to be violating: The individual's interest in a dignified death Ethical principle that a physician no long is required to provide

treatment to a patient declared dead.

Does the state have the responsibility to protect its citizen (the citizen) from a certain death?

At 14 weeks gestation the fetus would not have been viable outside of the womb. Thus the patient’s constitutional privilege for abortion would have been protected?

How does the fact that the fetus was likely severely malformed? If so what is the husband’s rights to reject the imposition of raising a

handicapped child as a widower?

How much liability does the state have to avoid actions that add to the personal tragedy and grief suffered by the husband during forced life sustaining measure?

May I be moderate in everything except in the knowledge of this science; grant me the strength and opportunity always to correct what I have acquired, for knowledge is boundless and the spirit of man can also extend infinitely…Today he can discover his errors of yesterday, and tomorrow he may obtain new light on what he thinks himself sure of today.