Miami Dade College Ethics in Healthcare and Finance Paper

16‐Feb‐21
Trending (continued)
Healthcare
Ethics-3
17 February 2021
Barr y A. Bleidt, PhD, Phar mD, RPh, FAPhA, FNPhA
Professor, Sociobehavioral and Administrative Phar macy
1
2
Today
Your Patients
Ethical Principles
 are entitled to the best standards of care and practice
from their pharmacist
Patient Autonomy
Essential elements of these standards are:
Patient Confidentiality






Veracity
Withholding / Withdrawing Therapies
Resource Allocation
End-of-Life Treatment
Professional competence
Good relationship
High professional ethical standards
Communicate honestly
Safeguard their PHI
Value self-determination
 {slide used in Leadership Course}
It is about Human Dignity
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Polling
Ethical Principles
• Autonomy / Self Determination
• Veracity / Truth Telling
• Beneficence
• Non-Maleficence
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16‐Feb‐21
Principles (continued)
Non-Maleficence
• Privacy / Confidentiality

Primum non nocere
• Preservation of Life

Based on Hippocratic maxim => First do no harm
• Fidelity

Principle of bioethics that asserts an obligation not to
inflict harm intentionally through acts of commission
or omission

Useful in dealing with difficult issues surrounding the
terminally or seriously ill and injured

Is it negligence to impose an
unreasonable or careless risk
upon someone else?
• Respect for the Individual
• Justice
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Beneficence
Beneficence

The ethical principle of doing good.

The habit, intention, or practice of doing good.

The doing of active goodness, kindness, or charity,
including all actions intended to benefit others

Principle of beneficence refers to a moral obligation
to act for the benefit of others
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Not all acts of beneficence are obligatory, but a
principle of beneficence asserts an obligation to help
others further their interests

Obligations to confer benefits, to prevent and remove
harms, and to weigh and balance the possible goods
against the costs and possible harms of an action are
central to bioethics
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Beneficence
Conflicts of Interest
(continued)
• a conflict between the private interests and the
official responsibilities of a person in a position of
trust
Considered to include four components:
(1) one ought not to inflict evil or harm (Nonmaleficence);
(2) one ought to prevent evil or harm;
• Potential  an external tie is disclosed and steps
taken to remove the chance of bias  potential
conflict resolved
(3) one ought to remove evil or harm; and
(4) one ought to do or promote good.
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(continued)
• Training usually required
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16‐Feb‐21
Is there a Conflict of Interest?
Trust must be nurtured
• Position requiring judgment
• Paramount is the good of patient
• Interests that might cloud judgment present
• Avoid COI
• Financial
• Familial
• Prior connection
• Personal
• Poses a conflict with the patient’s (or public’s)
interest
• Avoid perceptions of COI
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• Ensure fair and equitable conduct
• Can undermine public trust if ignored
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Answer
Managing Conflict of Interest
• Not necessarily  NO requirement to leave
advocacy organization
• Disclosure
• Manage
• Significant involvement can cause an actual conflict
of interest
• Do NOT continue or start
• Official must balance this risk and be careful so
there is no appearance of a COI or a COI.
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Healthcare Environment
Environment (continued)
• Managed Care
• Young and old life spans
• Increased Healthcare Costs
• Decrease in healthy lifestyles
• Technology
• Lack of healthcare access / Insurance
• Baby Boomers
• Feelings of entitlements for healthcare at a
minimal personal cost
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16‐Feb‐21
Long-Term Effects (continued)
Long-Term COVID-19 Effects
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Ethical Dilemma
• Value conflicts, no clear consensus as to the “right”
thing
• Choice between two equal, usually undesirable,
alternatives
Dilemma?
Should medications be withheld from homeless or
incompetent people because they don’t have the
means to store or manage the medication properly?
• Should a parent have a right to refuse immunizations
for his or her child?
• Does public safety supersede an individual’s right?
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How Can Harmony Be Achieved?
External Forces
Political Influences / Forces
• Immigration / Migration of the elderly
Through ethical principles / behaviors; they:
• Provide a unique opportunity for personal fulfillment and
self respect
• Medicare / Prescription drugs – life
style driven
• Serve to make it possible for professionals to deal with
each other on a human level with respect across all
disciplines
• Decrease in extended families
• Decrease in resources
• Work force
• Family Caretakers
• Support/Finances Services in the Community
Socio-economic Disparities – healthcare right or
privilege?
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16‐Feb‐21
Principles (continued)
Principles (Continued)
• Serve to make it possible for professionals and clients to
deal with each other on a human level with respect across
all cultures and communities
• May make it possible for professional and clients to agree
on and respect each others rights
• May make it possible for this agreement to carry over into
other aspects of life outside the healthcare setting where
the idea of Ethics may be first introduced to the
professional
• Make it possible for strangers to achieve understanding (if
agreement is not reached, toleration may be achieved)
• May make it possible for provider and patient to interact
on the basis of shared goals
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Utility
Utility
Distribution

Collective
Based on internal contradiction shown
Measurement
• Impossible to do an interpersonal comparison of utility
• Hard to measure utility concretely
01 man

10 men +100 utils
9 utils
– 12 utils
+ 88
concentrated costs –
distributed benefits
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Autonomy
Autonomy (continued)




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+ 100 utils
10 men
concentrated benefits –
distributed costs
• Might place an innocent person
in jail to make community feel better
• Unjust
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01 man
+ 91
Justice
Distributive
From Greek: autos (self) Nomos (rule of law)
The right to participate in and decide on a course of
action without undue influence
In our diverse society, individuals often
misunderstand each other



The right to participate in and decide on a course of
action without undue influence
In our diverse society, individuals often
misunderstand each other
Even when they do understand each other, it is
possible for them to disagree
Healthcare arena, in common with every other
segment of society, has found it necessary to find
ways to create understanding and agreement
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16‐Feb‐21
Autonomy (continued)


Autonomy (continued)
Implies capacity to think, decide, take action
Mental incompetence = no autonomy
Autonomy vs. Paternalism
• When patient is not autonomous => no clash
• When patient is autonomous => questionable
procedure

Patients have right to choose or refuse
Self-Determination

In USA, the accepted Standard of Care

Healthcare team members offer reasonable, wellexplained options

Work with patients to make sound and reasonable
decisions for them and their family

May need a second opinion

May need a psych consult
• Freedom to act independently
• Individual actions are directed toward goals that are
exclusively one’s own
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Should Patients Have Access to
their Medical Notes?
Privacy / Confidentiality
• Respecting privileged knowledge
• Respecting the “self” of others
Act against this principle and you destroy patient’s
trust
• Conflict => when keeping confidentiality would
harm others (e.g., child abuse)
AGAINST
FOR
• Layman unable to cope
with data
• Data belongs to patient
• Accuracy improved by
sharing
• Opinions are not facts;
may cause anxiety
• Third-party information
• Defensive medicine
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HIPAA*
HIPAA (continued)
Health Insurance Portability and
Accountability Act of 1996
• Holds all healthcare providers accountable for nonconsented release of medical information
(Implemented April 2003)
Violations
• Ensures privacy and confidentiality of medical records (a
legal document that identifies the patient, diagnoses, and
justification for treatment)
• Easy electronic access; misuse of patient data
• Overhearing telephone conversations
• Leaving patient records unattended
• Healthcare providers are responsible for hiring and
educating personnel to be knowledgeable of HIPAA rules
and regulations governing privacy and security of patient
healthcare information
• Unauthorized duplication of records
• Inappropriate discussion of patient information
Repeat slide from
EPP-1
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16‐Feb‐21
Confidentiality Exceptions
Exceptions (continued)
• Patient gives written and valid consent
• Statutory requirements
• To other participating professionals
• Ordered by a Court
• Where undesirable to seek patients consent
info can be given to a close relative
• Public interest
• Approved research
• Financial interests
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Veracity
Polling
The duty to tell the truth; honesty
Truth-telling
In much wisdom is much grief: and he that
increaseth knowledge increaseth sorrow
(Ecclesiastes 1:18)
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Truth Telling
Fidelity
If you override it, you endanger the pharmacistpatient relationship (based on trust)
• Strict observance of promises or duties
• This principle, as well as other principles, should be
honored by both provider and client
Failure to tell the truth is an offense against the
principle of autonomy
Are there ever good reasons for overriding the truth
telling principle?
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16‐Feb‐21
Case for Patient Deception
Justice
The principle that deals with fairness, equity, and
equality; provides for an individual to claim that to which
they are entitled
BASED ON THREE FALLACIES
1.
Hippocratic obligations
2.
Not in a position to know the truth
3.
Patients do not want the truth, if the news is
bad
How do you determine who qualifies for one available kidney?
Comparative Justice
• Making a decision based on criteria and outcomes.
kidney
• 55-year old male with three children versus a 13-old girl
Non-comparative Justice
• Method of distributing needed kidneys using a lottery
system
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Preservation of Life
At what stage does human life begin?
• Contraception / “quickening” / birth
What is life?
• Brain activity, heart beat (assisted-unassisted)
Is each life equal?
• Death penalty, brain dead
Living Wills
• Patient unconscious\severely mentally disabled,
and two docs agree it unlikely he will be able to
communicate treatment decision
• Refuse treatment if prolongs life with no further
benefit to patient
• Is you family prepared?
Can we assess another person’s quality of life?
• Jehovah’s Witnesses / Christian Scientists
Do we have the right to self determination?
• Euthanasia, DNR
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Euthanasia
Active

Active intervention to end life
Passive
• Deliberately withholding treatment that might help a
patient live longer
Voluntary
• Performed following a request from a patient
Euthanasia (continued)
Doctor-assisted suicide
• Doctor prescribes a lethal drug which is self
administered by the patient
Non-voluntary
• Ending the life of a patient who is not capable of giving
permission
Involuntary
• Ending life against a patients will
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16‐Feb‐21
Creating Understanding
Other Moral doctrines
Acts and Omissions Doctrine
• Held by those who believe that passive euthanasia is
not killing
• Killing is an act; an omission is not an act
Doctrine of Double Effect
• Makes a distinction between what I intend and what I
merely foresee
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• Common ground must be created or found
• A function of Ethics, in our society, is to make agreement
possible
• As healthcare professionals and patients meet, they
encounter as strangers from diverse backgrounds therefore,
their ways of looking at and approaching the world are
usually quite different   
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Differences
Differences (continued)
• Power
• Education Level
• Self-esteem
• Socioeconomic Class
• Communication
• Culture (which may constitute the most profound
difference)
• Personality / Attitude
• Values
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Polling
Sources of Waste in Our System
Disc
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16‐Feb‐21
Resource Allocation
How do we allocate scarce resources?
• Expensive drugs
• Medical procedures
• Donated organs
4 primary issues
• Distribution
• Measurement
• Justice
• Distortion Effects
Decision-Making Rules
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Resource Allocation Rules
1. Best chance of survival
• How to measure?
2. # of dependents/ relatives
• Fertility
3. Social productivity /
research potential
4. $$$$$$
5. < $ • 7. Randomly 8. 1st come; 1st serve 9. Politics 10. Maximum number served 11. Cooperability Suffrage 56 Resource Allocation  ↓ ↓ Drug Shortages ↓ ↓ Allocation (continued) Overarching Ethical Principles • • • • • • Overarching Ethical Principles Beneficence Solidarity Utility Equity Stewardship Trust 57 When resources are scarce, tough decisions must often be made about how to meet health needs ethically within resource constraints. Key ethical principles that will be relevant in responding to a drug supply shortage are outlined below. These ethical principles are not exhaustive of all principles that might guide our typical practice, but rather these are the ethical principles that are most relevant to the situation we find ourselves in, where difficult decisions need to be made about how drugs in short supply will be allocated to meet patients’ needs and about whether health services will need to be modified in response to the drug shortage. 58 Beneficence Solidarity Maintain highest quality of safe and effective care within resource constraints by: Build, preserve and strengthen inter-professional, interinstitutional, inter-sectoral, and where appropriate, interprovincial/territorial collaborations and partnerships by: • Ensuring standard of care and best practices whenever possible • Minimizing pain and suffering of individuals • Using alternative drugs or treatments where evidence suggests similar clinical efficacy  • Informing and educating health providers about benefits, risks and appropriate use of alternative treatments, including risk mitigation strategies • Enabling individuals to receive care in the most appropriate setting 59 6. Age • Embracing a shared commitment to the well-being of patients regardless of care setting or geographic location • Establishing, encouraging, and enabling open lines of communication and coordination amongst health professionals, health institutions, and health sectors • Encouraging sharing of resources across health sectors, health institutions, and, where appropriate, provinces/territories • Supporting each other’s allocation decisions consistent with the ethical framework 60 10 16‐Feb‐21 Equity Utility Promote just/fair access to resources by: Maximize the greatest possible good for the greatest possible number of individuals by: • Ensuring burdens are not borne disproportionately by any patient, patient group, health sector, or institution • Using allocation processes for distribution of drugs and modification of services that do not arbitrarily disadvantage any particular patient, patient group, health sector, or institution • Not discriminating between patients based on factors not relevant to their clinical situation (e.g., social status)  • Distributing drugs in short supply to those in most need and most likely to benefit  • Sharing drugs within and across institutions/sectors 61 62 Trust Stewardship Foster and maintain public, patient, and health care provider confidence in health system by: Use available resources carefully and responsibly by: • Ensuring drug utilization is consistent with available evidence of clinical efficacy • Postponing elective procedures/treatments that require use of drugs that are in limited supply • Prioritizing access to scarce drugs based on urgency and severity of need • Monitoring drug utilization and distribution to facilitate mid-course corrections as needed  63 • Communicating in a clear and timely fashion • Making decisions in an open, inclusive and transparent way with clearly defined decision-making authority and accountability at all levels • Evaluating health system response to capture short and long-term lessons learned  64 End-of-Life Care We all die Respect for the Individual • Experiences throughout our lifetime defines how we wish to end our own life • Personal preferences may conflict with family’s wishes, cultural norms, or other things • Advance directives  legal way to identify the patient’s wishes • Living Will • DNR / prolonging life declarations 2. Hospice care • Five Wishes 3. Palliative care • Allow Natural Death (AND) • increases in life expectancy => larger elderly population =>
more healthcare spending
Distribution of Individual Medical Care
Expenditures
The Concentration of Personal Health Expenditures

Getzen’s Health Economics & Financing, 5th Edition

Copyright © John Wiley & Sons, Inc.
Pharmaceutical Spending in the U.S.
U.S. Sources and Uses of Healthcare Funds, 2010
Pharmaceutical expenditures -10% of healthcare costs
Fastest growing segment
Expected to increase by 50% in the next decade
Americans spend more on medicines than Japan,
Germany, France, Italy, Spain, UK, Australia, New
Zealand, Canada, Mexico, Brazil, and Argentina…combined

Getzen’s Health Economics & Financing, 5th Edition

Copyright © John Wiley & Sons, Inc.
Sources of Funds for Pharmaceutical
Products

Getzen’s Health Economics & Financing, 5th Edition

Copyright © John Wiley & Sons, Inc.
Health Insurance
Healthcare in the U.S. – expensive
A small percentage of the population consumes a large share of the total
healthcare spent
Who pays for the healthcare of those who are sick?
Could the 1-5% with the greatest personal healthcare expenses be able to pay
for these without health insurance? Who pays?
Is it fair that we contribute to the healthcare expenses of others?
What is the reason we agree to contribute to the expenses of others?
Risk aversion
Health insurance protects us against this risk of sudden large healthcare
expenses
Trade health insurance premium every month for expenses coverage if sick
Methods for Covering Risks
Use private savings to pay for current expenses
Individuals trade with themselves at different time periods
Assistance from family and friends
Mutual obligation and reciprocity
Charity as a means of social exchange
Limited for most people
Social healthcare insurance
Contributions are mandatory through the tax system
Private medical care insurance
Individual perspective: trade monthly premium for affordable
treatment if/when sick
Societal perspective: risk pooling
Private Health Insurance Risk Pooling
Club with 100 members
Risk of getting sick: 1/100 (1%)
Healthcare expenditure: $5,000
Annual contribution per member: $50
Money earns interest in a bank account
Every year, money used to pay healthcare expenses of sick member
Society’s point of view: insurance is a method of pooling risk such that a
person’s loss (when sick) is shared across many people
Risk pooling: funds are collected from many people (most healthy) and used
to cover for a few people’s illnesses
Health Insurance Terminology (cont.)
Copayment
A form of medical cost sharing in a health insurance plan that requires an
insured person to pay a fixed dollar amount when a medical service is
received
Maximum plan dollar limit
The maximum amount payable by the insurer for covered expenses for
the insured and each covered dependent while covered under the health
plan
Maximum out-of-pocket expense
The maximum dollar amount a group member is required to pay out of
pocket during a year
Until this maximum is met, the plan and group member shares in the cost
of covered expenses
After the maximum is reached, the insurance carrier pays all covered
expenses, often up to a lifetime maximum. (See previous definition.)
Health Insurance Terminology
Premium for coverage
Agreed upo…

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