AETCOM DR BHAVIKA.pptx (Autonomy�&Non-maleficence)

Autonomy�&Non-maleficence

1. Dr Bhavika patel MBBS,MD Microbiology,DIPC Assistant Professor Department of microbiology GMERS MC, Valsad . Autonomy &Non-maleficence

2. Role of non-maleficence as a guiding principle in patient care. Role of autonomy and shared responsibility as a guiding principle in patient care Learning objectives

3. Autonomy Benefiecence Non-maleficence Social justice Principles of Medical Ethics

4. ROLE OF NON-MALEFICENCE AS A GUIDING PRINCIPLE IN PATIENT CARE

5. “I will prescribe regimen for the good of my patients according to my ability and judgment and never do harm to anyone” Hippocratic Oath

6. Maleficence:  is the deliberate infliction of a negative act or effect on another individual or a group Non-maleficence: is the principle of refraining from causing intentional harm toward another human being. Non-maleficence , therefore, indicates that a person genuinely works for a positive outcome for those with whom they come in contact Definition

7. Distinction between Non-maleficence and Beneficence INSTRUCTIVE PRINCIPLE BIOETHICAL PRINCIPLE One ought not to inflict evil or harm Non-maleficence One ought to prevent evil or harm Beneficence One ought to remove evil or harm Beneficence One ought to do or promote harm Beneficence

8. Examples of No maleficence by Gert (bioethicist) Do not kill Do not cause pain or suffering to other Do not cause offense to others Do not incapacitate others Do not deprive others of the goods of life

9. Beneficence Literally – “Being charitable or doing good” Where a doctor should act in the “best interests” of the patient, the procedure be provided with the intent of doing good to the patient Non–maleficence primum non nocere first , do no harm Literally- “Doing no harm” Make sure that the procedure does not harm the patient Definition

10. An action must not be intrinsically wrong A good effect must be intended by the action The good outcome must not be a byproduct of a bad effect If there are negative outcomes of an action, the good outcomes of the action must outweigh the bad K ey components

11. Refrain from providing ineffective treatments or acting with malice toward patients The pertinent ethical issue is whether the benefits outweigh the burdens. Description

12. The principle of non-maleficence can be applied in one’s own common language, that is called NEGLIGENCE, that is, if one imposes harm or become careless and produces unreasonable risk of harm upon another Criteria in determining Negligence: 1 . The professional must have the duty to the affected party 2 . The professional must breach that duty 3 . The affected party must experience a harm 4 . The harm must be cause by the breach duty Non-Maleficence: Negligence

13. Forbids From providing ineffective therapies From acting maliciously or selfishly [if no benefit, at least not harm or make situation worse] Provides Limited guidance since many interventions also entail serious risks and side effects Standard care [if benefit equals harm, do not intervene] Non-maleficence

14. Not to provide ineffective treatments to patients as these offer risk with no possibility of benefit and thus have a chance of harming patients Not do anything that would purposely harm patients without the action being balanced by proportional benefit The risk of treatment (harm) must be understood in light of the potential benefits Clinical applications

15. 1. Withholding Treatment and Withdrawing Treatment Many health care professionals and the family feel guilty when treatment is withdrawn (stopped) and withhold (not started) Both withholding and withdrawing treatment are bioethical issues which can be acted upon or justified by the following conditions: 1 . When the case is irreversible any form of treatment will not benefit the patient 2 . When death is immanent or when patient is already dead Clinical applications

16. 2. Ordinary and Extra-ordinary Treatments Ordinary Treatment – comprises of the provision of necessities of life that usually pertain to food, normal respiration and elimination process Hence like, intravenous fluids, nasogastric tube feeding, indwelling catheters, are some among the many considered ordinary and necessary measure of treatment and may be sustained even if the case is irreversible Extra-ordinary Treatment – comprises the use of aggressive modalities vis-à-vis the capacities of the family maybe some family who can very well afford it, continue to give extra ordinary measure This is also a way of artificially prolonging the life of the patient Clinical applications

17. 3. Killing and Letting Die Killing people, In a medical environment it conjures up images of healthcare workers secretly and possibly involuntary killing their patients, of handicapped infants and elderly people in an institution being quietly snuffed out of wicked experimental programs Letting people die, suggest the much acceptable practice of ‘letting nature take its course’, facing up the limitations of medicine and the fact of impending death and avoiding heroic measures such as aggressive surgery, drug therapies or intrusive devices Clinical applications

18. 3. Killing and Letting Die… According to Beauchamp and Childress, 2001: Killing is a causal action that is deliberately brings about another’s death Example : Car accidents, one driver killed another when no awareness, intent of negligence was present Letting die is the intentional avoidance of causal intervention so that disease Example : System failure causes death Clinical applications

19. 3. Killing and Letting Die (according to Beauchamp and Childress, 2001 )… Letting die is ‘prima facie’ acceptable in medicine under two conditions: 1. A medical technology I useless (medically futile) 2 . Patients (or valid surrogate/proxy) have validly refused a medical technology That is, letting a patient die is acceptable if and only if satisfies the condition of futility or the condition of a valid refusal treatment So , it implies now that once the criteria of letting die was not satisfied, then letting the patient die involves negligence and may perhaps constitute a form of killing Clinical applications

20. 3. Killing and Letting Die… In short, whether killing and letting die is justified or unjustified are matters in need of analysis and argument and not matters that medical tradition and legal prohibition have adequately resolved. Clinical applications

21. As such, students or residents may violate this principle when they act prematurely and perform tasks outside of their respective scopes of practice For example, during training, medical students may need to learn how to obtain peripheral intravenous access However , practicing this skill may potentially result in unnecessary patient morbidity, through actions such as prolonged procedure time; repeat procedures; and increased risk of haematoma , contamination, and infection EXAMPLE

22. Often, physicians-in-training are unknowingly asked to weigh the patients’ rights to no harm with their own need to learn In many cases, the solution to such scenarios is to permit invasive learning opportunities when the patients’ potential for loss or harm is judged to be minimal For example, a new orthopaedics intern would not be permitted the opportunity to perform a complete open reduction internal fixation of a broken bone independently, a situation in which the potential for serious harm to the patient is great However , they may be permitted a first-assistant position and allowed to perform the opening incision, a substantially less risky portion of the operation These trade-offs are made daily, and throughout medical training, in order to attempt to maximise both patient safety and educational efficiency EXAMPLE

23. Role of autonomy and shared responsibility as a guiding principle in patient care

24. Ethics : Autonomy Prf . Utham Murali. M.S ; M.B.A.

25. Meaning From the Greek: autos (self) Nomos (rule of law), broadly meaning ‘self- determination, self-rule, being your own person, self governing.

26. Definition Autonomy can be defined as ‘”self-rule with no control, undue influence or interference from other ” ( Griffith and Tengnah, 2010). It is about respecting other peoples wishes and supporting them in their decisions (Beauchamp and Childress, 2009).

27. Autonomy The patient has the right to refuse or choose their treatment . Autonomy can be defined as the ability of the person to make his or her own decisions. This faith in autonomy is the central premise of the concept of informed consent and shared decision making.

28. Autonomy – Introduction In practice, the principle requires respect for the decision-making capacity of competent adults . We are “… a culture that celebrates the individual.” The rise of autonomy in bioethics is quite recent. Until the 1960s, medical ethics, as the field was then called, was largely “internal to medicine— those values, norms, and rules intrinsic to the actual practice of health care.”

29. During the last half of the 20th century , however, many traditional aspects of authority in our society were questioned, as manifested in the civil rights, feminist, and anti-war movements The practice of medicine was affected as well The discourse on medical morality that previously had been held within the profession gave way to a-New way of thinking in which the ethical values of society at large— including the rights of the individual— were applied to the practice of medicine Autonomy

30. Autonomy – Principles The principle of autonomy recognizes the rights of individuals to self- determination . The increasing importance of autonomy can be seen as a social reaction to a "paternalistic" tradition within healthcare . Respect for autonomy is the basis for informed consent and advance directives.

31. Autonomy – Principles Autonomy is a general indicator of health. This makes autonomy an indicator for both personal well-being, and for the well-being of the profession.

32. Personal autonomy is, at minimum, self-rule that is free from both controlling interference by others and from limitations, such as inadequate understanding, that prevent meaningful choice The autonomous individual acts freely in accordance with a self-chosen plan, analogous to the way an independent government manages its territories and sets its policies A person of diminished autonomy, by contrast, is in some respect controlled by others or incapable of deliberating or acting on the basis of his or her desires and plans AUTONOMY NOTION

33. Respect for patient autonomy is now fully integrated into the practice of medicine In the clinic, the patient’s right to accept or refuse medical care changes the balance of power in the physician-patient relationship and engages the patient more fully in ownership of care plans Shared decision-making has become the norm, and it is viewed by the patient and the physician as essential for honoring the individual and his or her dignity AUTONOMY - CLINICAL APPLICATION

34. Autonomy rights make sense and are easiest to defend and implement in the context of the well-informed adult of sound mind But we are routinely confronted with patients whose competence (legal status) or capacity (current ability) may be in question because they are minors, are imprisoned, have a cognitive impairment, are mentally ill, or are intoxicated We sometimes suspend or a bridge autonomy for such patients; but rarely do we put it aside in favor of another ethical principle—beneficence, nonmaleficence , or justice. Instead, we stretch and extend autonomy AUTONOMY - CLINICAL APPLICATION

35. In end-of-life care, the extension of autonomy has been promoted vigorously, but with mixed results To be sure, deference to the wishes of the patient and his or her family is a valuable starting point for all end-of-life care However , it is reasonable to question the role of autonomy when continued aggressive care will not lead to recovery, but only prolong dying Autonomy – End of life

36. Death teaches us that some things cannot be controlled. As the end of life approaches, the domains over which the patient or family can exercise control diminish to the vanishing point It is reasonable to ask whether it is even possible for a human being to exercise autonomy in any meaningful way when nearing death The approach of death signals that the other principles of medical ethics— beneficence, nonmaleficence , and justice—may be needed, and that perhaps they should even trump autonomy Autonomy – End of life

37. Today, we have “a patient-centered medical ethics that emphasizes autonomy rights over professional obligations of beneficence when they conflict” The rise of autonomy has brought “unprecedented challenges to [medical professional] authority” A worst-case scenario illustrates the point. When patients insist on decision-making authority, it is tempting to defer to them. However, the “it’s your decision” approach can be a form of abandoning the patient The physician may feel that without full authority to make decisions, he or she should not assume responsibility for outcomes. The physician may dispense with some of the soul-searching about the right course of action thinking that the patient will decide what he wants, anyway. Autonomy vs Physician

38. I ncludes respect for their privacy and confidentiality need to provide sufficient information for them to make informed choices truth telling protection of persons with diminished or impaired autonomy Recognize the capacity of mentally and legally competent patients. RESPECT : To think and make decisions independently To act on the basis of their decisions To communicate their wishes to health workers Uphold patient confidentiality Respect for Autonomy (Person)

39. Promoting Autonomous behaviour Presenting all treatment options to a patient . Explaining risks in terms that a patient understands . Ensuring that a patient understands the risks and agrees to all procedures before going into surgery.

40. Paternalism is defined as the overriding of individual choices or intentional actions in order to provide benefit to that individual. (Beauchamp & Childress, 2001) Autonomy vs Paternalism

41. Autonomy Agents have a right to be self-determining; individuals have a right to conduct their lives as they see fit Autonomy is typically taken to be a core component of a “good life.” Paternalism It is sometimes legitimate to restrict agent autonomy, for their own good Soft paternalism-agent is incompetent in some relevant way Hard paternalism-agent has less-than-ideal values Autonomy vs. Paternalism: The Central Conflict in Medical Ethics

42. Respecting autonomy means you must: Consider the words in the bubbles below, in groups of 2 or 3 create statements which include 1 or more of these words What obligations does respecting patient autonomy impose on us in practice? VERACITY COMMUNICATION PATIENT PERSUADED PREFERENCE INFORMATION

43. EXAMPLE -1 Examples include when a patient does not want a treatment because of, for example, religious or cultural views. In the case of euthanasia, the patient, or relatives of a patient, may want to end the life of the patient.

44. A doctor may want to prefer autonomy because refusal to please the patient's self-determination would harm the doctor-patient relationship .

45. CONCLUSION To sum up, there seems no perfect answer to an ethical dilemma. It is hard to justify the use of one principle over another. Yet the ethical decision making process provides a guide to take a step ahead and apply the best possible principle.

46. However, it may not be the perfect choice but it may result in maximum beneficence and minimum harm which could be avoided. Nevertheless, in any such situation, pros and cons and risks and benefits should be weighed against to get to the best possible solution which would be in favor of the patient. The potential benefits of any intervention must outweigh the risks in order for the action to be ethical.

47. CONCLU S ION

48. Principle of respect for autonomy and competence are crucial in moral decision making in medical ethics, and require a great deal of thought

49. THANK YOU…

50. https://study.com/academy/lesson/principle-of-nonmaleficence-in-nursing-definition-examples.html BIOETHICS BENEFICENCE / NON-MALEFICENCE Prof. Utham Murali BENEFICENCE AND NON-MALEFICENCE; S A N T I A G O , J O D I N E K I M B E R L Y M . S A L V A D O R , I S A B E L L E M . M A N Z O , C O R A Z O N M U H A M M E D . Ethics : Autonomy; prof. Utham Murali . M.S; MBA Ethics in Clinical Practice; Med Princ Pract 2021;30:17–28 27 DOI: 10.1159/000509119; Principles of Clinical Ethics and Their Application to Practice Basil Varkey The Medical College of Wisconsin, Milwaukee, WI, USA Autonomy vs beneficence; R AH U L K AR S O L I YA 20059 R AM P R AS A D 2 0 0 6 0 References