Oct 7, 2017 - Edmund Pellegrino, Mark Siegler, Peter Singer. 1997 Tavistock ... ethical issue. Richard Smith, Don Berwick, Frank Davidoff, Howard. Hiatt.
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Healthcare: ethical, affordable, safe Can we get there? Adjunct Prof Steve Bolsin University of Melbourne, Monash University & Specialist Anaesthetist Barwon Health Medical Director & Advisor Quality & Risk, St John of God Geelong Hospital
Ancient ethics History of Medicine
3000 BC Danube – Neolithic (New stone age)
2000 BC Seine/Ouise/Marne – Neolithic ‘trivial ritual’
1900-1500 BC Southern France – Neolithic
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A brief history of medical ethics Massachusetts Experiment 1945 – 1975 Nazi experiments WW2 Tuskegee Experiment 1932 -1972
Hippocrates 460 BC
Oregon Experiment 1963 – 1973
Declaration of Geneva 1964 Beauchamp & Childress Nuremberg Trials 1972 1947
Modern medical ethics
Autonomy Beneficence Nonmaleficence A ‘Rule of Thumb’ for Medical Ethics
Justic e
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Has ethics worked? Winnipeg – >12 unnecessary child deaths/injury
Ian Patterson, UK Bristol – 170 breast Mid unnecessary Staffs – surgeon, Coventryfor & mutilating jailed Francis Report deaths of - Raj Walsgrave operations on >1000Dr Patel of “suffering Mahtu;& 3200 excess children Bundaberg – deaths; CQC of women misery” of 100s Texas investigation Charged neurosurgeon patients jailed for ‘maiming patients’
>500 deaths; 1000s of patients harmed
with manslaughte r in Bacchus Marsh NZ Queensland cervical - Perinatal cancer treatment Mortality Cases scandal
Healthcare safety – a global issue
Canada – 7.5% AE rate; 37% preventable; 21% fatal
Ireland – cause 12.2% AE rate 70% preventable UK – 10.8% AE rate; 50%48,000-98,000 preventable; 33% >moderate disability or US – AEs deaths in France – 10-15% AE rate; 3.5-6.5% preventable death 2000
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What happens if you make changes? 10 Hospitals in North Carolina
Death 2.4% “Harms remain “little8.5% evidence of Life common”; threatening widespread improvement”
Permanent harm 2.9% Hospitalisation 43%
25% of all admissions suffered harm
Temporary harm 42% No significant change over time
What happens if you make changes?
3 of the safest hospitals in the US examined
Established operational patient safety programmes External funding for patient safety research Programmes focussed on safety incidents & reporting Had received external recognition & patient safety awards
(centres not named in the article)
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Ethics of modern medical students 100
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Ethics of modern medical students
Ireland, 2011: Shorten et al, document regression and levelling in the moral reasoning of final year medical students and a decrease in reflective ability applied in the medical context.
Quality improvement & Ethics How does it go wrong? The ‘hidden curriculum’ in medicine Hafferty & Franks Acad Med 1994;64:861-71 Wolf et al Med Educ 1989;23:19-23 Hundert et al Med Educ 1996;30:353-64
Rennie & Crosby Med Educ 2002;36:113-4
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Basis of ethics & morality Moral Philosophy & Reasoning
Deontology – Kant; absolute rules; absolute right/wrong;
Christian/Moslem/Hindu/Buddhist/Taoist
Utilitarianism – “Greater moral good” Jeremy Bentham
Virtue Ethics – Four Primary Virtues
Rights - based reasoning – Legalistic; UN proclamations
Care ethics – Developed with feminism; nursing ethic
Principlism – Establish principles; motivation of action
Ethics & morality Deontology Absolute right in the universe; required for the concept Religious ethics What was the view of the church/mosque/temple Utilitarianism The ‘greater moral good’ as a consequence of an action Principlism Autonomy, beneficence, non-maleficence & justice Virtue ethics Conscience, wisdom, courage & temperance
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Clinical ethics and healthcare safety 1991 Future directions in clinical ethics identifies medical error as an ethical issue Edmund Pellegrino, Mark Siegler, Peter Singer. 1997 Tavistock Group identifies patient safety as an ethical issue Richard Smith, Don Berwick, Frank Davidoff, Howard Hiatt. 2001 Clinical ethics revisited reasserted the importance of ethics and safety and clinical ethics education. Edmund Pellegrino, Mark Siegler, Peter Singer.
Clinical ethics and healthcare safety Edmund Pellegrino, Mark Siegler, Peter Singer. 2001 • The principal goal of teaching is to improve the quality of patient care • Teaching should focus on cognitive skills, behavioural skills, and character development • Teaching should be integrated into all stages of a physician's education, including medical school, residency, and continuing education • Practising clinicians with formal ethics education brought advantages to teaching, but philosopher bioethicists also had much to contribute • One of the most persistent and difficult questions was whether teaching clinical ethics made any difference
• There was a lack of trained clinicians to teach clinical ethics • There was a prevalent scepticism about whether virtue or character could be taught
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Clinical ethics and healthcare safety Edmund Pellegrino, Mark Siegler, Peter Singer. 2001
Ultimately, the teaching of clinical ethics needs integrating into the teaching of clinical medicine, so that it becomes, what Hafferty and Franks called the "hidden curriculum". ..we need to harness the informal curriculum. Clinicians in influential positions who do not respect patients, damage the education of medical students and residents in a way that no ethics education programme can overcome. We need to develop a culture in our academic programmes and clinical teaching units that is sensitive to the ethical concerns of patients and families. ..medical educators should pay attention to character formation because character is so central to moral life. This is a more complex subject than simply teaching about virtue. The key, of course, is role modelling by faculty members, and building a sustainable community of clinicians focussed on the ethical concerns of patients and families. Sadly, both are lacking in many of today's medical schools.
Clinical ethics and healthcare safety Edmund Pellegrino, Mark Siegler, Peter Singer. 2001
..we need to focus more on evaluation. Performance in clinical ethics should be part of the evaluation process for physicians at all levels. For example, in-training evaluation reports for residents should contain an item about how the resident performed with respect to challenges in clinical ethics. Finally, we need to strengthen our capacity to teach ethics. Teaching clinical ethics at the bedside requires staff with both clinical and ethical skills, and in most universities there are not enough people with such skills. Academic health science complexes need to develop faculties for teaching clinical ethics. Finally, although important improvements have occurred in clinical ethics processes, the goal of improved clinical outcomes has not been achieved. We find this conclusion disappointing, and urge our colleagues in clinical ethics to redouble efforts to demonstrate improvements in patient outcomes related to clinical ethics activities.
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Clinical ethics and healthcare safety Bolsin, Colson & Cawson 2015
The driving force for an effective and efficient revalidation process should be the professional and ethical responsibility that each doctor has to their patients and to the society which has granted them the right to practice.
We propose that effective revalidation processes based on performance measurement would be cost-effective and, if correctly applied, could lead to significant cost savings in Australian health care.
The medical profession should accept some responsibility for systemic health care error, particularly those errors which harm patients. We believe that the profession should be committed to rectifying current deficiencies and minimising future errors for ethical reasons, as well as the obvious reason of financial rectitude.
The importance of an ethical component to the approach to patient safety is that it imposes an overarching imperative to guide professional behaviour.
Clinical ethics and healthcare safety Peter Singer 2000 ‘on medical error’
Cooperation with each other and those served is the imperative for those working within the healthcare delivery system
All individuals and groups involved in health care, whether providing access or services, have the continuing responsibility to help improve its quality.
In developing a culture of safety, clinicians will need to act as role models for their students by applying these principles themselves the next time they encounter a medical error. Healthcare leaders will need to “feel personally responsible for error” and “declare error reduction to be an explicit organisational goal, and [devote] a significant proportion of the board and management agenda . . . to achieving this goal.”
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Behavioural insights in a medical context
Nearly 20% less likely to prescribe medication when deciding between 2 than deciding between 1
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Behaviour in medicine – ethical outcomes Performance monitoring & incident reporting
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Behaviour and safety Poor Performance Monitoring New York state 40% reduction in risk-adjusted mortality in 3 years. New Hampshire 28% reduction in risk-adjusted mortality in 3 years. California Reduction in complications in
