Evidence-Based Medical Ethics:: Cases for Practice-Based Learning / Edition 1

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Overview

In the modern practice of medicine, new challenges complicate the ethical care of patients. Today's times require a contemporary take on the concept of medical ethics. The idea for this textbook was born out of a need for a teaching resource that merges medical ethics theory with the practical needs of modern clinical medicine. In Evidence-Based Medical Ethics: Cases for Practice-Based Learning, the authors address what has been missing in existing text books and ethics courses to date - clear-cut ethical and legal guidelines that provide a method for the reader to learn how to systematically manage dilemmas seen in the everyday practice of medicine. The reader is guided through several "typical" patient scenarios and prompted by various questions that should be entertained by the treating health care provider. Then, relevant evidence-based medicine, legal precedent, and the ethical theory that applies to the situation are revealed. Often, finding the "best" ethical solution for each problem is automatic, as the solution often becomes self-evident during information-gathering. This general method is reinforced throughout the text with multiple different cases, using a practice-based approach by building on the reader's developing skills. Additionally, we have sought to emphasize a culturally competent manner in resolving these dilemmas, respectfully addressing issues of age, gender, and culture whenever possible. The main goal of Evidence-Based Medical Ethics: Cases for Practice-Bases Learning is to assist the reader in adapting a patient-centered and evidence-based approach to dilemmas faced in their future practice of medicine.

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Editorial Reviews

Doody's Review Service
Reviewer: Michele K Langowski, MA, JD (Saint Louis University)
Description: This is the newest addition to case-based clinical ethics books.
Purpose: Recognizing the need for a teaching resource that merges medical ethics theory with the practical issues confronted in patient-centered clinical medicine, the purpose of this book is "to provide a method for the reader to learn how to systematically manage dilemmas seen in the everyday practice of medicine."
Audience: The authors, an internal medicine physician and health care ethicist, have several audiences in mind for the book: medical students and residents, nursing students, undergraduate and graduate medical ethics courses, as well as clinicians.
Features: The 25 clinical ethics cases include "typical" patient scenarios and corresponding ethical dilemmas encountered in the healthcare setting, but with an evidence-based medicine approach. Each case begins with a detailed account of the patient's clinical presentation, followed by an explanation of the ethical dilemma and two or three short thought questions posed to the healthcare provider. There is a brief overview of the relevant evidence-based medicine, general legal precedent, and the ethical principles that apply in the specific situation.
Assessment: The authors do not provide ethical resolution of cases. Instead, at the end of each case presentation, readers are told to "consider delving further into the background medical literature to assist with making sound therapeutic decisions. Devise a treatment approach that addresses the needs of the patient and his [her] family, that is both ethically and medically sound, and that is culturally competent. Ensure that the strategy employs fair and appropriate utilization of medical resources, and that the approach is practical and feasible within the limits of the medical system at large." While the emphasis on evidence-based medicine is a modern approach, the case scenarios and ethical dilemmas are very familiar.
From The Critics
Reviewer: Michele K Langowski, MA, JD(Saint Louis University)
Description: This is the newest addition to case-based clinical ethics books.
Purpose: Recognizing the need for a teaching resource that merges medical ethics theory with the practical issues confronted in patient-centered clinical medicine, the purpose of this book is "to provide a method for the reader to learn how to systematically manage dilemmas seen in the everyday practice of medicine.
Audience: The authors, an internal medicine physician and health care ethicist, have several audiences in mind for the book: medical students and residents, nursing students, undergraduate and graduate medical ethics courses, as well as clinicians.
Features: The 25 clinical ethics cases include "typical" patient scenarios and corresponding ethical dilemmas encountered in the healthcare setting, but with an evidence-based medicine approach. Each case begins with a detailed account of the patient's clinical presentation, followed by an explanation of the ethical dilemma and two or three short thought questions posed to the healthcare provider. There is a brief overview of the relevant evidence-based medicine, general legal precedent, and the ethical principles that apply in the specific situation.
Assessment: The authors do not provide ethical resolution of cases. Instead, at the end of each case presentation, readers are told to "consider delving further into the background medical literature to assist with making sound therapeutic decisions. Devise a treatment approach that addresses the needs of the patient and his [her] family, that is both ethically and medically sound, and that is culturally competent. Ensure that the strategy employs fair and appropriate utilization of medical resources, and that the approach is practical and feasible within the limits of the medical system at large." While the emphasis on evidence-based medicine is a modern approach, the case scenarios and ethical dilemmas are very familiar.
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Product Details

  • ISBN-13: 9781603272452
  • Publisher: Springer-Verlag New York, LLC
  • Publication date: 8/14/2008
  • Edition description: 2008
  • Edition number: 1
  • Pages: 240
  • Product dimensions: 6.20 (w) x 9.30 (h) x 0.80 (d)

Table of Contents

Case-Based Medical Ethics in Practice

Preface by the authors

Foreword

Chapter 1: A brief introduction to medical ethics in Internal Medicine



• Definitions of ethics and medical ethics


• Why is medical ethics important? (teaching competency in ethics, teaching professionalism)





• Evolution of medical ethics and its importance/role in modern medicine (from paternalism to informed consent)


• Who determines ethical guidelines for medicine?





• Difference/similarities between ethics and law





• Purpose of the book (i.e. to stimulate thought and discussion, not cover all details of all ethical principles)


Chapter 2: The underlying principles of ethical patient care



• Beneficence - a practitioner should act in the best interest of the patient. (Salus aegroti suprema lex.)


• Non-maleficence - "first, do no harm" (Primum non nocere).


• Autonomy - the patient has the right to refuse or choose their treatment (Voluntas aegroti suprema lex.)


• Justice - concerns the distribution of scarce health resources, and the decision of who gets what treatment.


• Dignity - the patient (and the person treating the patient) have the right to dignity.


• Veracity - the patient should not be lied to, and deserves to know the whole truth about his/her illness and treatment.


Chapter 3: Putting ethics into practice – realities, limitations, and roadblocks



• Practitioners and personal belief systems


• Cultural competency and practice of ethical care


• Statement about pharmaceutical company influence on education and practice


• Medical oaths – Are they valid for medicine today? Are they fulfilled by practitioners?


• The Patient Bill of Rights


• Federal, state, local, and institutional regulations – how they intertwine and affect each other


Chapter 4: Advanced Directives, Living Wills, and the Health Care Power of Attorney (HCPOA)

Chapter 5: Case-based ethical dilemmas



• How the reader should approach these cases


• Where to find more information if needed


Case 1





• Topic: Consent in the mentally ill or otherwise unfit (and ‘in between’ situations: delirium, psychiatric decompensation)


• Subtopic: When does forcing an incompetent patient to undergo treatment limit their right to dignity and the principle of ‘do-no-harm’?



• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 2





• Topic: When the HCPOA neglects their responsibility, or has other personal interests/potential gains



• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 3





• Topic: When the patient/their family bullies practitioners into unnecessary diagnostics/therapeutics



• "C.Y.A." medicine




• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 4





• Topic: When an estranged family member or spouse suddenly appears to make decisions



• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 5





• Topic: How to deal with an inpatient behaving badly (psych consults, behavioral contracts, room restriction etc.)



• Outbursts


• Substance abuse


• Illegal activity (e.g. drug-dealing)


• Known criminal warrants


• Inappropriate actions or remarks


• Admitted for ulterior motives (secondary psychologic gains, homelessness, etc.)




• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 6





• Topic: When DSS consults are needed



• Child abuse/neglect


• Elder abuse/neglect


• Spousal abuse




• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 7





• Topic: When a patient has ‘burned all bridges’ and no discharge planning is possible



• No nursing home or rehab center will accept the patient


• No home health services will accept the patient




• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 8





• Topic: Can a practitioner refuse to admit a patient? To see a patient in the office (e.g. administrative discharge)?



• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 9





• Topic: When a patient makes ‘bad’ decisions (e.g. will accept some therapies and not others, such as some blood products but not others, some procedures but not others, DNI but not DNR, etc.)



• Does a practitioner follow the patient’s wishes? Do they refuse to treat?



• Subtopic: When a patient is guided by incomplete, or misinformation (e.g. from the internet)



• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 10





• Topic: When a patient’s same-sex partner has no legal rights and is excluded by a family



• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 11





• Topic: When a patient has a contagious disease (e.g. HIV) and their partner is not aware


• Subtopic: When a partner/family does not have all the information needed to make decisions for a patient (e.g. when to disclose diagnoses such as HIV-positivity, substance abuse, suicidality)


• Subtopic: When confidential information is inadvertently leaked to those who ‘don’t need to know’


• Subtopic: What diseases are ‘reportable’?


• Subtopic: Do patients avoid testing for confidentiality fears?



• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 12





• Topic: When a family will not accept a terminal prognosis (i.e. futile ‘full codes’)



• Should a family be present during the code?



• Subtopic: When a patient themselves is unrealistic about prognosis


• Subtopic: When is a patient ‘terminal’? (i.e. definition of brain death)


• Subtopic: When is it appropriate to change the focus of care to comfort/hospice?



• How do a practitioner’s personal beliefs affect this guidance?


• The concept of dignity/therapeutic death v. Euthanasia




• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 13





• Topic: When there is no one to make decisions for a patient (e.g. John/Jane Doe in ICU, wards of the state)



• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 14





• Topic: When a mistake has been made by a practitioner (what/how to/how much to disclose)



• Mistake by primary practitioner; mistake by other/outside practitioner



• Subtopic: Caring for a patient after a poor outcome or mistake (i.e. how is care affected)


• Subtopic: When a patient makes a reference to a grievance or verbally disparages another practitioner



• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 15





• Topic: When what a patient needs cannot be obtained (e.g. financial/insurance limitations)



• Tests/procedures (e.g. colonoscopy in an uninsured/pre-Medicare patient aged 50 to 64 years old)


• Treatments


• A different medical team ("I want a new doctor"), especially when no others will take your "difficult" patient




• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 16





• Topic: When next-of-kin (NOK) disagree with each other


• Subtopic: Which of the NOK has ‘seniority’? Are legal definitions for NOK equivalent to ethically ‘best’ choices?



• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 17





• Topic: When a toxicology screen is ordered without patient consent and comes back positive


• Subtopic: When tests are ordered ‘in emergency situations’ without patient consent (e.g. HIV tests)


• Subtopic: When a practitioner is potentially exposed to infectious agents (e.g. via a needlestick) and a patient is refusing further testing



• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 18





• Topic: When a patient ‘signs out against medical advice’



• Practitioner obligations


• How can competence be quickly assessed and assured?


• What about a patient with contagious disease (e.g. TB)? Can they be allowed to leave?




• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 19





• Topic: When a patient requests a clinical interaction be recorded



• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 20





• Topic: When a family member requests patient information not be shared with the patient, or with other persons



• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 21





• Topic: When a patient requests to not be seen by a (specific, or any) medical resident or student



• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 22





• Topic: When a patient requires or demands large amounts of time from a practitioner



• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 23





• Topic: How to prescribe medications to someone who has attempted suicide (e.g. with pills)


• Subtopic: How to accurately assess and document safety in a depressed patient



• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 24





• Topic: When a colleague demonstrates suspicious behavior



• Memory problems


• Substance abuse


• Outbursts


• Inappropriate relationships with or behavior toward patients, coworkers, etc.


• Dishonesty




• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 25





• Topic: When a language translator is not available (or only a family member/hospital employee is)



• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 26





• Topic: When a patient is repeatedly readmitted to the hospital due to non-adherence (e.g. with therapy, diet, etc.)



• Where does a patient’s responsibility for their own care and well-being begin?


• The ‘cry wolf’ syndrome


• Should a procedure be repeated if a patient’s behavior may have caused failure of the first one?




• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 27





• Topic: When lawyers or law enforcement want to know patient information (HIPAA/confidentiality and the law)



• Blood alcohol level or toxicology testing


• Rape exam results


• Hidden drug stores (e.g. body cavities)


• When should access to a crime victim be allowed? To a suspected perpetrator?


• What right to privacy do prisoners have with regard to history, physical exam?


• Can/should discharge plans be shared with prisoners?




• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 28





• Topic: When a patient requests disability certification, handicap plates, etc. – or when they request renewal of a revoked driver’s license (e.g. can a practitioner-patient relationship be maintained when a patient doesn’t get what they want?)



• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 29





• Topic: How much resources should be spent on a single patient’s case? (i.e. public health cost v. value of human life)


• Subtopic: When do you stop looking for answers to a patient’s ‘mystery problem’?


• Subtopic: When if ever do you call a case futile based on cost/public burden of care?


• Subtopic: What resources need to be made available at a hospital for ‘rare’ situations or patients?



• MRI for the morbidly obese


• Male Pap smear equipment




• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 30





• Topic: How much information must a practitioner share with a patient?



• Explanation of logic for decisions/opinion/treatment plan, explanation of test results


• Explanation of all potential side-effects


• How much information is needed for ‘informed consent’?




• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 31





• Topic: How to deal with a patient seeing two or more practitioners (same specialty, overlapping meds, etc.)



• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 32





• Topic: How to manage chronic pain (e.g. are ‘pain contracts’ ethical?; how is pain objectively assessed?)



• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 33





• Topic: At what age, if any, do you stop health maintenance disease screening?


• Subtopic: At what age, if any, to you stop invasive procedures? Placing pacemakers?



• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 34





• Topic: When can a practitioner withhold therapy from a patient based on their behavior?



• Examples: HAART therapy for HIV, HepC treatment, anti-coagulation


• Behavior: Non-adherence to therapy, substance use/abuse, continued tobacco use/abuse



• Subtopic: When does a patient qualify for a transplant? Is 6 months sobriety appropriate?



• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 35





• Topic: When a Jehovah’s witness needs a blood transfusion



• Are blood substitutes allowed?


• Should surgery/organ transplantation be withheld if transfusion will not be allowed by the patient?




• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Case 36





• Topic: How far does screening go?



• Breast cancer genes, hypercoaguability work-up in family members of a patient with a new diagnosis


• Will this lead to insurance decisions re: ‘pre-existing conditions’?




• Narrative of clinical scenario with specific example of ethical dilemma

• Questions for thought/discussion

• Explanations of underlying ethical and legal principles

Comprehensive Exam

Suggested reading and internet resources

Glossary of terms

Index

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