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what theory does the ama use to justify not allowing doctors to participate in lethal injections?

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Best medical exercise is founded upon legal and ethical principles that guide the choices physicians and wellness care providers make when caring for patients or performing research. The core ethical principles of medicine are autonomy, beneficence, nonmaleficence, and justice. For a patient to be considered able to make choices about their wellness care, they must demonstrate mental chapters and competence; when these are lacking, the patient may accept a surrogate brand choices in their place. Unemancipated minors are unable to make medical decisions on their own and and then must have a parent or flagman human activity brand decisions for them. The patient has the right to total disclosure near their health, medical status, medical records, and involvement in research protocols. End-of-life bug include medical aid-in-dying, organ donation, and the pronunciation of decease. The physician is legally and ethically obligated to keep patients' medical information confidential, and may but break this confidentiality in item settings. Social factors that may need to be considered include driving restrictions, elder abuse, and torture. Patients must be briefed on all of their treatment options, including potential risks and benefits, prior to handling or medical intervention. Conflicts of involvement occur when an external factor (e.thousand., payment from a pharmaceutical company) influences the doctor's ability to make an objective medical decision. Medical research must be conducted co-ordinate to ethical principles as well, and in that location is a specific set of guidelines for research on vulnerable populations (due east.k., pregnant women, children, prisoners).

Cadre upstanding principles [1]

Overview

Principles

  • Autonomy
    • Provide sufficient data for the patient to be able to make their own decisions regarding their care (i.due east., informed consent ).
    • Award the patient'southward choices to take or turn down care.
  • Beneficence
    • Advocate for the patient and act in their best interest (fiduciary relationship).
    • May disharmonize with autonomy
  • Nonmaleficence
    • Avoid causing injury or suffering to the patient.
    • May conflict with beneficence: The balance of risks and benefits must be favorable to the patient.
    • Frequently discussed in reference to drugs and surgical procedures
  • Justice
    • Treat patients fairly and equitably.
    • Disinterestedness is not the same equally equality.

Decision-making chapters [iv]

  • Definition : : the psychological and/or legal ability to process information, make decisions, communicate a choice, and empathize the consequences of a decision
  • Components: The patient must have all of the post-obit to demonstrate decision-making capacity.
    • Choice : the patient'south ability to clearly and consistently communicate their selection of handling
    • Understanding
      • The patient'southward power to cover the information provided by the doc , including therapeutic options and alternatives
      • Understanding can be assessed past request the patient, "Delight describe to me in your own words your understanding of what your physician told you regarding the status of your health, your treatment options, and the risks and benefits of treatment."
    • Appreciation of relevant facts
      • The patient's ability to recognize and evaluate the facts that are relevant to their situation
      • Appreciation tin can exist assessed by asking the patient, "What exercise you sympathize about what is good or bad about your health at this moment?" or, "Exercise you lot believe that you require some class of medical handling?"
    • Reasoning in medical decision making
      • The patient's ability to describe the thought procedure backside the decisions they make about their ain care
      • Reasoning can be assessed by asking the patient, "How did you make up one's mind to take or decline treatment?"
  • Caveats

Legal competence [9]

Shared decision-making [12]

  • Definition: a model in which patients and physicians decide on the best handling pick together
  • General
    • Empowers the patient, as it is based on the patient'due south personal values, cultural behavior, and preferences
    • Aimed at producing better health outcomes and increasing patient satisfaction
    • Is a key component of the patient-centered approach in patient-doctor advice
  • Three-step model for shared conclusion-making [13]

Surrogate decision-making [14]

  • Definition: a model in which another person makes treatment decisions for the patient because they lack controlling capacity and/or competence
  • General
  • Bureaucracy of controlling : The surrogate may be appointed past the patient (due east.one thousand., medical power of attorney ), legally appointed (e.g., courtroom-ordered guardian), or next of kin (if no Advertizement exists). [16] [17]
    1. A mentally competent patient capable of making their own decisions
    2. Advance healthcare directive : prespecified legal instructions from the patient used to guide medical decision-making
      • Living volition : a legal certificate in which individuals depict their wishes regarding their healthcare (e.yard., to maintain, withhold, or withdraw life-sustaining care) should they become incapacitated
      • Durable medical power of chaser (health care proxy): a legal document through which an individual designates a surrogate to make specific health care decisions
      • Oral accelerate directive : an incapacitated patient's prior oral statements regarding their preferences
    3. Side by side of kin
      • Spouse
      • Adult kid
      • Parent
      • Adult sibling
      • A close friend (in approx. 50% of U.S. states)
    4. Ethics committee or legal consult
  • Caveats: if the patient's preferences cannot be determined and there is a disagreement regarding the grade of activeness (e.g., the wishes of a designated surrogate who is not a family fellow member conflict with the wishes of family members)

Oral ADs may pose bug of interpretation, because oral statements are not as specific or easy to confirm as written statements. The validity of an oral Advert increases when the patient has made an informed choice, the instructions were specific, and the directive was confirmed by multiple people.

Patients with decision-making capacity and competence accept the right to provide or withdraw informed consent at whatsoever time (fifty-fifty during a process).

Overview [18]

  • Definition: the process of briefing a patient (or surrogate) nearly their medical status and handling options, then obtaining consent to pursue a selected class of treatment
  • Necessary components of informed consent [19]
    • Voluntariness: The patient must not be forced into a decision.
    • Capacity : The patient (or surrogate) must demonstrate decision-making capacity before they can consent to treatment.
    • Comprehension: The patient must empathize the ramifications of the proposed intervention.
    • Disclosure: Relevant medical information regarding the intervention must be discussed with the patient.
  • Timing: The patient must be informed far enough in advance of the procedure that they take adequate time to make a thoroughly considered decision.
  • Patient briefing : The patient should be educated about the benefits , risks , alternatives , and indications of handling likewise as the nature of their illness.
    • Known complications, including estimated risks of expiry and morbidity
    • Types and risks of anesthesia, if relevant
    • Alternative treatments
    • The diagnosis and natural grade of the disease without any treatment
  • Unexpected findings during surgery [20]
    • The patient should be informed about the possibility of intraoperative findings that may crave more than intervention than originally planned.
    • If consent was not obtained
      • If a finding requires immediate action (e.yard., appendicitis is found during surgery for ectopic pregnancy), the process can exist performed without obtaining the patient's consent.
      • If a finding does non require firsthand activity (e.yard., findings concerning for pulmonary malignancy during surgery for tension pneumothorax), the patient should give informed consent before any other procedures are performed.
  • Expressing a decision
    • The patient with controlling chapters is costless to provide or revoke their decision at any time and without the need for a written document.
    • The decision must be free from any coercive pressure.
    • The patient (or their surrogate) must clearly communicate their decision.

Use your Brain: B enefits, R isks, A lternatives, I ndications, N ature (to brief patients about informed consent ).

Obtaining patient consent is crucial because without it, any medical procedure can represent an attempt to initiate harmful or offensive contact with the patient.

Language and use of an interpreter [21] [22]

  • Discuss health care decisions with patients in terms they can chronicle to.
  • Communicate in a language that the patient understands.
  • Asking an interpreter if you are unable to communicate with the patient in a linguistic communication in which you can have a comprehensive discussion and appraise the patient'due south agreement of the relevant information.
    • Both in-person and remote (e.g., phone, video) interpreter services are advisable.
    • Communicating without an interpreter can outcome in patients accidentally consenting to unwanted procedures, misunderstanding their diagnosis, and poorly complying with medical communication.
  • For more information almost particular instances of the use of medical interpretation, see "General concepts of patient counseling" in the "Patient communication and counseling" article.

Multilingual relatives are not acceptable alternatives to professional person interpreters in the nonemergency medical setting.

Exceptions to standard informed consent [22]

Difficulties in obtaining consent should non delay life-saving procedures .

Total disclosure [33]

  • Patients accept the correct to full medical disclosure .
  • Family members practice non have the right to ask a physician to withhold information from a patient with controlling capacity and competence without expert reason . [34]
  • Exceptions
    • The patient requests that the physician withhold data from them.
    • Therapeutic privilege : The md determines that total disclosure would cause astringent psychological damage to the patient (e.chiliad., information technology may be reasonable to postpone disclosure of full diagnosis to a patient who is discovered to accept multiple sclerosis who is having a concurrent major depressive episode with suicidal ideation due to divorce).

Overview

  • The doctor is ethically and legally obligated to keep the patient's medical data (including information disclosed past the patient to the doc) confidential.
  • Confidentiality upholds patient autonomy and privacy.
  • The patient may waive the correct to confidentiality (eastward.g., if an insurance company requests patient information or the patient allows the doc to disembalm information to a family fellow member).
  • If the patient loses capacity, health data should be disclosed co-ordinate to the patient's best interest (due east.g., the md volition disclose relevant health information to friends, family, or the health intendance proxy to help guide medical decisions).
  • Healthcare providers should make their best efforts to ensure the condom of patient data (east.g., patient information should not be discussed in public areas, fifty-fifty within the infirmary setting ).

Minimum necessary standard [41] [42]

Patient privacy and permitted data disclosures

WAIT a SEC: W ounds, A utomobile-driving impairment, I nfections, T arasoff decision, S uicidal intention, Eastward lder abuse, C hild corruption (cases that override confidentiality).

Access to patient health records [43]

Under HIPAA, patients have a legal right to obtain copies of their medical records within thirty days of submitting the request.

Electronic data safety

Overview

  • A number of ethically challenging scenarios may arise in the context of end-of-life care.
  • At the terminate of life (as throughout life), the core upstanding principles of medicine should exist upheld and the physician should human activity in the best interest of the patient.
  • Proper knowledge of the legal and ethical aspects of end-of-life care allows the doctor to practise efficient and evidence-based medicine while respecting the patient'due south wishes.
  • In disputes over end-of-life issues, the doc plays a key role in facilitating communication and emphasizing the importance of focusing on what patients themselves would accept preferred.

Orders and legal considerations in end-of-life intendance

Standardized forms for end-of-life care directives [50] [51]

Death

See the commodity "Death" for more information virtually definitions, signs, pronouncing, addressing loved ones, documentation, investigation, and autopsy.

  • Criteria: Death can be diagnosed if a patient meets the criteria for brain expiry or cardiopulmonary death.
  • Brain expiry
  • Cardiopulmonary death : : the absence of a spontaneous heartbeat in an asystolic patient
  • Ethical issues concerning brain death [59]
    • If a patient has been declared to have encephalon death, no consent is needed to withdraw life-sustaining therapy.
    • The patient'south family unit should exist informed that the patient is being assessed for brain death as before long every bit the evaluation has started.
    • The patient's family unit should be given a reasonable amount of time to visit the patient and take the diagnosis before discontinuation of life-sustaining treatment. [lx]
    • If the patient'southward family disagree with a diagnosis of encephalon death:

Child protective services (CPS)

Foster care

Domestic violence [69]

  • Definition
    • Any form of bodily or threatened concrete or emotional harm committed by ane fellow member of a household against another, oft used as an extension power by the perpetrator against the person experiencing the violence
    • Intimate partner violence (IPV): any form of concrete, emotional, or sexual violence that is carried out past a cohabitating or noncohabitating intimate partner against the other [70]
  • General
    • Physicians may not report domestic violence without patient consent.
    • When a physician suspects domestic violence, they should speak privately with the patient, inquire farther, and offer assistance.
    • If the patient refuses assistance, the physician should reiterate that they support the patient and are available to provide help at any fourth dimension.
    • See "Abuse" in "Ethically challenging situations" below.
    • Come across "Domestic violence" in the commodity "Sexual violence, domestic abuse, and elderberry corruption" for more than details.

For more information about different types of errors leading to negligence, see "Medical error" in the article "Quality and safety."

The 4 D'southward of malpractice : D uty (obligation to deliver proper medical intendance to the patient), D ereliction of duty, D amage to the patient, D irect cause of damage.

The physician must disclose all COIs to all affected parties and, in the result of a COI, refer patients to an unbiased colleague whenever possible.

Physicians increasingly use social media and other net resources for learning, networking, interacting with patients, and disseminating health care related noesis. The following considerations can help ensure that their online presence aligns with professional ethics. [95]

Autonomy

  • An adult patient refuses treatment based on religious beliefs.
    • Explain the treatment options and available alternatives.
    • Make sure that the patient understands the consequences.
    • Respect the patient'south pick.
  • A patient wants to effort alternative medicine.
    • Identify the underlying reason.
    • Do not negate or devalue the patient's decision.
    • Evaluate for possible drug interactions , adverse effects, and prophylactic.
    • Allow handling integration if it poses no risk of impairment to the patient.

Abuse

  • A patient discloses abuse by a close partner.
    • Evaluate rubber and the presence of an emergency plan for the victim.
    • Evidence empathy and willingness to provide continuous support.
    • Counsel and evaluate for psychological comorbidities.
    • Perform thorough documentation of abuse (the patient may want to accept legal measures confronting their abuser).
    • Do not force the patient to leave their partner.
  • A pediatric patient has an injury inconsistent with the caregiver's study.

Confidentiality

  • Family members asking data about the patient's health condition: Practise not discuss bug with relatives without the consent of the patient.
  • Family members request that the physician withhold diagnostic information from a patient.
    • Explore why the family members want to withhold this information.
    • Evaluate the extent of the data that the patient wants to receive.
    • Deliver the patient information co-ordinate to their preferences.
    • According to therapeutic privilege , the doc may withhold information from the patient if disclosure increases their likelihood of causing self-harm.
  • A patient with HIV refuses to inform their partner.
    • Encourage the patient to disembalm the data to individuals they may have transmitted HIV to.
    • All cases of HIV must be reported to the local and state health departments.
    • If the patient refuses to inform their partner, the use of confidential partner notification procedures via the health department is encouraged.
    • For a more in-depth explanation of the legal nuances surrounding this issue, see "HIV" in "notification of diseases," above.

Competence and decision making

  • Parents turn down life-saving treatment for their child.
  • A pregnant sixteen-year-one-time wants to take an abortion. [97]
  • A 15-year-old wants to keep her baby against her parents' will.
    • Pregnant individuals take the right to decide to bear their infants to term, and to chose to keep the baby or put it up for adoption.
    • Provide applied information about all options.
    • Accept and support the patient's decision.
    • Encourage good advice between the patient and her parents to evaluate the options and make it at an agreement.
  • A fourteen-year-sometime girl requests contraceptives.
    • Offer advice on prophylactic sexual activity practices and prescribe contraceptives.
    • At that place is no demand to notify parents to get consent.
  • A patient'southward family insists on maintaining life support indefinitely despite evidence of brain death considering the patient still moves when touched.
    • Carefully explain to the family that encephalon death is equivalent to death and it excludes whatever chance of recovery.
    • Clarify that the movements are just an involuntary effect of spinal arc reflex.
    • Refer the example to the ethics committee regarding futile treatment and withdrawal of life-sustaining therapy.
  • A male parent and xiii-yr-quondam son are found unconscious with internal bleeding after a car accident; the father is found to accept a religious preferences menu, which states that he declines blood transfusions considering of religious beliefs.
  • A patient asks for a non-emergency treatment or process that is in opposition to the physician's personal or religious behavior.
    • Impartially inform the patient nigh all the options, in order to help them make an informed decision.
    • Respectfully explain that you lot practice not perform the requested intervention.
    • It is mandatory to facilitate the transfer of intendance to another qualified physician.
  • A patient is suicidal or homicidal.
    • The patient is considered to have dumb decision-making.
    • Assess the threat (organized plan, access to weapons).
    • Admit the patient voluntarily; admit involuntarily if the patient refuses.
    • If the patient produces homicidal threats, inform government and the threatened individual ( Tarasoff decision ).
  • A patient with terminal disease asks for aid in catastrophe their own life.

Malpractice

  • A patient receives wrong treatment/exam: Inform the patient, even if no harm has been inflicted, and repent.

Emotional support

  • A patient complains that she feels "ugly" after a mastectomy.
    • Support the patient in identifying and breaking down the reasons why she feels this way.
    • Avert comments that give imitation comfort (east.g., "You look good anyway").
  • A 6-year-old child experiences the death of a sibling and feels responsible.
    • Describe with unproblematic and honest words what happened, avoiding euphemisms and clichés.
    • Offer reassurance, explaining to the child with clear and logical arguments that they cannot be responsible in any fashion.
    • Aid the kid to label feelings and fears, and normalize them.
    • Encourage good for you coping behaviors (e.g., making time for playing, creating a special mode to remember their sibling).

Miscellaneous cases

  • Angry patient (due east.thousand., waiting at the office for a long time): Apologize, acknowledge acrimony, refrain from justifying or explaining the delay.
  • A patient complains about the handling received from another doc.
    • Propose that the patient contacts that physician directly to speak about their concerns.
    • If the issue regards a member of your staff, allow the patient know you lot volition address the issue with the staff member personally.
  • A patient requests an unnecessary intervention (e.grand., diagnostic or therapeutic process, unnecessary medication).
    • Find out why the patient wants the intervention and accost any underlying concerns.
    • Avoid performing unnecessary medical or surgical interventions.
    • Do not refuse to see the patient or refer the patient to another physician.
  • A patient has poor adherence to or difficulty taking medications.
    • Identify the underlying causes of nonadherence.
    • Accept a nonjudgmental stance and use motivational interviewing if possible.
    • Evaluate the patient's willingness to modify.
    • Describe the treatment programme in easily understandable language, requite written instructions, use the teach-back method, and involve close friends and relatives (with the permission of the patient).
    • Do not refer the patient to another physician.
  • A pharmaceutical company offers a physician a sponsorship to advertise a new drug.
  • A doctor is impaired in the work environment (e.g., due to substance utilise).
  • A patient shows allure to a md.
    • Romantic relationships between patients and physicians are never advisable.
    • Ask specific, close-ended questions.
    • Utilise a chaperone if needed.
    • Consider transitioning care to another dr..
  • A patient asks a medical student to disclose handling, diagnostic, or prognostic information. [98]
    • Medical students ordinarily lack the experience and noesis to disclose complex diagnostic, treatment, or prognostic data.
    • Hence, they should ensure the following:
      • Act in the best interest of the patient at all times.
      • Maintain honesty (if the data is available, explicate why disclosure has been postponed).
      • Inform the patient that complex treatment plans or diagnostic information will exist disclosed by senior members of the team.
      • Disclosure should accept identify in an advisable environment and at a suitable fourth dimension to ensure that the patient'southward privacy and emotional needs are met.
  • A patient needs medical therapy that is non covered by their insurance.
  • Parents turn down to vaccinate their child. [31]
  • Cocky-treatment and handling of relatives [99] [100]
  • A patient requests that a doctor intervenes in a conflict with one of their family members. [101]
    • Encourage the patient to vocalization their concern directly to the family member.
    • Avoid a triangulated relationship : A triangulated relationship occurs when two individuals that are in conflict both effort to marshal with a 3rd individual for back up and/or arbitration.
    • If both the family unit members are the dr.'s patients and one of the family members has difficulty voicing their business to the other, the physician can:
      • Offering a space for advice between the two individuals during a family consult (family unit interview).
      • Refer the patients to a family unit therapist.
    • In the case of suspected abuse or neglect, the physician should intervene on the patient's behalf. (See elder abuse, child maltreatment, and domestic violence.)
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