Monday, May 12, 2014

A Little Bit on Bioethics

I know that most of us are by now fairly conversant in research bioethics. We are aware of the need to submit an IRB application for all human subject research, and we know that consent is a critically important aspect of all human research projects. But this is just one area of bioethics, and there are others, each with their own specific approaches and requirements. This is a brief overview of 4 of these sub-disciplines in bioethics.

Research Bioethics: As noted above, we are all pretty aware of research ethics. This discipline is focused on the protection of human subjects in scientific research. It grew from discoveries made in World War II related to unwilling use of prisoners in concentration camps, as well as purely American findings related to Tuskegee and to Willowbrook Hospital. The movement here is toward autonomy, leading to the need for informed consent and risk-benefit analysis in scientific research. An entire edifice has been erected under our laws: 45CFR46 (The Common Rule) and 21CFR56; these govern the use of human subjects in research and the composition and function of institutional review boards.
Clinical Bioethics: This branch of ethics governs how we obtain consent from patients to treat them. Again, informed consent is important, but it takes on a different flavor in the clinical setting. Before we can treat a patient, we need to let them know of the risks of treatment so that they can decide whether or not they wish to be treated. In our country, patients have a right to accept or refuse a doctor’s recommendation. Some of the thorniest issues in medical ethics arise in the clinical setting. How do we decide what to do if a patient cannot provide us guidance on treatment, and has left no record of what they might wish? Or if their children argue and disagree on a course of care? Ethics consultation is an important sub-branch of clinical bioethics.

Public Health Ethics: This is an area that seems to upend research and clinical bioethics, because it does not focus on the primacy of the individual and his or her individual rights. Instead, public health focuses on community health, and was developed in response to and anticipation of large-scale medical crises. Current examples of public health ethics is the fact that in certain occupations you may be required to have a flu shot- if you work in critical care hospital settings or, as my wife does, in early childhood development, for example. This is required in order to secure the safety of the community. You can opt out, but you will lose your job should you do so. Consider this question: how should the government respond if there is a deadly disease outbreak, such as an airborne influenza virus? Could it curtail travel, or force confinement? We have even had movies, such as Outbreak and Contagion, to look at this question.
Professional Ethics: This governs our behavior as members of a profession and as business people. We all follow professional codes of ethics. These tell us to keep our patients’ confidences, to treat patients with respect, to help others, etc. We should never take advantage of our patients, upsell them services, and we should always act in their best interest, not ours. Our role as a practitioner is sort of sacred and it differs from others businesses where maximizing profit is all that matters.

Each of these 4 branches has a wealth of literature and each is fascinating in its own right. Each is worth studying and applying to our daily life as a faculty member.

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