I.    Scope of Ethical Issues When Treating Critical Care Patients in the ICU
A.    Relevant Ethical Principles
1. AMA Code of Medical Ethics (1997)
a. When a patient experiences significant medical complications that
may have resulted from a physician’s mistake or judgment:
b.  The physician is ethically required to inform the patient of all the
facts necessary to ensure understanding of what has occurred,
so as to enable the patient to make informed decisions regarding
future medical care
c.  Although this professional group clearly mandates disclosure of
“significant” medical error, it is unclear about the obligation to
disclose minor errors (errors without material consequence to the
patient’s well being).
2. American College of Physician’s Ethics Manual (1998)
a.    “Physicians should disclose to patients information about procedural or judgment errors made during care”
b.    “If such information is material to the patient’s well-being”
c.    Although medical errors do not necessarily constitute improper, negligent, or unethical behavior, failure to disclose them are all three.
d.    Although this professional group clearly mandates disclosure of “significant medical error, it is unclear about obligation to
disclose minor errors (errors without material consequence to
patient’s well being).
1.    Consequentialist Theory(Merry, 2009; Wu, Cavanaugh, & McPhee, 1997)
a. Supports behavior that maximizes net good
b. Requires specifying harms and benefits to a specifically identified moral group
c. Problem: multiple moral groups are involved in medical error – patient, family, physician, nurse, hospital administration
4.  Deontological Theory of Principalism(Wu, Cavanaugh, & McPhee, 1997)
a. Some rights must not be violated even it would produce the most
overall good
b.  Principles of tension
1. Principle of patient autonomy
a. Freedom to choose
b.  Informed consent principle
2. Principle of non-maleficence
a. Legal/ethical term for “do no harm”
b. Similar to medical term “primum non nocere”
3. Did the error harm the patient?
a. Significant/serious
b. Minor
4.  Will disclosure promote patient autonomy
a. Empowered to make therapy or provider choices
5.  Will disclosure of the error harm the patient?
a. Emotional distress
b. Erode patient trust
B.    Ethics in the Intensive Care Unit
1.    History of Ethics in Intensive Care Unit
2.    Learning Objectives: Knowledge, Skill, and Attitudes
C.    Involvement, interaction and decision making of critical participants
1. Physicians generally feel they should disclose medical error (iatrogenic
incident)
a.    70% of European Intensivists (Vincent, 1998)
b.    80% of MSIV and Residents (Sorokin, 2005)
c.    71% of Emergency Physicians (Hobgood, 2005)
d.    77% of Family Physicians (Gallagher, 2003)
2. But fewer Physicians actually do or would disclose an iatrogenic issue.
a. 30% in general (Vincent, 1998)
b. 32% of European Intensivists tell patients/families (Vincent,
1998)
c. 24% of House Officers tell patients (Wu, 1997)
d. 54% of House Officers tell attendings (Wu, 1997)
3. Most patients desire disclosure.
a. 76% of emergency department patients (Hobgood, 2002)
b. 98% of Callifornia Internal Medicine patients (Witman, 1996)
c. 98.8% of New England Health Plan patients (Mazor, 2004)
d. 99% of parents of North Carolina Pediatric patients (Hobgood,
2005)
D.    Maintenance of patient autonomy and informed consent