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Module A7:
Addressing ethical issues in clinical care and public health

Entry Scenario  

The entry scenario addresses a variety of issues and problems associated with the module topic. It may be used at the beginning of the course to stimulate the students to identify their own needs and interests. The results may be utilized by the individual to assess own learning process, or be integrated with class objectives. This module proposes two similar approaches to address ethical issues in the field of clinical care and public health.

Clinical vignette

A sixteen year old girl is brought to a health professional by her teacher. The teacher suspects that she may be pregnant as her last period was ten weeks ago. A pregnancy test/examination is performed, and it is positive. She has a regular boyfriend. The father is a politician running for the position of mayor. She is afraid that her parents may find out about her pregnancy. The girl is shocked about being pregnant and does not know what to do.

Public health situation

An increasing number of young people of both sexes aged between 16 and 18 in your country are becoming HIV positive. Those responsible for the overall health policy have decided that a program of sex education needs to be introduced into all schools. The best way to introduce and organise this program is for it to be the responsibility of the local health workers as they will know the needs of their own individual communities. The government has decided that the program should begin when children are 10 years old, but that its content should be decided locally. You know that, in order to be effective, these programs need to be explicit. This fact comes into conflict with the religious and cultural beliefs of your local community.  In introducing the sex education program you want to make sure that it is acceptable to your local community from the start.

General Goals for Learners
by completing the module the participant will be able to :

  1. Describe the need for bioethics in the field of adolescent health and its fundamental principles
  2. Define the necessary steps in a strategy for deliberation when faced with an ethical dilemma in adolescent care
  3. Apply the deliberation approach to addressing ethical dilemmas encountered in clinical practice
  4. Apply the deliberation approach to addressing ethical dilemmas encountered in adolescent public health

 

Goal 1: Describe the need for bioethics in the field of adolescent health and its fundamental principles

Knowledge

Training objectives Educational Methodology Activities, issues and question Pertinent resources
A. Explore the audience’s experiences in situations with adolescents where there was no clear solution to the problem.

Short group work

Plenary

Ask each group to discuss their experiences of difficult situations, selecting one for discussion.

The facilitator lists the various problems and promotes exploration of the following questions:

  1. Why do the participants think that these were challenging situations?
  2. Were there different ways to handle these situations?
  3. What were the conflicting values involved?
  4. Which of these situations represented ethical dilemmas?
  5. How do they define an ethical dilemma?
B. Review principles of bioethics
C. List moral values which apply to bioethics

Minilecture

Group discussion

Some definitions of bioethics

Discuss the meaning of moral values:

Autonomy
Beneficence
Non malfeasance
Justice and equity

Solidarity
Integrity
Participation
Vulnerability etc.

Slides A1-A18

(1-9)

D. Describe and discuss  the particular characteristics of adolescence that give rise to ethical dilemmas related to their health care.

  • Under age
  • Different dimensions of maturity (esp. decisional)
  • Vulnerability (at risk)
  • Cultural + religious restrictions
  • Financial dependence
 Group work followed by summary in plenum What is unique in the situation of adolescents that makes it mandatory to address ethical dilemmas ?

Slides B1-B15

References:
(1, 10-21)

Hyperlinks

E. List the main issues that tend to create ethical dilemmas

In adolescent clinical health care:

  • Informed consent
  • Competence
  • Confidentiality
  • Financial responsibility

In public Health:

  • Data (production, protection)
  • Organization of service delivery
  • Ethics of preventive interventions

Interactive lecture

Discuss this referring to the entry scenario

Give examples of public health situations which raise ethical concerns

  • Sexual education (see entry scenario)
  • Drug testing in school
  • Addressing nutrition in multicultural contexts

References:
(22-25)

Slides D1-D11

F. Understand the strengths and constraints of the guideline documents for medical ethics in adolescent health

  • UN Convention of the Rights of the Child
  • Belmont report
  • Country/Local
 References:
(26, 27)

 

Goal 2 : Define the necessary steps for deliberation when faced with an ethical dilemma in adolescent care

Knowledge and Attitudes

Training objectives Educational Methodology Activities, Issues and Questions References

A. Strengthen the provider’s skills directly related to addressing ethical dilemmas in adolescence:

  • Assess development level of adolescent
  • Assess competence of adolescent
  • Effective communication with adolescents

Interactive lecture.

Group discussion

Participants report on their own experience in these areas

Slides  B1-B15

Facilitator’s guide

Handout

B. Strengthen the provider’s skills related to the adolescent’s environment

  • Dealing with parents (confidentiality vs. connectedness)
  • Responding to religious-legal-cultural arguments
 Group discussion Use some examples of situations reported earlier by the audience

References:
(1, 10-21)

Slides C1-C23

Facilitator’s guide

Handout  Hyperlink

C. Identify the steps for addressing ethical issues (the deliberation process)

  1. Define the ethical dilemma in the case to be discussed
  2. Identify contributing factors e.g. legal framework
  3. Identify main stakeholders involved
  4. Define the options
  5. Assess medical/health/social consequences of each option
  6. Consider ethical values linked with each option
  7. Discuss  which are the best options for the client
  8. Choose option/s
 Interactive lecture

Use following scenario to exemplify the step by step process to address ethical issues:

You work as the head public health officer in a large city and have developed a health promotion program. Your public health administration thinks it is an excellent program but is unable to support it financially. You have been totally unsuccessful in getting financial support for this elsewhere.

A tobacco company offers to finance a health promotion program including HIV prevention. The sexual health problems are on the increase locally and you are pressed to do something about it. How do you decide whether to accept the offer or not ?

References:
(10, 17, 28-30)

 

Goal 3 : Apply the deliberation approach to addressing ethical dilemmas encountered in clinical practice

Skills

Training objectives Educational Methodology Activities, Issues and Questions References
Apply the step by step process to solve the ethical issues provided in the adjacent scenario.

Group work (role play)

The facilitator goes from one group to another to help

Use any of the clinical case scenarios:

  1. Entry scenario
  2. A 15 year old boy, Joachim,  comes to your services and consults for a spot on his penis. His family is migrant. For the last five years the parents and the boy have been employed by an affluent family in your area. On questioning the boy, it turns out that six months before, the household owner has asked the boy to perform mutual oral sex with him. The household owner has threatened to throw the whole family out if the boy says anything about this single incident
  3. Kim is 17 year old and suffers from a brain tumour. He has already undergone chemotherapy with severe side effects (loss of hairs, nausea, etc). The tumour is potentially curable with a second step of chemotherapy plus radiotherapy. Both the adolescent and his parents refuse the second cure and want to use some herbal treatment which is supplied by a naturopath. You are the doctor in charge of the patient and have to make a decision.

Slides with clinical case scenario

References:
(31, 32)

References:
(9, 11, 14, 15, 33-36)
Discuss the strengths and limitations of the deliberation procedure Discussion in plenary

What are the main difficulties encountered?

Audience discusses if they see a possibility to apply this technique in their everyday clinical environment

 

Goal 4 : Apply the deliberation approach to addressing ethical dilemmas encountered in adolescent public health

Skills

Training objectives Educational Methodology Activities, Issues and Questions References
Apply the step by step process to solve the ethical issues provided in the adjacent scenario.

Group work (role play)

The facilitator goes from one group to another to help

Use any of the public health scenarios:

  1. Entry scenario
  2. You are a professional working in the area of sexual & reproductive health in a deprived area of a large city. A 15 year old adolescent male comes to see you for treatment of a sexually transmitted infection. He has had unsafe sex with a male partner in order to finance his intravenous drug habit. You realise that a large number of local young boys are also consulting for STI’s. You want to set up a prevention program and invite the local medical officer to help. The health officer says that the available funding is going to pay only for programs promoting abstinence. He does not see any possibility of raising more money for another prevention program. As homosexuality is heavily condemned, it is unacceptable to put financial resources into targeting this high risk group. You organize a meeting with colleagues and other professionals to discuss different options.
  3. You work in a western middle-size city of 100,000 inhabitants with about 60% of immigrants from several parts of the world. You are offered a 200,000 US$ grant from a large nutrition company making ready-for-use meals to fight against a high rate of obesity among young people. They are willing to pay for dieticians giving courses in the schools and to set up school centres to treat obese adolescents. They have already printed a large number of fact sheets focusing on healthy eating.

Slides with public health scenario

References:
(22, 24, 31, 32, 37-39)

References:
(39)
(40)
Discuss the strengths and limitations of the deliberation procedure Discussion in plenary Audience discusses if they see a possibility to apply such technique in their everyday clinical environment

 

References

  1. Appelbaum PS. Clinical practice. Assessment of patients' competence to consent to treatment. N Engl J Med 2007; 357:1834-40.
  2. Beauchamp T, Childress J, . Principles of biomedical ethics. 5th ed ed. New York: Oxford: Univ. Press, 2001.
  3. Benaroyo L. Ethique et responsabilité en médecine. Geneva: Médecine & Hygiène, 2006.
  4. Callahan D. Bioethics. In: Macmillan SS, ed. Encyclopedia of Bioethics. 3rd ed. Toronto: Prentice Hall International, 1995:278-287.
  5. Crosbie S. Consent in practice: a case review. Paediatr Nurs 2007; 19:34-6.
  6. Doucet H. Au pays de la bioéthique. Geneva: Labor & Fides, 1996.
  7. Fox E, Arnold RM, Brody B. Medical ethics education: past, present, and future. Acad Med 1995; 70:761-9.
  8. General Medical Council. Confidentiality: protecting and providing information: General Medical Council,   London, 2000.
  9. Grisso T, Appelbaum P. Assessing Competence to Consent to Treatment. New-York & Oxford: Oxford Univers Press, 1998.
  10. American Academy of Pediatrics Committee on Bioethics. Informed Consent, Parental Permission, and Assent in Pediatric Practice. Pediatrics 1995; 95:314-317.
  11. Dickens BM, Cook RJ. Adolescents and consent to treatment. Int J Gynaecol Obstet 2005; 89:179-84.
  12. Grant VJ. Consent in paediatrics: a complex teaching assignment. J Med Ethics 1991; 17:199-204.
  13. Harvey MT. Adolescent competency and the refusal of medical treatment. Health Matrix Clevel 2003; 13:297-323.
  14. Hester CJ. Adolescent consent: choosing the right path. Issues Compr Pediatr Nurs 2004; 27:27-37.
  15. Mercurio MR. An Adolescent's refusal of Medical Treatment. Pediatrics 2007; 120:1357-1358.
  16. O'Donovan K. Mature minors are individuals. Politics Life Sciences 1996; 15:301-2.
  17. Ross LF. Adolescent autonomy in health care? APA Newsl Philos Med 2003; 2:193-200.
  18. Spear HJ, Kulbok P. Autonomy and adolescence: a concept analysis. Public Health Nurs 2004; 21:144-52.
  19. Storrow RF, Martinez S. "Special weight" for best-interests minors in the new era of parental autonomy. Wis L Rev 2003:789-841.
  20. Tillett J. Adolescents and informed consent: ethical and legal issues. J Perinat Neonatal Nurs 2005; 19:112-21.
  21. Waxse DJ. The role of minors in health care decision making: current legal issues. Bioethics Forum 1995; 11:17-21.
  22. Guttman N, Salmon CT. Guilt, fear, stigma and knowledge gaps: ethical issues in public health communication interventions. Bioethics 2004; 18:531-52.
  23. Callahan D, Jennings B. Ethics and Public Health: Forging a Strong Relationship. 2002; 92:169-176.
  24. Colgrove J. The Ethics and Politics of Compulsory HPV Vaccination. N Engl J Med 2006; 355:2389-2391.
  25. Howard DE, Lothen-Kline C, Boekeloo BO. Using the case-study methodology to teach ethics to public health students. Health Promot Pract 2004; 5:151-9.
  26. United Nations. Convention on the Rights of the Child, 1989.
  27. Cook RJ, Erdman JN, Dickens BM. Respecting adolescents' confidentiality and reproductive and sexual choices. Int J Gynaecol Obstet 2007; 98:182-7.
  28. Arnstein RL. Divided loyalties in adolescent psychiatry: late adolescence. Soc Sci Med 1986; 23:797-802.
  29. Blustein J. Parental authority, children's rights, and health care. APA Newsl Philos Med 2002; 2:192-5.
  30. De Ville K. Adolescent parents and medical decision-making. J Med Philos 1997; 22:253-70.
  31. Bailey CE, Piercy FP. Enhancing ethical decision making in sexuality and AIDS education. Adolescence 1997; 32:989-98.
  32. French K. Young people and sexuality: consent and confidentiality. Nurs Times 2006; 102:50-1.
  33. Baren JM. Ethical dilemmas in the care of minors in the emergency department. Emerg Med Clin North Am 2006; 24:619-31.
  34. Bridge C. Religious beliefs and teenage refusal of medical treatment. Mod Law Rev 1999; 62:585-94.
  35. George R, Hutton S. Palliative care in adolescents. Eur J Cancer 2003; 39:2662-8.
  36. Kon AA. When parents refuse treatment for their child. JONAS Healthc Law Ethics Regul 2006; 8:5-9, quiz 10-1.
  37. Ross LF. Adolescent sexuality and public policy: an unrepentant liberal approach. Politics Life Sciences 1996; 15:323-8.
  38. Michaud PA, Blum RW, Slap GB. Cross-cultural surveys of adolescent health and behavior: progress and problems. Soc Sci Med 2001; 53:1237-46.
  39. Rademakers J, Mouthaan I, de Neef M. Diversity in sexual health: problems and dilemmas. Eur J Contracept Reprod Health Care 2005; 10:207-11.
  40. Massé R. Culture et Santé publique: Les contributions de l'anthropologie à la prévention et à la promotion de la santé. Boucherville: Gaëtan Morin éditeur, 1995.
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