Health Care Ethics Consortium of Georgia

2012 Upcoming Workshops

September 14, 2012
Ethics Consultation Workshop
Location: Emory University Center for Ethics

November 9, 2012
Topic TBA
Location: Emory University Center for Ethics

Special Note:

The Annual Conference of the Health Care Ethics Consortium of Georgia
"Mixed Messages: Ethical Tensions in Healthcare Conversations" was well attended on
March 13-14, 2012.

Thanks to everyone who participated. We hope it was informative and enjoyable.

1 attachment

The Health Care Ethics Consortium of Georgia (HCECG) was founded in January 1994 following a three year planning period funded by Emory University and the Georgia Humanities Council. Clinicians and health administrators statewide participated in the formation of a network of health care organizations that shared a common interest in bringing ethics analysis to patient care and organizational issues. The membership is comprised of hospitals and health systems, home health agencies, hospices, long term care facilities, managed care organizations and rehabilitation centers. The Emory University's Center for Ethics houses and staffs the Consortium.

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It’s You vs. the World by Michael Arenson

Submitted by cpowell on Fri, 01/06/2012 - 11:37am

If public health ethics could be generalized into a few dramatic words, it would be, “It’s you versus the world”. The reason being that the ethical tangles in public health often lead to difficult balancing acts between an individual’s dignity, autonomy, and liberty and the greater public’s requirement of social justice, equity and interdependence. In other words, the individual’s values are pitted against the public’s values. One fascinating example of ‘public vs. individual’ is public health surveillance.

Surveillance is the, “collection, analysis, and use of data to target public health prevention. It is the foundation of public health practice.”1 Surveillance is necessary to plan, implement and evaluate public health programs, and without it public health is “blind”.

Patricia Sweeney, MPH and Leonard Ortmann, PhD came to Emory Center for Ethics on Thursday, December 15, 2011 to discuss the latest ethical tangles in HIV surveillance in America. In a talk titled, “New Uses of Public Health Surveillance Data to Improve HIV Care and Reduce Transmission: The Ethical Challenges of Innovation,” the pair described the latest efforts to link HIV surveillance back to the patient’s clinical care.

Currently, the CDC collects information about HIV-infected individuals from their physicians for surveillance purposes. This is called case reporting. This gives the CDC a large list of identifiable people that are HIV-infected. It also lets the CDC know where this patient is receiving care, whether they’ve had various tests performed in the last year, among much more information that can help the CDC track HIV infection in America.

If HIV surveillance collected from patients were to be kept confidential by the CDC and other public health institutions, the patient’s right to privacy and confidentiality would be honored. But, Patricia and Leonard ask, by having data about identifiable individuals, do we have a moral obligation to use that information? For example, many HIV-infected individuals do not know they are infected, but have been tested for HIV surveillance purposes. The CDC knows they’re infected, but they don’t know they’re infected. Informing people of their status and getting them into care could save not only their lives, but also their loved ones, or – if they are a pregnant woman – their unborn baby from becoming HIV-infected.

Lately, state and federal public health agencies (i.e. in Louisiana, New York, and Washington DC) have been experimenting with taking the information gained for HIV surveillance purposes and linking it back to patients who visit the doctor. If a person who is an HIV-infected pregnant woman goes to an antenatal clinic, a message could pop-up in her medical record saying so.

But does tracking individuals like this look too much like “big brother” watching your every move? Also, some epidemiologists might say, “Don’t rock the boat! We’ve always done it this way.” As Leonard said, such is the challenge with innovating – whenever the government changes something, people will say, “Whoa! What are you doing? Don’t go changing things on me.” Whenever innovation happens, efforts must be made to maintain the trust of the public. This is part of the reason why change should be made with collaboration from the public, so that they are involved in the process and understand the need for change.

In the case of HIV surveillance, linking surveillance data to clinical care is a way to honor the individual while still carrying out the responsibilities of public health. But doing so is more than a big change – it affects the public health infastructure as well as the health system. Thomas Frieden, director of the CDC, came up with the health impact pyramid (see figure).2 The things that have the biggest impact on the public’s health are the lowest on the pyramid. But they also are the most controversial. This is where the ethics comes in. When people have different perspectives, how do we decide whose perspective should be turned into action? Should the public’s health take precedence over the individual’s right to privacy and confidentiality? Should an HIV-infected individual be able to go to the doctor without being harassed to take an HIV test? Should surveillance – which often collects information about someone not for his or her own benefit but for the benefit of the public – be linked to clinical care so that someone not aware of their HIV status be informed that they are infected?

What do you think? Do you advocate for “you” or the world?

Michael Arenson is a graduate student in the Master's of Arts in Bioethics program at Emory University.

1. http://www.cdc.gov/surveillancepractice/index1c.html.
[PDF] from oregon.gov

2. TR Frieden
- American journal of public health, 2010 - ajph.aphapublications.org

Dr. John Banja Reflects on Ethical Surveillance and HIV Care

Submitted by cpowell on Mon, 12/19/2011 - 1:42pm

On December 15th, Patricia Sweeney and Leonard Ortmann from the Centers for Disease Control and Prevention presented a talk at the Ethics Center's monthly clinical seminar. Their topic was on the ethical dimensions of public health surveillance data in improving HIV care and reducing transmission. Because I'm not a specialist in this area, I was surprised to learn that of the 1.2 million Americans with HIV, only a third receive the standard of care treatment, whose centerpiece is anti-retroviral therapy (ART). The other two-thirds of the HIV population either do not or cannot avail themselves of ART, or don't know they're carrying the virus. This latter figure is heartbreaking in that ART is a monumental discovery in treating HIV--transforming it from the tragically lethal disease it was decades ago to a chronic illness that now allows those afflicted a good quality life. Furthermore, ART reduces the viral load of HIV and thus reduces its risk of transmission. Clearly, it is a win-win intervention.

What Patricia and Leonard discussed was the extent to which new public health surveillance data--that, for instance, notifies physicians who are treating persons with HIV that their patient hasn't had a checkup in over 6 months--could appear nonthreatening. The history of HIV, of course, is fraught with stigmatization and accompanying horror stories of patients losing their jobs, their health benefits, and their social networks because their health information was disclosed to persons who had neither a right nor need to know it. The challenge for new surveillance strategies to work--which largely involve data traveling from an initial diagnosis that is sent to a state data repository and then back to a treating professional or facility--is to continue to diminish the public's fear of the disease, its discriminatory potential, and deep seated anxieties about information sharing.

Just as the extraordinary research efforts of the last 25 years in HIV treatment have recently witnessed astonishing success, let us hope we can realize the same in our educational efforts to bring social attitudes and behaviors in line with contemporary science and HIV therapy. It would constitute a sure win-win.

John Banja, PhD, is a Professor of Rehabilitation Medicine, a Medical Ethicist at the Center for Ethics and the Director, Section on Ethics In Research – Atlanta Clinical and Translational Science Institute Associate Editor.

Do recent changes in work schedules described by Dr. Williams make for a more efficient teaching hospital?

Yes

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Total votes: 0

Kathy Kinlaw: What do we do when there is no one to make medical decisions for a patient?

Submitted by cpowell on Fri, 12/09/2011 - 11:49am

Does this story sound familiar?

An elderly patient with diabetes from an area nursing home has developed gangrene and is at risk of sepsis. The medical team recommends amputation of the left lower leg, but needs someone to provide consent for surgery. The patient does not have the cognitive ability to make decisions and does not have an advance directive. The physicians will not perform surgery without a signed consent. There is a problem locating relatives, and the only known relative, a nephew, has not been involved in the patient’s care. The surgery is not considered a true emergency, but neither is there time to appoint a guardian for the resident.

Decision making for patients without family is a frequent concern in hospitals, nursing homes and other settings. One study in the journal Critical Care Medicine in 2006 concludes that 16% of patients without decision-making capacity in the medical ICU of a metropolitan hospital also lacked a surrogate decision maker. A New York state report concluded that approximately one third of nursing home residents are without decision makers when medical decisions need to be made.

In 2010 HCECG and the Emory University Center for Ethics led a working group that drafted legislation creating a process to provide consent for surgical or medical treatment for a patient who 1) does not have decision making capacity and 2) who lacks a family member or other surrogate authorized under Georgia law. The resulting legislation passed and was signed into law in the summer of 2010. Practice highlights of the law are included at the end of this article.

So how is implementation of the law progressing at the end of 2011?

Hospitals informally report that it has been very helpful to have the expanded list of individuals who are authorized to consent to treatment. Both extended family members and adult friends have provided consent for treatment for patients without decision-making capacity.

Implementation of the temporary medical consent guardianship process has not been as straightforward. We have reports of some cases in which the process was not initiated due to concerns regarding costs for filing or difficulty in identifying individuals who are willing to serve as guardians.

We would like to hear from you about whether you have utilized the legislative changes to assist with consent for patient treatment. In the coming days look for an HCECG email with a link to a brief survey on the topic. Emails addressing this issue are also welcome. Let us know about whether the legal changes have been helpful, or about other concerns in caring for patients who are unable to make decisions about their own treatment. (kkinlaw@emory.edu)

Legislation Highlights:

·

The list of individuals who are authorized to give consent under Georgia law was extended (beyond durable power of attorney for health care, spouse, guardian, adult child, parent, adult sibling, and grandparent) to include:

o
Any adult grandchild

o
Any adult niece, nephew, aunt, or uncle of the patient who is related to the patient in the first degree

·

In the absence of any of the above, an adult friend of the patient may be authorized to consent. (The friend is further defined as one who has exhibited special care and concern, who is generally familiar with the patient’s health care views, and who is willing to be involved in health care decisions and to act in the patient’s best interests.)

·

In the absence of any of the above decision makers, the health care facility or an interested person may initiate proceedings for an expedited judicial intervention to appoint a temporary medical consent guardian. This petition would be filed in the Probate Court in either the county in which the patient lives or the county in which the patient is in a health care facility.

The full text of the bill can be found on-line at:

http://www.legis.state.ga.us/legis/2009_10/pdf/sb367.pdf

kinlaw Kathy Kinlaw is Associate Director of the Emory University Center for Ethics and Director of the Center's Program in Health Sciences and Ethics. She serves as Bioethics Associate in Pediatrics, Emory School of Medicine; and Executive Director of the Health Care Ethics Consortium of Georgia.

Left Behind: Caring for Vulnerable Populations in the HIV/AIDS Pandemic

Submitted by cpowell on Thu, 12/01/2011 - 3:05pm

photo by Shamus Finnigan

Up at Night: Dr. Helen O. Williams Reflects on Resident Work Hours

Submitted by cpowell on Tue, 11/22/2011 - 11:36am

Helen A few weeks ago I was sitting in the physicians work area at 2 AM. I was waiting for the delivery of a high risk preterm infant that was expected to be imminent. I passed the time catching up on some charting and reading an article, and as I sat there, I was struck by the fact that I was all by myself. My residents had previously said goodnight and scurried off to their call rooms for a nap. It was ironic to me that they felt the need to sleep; after all, this was only a 12 hour shift for them. I would round on the unit the next morning and continue caring for patients until 4pm, when my partner would come for sign-out. And yet they slept and I didn’t; they had a call room and I didn’t. In that moment I felt like an old soul from a different generation even though I have only been an attending physician for 4 years. Sure this wasn’t walking uphill both ways in the snow, but I could claim the medical equivalent of that feat, having trained to a large degree before the enforcement of the physician duty hours.

Important Organizational Note

Submitted by cpowell on Fri, 11/18/2011 - 7:42pm

Marian

Marian Osborne photo courtesy of Carlton Mackey

Marian Osborne, who worked with HCECG for many years, has taken on the role of Human Resource Coordinator for the Center for Ethics and Academic Program Coordinator for the Master of Arts in Bioethics program. Though she will be moving away from her official responsibilities with the Consortium, we are grateful that she remains close by at the Center and we are very happy for her as she accepts her new roles. Marian has been an important part of the HCECG family, working hard to help in many phases of the Consortium’s life: membership renewal, event registration, website updating, problem solving, and much more. Each of us has benefited from the chance to work with her, and her thoughtful, welcoming spirit will be missed. Please join us in thanking Marian for her important work.

dianne

Dianne Becht photo courtesy of Ms. Becht

As Marian leaves, we welcome Dianne Becht to the work of the Center for Ethics and HCECG. Dianne joins us after 24 years at Georgia State University’s Department of Chemistry. Please welcome Dianne as you begin to work with her. (Dianne.becht@emory.edu)

The Relationship Between Ethics and Public Health

Submitted by cpowell on Wed, 11/09/2011 - 11:01am

publichealthethics

We sat down with Michael Arenson, a student in the master’s of
Bioethics program housed at Emory’s Center for Ethics, to talk about how
ethics plays into public health. Arenson’s goal is to help facilitate
more collaborations and conversations that include both ethics and
public health. He says that,“ethics is often viewed as something to be
complied with before public health can do its work, but both ethics and
public health are at their best when ethics becomes more a part of the
process instead of the oversight of public health.” In considering a
dual major in Bioethics and Public Health, Arenson sat down with Kathy
Kinlaw of the Center for Ethics to talk about possibilities. During this
conversation, the Public Health Ethics Organization was conceived. With
co-founder Andrea Fletcher, a Masters of Public Health student at
Emory, the organization is gaining momentum. They took off by organizing
a packed panel discussion on the Troy Davis verdict. The intention of
the organization, Arenson notes, is to be a “nexus for
multi-disciplinary collaboration.” Pairing ethics with public health, to
Arenson, “makes sense because, in the words of Paul Root Wolpe, all
ethics really is, is a conversation,” and this conversation must be a
part of every aspect of public health.

Look out for the Public Health Ethics Organization on facebook
or email at phethics@emory.edu!

Holly Tucker: Blood in the Scientific Revolution

Submitted by cpowell on Fri, 10/28/2011 - 9:58am

(Holly Tucker photo by John Breinig)

Dr. Cory Labrecque, scholar and lecturer in the Bioethics graduate program housed at the Center for Ethics, described Holly Tucker first as a "gifted story-teller." Dr. Tucker, an Associate Professor at Vanderbilt University, spoke on the controversies that were sparked in 17th century France by the earliest blood experiments. The lecture was presented at the Center for Ethics in collaboration with the Winship Cancer Institute at Emory University and the Emory Center for Transfusion and Cellular Therapies.
Although Labrecque does not specialize in issues directly related to blood, Tucker's presentation was effectively interdisciplinary, sparking the interest of audience members from many academic disciplines. Labrecque found "dimensions of Bioethics" in the descriptions of decisions made about blood experiments. Tucker illustrated that decisions in transfusions and transplants were closely related to autonomy and personhood. The information that Tucker shared inspired questions about the kinds of patients that participated and their religious values. Tucker expatiated controversies that arose about the ethical differences in treating humans and animals. The lecture was especially insightful as blood experiments reveal critical tensions in the interplay between religion, science and history.

Join the conversation: Do religious values have a critical impact on the average individual's medical decisions?

Welcome to the HCECG Blog!

Submitted by cpowell on Mon, 10/24/2011 - 9:16am

As part of our mission to broadcast our activities and initiatives as well as garner community involvement, we will now be posting regular blog articles on the front page of this website. As an organization based on community collaboration and housed at the Center for Ethics at Emory, it is our goal to employ innovative approaches to engage with communities throughout Georgia. The articles will reflect a diverse array of issues and will include perspectives from health care providers, health care advocates, scholars, experts and patients as well. This blog will be a forum for anyone who is concerned about health care in Georgia to find out more and join the conversation. If you wish to contribute to the blog please contact Kathy Kinlaw (kkinlaw@emory.edu) or Catherine Powell (chpowel@emory.edu) with your ideas.

Senate Bill 367 - Medical consent for those without decision making capacity

Senate Bill 367, which addresses a process for consent for surgical or medical treatment for a patient who 1) does not have decision making capacity and 2) who lacks a family member or other surrogate authorized under Georgia law, has been signed by the Governor and will go into effect July 1, 2010. The full article can be found in the attachment below. The full text of the bill can be found online: http://www.legis.state.ga.us/legis/2009_10pdf/sb367.pdf