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Upon completion of the chapter and exercises, the student pharmacist will be able to

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  1. Identify and explain why the core of clinical ethics is the doctor/clinician-patient relationship, what responsibilities and potential abuses are inherent in that relationship, and why there need to be guidelines for clinicians.

  2. Recognize what behavior is ethically their duty to provide to the patient and what is ethically unacceptable behavior.

  3. Use the Jonsen and Siegler "four topics box" system of clinical ethics—(1) medical indications, (2) patient preferences, (3) quality of life, and (4) contextual features—when approaching cases of ethical decision making.

  4. Reference and incorporate the four Georgetown bioethics principles of autonomy, beneficence, nonmaleficence, and justice into decision-making processes.

  5. Follow codified ethical practices such as those published by the American College of Physicians.

  6. Appreciate that ethical duties also extend to the family, to your profession, to society, and to patient research.

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Ethics

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A 26-year-old African American Gold Medal Olympic bicyclist was struck by a car, flung 30 ft into the air, and fell into an embankment. He was training for his second Olympic trial and was well known in the community as being devoted to his sport. He was unconscious at the scene. After stabilization in the hospital, it was determined that his spinal cord was completely severed below T10. He sustained a serious head injury, but it was anticipated that he would probably be able to talk and communicate his wishes over time. However, a long rehabilitation period was anticipated for the head injury with uncertain degree of return to full preaccident mental abilities, and the paraplegia was permanent. During his recovery period he needed surrogates (proxies) to make his decisions for him because of his temporary lack of decision-making capacity. The patient had several medical complications including pneumonia and urosepsis. After several weeks, several family members, including his wife, who was the main surrogate decision maker, voiced their concern that the patient, given his athletic prowess, would "never want to be a cripple" and suggested that, because of the patient's poor quality of life, antibiotics be withheld and the patient be allowed to "die with dignity." Both the patient and his wife were avid athletes, and the subject of paraplegia had never been discussed. But because of his love of the sport and their lifestyle of athleticism, she was sure he would not want to be a "cripple." You, as the pharmacist, are approached by the family to cease administration of antibiotics.

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Discussion—A Case Involving Quality of Life

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It is difficult to know what a patient's preferences are when he cannot speak for himself. Quality-of-life assessment is often made by a third party making pronouncements about someone else's quality of life. It is important to note that there is significant bias introduced here.

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Studies consistently show that physicians (not to mention family members) consistently rate the quality of life of their patients lower ...

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