Case Study Of Healing And Autonomy Discussion

This assignment will incorporate a common practical tool in helping clinicians begin to ethically analyze a case. Organizing the data in this way will help you apply the four principles of principlism.

Based on the “Case Study: Healing and Autonomy” and other required topic study materials, you will complete the “Applying the Four Principles: Case Study” document that includes the following:

Part 1: Chart

This chart will formalize principlism and the four-boxes approach by organizing the data from the case study according to the relevant principles of biomedical ethics: autonomy, beneficence, nonmaleficence, and justice.

Read “Teaching Clinical Ethics Using the Four Topic Method” (attached). Use the example provided in the article to guide you in the completion of the chart in the topic assignment.

Part 2: Evaluation

This part includes questions, to be answered in a total of 500 words, that describe how principalism would be applied according to the Christian worldview. Case Study Of Healing And Autonomy Discussion

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This assignment should consist of completing a chart using the four-box method as a way to organize a case according to the four principles of Principlism. As you fill in each box in section once, be sure there is a clear connection to the items you include in the box and one or more of the principles in the box’s heading.

Bullet points are typically used to complete the boxes in Part I. Make a brief comment in parentheses to show how the information you include relates to the principles for that box. For example:

• “I include this item in this box” (this supports the autonomy of the patient)
• Do not include lengthy descriptions of what, for example, “autonomy” is. Give concrete information in each box. For example, in box one, medical indications, the diagnosis current state of the patient must be included. Case Study Of Healing And Autonomy Discussion

Remember to support your responses with the topic study materials.

APA style is not required (except for resources), but must have solid academic writing.

Applying the Four Principles: Case Study Part 1: Chart (60 points) Based on the “Healing and Autonomy” case study, fill out all the relevant boxes below. Provide the information by means of bullet points or a well-structured paragraph in the box. Gather as much data as possible. Medical Indications Patient Preferences Beneficence and Nonmaleficence Autonomy Quality of Life Contextual Features Beneficence, Nonmaleficence, Autonomy Justice and Fairness ©2019. Grand Canyon University. All Rights Reserved. Part 2: Evaluation Answer each of the following questions about how principlism would be applied: 1. In 200-250 words answer the following: According to the Christian worldview, which of the four principles is most pressing in this case? Explain why. (45 points) 2. In 200-250 words answer the following: According to the Christian worldview, how might a Christian rank the priority of the four principles? Explain why. (45 points) References: ©2019. Grand Canyon University. All Rights Reserved. CLINICAL REVIEW © 2015 Human Kinetics – IJATT 20(6), pp. 10-13 http://dx.doi.org/10.1123/ijatt.2014-0118 Teaching Clinical Ethics Using the Four Topic Method Mike J. Ediger, DHSc • Whitworth University A thletic training and sports medicine are branches of health care, presenting a unique set of ethical problems when making clinical decisions. Very few health professionals face the potential threats and difficulties in maintaining doctor–patient confidentiality, the possible impediments to obtaining informed consent, and the temptation or requirement to use the application of medical arts for enhancing athletic performance or potentially-dangerous behavior.1 As a health care profession, athletic training demands foundational behaviors of professional practice such as primacy of the patient, a team approach to practice, legal and ethical practice, advancing knowledge in the field, cultural competence, and professionalism.

2 The ability to be part of a health professional team and effectively manage the sometimes difficult interplay between the unique aspects of competitive sports and medicine often only comes with experience. When athletic training students are involved with injury evaluations but are not intentionally challenged to consider the many variables that go into making difficult clinical decisions, their growth as professionals will be stunted. Even though clinical educators may be diligent at discussing the decisions with students, if students are not versed at identifying and analyzing all of the variables, they may be left understanding the decision yet not possessing the tools to work through a case on their own. If athletic training students are expected to one day become excellent clinical decision-makers and engage in interprofessional practice, they must understand the biomedical principles that provide uniformity and unity among health care pro10  NOVEMBER 2015 fessionals and create the foundation of ethical decision-making in clinical practice. The Four Topic Method: A Practical Approach to Ethical Decision-Making In Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine3, Jonsen, Siegler, and Winslade present a practical approach to ethical decision-making in clinical medicine, and build on the philosophical study of underlying principles in biomedical ethics (autonomy, beneficence, nonmaleficence, and justice) originally devised by Beauchamp and Childress in their textbook, Principles of Biomedical Ethics. Jonsen et al. acknowledge the work of Beauchamp and Childress, and then direct readers on how these general principles intersect with the specific circumstances of a clinical case Case Study Of Healing And Autonomy Discussion.

The authors suggest that every clinical case is to be analyzed based on a systematic review of four basic topics: medical indications, patient preferences, quality of life, and contextual features (see Table 1). While the book was written for clinical medicine, it can also provide athletic training educators and students a framework that can be applied to a real or theoretical case analysis, providing a practical guide to ethical clinical decision-making in athletic training settings. Because each injury situation will present a unique set of ethical and clinical variables, the scope of this article will not fully explore every possible issue in each of these topics. However, hopefully it can serve as a guide to stimulate further discussion and exploration of these issues between clinical athletic trainers, athletic training educators, and athletic training students. There INTERNATIONAL JOURNAL OF ATHLETIC THERAPY & TRAINING Table 1 The Four Topics Chart,3 with Example Questions Adapted for Athletic Training Medical Indications Patient Preferences The principles of beneficence and nonmaleficence • What is the athlete’s injury or problem? • Is the problem acute, chronic, or critical? • What is the history, diagnosis, and prognosis? • What are the subjective and objective signs or symptoms? • What therapeutic interventions may be appropriate? • What does research or evidence suggest in terms of treatment or intervention? • What are the medical facts based on this particular case? The principle of respect for autonomy • Has the athlete been informed of the indications, risks, and benefits? • What are the athlete’s wishes for treatment, therapy, or return to competition? • Is the athlete competent? Case Study Of Healing And Autonomy Discussion

• Is the injury or pain severe enough to interfere with the athlete’s decision-making capacity? • Is the desire to compete clouding the athlete’s judgment? • Is the athlete feeling pressure related to opinions or attitudes of others? • Is the athlete’s right to choose being respected to the extent possible? Quality of Life Contextual Features The principles of beneficence and nonmaleficence and respect for autonomy • How might the injury or problem be impacting the athlete in other areas of life? • How might the injury impact the athlete’s relationship to the team, coaches, or others? • Will the injury create any academic impediments if the athlete is in school? • Are there any short- or long-term health risks? • Are there any physical, mental, or social implications that are secondary to the original injury? • Does the injury impact identity, self-worth, or cause depression? • Are there biases that might prejudice the athletic trainer’s evaluation of what is right for the athlete? The principles of loyalty, justice, and fairness • Are there other parties who are stakeholders in the clinical decision? • What are the limits of, or imposed restrictions on, confidentiality? • What is the coach’s attitude toward the injury or treatment plan? • What is the athlete’s role on a team? • Does the athlete play a particular position, or does the time of season have any impact on the decision-making process? Case Study Of Healing And Autonomy Discussion

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• Was it a nonathletic-related injury that will impact athletic participation or have financial implications (insurance coverage)? • Are there religious issues that may impact treatment? • Is the athlete a minor, or should parents be consulted? will certainly be overlap between the four topics, but it is recommended that the ethical analysis of clinical decisions follow the same order in all cases: (1) medical indications, (2) patient preferences, (3) quality of life, and (4) contextual features.3 Note: For the context of this article, patients will be referred to as athletes, since most athletic training education takes place at the collegiate setting. Topic 1: Medical Indications Medical indications simply refers to the indications for or against a particular medical intervention, and recognizes the principle of beneficence and nonmaleficence. In this step, athletic trainers are to evaluate the medical INTERNATIONAL JOURNAL OF ATHLETIC THERAPY & TRAINING facts of a particular case in light of the individual, not in light of what decision would best benefit the team or allow the athlete to return to play most quickly. In the broadest scope of medical ethics, this incorporates the principles of beneficence and nonmaleficence, or how the medical intervention brings benefit to the athlete without doing any harm. Through clinical examination, the athletic trainer will take the athlete’s history and attempt to determine the diagnosis and prognosis. Other considerations regarding this topic include: Which therapeutic interventions may be appropriate to evaluate and treat the injury, and what does evidence or research suggest might be the best treatment? Pure medical ethics condemn any action during this step dictated by interests or pressures not related to the goal NOVEMBER 2015  11 of good health or beneficience.4 This does not mean performance or participation will not be taken into account as a treatment plan is developed, however, it is a secondary issue and will be considered later. Helping students identify medical indications might be the most objective step, and one that athletic training clinicians and educators do very well Case Study Of Healing And Autonomy Discussion.

Topic 2: Patient Preferences Patient preferences recognizes the principle of respect for autonomy, and highlights the importance for any athlete to have input into their care, treatment, and return to activity. Important considerations may also include the athlete’s competence and if they are free from feeling pressure from others. Observance of an athlete’s preferences hinges on the athlete’s decision-making capacity, or competence, and it must be voluntary and cannot be made under pressure or coercion. Herein lies the potential for both internal and external barriers to recognizing an athlete’s preferences in the athletic setting. When an athlete is injured, internal obstacles to autonomous decision-making may be presented; the athlete suffers pain, and potentially loses the ability to compete and excel.5 A motivated athlete may view the appropriate medical decision as interference to getting back to play. The internal desire to return to competition can inhibit the ability to hear and comprehend a rational discussion of risks and benefits. In these cases, the athlete may make a decision that will allow them to play rather than making a decision based truly on the medical indications. External barriers to informed consent and athlete autonomy can be both blatant and subversive. Bunch and Dvonch5 state that the assumption that injured athletes, especially those involved in team sports, are self-controlled decision-makers allowed to make autonomous decisions, is simply untrue. Instead, they describe a decision-making process that is subject to group input, a situation called a “constellation of consent”. Injured athletes may have a constellation of people who have a vested interest in their health and ability to compete. Athletes may view playing through an injury as a badge of honor, as dedication to the team, and, at times, an expectation of the team. However, only the athlete assumes the risks, which they may minimize to justify getting back as quickly as possible so as to not let everyone down. For these reasons, medical decisions made to assist an athlete’s return to competition based solely 12  NOVEMBER 2015 on the player’s desire to compete, in hindsight, could be construed as coercive and negligent by anyone in the constellation, and could have significant legal implications.4,6 As an advocate for the athlete, the athletic trainer must sometimes protect athletes from themselves. While athlete autonomy is primary and should never be summarily dismissed, medical ethics will occasionally allow a form of weak paternalism. In the case of an injured or overwhelmed athlete, cautious, beneficence-based paternalism may be an acceptable position when making clinical or return-to-play decisions.5 The question really becomes how far can athletic trainers let medical self-determination or athlete autonomy go when the athlete is under extreme pressure, internal or external, to play with an injury? Case Study Of Healing And Autonomy Discussion

7 Topic 3: Quality of Life Quality of life recognizes that any injury, especially when severity is not initially known, may pose both real and perceived threats to the athlete’s lifestyle, and represents the principles of beneficence, nonmaleficence, and respect for autonomy. In addition, quality of life will mean different things to different people, and each athlete must be allowed to fully articulate what is acceptable for them. The athletic trainer must also be careful not to let personal bias prejudice the evaluation of a situation and how the athlete is advised. Careful consideration should be given to any potential short- or long-term health risks due to the injury, with or without intervention. What physical, mental, and social deficits might the athlete experience if away from their team or sport for a significant amount of time? What academic impediments may be experienced based on the injury? The goal of the athletic trainer is to ensure the athlete’s health and well-being and to minimize the pain and suffering. However, the goal of the athlete might not always align with the athletic trainer, where pain and suffering are often acceptable by-products of athletic participation and competition. An athletic trainer must realize that injuries can affect not only an athlete’s physical health and performance on the field of competition, but also enjoyment of social roles, intellectual functioning, emotional states, and a sense of life-satisfaction or personal well-being. Topic 4: Contextual Features Contextual features recognizes that most athletic injuries are clearly embedded within a larger context of INTERNATIONAL JOURNAL OF ATHLETIC THERAPY & TRAINING factors. Clinical decisions are rarely made in a vacuum and often require input from several individuals to determine the course of action (e.g., athlete, athletic trainer, coach, parents, and physician).7 Contextual features bring into play the principles of justice and fairness within the context of injury. Is the athlete the best or worst player on the team, and what impact might or should this have? Is the team in the off-season, preseason, or competing for a championship? Case Study Of Healing And Autonomy Discussion

Are there provider issues, such as a specific team physician, specialist, or family physician that the athlete or family wants to be consulted? Are there financial and economic factors? Is the injury nonathletic-related, which may or may not have insurance implications? Are there confidentiality limits with personal issues, such as an eating disorder or an abortion, which the athlete may come to you for help but does not want the coach to know? In every limiting medical condition, the relevance of the contextual features must be determined and assessed. Skill in recognizing and understanding these features, and learning how to diplomatically manage each, will be crucially important in making ethical clinical decisions. Ultimately, the ability to navigate and anticipate some of the contextual complications may dramatically influence the support or resistance an athletic trainer may face in working toward resolution with all of the parties involved. The Four Topic Method as a Pedagogical Tool Peer and Schlabach8 state that cognitive understanding of ethics in clinical education is critical for students to establish the foundational behaviors of professional practice. One of the difficulties in teaching clinical decision-making is that students are often not fully involved in the decision-making process in their clinical experience, and replicating the process in the classroom can be difficult. The Four Topic Method may bridge this gap, allowing both clinical and classroom educators an organizational tool to intentionally challenge students to identify variables involved with injury management situations. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine3 may also be an excellent text for a senior seminar or reading group. After being presented with case studies, students could brainstorm variables relevant to each of the four topics. Then, working groups could carefully analyze, evaluate, and present these variables to class members. This same process could be used with clinical instructors when INTERNATIONAL JOURNAL OF ATHLETIC THERAPY & TRAINING evaluating current injuries seen in the training room. This systematic, integrated, and ongoing practice of working through clinical dilemmas will ultimately help students establish the foundational professional behaviors required to become ethical decision-makers in daily practice. Athletic training education must help students become ethical decision-makers and prepare them for interprofessional practice with the general medical community. The Four Topic Method is an organized model for clinical decision-making that is grounded in principles of biomedical ethics. Using this method in the clinic or classroom will intentionally and deliberately challenge students to critically analyze clinical scenarios and help them master the foundational behaviors revealed in the ethics of professional practice. If students can recognize the appropriate medical indications, give athletes’ preference and quality of life desires appropriate consideration, and learn to recognize associated contextual features, they can more objectively and effectively advocate for athletes’ health and well-being through competent and ethical clinical decisions.  References 1. Bernstein J, Perlis C, Bartolozzi AR. Normative ethics in sports medicine. Clin Orthop. 2004;(420):309–318. PubMed doi:10.1097/00003086200403000-00044 2. National Athletic Trainers’ Association. Athletic training educational competencies. 5th ed. Carrollton, TX: National Athletic Trainers’ Association; 2011. Available at http://www.nata.org/sites/default/ files/5th_Edition_Competencies.pdf. 3. Jonsen AR, Siegler M, Winslade WJ. Clinical ethics: A practical approach to ethical decisions in clinical medicine. 7th ed. New York, NY: McGrawHill; 2010. 4. Liotard P. Sport medicine: to heal or to win? UNESCO Cour. 2000;53(9):37–39. 5. Bunch WH, Dvonch VM. Informed consent in sports medicine. Clin Sports Med. 2004;23(2):183–193. PubMed doi:10.1016/j. csm.2004.01.004 6. McCrory P. No pain, no gain. The dilemma of a team physician. Br J Sports Med. 2001;35(3):141–142. PubMed doi:10.1136/ bjsm.35.3.141-a 7 Case Study Of Healing And Autonomy Discussion.

Gould MT, Hansted KT. The fix is in: legal and malpractice standards regarding the treatment of athletic injuries. Clin Sports Med. 2003;22(3):631–638. PubMed doi:10.1016/S0278-5919(03)00020-6 8. Peer KS, Schlabach GS. Ethics education: the cornerstone of foundational behaviors of professional practice. Athl Ther Today. 2007;12(1):2–6. Mike Ediger is an associate professor and department chair of Health Sciences, Whitworth University, Spokane, WA. Malissa Martin, EdD, ATC, CSCS, Rocky Mountain University of Health Professions, is the report editor for this article. NOVEMBER 2015  13 Copyright of International Journal of Athletic Therapy & Training is the property of Human Kinetics Publishers, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use. Applying the Four Principles: Case Study Part 1: Chart (60 points) Based on the “Healing and Autonomy” case study, fill out all the relevant boxes below. Provide the information by means of bullet points or a well-structured paragraph in the box. Gather as much data as possible. Medical Indications Patient Preferences Beneficence and Nonmaleficence Autonomy Quality of Life Contextual Features Beneficence, Nonmaleficence, Autonomy Justice and Fairness ©2019. Grand Canyon University. All Rights Reserved. Part 2: Evaluation Answer each of the following questions about how principlism would be applied: 1. In 200-250 words answer the following: According to the Christian worldview, which of the four principles is most pressing in this case? Explain why. (45 points) 2. In 200-250 words answer the following: According to the Christian worldview, how might a Christian rank the priority of the four principles? Explain why. (45 points) References: ©2019. Grand Canyon University. All Rights Reserved. Case Study: Healing and Autonomy Mike and Joanne are the parents of James and Samuel, identical twins born 8 years ago. James is currently suffering from acute glomerulonephritis, kidney failure. James was originally brought into the hospital for complications associated with a strep throat infection. The spread of the A streptococcus infection led to the subsequent kidney failure. James’s condition was acute enough to warrant immediate treatment. Usually cases of acute glomerulonephritis caused by strep infection tend to improve on their own or with an antibiotic. However, James also had elevated blood pressure and enough fluid buildup that required temporary dialysis to relieve. The attending physician suggested immediate dialysis. After some time of discussion with Joanne, Mike informs the physician that they are going to forego the dialysis and place their faith in God. Mike and Joanne had been moved by a sermon their pastor had given a week ago, and also had witnessed a close friend regain mobility when she was prayed over at a healing service after a serious stroke. Case Study Of Healing And Autonomy Discussion

They thought it more prudent to take James immediately to a faith healing service instead of putting James through multiple rounds of dialysis. Yet, Mike and Joanne agreed to return to the hospital after the faith healing services later in the week, and in hopes that James would be healed by then. Two days later the family returned and was forced to place James on dialysis, as his condition had deteriorated. Mike felt perplexed and tormented by his decision to not treat James earlier. Had he not enough faith? Was God punishing him or James? To make matters worse, James’s kidneys had deteriorated such that his dialysis was now not a temporary matter and was in need of a kidney transplant. Crushed and desperate, Mike and Joanne immediately offered to donate one of their own kidneys to James, but they were not compatible donors. Over the next few weeks, amidst daily rounds of dialysis, some of their close friends and church members also offered to donate a kidney to James. However, none of them were tissue matches. James’s nephrologist called to schedule a private appointment with Mike and Joanne. James was stable, given the regular dialysis, but would require a kidney transplant within the year. Given the desperate situation, the nephrologist informed Mike and Joanne of a donor that was an ideal tissue match, but as of yet had not been considered—James’s brother Samuel. Mike vacillates and struggles to decide whether he should have his other son Samuel lose a kidney or perhaps wait for God to do a miracle this time around. Perhaps this is where the real testing of his faith will come in? Mike reasons, “This time around it is a matter of life and death. What could require greater faith than that?” © 2019. Grand Canyon University. All Rights Reserved. Case Study Of Healing And Autonomy Discussion

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Applying the Four Principles: Case Study Part 1: Chart (60 points) Based on the “Healing and Autonomy” case study, fill out all the relevant boxes below. Provide the information by means of bullet points or a well-structured paragraph in the box. Gather as much data as possible. Medical Indications Patient Preferences Beneficence and Nonmaleficence Autonomy Quality of Life Contextual Features Beneficence, Nonmaleficence, Autonomy Justice and Fairness ©2019. Grand Canyon University. All Rights Reserved. Part 2: Evaluation Answer each of the following questions about how principlism would be applied: 1. In 200-250 words answer the following: According to the Christian worldview, which of the four principles is most pressing in this case? Explain why. (45 points) 2. In 200-250 words answer the following: According to the Christian worldview, how might a Christian rank the priority of the four principles? Explain why. (45 points) References: ©2019. Grand Canyon University. All Rights Reserved Case Study Of Healing And Autonomy Discussion