Medical Ethics: Basic Principles

Overview

Definition

Medical ethics are a set of moral values that guide the decision-making of health care professionals in their daily practice. 

• A subdivision of applied ethics
• Combination of ethical principles, virtue ethics, professional oaths, and personal values

Historical background

Antiquity:

• Hippocrates of Cos (460–370 BCE): attributed with composition of the Hippocratic oath, which established a moral requirement for physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship to be committed to ethical ideals of benevolence and nonmaleficence:
  • Oath later adopted in the 1500s at the University of Wittenberg as part of the graduation ceremony for physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship. 
  • “First, do no harm” is not a phrase explicitly stated in the Hippocratic oath.
• Aristotle (384–322 BCE) defined ethics as a set of moral behaviors derived from logic, carried out as habits (virtue ethics): early distinction of actions that lead to human well-being.
• Many other philosophers and theologians throughout the centuries have written extensively on the distinction of virtue from evil. 

20th century:

• After World War II, the Nuremberg code Nuremberg Code 10-point statement introduced as the final judgement of the tribunal at the Nuremberg trials (1947), when the atrocious experiments carried out by Nazi physicians and researchers on human test subjects in concentration camps came to light. Research Ethics was introduced as the final judgment Judgment The process of discovering or asserting an objective or intrinsic relation between two objects or concepts; a faculty or power that enables a person to make judgments; the process of bringing to light and asserting the implicit meaning of a concept; a critical evaluation of a person or situation. Psychiatric Assessment of the tribunal at Nuremberg (1947), which greatly increased the importance of the principle of autonomy in medical research Research Critical and exhaustive investigation or experimentation, having for its aim the discovery of new facts and their correct interpretation, the revision of accepted conclusions, theories, or laws in the light of newly discovered facts, or the practical application of such new or revised conclusions, theories, or laws. Conflict of Interest and practice. 
• The next documents ( Belmont Report Belmont report Issued by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, formed after the passing of the Research Act of 1974. Research Ethics and Declaration of Helsinki Declaration of Helsinki First adopted in 1964 as a set of guidelines for human experimentation published by the World Medical Association. Research Ethics) further develop the core ethical principles of research Research Critical and exhaustive investigation or experimentation, having for its aim the discovery of new facts and their correct interpretation, the revision of accepted conclusions, theories, or laws in the light of newly discovered facts, or the practical application of such new or revised conclusions, theories, or laws. Conflict of Interest.
• In 1948, the Declaration of Geneva Declaration of Geneva The Declaration of Geneva was adopted in September 1948 by the 2nd general assembly of the World Medical Association in Geneva, Switzerland. Research Ethics was adopted as a modernization of the Hippocratic oath. The professional oath remains an important rite of passage, where the physician publicly declares adherence to the ethical principles of the profession.
• The term “bioethics” was first coined in 1970 by Van Rensselaer Potter, defined as “the study of the moral relationship between humans and their social and physical world.”
• Medical ethics takes a secularized approach, leaving the enforcement of moral principles to the government and professional societies.
• Currently, the American Medical Association Code of Ethics (1847) provides guidance on the application of ethical principles to clinical practice.

Basic Principles (Duties) and Application

Medical ethics are based on deontology, a theory that states that actions are classified as good or bad based on a clear set of rules.

Core principles of medical ethics (Beauchamp and Childress)

• Beneficence:
  • Acting only with the intention to do good and for the patient’s benefit
  • Some herald it as the greatest of all ethical principles in medicine 
  • Ensures that, even when the patient’s autonomy is compromised, their best interest would be advocated for and defended by the physician 
• Autonomy:
  • Respect for the patient’s right to self-rule
  • Basis for decision-making capacity Decision-making capacity Decision-making capacity describes a patient’s ability to make autonomous decisions regarding their care, as determined by a physician. Decision-making Capacity and Legal Competence and informed consent Informed consent Informed consent is a medicolegal term describing the documented conversation between a patient and their physician wherein the physician discloses all relevant and necessary information to a patient who is competent to make an informed and voluntary decision regarding their care. Competency, disclosure, and voluntariness are the key elements upon which IC is based. Informed Consent. Note that in special situations (emergency situations) a physician is permitted to act based on beneficence, even if the patient is not capable of providing consent as an expression of their autonomy (e.g., performing CPR CPR The artificial substitution of heart and lung action as indicated for heart arrest resulting from electric shock, drowning, respiratory arrest, or other causes. The two major components of cardiopulmonary resuscitation are artificial ventilation and closed-chest cardiac massage. Cardiac Arrest for cardiac arrest Cardiac arrest Cardiac arrest is the sudden, complete cessation of cardiac output with hemodynamic collapse. Patients present as pulseless, unresponsive, and apneic. Rhythms associated with cardiac arrest are ventricular fibrillation/tachycardia, asystole, or pulseless electrical activity. Cardiac Arrest).
• Nonmaleficence:
  • Not acting with the intention to do harm
  • Expressed in the maxim Primum non nocere (First, do no harm)
• Distributive justice Justice An interactive process whereby members of a community are concerned for the equality and rights of all. Research Ethics:
  • Recognizing the right of all to be treated equally
  • Equal rationing of beneficence among patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship

Additional principles

• Confidentiality Confidentiality Confidentiality is a set of rules that dictates the protection of health information shared by a patient with a physician. In general, this information should only be used to dictate medical decision-making steps and can only be disclosed to a 3rd party with the patient’s express consent. Patient-Doctor Confidentiality
• Fidelity Fidelity Conflict of Interest
• Trustfulness
• Respect for the law

Further duties of a physician (Gert, Culver, and Clouser)

• Do not kill.
• Do not cause pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways.
• Do not disable.
• Do not deprive of freedom.
• Do not deprive of pleasure.
• Do not deceive.
• Keep your promises.
• Do not cheat.
• Obey the law.
• Do your duty.

Approach to application of ethics in clinical practice: 4-box method

Medical indications (general goals of medical treatment):

1. What is the chief symptom? History of present illness? Diagnosis? Prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas?
2. What is the timing of the illness (acute, chronic, critical, emergent, reversible)?
3. What is the objective of treatment?
4. Is complete remission Remission A spontaneous diminution or abatement of a disease over time, without formal treatment. Cluster Headaches likely? What are the chances of treatment success?
5. If the treatments failed, what would the follow-up plan be?
6. How can the patient benefit from care, and how can harm be avoided?

Patient preferences (patient’s values and assessment of relative benefits):

1. What are the patient’s expressed treatment preferences?
2. Has informed consent Informed consent Informed consent is a medicolegal term describing the documented conversation between a patient and their physician wherein the physician discloses all relevant and necessary information to a patient who is competent to make an informed and voluntary decision regarding their care. Competency, disclosure, and voluntariness are the key elements upon which IC is based. Informed Consent been obtained after providing the patient with a full account of possible benefits and risks?
3. Is the patient mentally capable and legally competent? Is there any evidence to the contrary?
4. Are there any preexisting preferences that have been stated by the patient regarding their care (e.g., advance directives Advance Directives The term advance directive (AD) refers to treatment preferences and/or the designation of a surrogate decision-maker in the event that a person becomes unable to make medical decisions on their own behalf. Advance directives represent the ethical principle of autonomy and may take the form of a living will, health care proxy, durable power of attorney for health care (DPAHC), and/or a physician’s order for life-sustaining treatment (POLST). Advance Directives)?

Quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement of life:

1. What will the patient’s quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement of life be with or without treatment? Will the patient be able to return to the previous lifestyle?
2. Are there biases that might prejudice the provider’s evaluation of the patient’s quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement of life?
3. What deficits (physical, mental, or social) would likely result from successful treatment?
4. Is the present or future condition such that continued life might be judged undesirable by the patient?
5. Is there a plan or rationale to not undergo treatment?
6. Are there comfort/palliative care plans in place? What are they?

Contextual features (patient–physician partnership):

1. Are there family issues that might alter the patient’s treatment choices?
2. Are there provider issues that might alter the patient’s treatment choices?
3. Are there financial and economic factors?
4. Are there religious or cultural factors?
5. Is there any reason to breach confidentiality Confidentiality Confidentiality is a set of rules that dictates the protection of health information shared by a patient with a physician. In general, this information should only be used to dictate medical decision-making steps and can only be disclosed to a 3rd party with the patient’s express consent. Patient-Doctor Confidentiality?
6. Are there any issues of resource allocation?
7. What are the legal implications of treatment decisions?
8. Is clinical research Research Critical and exhaustive investigation or experimentation, having for its aim the discovery of new facts and their correct interpretation, the revision of accepted conclusions, theories, or laws in the light of newly discovered facts, or the practical application of such new or revised conclusions, theories, or laws. Conflict of Interest or teaching involved?
9. Are there any conflicts of interest?

Principles of Medical Ethics

The following principles summarize the standards of conduct to be expected from a physician.

1. Physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship must provide competent, compassionate medical care Medical care Conflict of Interest, always championing human rights.
2. Physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship must uphold standards of professionalism.
3. Physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship must respect the law and take on the responsibility of changing laws that are contrary to the best interests of a patient.
4. Physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship must respect rights and privacy of patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship and colleagues within the constraints of the law.
5. Physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship must maintain a commitment to continue medical education Medical education Conflict of Interest.
6. Physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship must be free to choose whom to serve and the environment in which to provide medical care Medical care Conflict of Interest.
7. Physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship must take responsibility to participate in activities that will improve public health.
8. Physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship must regard responsibility to the patient as their highest priority while caring for the patient.
9. Physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship shall support expansion of access to medical care Medical care Conflict of Interest for all people.

Progression of Medical Ethics

Medical ethics progress in a casuistic manner, applying ethics to individual cases. Thus, the result is a historical line of events of cases when a dilemma arose and a solution was proposed. The steps are:

1. A policy is created or changed.
2. The policy eventually leads to a problematic situation, or dilemma.
3. An action or inaction in response to the dilemma is proposed and carried out. This response includes research Research Critical and exhaustive investigation or experimentation, having for its aim the discovery of new facts and their correct interpretation, the revision of accepted conclusions, theories, or laws in the light of newly discovered facts, or the practical application of such new or revised conclusions, theories, or laws. Conflict of Interest into previous solutions to similar dilemmas in the literature as well as philosophical, ethical, and even religious literature (The Great Conversation).
4. Ethicists review the action or inaction and provide commentary on it being acceptable or unacceptable.

Ethical Challenges

Dilemmas

• A clinical situation in which 2 ethical principles are at odds, and a course of action must be taken in transgression of 1 of the 2. 
• Often, there is no obviously “correct” answer. 
• When these situations arise, institutions rely on ethics boards or committees to define the course of action that better suits the best interests of the patient.

Conflicts of interest

• Within the medical context, conflict of interest Conflict of interest Conflict of interest within the medical context occurs when a doctor’s ability to act in the best interest of the patient is influenced by an outside relationship with a person, group, or business. The conflict may be expressed at the individual or institutional level. Conflict of Interest describes situations in which a doctor’s ability to act in the best interest of their patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship is influenced by outside relationships with people, groups, or businesses.
• Conflicts of interest should always be disclosed, and attempts should be made to minimize biases.

Laws and Medical Ethics

The legal corpus (including laws and policies) of a nation or state dictate the practice of medicine, and should reflect the ethical values of the community represented.

Authority

• Not the only determinant of what is ethical.
• Can be overruled by the pronunciation of an ethical principle by an individual under the quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement of free speech.

Relevant laws and policies for medical practice in the United States

• United States, or governmental law (statutory law, common laws, executive law)
• National policies for health care providers 
• Board/society of practice or Accreditation Council for Graduate Medical Education Medical education Conflict of Interest (ACGME) policies
• Hospital or institutional policies
• Department policies