Chapter 2: Overview of Ethical Guidelines

Intro

Introduction

Ethical dilemmas arise in clinical medicine because there are often sound reasons for conflicting courses of action. In resolving dilemmas, physicians need to refer to general ethical guidelines to inform their choices and justify their decisions. This chapter provides an overview of guidelines in clinical ethics. Subsequent chapters discuss them in detail and apply them to specific cases.

Respect for Persons

Treating patients with respect entails several ethical obligations. First, physicians must respect the medical decisions of persons who are autonomous [1]. The term autonomy literally means “self-rule.” Autonomous people act intentionally, are informed, and are free from interference and control by others. People should be allowed to shape their lives in accordance with their core values and free from unwanted bodily intrusion or touching. The concept of autonomy includes the ideas of self-determination, independence, and freedom. Doctors should promote patient autonomy, for example, by disclosing information and helping patients deliberate.

With regard to health care, autonomy justifies the doctrine of informed consent (see Chapter 3). Informed consent has several specific aspects. Informed, competent patients may refuse unwanted medical interventions, such as surgery and invasive procedures, and may choose among medically feasible alternatives. Important clinical choices need not involve a major bodily invasion, for instance, choices whether to have an electrocardiogram or choices among several drugs for a condition. Competent, informed patients have the right to make choices that conflict with the wishes of family members or the recommendations of their physicians.

A person’s autonomy is not absolute and may be justifiably restricted for several reasons. If a person is incapable of making informed decisions, trying to respect his or her autonomy might be less important than acting in his or her best interests. Autonomy might also be constrained by the needs of other individuals or society at large. A person is not free to act in ways that violate other people’s autonomy, harm others, or impose unfair claims on society’s resources.

A second meaning of respect for persons concerns patients who are not autonomous because their decision-making capacity is impaired by illness or medication. Physicians should still treat them as persons with individual characteristics, preferences, and values. Decisions should respect their preferences and values, so far as they are known. In addition, all patients, whether autonomous or not, should be treated with attention, dignity, and compassion.

Third, respect for persons requires physicians to avoid misrepresentation, maintain confidentiality, and keep promises. There are additional reasons for these other guidelines, as we will discuss.

Maintain Confidentiality

Maintaining the confidentiality of medical information respects patient privacy. It also encourages people to seek treatment and to discuss their problems frankly. In addition, confidentiality protects patients from harms that might occur if information about psychiatric illness, sexual preference, or alcohol or drug use were widely disseminated. Patients and the public expect physicians to keep medical information confidential. However, maintaining confidentiality is not an absolute duty. In some situations, physicians need to override confidentiality to protect third parties from harm (see Chapter 5).

Avoid Deception and Nondisclosure

Truth telling—avoiding lies—is a cornerstone of social interaction. If people cannot depend on others to tell the truth, no one will make agreements or contracts. Physicians might mislead patients without technically lying, for example, by giving partial information that is literally true but intended to mislead. Deception violates the autonomy of people who are deceived because it causes them to make decisions on the basis of false premises.

To cover these broader issues, this book uses the term “deception” rather than “lying.” In addition, physicians sometimes withhold information about their diagnosis or prognosis from patients. Doctors may do so to protect patients from bad news. However, patients cannot make informed decisions about their medical care if they do not receive all pertinent information about their condition.

Keep Promises

Promises generate expectations in other people, who, in turn, modify their plans on the assumption that promises will be kept. The very concept of promises is undermined if people are free to break them. It is unfair for someone to expect others to honor their promises, but to break his or her own. Keeping promises also enhances trust in both the individual physician and the medical profession. Furthermore, promises relieve patients’ anxiety about the future by providing reassurance that doctors will not abandon them.

Act in the Best Interests of Patients

The guideline of nonmaleficence, or “do no harm,” forbids physicians from providing ineffective therapies or from acting selfishly or maliciously [2], [3]. This oft-cited precept, however, provides only limited guidance, because many beneficial interventions also entail serious risks and side effects. Literally doing no harm would preclude risky treatments such as surgery and cancer chemotherapy.

The guideline of beneficence requires physicians to provide a net benefit to patients: the benefits of an intervention must outweigh the burdens and be proportionate (see Chapter 4). Because patients do not possess medical expertise and might be vulnerable because of illnesses, they rely on physicians to provide sound advice and to promote their well-being. Physicians encourage such trust. For these reasons, physicians have a fiduciary duty to act in the best interests of their patients.

Unwise Decisions by Patients

Acting in patients’ best interests might conflict with respecting their informed choices, as when patients’ refusals of care might thwart their own goals or cause them serious harm. Simply accepting such refusals, in the name of respecting autonomy, would be highly problematic. Physicians should listen to patients, educate them, and try to persuade them to accept beneficial treatment, or negotiate a mutually acceptable compromise. If disagreements persist, the patient’s informed choices and judgment of his best interests should prevail.

Patients Who Lack Decision-Making Capacity

The choices and preferences of many patients who lack decision-making capacity are unknown or unclear. In this situation, respecting autonomy is not pertinent. Instead, physicians should be guided by the patient’s best interests (see Chapter 4).

Conflicts of Interest

Physicians should act in the patient’s best interests rather than in their own self-interest when conflicts of interest occur (see Chapter 29, 30, 31, 32, 33, 34, 35, 36). Patients trust their physicians to act on their behalf and feel betrayed if that trust is abused. When considering whether or not a conflict of interest exists, physicians should consider how patients, the public, and colleagues would react if they knew about the situation. Even the appearance of a conflict of interest might damage trust in the individual physician and in the profession.

Allocate Resources Justly

The term justice is used in a general sense to mean fairness—that is, people should get what they deserve. People who are similar in ethically relevant respects should be treated similarly, and people who differ in ethically significant ways should be treated differently. Otherwise, decisions would be arbitrary and biased. To make this formal statement of justice operational, the physician would need to specify what counts as an ethically relevant distinction and what it means to treat people similarly.

In health care settings, “justice” also refers to the allocation of health care resources. Allocation decisions are unavoidable because resources are limited and could be spent on other social goods, such as education or the environment, instead of on health care. Ideally, allocation decisions should be made as public policy and set by legislatures or government officials, according to appropriate procedures. Physicians should participate in public debates about allocation and help set policies.

In general, however, rationing medical care at the bedside should be avoided because it might be inconsistent, discriminatory, and ineffective. At the bedside, physicians usually should act as patient advocates within constraints set by society and sound clinical practice (see Chapter 30). In some cases, however, two patients might compete for the same limited resources, such as physician time or a bed in intensive care. When this occurs, physicians should ration their time and resources according to patients’ medical needs and the probability and degree of benefit.

The Use of Ethical Guidelines

Having summarized guidelines for clinical ethics, we next discuss how physicians should use them in specific cases. This book uses the term guidelines to connote that ethical generalizations cannot be mechanically or rigidly applied but need to be used with discretion and judgment in the circumstances of a particular case. Guidelines are derived from decisions made in previous cases and from moral theories [4], [5]. In turn, guidelines shape decisions in similar cases in the future. Guidelines might be difficult to apply in new cases for several reasons.

Guidelines Need to Be Interpreted in the Context of Specific Cases

The meaning or force of a guideline might not be clear in a particular case. Uncertainty and case-by-case variation are inherent in clinical medicine. Furthermore, patients have different priorities and goals for care. A crucial issue is whether the case to be decided can be distinguished in ethically meaningful ways from previous cases to which the guideline was applied. Unforeseen or novel cases might point out the shortcomings of an existing guideline and suggest that it needs to be modified or an exception made.

Exceptions to Guidelines Might Be Appropriate

Guidelines are not absolute. A particular case might have distinctive features that justify making an exception to a guideline [4]. To ensure fairness, physicians who make an exception to a guideline should justify their decisions. The justification should apply not only to the specific case under consideration, but also to all similar cases faced by other physicians. Guidelines are stronger than rules of thumb that provide advice but are not binding.

Many philosophers regard ethical guidelines as prima facie binding: they should be followed unless they conflict with stronger obligations or guidelines or unless there are compelling reasons to make an exception [5]. The burden of argument is on those who claim that an exception to the guideline is warranted. Furthermore, when prima facie guidelines are overridden, they are not simply ignored. People often experience regret or even remorse that guidelines are being broken. Thus, people should minimize the extent to which prima facie guidelines are violated and mitigate the adverse consequences of doing so.

Different Guidelines Might Conflict

In many situations, following one ethical guideline would require the physician to compromise another guideline. Respecting a patient’s refusal of treatment might clash with acting in the patient’s best interests. Maintaining confidentiality might conflict with protecting third parties from harm. Allocating resources equitably might conflict with doing what is best for an individual patient.

The practice of medicine would be much easier if there were a fixed hierarchy of ethical guidelines; for example, if patient autonomy always took priority over beneficence. Life is not so simple, however. In some clinical situations, respecting a patient’s wishes should be paramount, whereas in others, a patient’s best interests should prevail. Physicians need to understand why an ethical guideline should take priority in one situation but not in others.

The ability to make prudent decisions in specific situations has been described as discernment or practical wisdom. Discernment involves an understanding of how ethical guidelines are relevant in a variety of situations and to the particular case at hand [6].