Core Ethical Principles in Healthcare

Core Ethical Principles

• The main ethical principles, including beneficence, nonmaleficence, autonomy, and justice, are explored.
• Autonomy serves as the foundation for informed consent, truth-telling, and confidentiality in healthcare.
• Conflicts among ethical principles can arise, and a model for their resolution is presented.
• Cases that illustrate ethical dilemmas and their resolutions are highlighted.
• It includes a patient care model emphasizing ethics, professionalism, and physician expertise.

Abstract Overview

• An overview of ethics and clinical ethics is provided.
• Beneficence, nonmaleficence, autonomy, and justice, the 4 main ethical principles, are defined.
• Informed consent, truth-telling, and confidentiality stem from autonomy.
• Conflicts can occur between ethical principles, especially beneficence and autonomy.
• A systematic approach to ethical problem-solving, along with illustrative cases, is included.
• A patient care model is presented, integrating ethics and professionalism with clinical and technical expertise.

Introduction to Ethics in Medicine

• Physicians routinely make patient care decisions in various settings.
• These decisions go beyond selecting treatments or interventions.
• Ethics is integral to clinical medicine, as physicians must benefit patients, minimize harm, and respect patient values.
• Educational programs enhance ethical awareness, attitudes, knowledge, reasoning, and confidence.

Ethics, Morality, and Professional Standards

• Ethics encompasses moral nature and moral choices.
• Normative ethics seeks general moral norms for guidance.
• These norms transcend cultures and form common morality like not killing, stealing, etc.
• Societies have particular moralities based on culture, religion and profession.
• A physician's role is to provide competent, trustworthy service.
• Physician organizations codify standards, although these may prioritize professional interests over broader concerns.

Bioethics Evolution

• Bioethics evolved from professional conduct concerns, to research ethics, public health, organizational and clinical ethics.

Clinical Ethics Principles

• Ethics, as a term, is used to refer to the principles of clinical ethics and their application.
• Beneficence, nonmaleficence, autonomy, and justice are the four fundamental principles of ethics.
• The first two trace back to Hippocrates, while the latter two evolved later.
• Autonomy and justice have become accepted principles of ethics over time.
• Beauchamp and Childress' book on Principles of Biomedical Ethics is a classic exposition.

Principle of Beneficence

• Beneficence is the obligation to act for the patient's benefit, protecting rights, preventing harm, helping persons with disabilities, and rescue.
• It involves positive requirements, not just avoiding harm, but also promoting patient welfare.
• Beneficence is altruistic and can be seen as repaying society for education and privileges.

Principle of Nonmaleficence

• Nonmaleficence is the obligation not to harm the patient, supporting rules such as don't kill, cause pain, incapacitate, or deprive of goods.
• Weighing benefits against burdens is crucial in applying nonmaleficence.
• It's important in end-of-life care for withholding treatment.

Principle of Autonomy

• Philosophical basis: all persons have intrinsic worth and should make decisions.
• Autonomy was affirmed in a 1914 court decision by Justice Cardozo.
• Autonomy is weighed against other principles and can be overridden if it causes harm.
• The principle doesn't extend to those lacking capacity like infants or those with mental disorders.
• Health-care institutions assess incompetence.
• Relational autonomy broadens the concept beyond the individual.
• Some cultures have conflicting views.

Cultural Sensitivity and Patient Autonomy

• Resistance to patient autonomy exists in non-Western cultures.
• Paternalism often stems from beneficence
• Cultural beliefs can be static and autonomous
• Critical examination is needed due to technological and socioeconomic changes
• Respecting autonomy requires disclosing information for self-determination, informed consent, truth-telling, and confidentiality.

Essential Components of Informed Consent

• Requirements include the patient must be competent, fully informed, comprehend, act voluntarily, and consent to the proposed action.
• Its universal applicability, rooted in Western culture, faces resistance.
• A core of human rights is needed, regardless of local laws.
• Self-determination is a fundamental right.

Assessing Competence for Informed Consent

• The accepted standards include the inability to state a preference, to understand their situation and its consequences, and to reason through a decision.
• Previously expressed preferences are respected in an incompetent patient.
• Incompetent patients require a surrogate decision-maker, using either substituted judgment or best interests standards.
• "Substituted interests" can base decisions when patient preferences are not known.

Importance of Truth-Telling

• Truth-telling is a vital component in a physician-patient relationship.
• Patients have the right to know and forgo disclosure of their diagnosis and prognosis.
• Full disclosure is now the norm in the United States.
• Shifts are due to progress, accountability, and awareness of past transgressions.
• Patients with cancer want full information.
• Consequences of withholding can deprive the patient of important life-task opportunities.
• In non-Western societies, information is disclosed to family.

Confidentiality

• Physicians must not disclose patient information without authorization.
• Exceptions include sharing necessary information with healthcare teams.
• Electronic records led to an erosion of confidentiality.
• Physicians must practice discipline in discussing patient information.
• Exceptions to confidentiality include gunshot wounds or epidemics.

Understanding Justice Principal

• Justice means fair, equitable treatment.
• Distributive justice, of several types of justice, is most pertinent to clinical ethics.
• Its objective is fair resource distribution under social cooperation terms.
• Valid principles involve equal share, need, effort, contribution, merit, and free-market exchanges.

Medical Resource Distribution

• Difficulties arise in choosing principles for medical resource distribution.
• Examples include scarce resources, uninsured patient care, and outpatient visit time.
• Physicians must accept fairness despite constraints.
• Conflicts of interest violate this principle.

Ethical Principles & their Conflicts

• Conflicts arise, and physicians must determine obligations based on content and context.
• Beneficence can override nonmaleficence.
• Conflicts occur with life-saving interventions or end-of-life actions.

Navigating Beneficence and Autonomy

• Beneficence historically took precedence, but autonomy is now considered important.
• Paternalism, where physicians act like parents, can be soft or hard.
• Soft paternalism relates to non-autonomous patients and is ethically defensible.
• Hard paternalism acts against autonomous patients and is ethically indefensible.
• Consumerism allows the patient selects from available medical interventions but it is ethically indefensible.
• The physician should use clinical judgement and skills to advocate for the patient and treatment.
• Pellegrino and Thomasma argue beneficence includes patient autonomy.
• Differing views on treatment goals cause disagreement between physician and patient.
• Clear communication helps to define goals.

Applying Ethical Principles

• A well-accepted model involves clinical assessment, patient preferences, QOL, and context
• It allows identification of conflicting principles, weighing of factors, and consultation of resources.

Clinical Cases Highlights

• Ethics is applied to real-world scenarios via multiple illustrative cases.
• Medical indications and patient preferences can be in conflict.
• Beneficence can take precedence over autonomy.
• Patient choices should be respected, but physicians must continue to provide advise.
• There are varying views on the term futility.

Real World Cases in Ethics

• Cultural values and patient preferences determine approaches to treatment and informing patients.
• Truth-telling and patient autonomy are crucial in cases of medical error.
• Scarce resources require allocation decisions which should not be emotional or arbitrary; it must be an ethically justified decision.

Scarce Resources in Healthcare

• A key decision is not to be based on social or wealth standing.
• Priorities are needed institutionally and nationally.
• Maximizing benefits is the main decision-making value and can be understood in different ways.

Resource Allocation - A key decision

• Instrumentality(Benefit to other) and illness severity are secondary considerations.
• During a pandemic, the burden should not lie on front-line professionals.
• Allocation decisions may be made by committee.
• Fairness in allocating scarce resources based on maximizing benefits & preference towards instrumental value remains questionable

Conclusion - Ethics in Medicine

• Ethics, professionalism, and desired physician virtues are essential.
• Professionalism involves competent, compassionate care and meets patient expectations.
• Professionalism requires prioritizing patient interests and advising on health.
• Envisions physicians with ethical and humanistic qualities alongside knowledge and skills.