Main Ethical Principles in Medicine

• Dr. Lamis Nader is the Assistant professor presenting about Main Ethical principals on March 8, 2025

Objectives

• To identify the main ethical principles
• To apply the ethical principles in real case scenarios
• To explain the conflict between autonomy and beneficence
• To recognize the importance of medical confidentiality
• To know in which situations confidentiality could be breached

Ethical Principles

• Beneficence: A practitioner should act in the patient's best interest.
• Non-maleficence: To do no harm to the patient.
• Autonomy: The patient is free to decide.
• Justice: There is fairness and equality.

Beneficence

• It is defined as the duty of the physician to benefit the patient and to prevent and remove harm
• The physician should do only what benefits the patient
• Patient's welfare is the first consideration
• Provide patients with benefits of the treatment and balance benefits against harm
• Weigh the chance of success against costs and risk
• It should apply to individual patients by curing their diseases and promoting their health, and to society by preventing diseases through research and vaccination

Pharmaceutical Marketing

• Doctors can be influenced by drug company inducements such as gifts, food, and trips
• Industry-sponsored Continuing Medical Education programs influence prescribing patterns
• Patients believe that physician gifts from drug companies influence prescribing practices
• A movement to diminish the influence of pharmaceutical industry marketing exists among physicians
• Stanford University banned drug company-sponsored lunches and gifts
• Other academic institutions have also banned pharmaceutical industry-sponsored gifts and food

Sexual Relationships

• Sexual relationships between doctors and patients can create ethical conflicts
• Sexual consent may conflict with the physician's fiduciary responsibility
• Doctors who enter into sexual relationships with patients face the threats of losing their medical license and prosecution

Non-Maleficence

• Defined as the duty of the physician to avoid inflicting physical or emotional harm on the patient or increasing the risk of such harm.
• Some writers state that non-maleficence should be re-defined to balance the benefit (beneficence) against the harm of any specific action.

Autonomy

• Requires that the patient have autonomy of thought, intention, and action when making decisions regarding health care procedures
• The decision-making process must be free of any influence
• A patient must understand all risks and benefits of the procedure and the likelihood of success to make a fully informed decision

Informed Consent

• The principle of autonomy involves informed consent, protection of privacy, and confidentiality
• The regulatory procedures allow participants to express their free will with respect to the various dimensions of the research.
• Free will includes the risks/benefits, alternative treatments, exit procedures, study objectives, conflicts of interests, affiliations, and funding sources
• Elements of consent include name of patient, purpose of disclosure, how much and what kind of information to be disclosed, patient’s signature, date of signature, date when the consent will automatically expire, and a statement that the consent may be revoked
• Children and individuals with special needs are generally unable to give free informed consent and require special protections

Conflict Between Autonomy and Beneficence

• Autonomy can conflict with beneficence when patients disagree with recommendations that healthcare professionals believe are in the patient's best interest
• Different societies approach this matter in different ways
• Western medicine often defers to the wishes of a mentally competent patient to make their own decisions, even when the medical team believes they are not acting in their own best interests
• Many other societies prioritize beneficence over autonomy
• Examples include when a patient does not want a treatment due to religious or cultural views or wants euthanasia
• It can also include when a patient wants unnecessary treatment, as with cosmetic surgery
• The practitioner may be required to balance the desires of the patient for medically unnecessary potential risks against the patient's informed autonomy in the issue
• A doctor may want to prefer autonomy because refusal to serve the patient's self-determination would harm the doctor-patient relationship

Justice

• There are three elements to justice:
  • Distributive: Fair distribution of limited healthcare resources
  • Rights-based: Respect for people's rights, such as prohibition of discrimination
  • Legal: Respect for the law
• The right to be treated equally and equal access to treatment, can be found in many constitutions
• Factors that influence actual access to treatment include age, place of residence, social status, ethnic background, culture, sexual preferences, disability, legal capacity, hospital budgets, insurance coverage, and prognosis
• Some people are not treated with the same degree of respect as that accorded to others when providing care
• Such attitudes, prejudice, and discrimination may reflect the stigmatization of people belonging to groups identified and devalued on the basis of a particular attribute, such as dementia

Reviewing Ethics and Common Controversies in Medicine

• Ethical principles are useful in theory, but their application is more complex
• Each situation is different, and ethical issues in medicine should be approached on a case-by-case basis
• Some common controversies and how principles of medical ethics apply:
  • Abortion: Autonomy and non-maleficence come into conflict in this issue by seeking to achieve how much right does a woman have over her body, and how does that right balance with the rights of the fetus?
  • Physician assisted suicide: The questions addressed with this ethical issue address the dilemma of whether or not it is right to deny a patient's request if we respect autonomy, and whether or not doctors, traditionally committed to prolonging life, should be involved in assisted suicide
  • Conflicts of interest: For informed consent and patient autonomy to mean something, providers must tell patients what matters to their decision, including the potential for conflicts of interest, such as provider relationships with drug companies
  • Confidentiality: All four principles play a part in the issue of keeping a patient's medical information confidential in the electronic age and determining when/to whom the confidentiality can be breached
  • Healthcare rationing: Addresses how to fairly allocate limited healthcare resources to as many people as possible, without limiting resources to those who currently have them, and reaching a bare minimum level of care for all
  • Stem cell and genetic research: The questions to be answered here seek at balancing beneficence and justice if embryos must be destroyed to perhaps find cures for devastating diseases, whether or not patient know everything there is to know about his health and potential health risks, and the possibility of whether the research can be harmful to some in order to benefit many?

The Moral Context of the Doctor-Patient Relationship

• Honesty and integrity
• Mutual respect
• Trust
• Empathy
• Mutual goals

Hippocratic Oath

• "Whatsoever things I see or hear, concerning the life of men, in my attendance on the sick ... I will keep silence thereon, counting such things to be as sacred secrets."

Medical Confidentiality

• Physicians have no right to disclose any secret concerning their patients
• Publication of patients' names or photographs in scientific journals is considered a disclosure of secrecy
• Medical professionals must keep the professional secrecy; The hospital papers, prescriptions, and laboratory reports must be kept away from non-responsible persons

Medical Confidentiality - Exceptions for Disclosure

• With the consent of the patient
• For the sake of the patient
• For the sake of the public
• For the sake of the physician
• If the physician is called by the court as an expert witness
• To other doctors

Breach of Medical Confidentiality with Patient Consent

• This would be needed if the patient asks for a certificate
• Information contained in a patient's medical record can be released to third parties only if the patient has consented
• The patient's authorization is required before the medical records can be released to the following parties: patient's attorney or insurance company, patient's employer (unless a worker's compensation claim is involved), member of the patient's family, government agencies

Disclosure of Medical Confidentiality for the Sake of the Patient

• Caution is required over the disclosure of sexual matters like pregnancy, abortion, or venereal diseases as they might cause severe conflict between close relatives like husband and wife

Disclosure for the Sake of the Public

• If it is necessary to protect the community from a dangerous disease or crimes
• Infections and quarantinable diseases should be notified to the proper authorities such as Health office and Ministry of Health

Disclosure for the Sake of the Physician

• If the physician is accused of malpractice, they may write a report and give it to the court to avoid disclosure
• If the physician is called by the court as an expert witness

Disclosure to Other Doctors

• It is allowed for a doctor to disclose the medical facts of a case with other doctors as well as non-medical health staff, such as physiotherapists, radiologists, and nurses, because it is thought that it offers added benefit to the patient

HIPAA

• The Health Insurance Portability and Accountability Act of 1996 mandates that federal laws or regulations ensure the confidentiality of medical records
• Patients or representatives should have access to all records except in two cases:
  • The provider feels that it is not in the best interest of the patient's health to have access
  • If the knowledge of the health care information could cause danger to the life or safety of any person