Navigating ethics in a health-care setting
The field of medical ethics was developed primarily for the benefit of the patient.
Ethics is a subject that is as broad and deep as it is complex. Few topics create such a sense of "dis-ease" among health-care professionals. This discomfort is usually attributable to the lack of a clear-cut direction in a given situation. Rather than dealing with the rights and wrongs of a subject, ethics deals with the shoulds and oughts.
Many different philosophies exist regarding ethics, and the terminologies and concepts are far too numerous to discuss here. While resolving an ethical dilemma is unlikely to appease all parties, there are several clear theoretical methodologies available for reaching a decision. This discussion will review several of the critical ideologies of ethical decision-making and how they might be applied in a provider's daily practice.
The history of ethics in health care
Medical ethics is not new. While the technologies available to health-care professionals have advanced dramatically over the years, the basics remain unchanged. Possibly the first documentation of the concept of medical ethics is found in the Hippocratic Oath, which states, "I will benefit my patients according to my greatest ability and judgment, and I will do no harm or injustice to them."1 In a more modern rendition of the oath, Louis Lasagna, dean of the School of Medicine at Tufts University, wrote, "I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism."2
Autonomy. Obviously, autonomy is a concept that can be found in many different venues. In the field of health care, however, autonomy traditionally implies that patients have the right to decide for themselves what treatment they will or will not accept. This seemingly simple concept becomes extremely complex in modern medicine with the insertion of such issues as informed consent, advance directives, and care of minors and the mentally ill.
Beneficence and non-malfeasance. These two principles are the balancing guides in health care. Beneficence means "benefit the patient," and non-malfeasance means "do no harm." Taken together, these terms represent the idea that clinicians should strive to "seek the greater balance of good over harm."3
Justice. As thorny as the previous concepts may become in complex health-care issues, justice is even more difficult to achieve. Also referred to as distributive justice or fair processes and outcomes, the idea of justice refers to the distribution of benefits and burdens, typically within society.4 To many Americans, this brings to mind the current debate regarding universal health coverage mandated by a central authority vs. independent management by the patient, employer, or other entity. The debate over allocation of scarce resources, often used when discussing such topics as organ transplantation, falls into this area of justice as well.
The language of ethics
A clear understanding of the nomenclature is required before any discussion of ethical guidelines can occur (Table 1). In the realm of ethics, an issue is defined as a situation that is highlighted by an uncomfortable or disturbing emotional response.5 Clinicians frequently encounter situations that require a considerable amount of discussion and fact-finding to simply identify the actual issue at hand.
Many times, a problem reaches the level of dilemma, defined as "an argument necessitating a choice between equally favorable or disagreeable alternatives; any situation in which one must choose between unpleasant alternatives."5 To put it more simply, in a dilemma, there appears to be no good answer.
Finally, a conflict is considered a mismatch between the available options and the provider's own opinion.5 For instance, the available information may indicate that a certain patient is terminally ill and a candidate for hospice care. But the provider has known this patient for many years and is very reluctant to make that decision. Aside from discussions of professional detachment and similar issues, the provider has a personal conflict regarding the available choices for this patient. Other major factors in conflicts include religion, family decisions, and regulatory or legal mandates.
Types of issues
Ethical vs. moral vs. value. Just because something has value does not make it moral, and something seen as moral is not necessarily ethical.6 Clinicians need to define where the question lies. In modern society, monetary value frequently takes precedence over everything else. If a medication is too expensive, the reality that the patient might die without it seems neither moral nor ethical but may nonetheless represent reality.