Ethical vs. legal. This arena is possibly the most hotly debated in recent history. The landmark 1973 Roe v. Wade Supreme Court ruling legalizing abortion in the United States is a prime example of this type of conflict. Although abortion is considered legal in this country, whether or not it is ethical (or moral) will likely always be debated.

Informed consent. Most providers would not dream of performing a procedure or even prescribing a medication without explaining the elements of informed consent. In cases in which a patient is incapable of giving consent, things become very convoluted and murky. In recent history, the Nancy Cruzan and Terri Schiavo cases clearly exemplify the quandary of informed consent. When patient autonomy is invalidated, extreme care must be taken to adequately sort out what might have been the patient’s wishes.

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From a practical standpoint, the more parties involved in an ethical issue, the more complex the questions become — especially when those parties are actual systems.

Beidler proposed a system for classifying ethical deliberations based on the parties involved and the complexity of those entities:7

Level 1 consists of the provider and the patient as the sole stakeholders. Direct communication is the norm, with each individual holding equal power in the decision-making process.

Level 2 places the provider and the patient together as one stakeholder working with an entire system. This implies that the patient and provider must negotiate the issue while working with a larger more complex system to reach a resolution.

Level 3 involves the provider and the patient working within multiple systems. Depending on the ethical question involved in these instances, the resolution process can become exponentially more protracted since the entities may have opposing opinions.

Ethics by committee

In addition to determining a personal ethical code and thought process, ethical consultation committees are becoming more common in the United States. Although such regulatory agencies as the Joint Commission on Accreditation for Healthcare Organizations do not require medical institutions to utilize such committees, some individual health systems—including the Veterans Health Administration—have established this mandate for their facilities.8,9 Most health-care institutions have a formal system for seeking input from a group of experts. Private practices often are able to access a community ethics council for assistance.

A step-by-step approach

The ethical process can be broken down into seven steps:

Define the true issue.Define the actual players.Identify the existing legal/regulatory input.Assess the availability of autonomy.Define the balance of beneficence and non-malfeasance.Determine the anticipated level of justice/distribution of resources.Decide a course of action (or inaction).

To more fully illustrate this chain of events and the stakeholder levels described earlier, consider the following case studies.


Ms. A, a 32-year-old single woman, has a severe mental illness and a history of multiple suicide attempts, but she functions independently in society. After a routine annual exam, her provider reported that she had a significantly abnormal Pap test and would need further examination. After a moment’s pause, Ms. A stated that she would not pursue further workup. “It doesn’t matter,” was her response, “Death would be a relief.”

Level 1 issue

Issue: Refusal of care for potentially fatal condition

Players: Patient and provider

Existing regulations/law: Patient considered legally competent

Autonomy: Patient’s right of refusal remains intact

Balance: For provider to honor wishes, negative impact assured

Justice: Dying of cervical cancer known to be painful, protracted, and costly to patient and system(s).

Course of action: With the patient’s consent, the provider consulted with Ms. A’s psychiatrist, who talked her through the issue. The patient agreed to treatment with the stipulation that her psychiatrist be present during the appointments.