Year : 2002 | Volume
: 3 | Issue : 2 | Page : 11-
An overview of clinical ethics
Horacio F Zaglul
University of Kentucky Chandler Medical Center Children's Hospital, Lexington, Kentucky, USA
Horacio F Zaglul
University of Kentucky Chandler Medical Center, Children«SQ»s Hospital, 800 Rose Street, Room MN 464A Lexington, KY 40536-0298
Advances in clinical medicine, variable economic environment with increasing emphasis in cost-containment, and social and cross-cultural influences have brought significant changes to the way health care is delivered and medicine is practiced. In this evolving and complex environment, ethical dilemmas perplex physicians. Clinical ethics help us identify those ethical dilemmas and appropriately respond to them. What follows is an overview of clinical ethics, with a brief discussion of the basic theories and principles involved, and summary information needed to provide comprehensive, ethical, patient-centered care. The overview finishes with a list of important references for those who wish to pursue further a given subject.
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Zaglul HF. An overview of clinical ethics.Heart Views 2002;3:11-11
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Zaglul HF. An overview of clinical ethics. Heart Views [serial online] 2002 [cited 2022 Sep 30 ];3:11-11
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No country today is so isolated from the rest of the world that it can remain immune to cross-cultural influences. Cultural pluralism poses a challenge to physicians and patients alike. Philosophers, anthropologists, ethicists debate whether there are universal ethical precepts. Defenders of "Cultural and Ethical Relativism" sustain that "context is everything" and what is right or wrong can be determined only by the beliefs and practices within a particular culture, tradition, or religion. If ethical relativism is absolutely true, we have no choice but to be nonjudgmental. There are, however, events or actions that prompt universal condemnation (example: ethnic cleansing), as demonstration that it is possible to analyze individual conduct by seeing how they conform to fundamental ethical principles. These principles are seen by the supporters of "Ethical Universalis" as the road to moral progress, improvements in our customs, laws and social institutions, and sustain that without ethical justification our judgment would be arbitrary, if not capricious  . A universal set of ethical norms has not yet been agreed upon. To complicate matters, common sense, clinical experience, integrity, and good intentions do not always guarantee an appropriate response to ethical problems  . Moral dilemmas are circumstances in which moral obligations demand or appear to demand that a person adopt each of two (or more) alternative actions, yet the person cannot perform all the required alternatives  . Modern clinical ethics is more concerned with the moral dilemmas that confront all health care professionals than a deep discussion of the philosophy of virtues and values, as existed several decades ago. The following discussion will take the reader through 1) the distinction between morals and ethics, with a brief discussion of the basic theories and principles involved, 2) basic ethical obligations and common issues in clinical ethics, 3) methodology of work, how to approach an ethical problem. This overview does not depend on particular religious commitments and respects the contribution that religious traditions and thought have made to medical humanities.
Distinction between morals and ethics Clinical ethics
Reflections on the patient-doctor relationship can be found in major ancient, medieval, and modern writings[Table 1]. Although the terms ethics and morality are often used interchangeably, it is useful to distinguish between them ,, . "Ethics" comes from the Greek "ethos", meaning "disposition" or "character." Ethics is a generic term for various ways of understanding and examining the moral life  . The study of ethics is critical, analytic, and interpretative, as it is pragmatic. Ethics is a practical discipline, in that it deals with real-world problems and practices. It produces reflective and critical judgments about acts and beliefs  . Ethics is very close to the law: both try to establish a guide of conduct, but ethics concentrates on the values on which the behavior is based; the law tries to define the basic behavior that is in accordance with known societal values. Although the interaction with the law is dynamic, ethics projects beyond the law. "Morals" comes from the Latin "moralis": what belongs or relates to the actions or character of persons, from the point of view of good or bad. Emphasis is in character, customs, or habits and traditions that prevail in a particular culture. Moral disagreements and controversies can result in a wide range of actions: from one group morality to be imposed on others or -at the other extreme- absolute tolerance to cultural differences and noninterference in the moral lives of others. Ethics, however, means both to understand and to critique particular moralities when necessary. For those readers interested in a deep discussion on the subject and in learning how ethics can illuminate problems in health care, I recommend consulting the books by Drs. Beauchamp and Childrens  and Drs. Fletcher Lombardo, Marshall, and Miller .
Ethics can further be divided into
Social Ethics: ethical analysis applied to social groups.
Professional Ethics: ethical analysis applied to a profession, i.e. Medical Ethics. It refers to those rules of conduct established by formal bodies (i.e. the medical profession)  . Medical Ethics gained formal recognition in the U.S.A. with the founding of the Hastings Center in 1969, and the Kennedy Institute of Ethics in 1971. Today, the AMA Principles of Medical Ethics and the Current Opinions of the Council on Ethical and Judicial Affairs constitute the primary compendium of medical professional value statements in the USA .
Bioethics: ethical analysis applied to the life sciences including health care, research, care of animals, and the biological environment,
Clinical Ethics: "It is ethics at the bedside"… "a bridge between theoretical bioethics and the bedside"  ."Is an interdisciplinary activity (intended) to identify, analyze, and resolve ethical problems that arise in the care of particular patients. The major thrust of clinical ethics is to work for outcomes that best serve the interests and welfare of patients and their families."  Clinical ethics have certain peculiarities: 1) it provides a clinical service, 2) makes case revisions, 3) participates in the education of hospital staff and the community, 4) is very active in advanced education, 5) formulates and critiques health care norms  , 6) researches issues of concern to clinicians, patients, and societies. The place of clinical ethics as a bridge between society, the clinical world, and the theoretical disciplines of bioethics and medical humanities, has been defined by Dr. Fletchers and collaborators  and graphically depicted in [Figure 1]. The philosophical theoretical bases for biomedical ethics are many. Some of them lead to similar virtues and actions, but none can be named as the most satisfactory theory.
The most frequently cited are the following:
Duty-based ethics: Identified with the German philosopher Immanuel Kant (1724-1804). There are immutable rules or principles to follow: we must act not only in accordance with but also for the sake of obligation. The moral worth of our actions depends exclusively on the moral acceptability of the rule of obligation on which the person acts.
Consequence-based theories (i.e. Utilitarism): Identified mostly with Jeremy Bentham (1748-1832), John Locke (1632-1704), and John Stuart Mill (1806-1873). Actions or policies are morally evaluated according to the extent to which they promote happiness or well-being. Here, results are most important: the right act is the one that produces the best overall result (Careful! Ends may justify the means!).
Liberal Individualism: personal rights-based theory. Society must protect individual basic liberties and interests (i.e. life, liberty, expression, and property). Statements of rights protect against oppression, unequal treatment, intolerance, and arbitrary invasion of privacy.
Communitarianism or Community-Based theory: Everything derives from communal values, social goals, and the common good. People are expected to behave in conformity with social traditions, with its communal goods, codes, and virtues. Issues regarding how much control the community exercises divide communitarianism into militant and moderate forms.
Ethics of care: Relationship-based accounts. Emphasis is placed on traits valued in intimate personal relationships, such as love, sympathy, compassion, fidelity, and discernment. Focus is on care, responsibility, trust, fidelity, and sensitivity.
Virtue (character of actor is most important). Character develops via learning and experience
Aristotle, 384-322 BCE). Many virtues are important to the health professional, but five have been established as "focal virtues": compassion, discernment, trustworthiness, integrity, and conscientiousness.
Religion and ethics
In pluralistic societies, contemporary clinical ethics is essentially a secular discipline. However, religion plays a leading role in deliberating on moral dilemmas in the clinical setting. Religious considerations at least occupy the following places: 1) competent adult patients are entitled to have their own religious beliefs respected, so long as those beliefs do not unduly restrict or compromise the beliefs of anyone else, including those of health care professionals; 2) various religions can be sources of wisdom in territory uncharted by secular society, even if the religion that is the source of this wisdom is not one to which an individual might subscribe; 3) the role of systematic religious beliefs in clinical ethics should be distinguished from that of spirituality. Individuals may have deeply held spiritual values or attitudes that affect their health care decisions without subscribing to a faith tradition .
Ethical Obligations and issues in clinical ethics
The moral dilemmas, which is learning how to frame and/or project the issues as ethical problems. In order to do this, we should understand the language and the accepted methods for approaching an ethical dilemma. Confronted with an ethical problem, we appeal to certain bases for the analysis of the ethical issues.
These bases are:
shape the clinician's basic obligations to patients. Four ethical principles are relevant: Beneficence: The obligation to benefit patients by sustaining life, treating illness, and relieving pain. It might be extended to further the patient's welfare and interests. It implies taking action by helping. Nonmalificence: The obligation not to inflict harm on others, to prevent harm or, if risk of harm must be taken, to minimize those risks. It requires intentionally refraining from actions that cause harm; Autonomy: The human capacity for self-rule or self-determination  . The capacity to act intentionally, with understanding, and without controlling influences (USA). The capacity of human reason to impose absolute moral laws upon itself (Europe). "Capacity" is the appropriate moral concern; "competence" is the legal term. The "value" accorded to the individual person varies from one society or culture to the other. Some societies place the interest of the community over the interest of the individual person; in others the individual "reigns supreme", making autonomy the most prominent value in the field of medical ethics (i.e. USA). Respect for persons does not necessarily imply granting decision-making autonomy to those persons (i.e. China) Justice: Fair, equitable, and appropriate treatment in accordance to the medical need. Fairness also involves equal access to health care and issues of rationing at the bedside (allocation of medical resources.) Ethical judgments rely on these fundamental principles. They serve as a yardstick for measuring the behavior of individuals and groups. Moral dilemmas are ranked based on which ethical principle(s) is (are) involved. However, there is no universal agreement regarding the relative importance of the ethical principles. In the United States, autonomy is the highest-ranking ethical principle, whereas in Cuba, for example, justice and equal access to health care ranks first.
Case based analysis (Casuistry)
"The answer lies in the specifics." Although this basis is analogical, contributing with "paradigm cases"  , it is difficult to apply systematically to ethical problems. Individual cases may be so complex that ethical decisions based on previous cases cannot be applied.
Mediterranean bioethics emphasizes virtues rather than rights (i.e. trustworthiness is more crucial to patients than the right to information). Emphasis is on character, the actor not the act is the determining factor (technical competence, objectivity and detachment, clinical benevolence, humility, practical wisdom, courage); traditional attention to "caring."
Pragmatism (whatever works)
Uses parts of other methods if they will enhance the process of reaching a solution. Some clinicians might see medical ethics as unnecessary, unhelpful, or even counterproductive. Dr. Lo produced a colorful discussion on skepticism about clinical ethics  . It can be summarized as follows: 1. "Ethics is a matter of character." Doing right and wrong is a matter of the clinicians' character. From this perspective, studying ethical issues offers few benefits. 2. "Only unethical persons have ethical problems." Clinical ethics deals with situations in which there are reasons both for and against a course of action. Decisions here are difficult because ethical guidelines conflict and people of integrity and good will may disagree over what to do. To acknowledge that such ethical issues are difficult demonstrates realism and courage, not moral failing. 3. "Ethics is being a good person, not a system of rules." But being a good person is neither necessary nor sufficient for appropriate action. 4. "By the time you're a doctor, your ethics are set", "Ethics is following the Hippocratic Oath." Although professional oaths and codes present rules for behavior, they are unilateral declarations by physicians without input from patients and the public. The Hippocratic tradition is at least highly paternalistic, granting patients little role in making decisions. Finally, traditional codes of conduct could not anticipate modern ethical issues. 5. "We already know how to handle ethical issues." "Ethics is common sense and clinical experience". Ethical dilemmas in modern medicine can be so complicated that experienced physicians may be perplexed or may disagree over what to do. 6. "Ethics is following the law." The law may be an inadequate guide for resolving ethical issues in clinical practice. Most of the time it sets only a minimally acceptable standard of conduct, provides no clear guide to action, and may even conflict with ethics. 7. "Every case is unique, so guidelines are impossible." Physicians often make decisions on a case-by-case basis. But it is important to act consistently in cases that are similar in all ethically relevant respects. Otherwise, decisions would be arbitrary, biased, and unfair. 8. "Ethics is merely personal belief." However, everyday experience shows that people can be persuaded by convincing arguments and that individuals with widely different worldviews can agree in specific cases.
Is clinical ethics useful?
Clinical ethics can help patients and clinicians. Reading about clinical ethics sheds light in the identification and analysis of ethical problems. By acknowledging that a problem exists, by making an effort to understand the patient's perspective, we start working towards conflict resolution, eventually negotiating mutually acceptable grounds for continued care. At the minimum, it improves communication and can serve as a motivation for the provision of emotional support. Moreover, learning about ethics can teach us how to practice ethics preventively, rather than just conduct "crisis management." Ethical discussions can also serve to better document the rationale for medical decisions. As a clinician, I can testify to the extent to which ethical discussions have helped the individuals involved in the decision making process to feel more comfortable with their decisions, particularly with the complexity of modern ethical subjects [Table 2]
Access to "ethics advice" is becoming a standard of care issue. A Hospital Ethics Program can be formed to provide: a) an ethics committee, the forum or institutional base for a comprehensive ethics program; b) ethics education for staff and community; c) ethics consultation (help with patient care decision-making); d) resource persons (staff for the program); e) networking (discussion forum), research, evaluation (internal method for resolving disputes). An ethics program is not designed to usurp physician authority, its involvement is consultative and by request; it is not "ethics police."
The process of ethical evaluation
A prerequisite to a successful clinical ethics assessment is that the organization or institution in which the care is delivered must be committed to a fair and open process of ethics consultation and intervention where needed. The health care organization can be supportive, dismissive, or even hostile to clinical ethics. Multiple factors are at work in any ethical decision-making process. In the U.S.A., courts, legislatures, commissions, media, ethics committees, and others define the parameters for ethical decision-making related to medical care. The U.S. Congress passed the Patient-Self-Determination Act (PSDA)  , which set the foundations for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)  mandate to all health care organizations for the establishment of an organizational method for addressing patient care ethics problems. The discussion of organizational/institutional ethics is beyond the scope of this article; for those interested, various USA universities run training courses on developing hospital ethics programs (see Internet references.) Drs. Miller FG, Fletcher JC, and Fins JJ adopted a method of moral problem solving inspired by the American philosopher John Dewey  , called "clinical pragmatism"  . Other methods have been published ,, , and the reader is encouraged to contact the International Directory of Bioethics Organizations, Kennedy Institute of Ethics, Georgetown University, Washington, DC 20057, USA, for a complete list of programs. While Drs. Miller, Fletcher and Fins' method is highlighted in this article, this author supports their stated opinion that "No method of clinical ethics can substitute for the cultivation of competence, insight, and virtue."
Clinical Pragmatism proceeds by four logical steps
Assessment of medical facts
What is the patient's medical condition? (i.e. prognosis; what are the goals of treatment and care? treatment recommendations and reasonable alternatives?) What are the relevant contextual factors? (i.e. demographics, life situation and lifestyle, family relationships, socioeconomic factors, setting of care -home or institution, language spoken, cultural factors, religion)
Is the patient capable of making decisions?
What are the patient's preferences? (understanding of condition, current wishes for treatment, advance directives, etc.) What are the needs of the patient as a person? (adequacy of home environment for care of patient, preparation for dying) What are the preferences of family/surrogate decision makers? (competence as a surrogate decision maker, opinions on quality of life and best interest of patient) Are there interests other than, and potentially competing with, those of the patient? (family, scarce resources and competing needs for their use, interests of health care providers, interest of healthcare organization) Are there issues of power or conflict? (between clinicians and patient/family, between patient and family members, among family members/surrogates, between members of the healthcare team) Have all the parties involved in the case had the opportunity to be heard? Are there institutional factors contributing to moral problems posed by the case? (work routine, fears of medico-legal problems, biases favoring disproportionately aggressive treatment or neglect of treatable conditions, cost constraints/economic incentives)
Examine how the participants are framing the moral problems. Should this framing be reconsidered? Replaced by an alternative understanding? Identify and rank the range of relevant moral considerations. Identify any relevant institutional policies pertaining to the case. Consider ethical standards, guidelines, consensus statements of commissions or interdisciplinary or specialty groups. Consider similar cases and discussions in the literature that might shed light on the analysis and resolution of moral problems in the case. Identify the morally acceptable options for resolving the moral problems posed by the case.
Goal setting, decision making, and implementation of a plan of action
Consider or reconsider and negotiate the goals of treatment and care for the patient. Consider the ideas for possible interventions to meet the needs of the patient and resolve moral problems. Discuss the merits of alternative options for resolving the moral problem. Try to resolve conflicts. Assess whether ethic consultation is necessary or desirable. Negotiate an acceptable plan of action and implement it.
Evaluation of results
Continuous evaluation (Is the plan working? If not, why not? Do we need to modify the plan? Have conditions changed in a way that suggests the need to rethink the plan?
Retrospective evaluation (what opportunities for resolving the moral problem were missed? How did the care received by the patient match up to standards of good practice? What might have been done to improve the care of the patient? Are there desirable changes in institutional policy, feasible changes in the clinical environment, or educational interventions that might help to prevent or resolve the moral problems posed by similar cases? Resolution of disagreement should be by discussion, consultation and consensus. Clinical ethics decisions tend to be process oriented and not outcome oriented and often require a process of consensus building no matter the outcome. There are, however, potential problems with consultation by ethics committees: recommendations may be unsound, the ethics "experts" may receive undue deference, procedures may be unfair, consultations may not be timely, problems may be outside the scope of the ethics committee or consultant. Nonetheless, recognizing the limitations of ethics consultation neither negates the potential for positive impact on patient care nor absolves us from our responsibility (obligation) to prepare for ethical dilemmas.
While an individual's values often mirror the predominant values of their country and culture, they do not always do so. In either circumstance, we must be sensitive to those values and respectful of the people who hold them. Western medicine does not have all the answers. We can strive to respect cultural diversity without accepting every single feature embedded in traditional beliefs and rituals. The identification of potential ethical problems, as well as patient preferences and philosophy, facilitates the inclusion of "preventive ethics" in the overall patient care plan. Giving forethought regarding ethical issues and processes, as well as having knowledge of the ethical resources available to us for consultation (individual, institutional, and communal), are as important to patient care as any diagnostic or management technique.
The author wishes to thank Mrs. Marta H. Wood for her help with the manuscript.
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