MEDICAL ETHICS

AN OVERVIEW OF CLINICAL ETHICS

Horacio F. Zaglul, MD* University of Kentucky Chandler Medical Center Children’s Hospital, Lexington, Kentucky, USA

   Abstract
   Introduction
   Distinction between morals and ethics Clinical ethics
   Ethics can further be divided into
   Religion and ethics
   Ethical Obligations and issues in clinical ethics
      Ethical Principles
      Case based analysis (Casuistry)
      Virtue/care
   Pragmatism (whatever works)
   Is clinical ethics useful?
   The process of ethical evaluation
   Clinical Pragmatism proceeds by four logical steps
      Assessment of medical facts
      Is the patient capable of making decisions?
      Moral diagnosis
    Goal setting, decision making, and implementation of a plan of action
   Evaluation of results
   CONCLUSION
   References

   TRAIN OF THOUGHT: MORAL DILEMMAS EXERCISE OUR EMOTIONS

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.

(Heart Views. 2002;3(2):92-99) © 2002 Gulf Heart Association.

Key Words:

   ethics    life support care     decision making     physician-patient relations  
   conflict of interest

Introduction

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 (1). 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 (2). 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 (3). 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,

Table 1. Major Writings in Ancient, Medieval, and Modern Health Care

it is useful to distinguish between them (3-5). "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 (2). 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 (5). 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 Childress (3) and Drs. Fletcher Lombardo, Marshall, and Miller (5).

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)(6). 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 (7).

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"(5)."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." (8) 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 (9), 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 (5) 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

Fig.1

Fig.1. Place of Clinical Ethics in Society. Reprinted from Introduction to Clinical Ethics, edited by John C. Fletcher, Paul A. Lombardo, Mary Faith Marshall, and Franklin G. Miller, with the permission of University Publishing Group, copyright 1997. All rights reserved. www.upgbooks.com

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 (10).

Ethical Obligations and issues in clinical ethics

h 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:

Ethical Principles         Case based analysis (Casuistry)        Virtue/care      Pragmatism (whatever works)

Ethical Principles

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 (1). 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” (11), 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.

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 (Table2)

Table 2. Examples of Subjects in Clinical Ethics

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)(12), which set the foundations for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)(13) 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 (14), called “clinical pragmatism” (5). Other methods have been published (2, 5, 16), 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        Is the patient capable of making decisions?       Moral diagnosis      Goal setting, decision making, and implementation of a plan of action

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)

Moral diagnosis

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.

CONCLUSION

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.

Useful Internet References

http://www.ama-assn.org/sitemap.htm
Ethical opinions of the American Medical Association
Council on Medical and Judicial Affairs

http://www.aap.org/policy
Policystatements of the American Academy of Pediatrics

http://www.guideline.gov
U.S. Department of Health and Human Services, Agency for Health Care Policy and Research

http://www.nih/gov
National Institutes of Health home page

http://www.med.virginia.edu/bioethics
University of Virginia Center for Biomedical Ethics

http://www.med.umn.edu/bioethics
Center for Bioethics, University of Minnesota

http://www.pitt.edu/~bioethic/
Center for Bioethics and Health Law, University of Pittsburgh

http://www.stanford.edu/dept/scbe/
Stanford University Center for Biomedical Ethics

http://guweb.georgetown.edu/kennedy/
Kennedy Institute of Ethics, Georgetown University

http://www.mcw.edu/bioethics/
Center for Study of Bioethics, Medical College of Wisconsin

http://www.facs.org/fellows_info/statements st-19.html
Advance Directives by Patients: “Do Not Resuscitate in the Operating Room

http://www.upenn.edu/Idi/issuebrief2-5.html
University of Pennsylvania: "Organ Procurement and Transplantation: Ethical and Practical Issues"

http://www.nho.org
National Hospice Organization

http://www.lastacts.org
Robert Wood Johnson Foundation’s Last Acts Campaign
(USA national coalition to improve care at the end of life)

http://www.healthlawyers.org
American Health Lawyers Association

References

1. Macklin R. Against Relativism: Cultural Diversity and the Search for Ethics Universals
    in Medicine. Oxford University Publishing Group; 1999.

2. Bernard, LO. Resolving ethical dilemmas: a guide for clinicians. 
    Baltimore (MD): Williams & Wilkins; 1995.

3. Beauchamp, TL and Childress, JF. Principles of Biomedical Ethics, 5th ed. 
    Oxford University Press, New York, 2001.

4. Becker, LM and Becker, CB (Eds.) Ethics and Morality. 
    In Encyclopedia of Ethics. Garland Publishing, New York, 1992. 329.

5. Fletcher JC, Lombardo PA, Marshall MF, Miller FG (ed). Introduction to 
    Clinical Ethics, 2nd Edition. Hagerstown (MD): University Publishing Group, Inc.; 1997.

6. Veatch RM. Cross-Cultural Perspectives in Medical Ethics, 2nd Edition. 
    Sudbury (MA): Jones and Bartlett Publishers; 2000.

7. American Medical Association Code of Medical Ethics, 2000-2001 Edition.
    AMA press.

8. Fletcher, J. The Bioethics Movement and Hospital Ethics Committees, 
    Maryland Law Review, 1991, 50: 859n, note 1.

9. Beauchamp D.E., Steinbock B. (ed) New Ethics for the Public’s Health.
    Oxford University Press; 1999.

10. Ethics in Clinical Practice, 2nd edition. Ahronheim J.C., Moreno JD, Zuckerman C.
     (ed). Aspen Publishers Inc.; 2000.

11. Pence GE (ed). Classic Cases in Medical Ethics, 3rd Edition. McGraw Hill; 2000.

12. Omnibus Budget Reconciliation Act of 1990. Public Law 101-508 
      (Nov 5. 1990) §§ 4206, 4751. See USC, scattered sections.

13. Joint Commission on the Accreditation of Healthcare Organizations, 
     1995 AMH Standards, Rights, Responsibilities and Ethics (Chicago, Il.).

14. Miller, FG, Fins, JJ, Bacchetta, MD. Clinical Pragmatism: John Dewey and 
      Clinical Ethics. Journal of Contemporary Health Law and Policy, 1996 3:27-51.

15. Orlowski JP. Ethics in Critical Care Medicine. Hagerstown (MD):
      University Publishing Group; 1999.

16. Snyder L, Quill TE. Physician’s Guide to End-of-Life Care. Philadelphia (PA): 
      American College of Physicians; 2001.

TRAIN OF THOUGHT: MORAL DILEMMAS EXERCISE OUR EMOTIONS

TRAIN OF THOUGHT: MORAL DILEMMAS EXERCISE OUR EMOTIONS f five people are trapped on a railway track and a train is approaching, is it morally right to divert the train onto another track where there is only one person? Most people would say yes. Would it be right to push a person onto the track to prevent the train from hitting the other five? This time, most people would say no. The different responses puzzle philosophers, because the principle - sacrifice one life to save five - is the same in both cases. We do not know how the brain handles moral dilemmas. However, magnetic resonance images are providing some insights into moral decision-making. Magnetic resonance images now show that our brains process the two dilemmas cited above in fundamentally different ways, using brain regions responsible for emotion only in the second situation. It appears that when people make moral decisions, emotional responses play as much of a role as logical analyses. In a fascinating experiment conducted at Princeton University in New Jersey, psychologists observed that when study participants made moral decisions about situations that have a personal element, such as throwing people off a sinking lifeboat, activity soared in four parts of the brain involved in processing emotion. Meanwhile, it sank in three regions associated with working memory, which stores and processes information in the short term. The reverse happened when subjects judged less personal moral dilemmas, such as keeping the money found in a lost wallet, or considered questions that were not moral issues, such as whether to travel by bus or train in a given situation. In the past, many researchers regarded moral reasoning as a purely analytical process, and deemed emotion as something that gets in the way of reason but the findings of the research brings emotion firmly into the process of reasoning itself. Perhaps the most crucial finding of the study was that people took significantly longer to conclude that it was appropriate to push a person in front of the train than to decide it was inappropriate. The people who said it was appropriate had to fight their emotions, so they were more hesitant, indicating that emotion isn’t just incidental, but really exerts a force on people’s judgements. The investigators emphasized that the study makes no judgment about what decisions are moral, but rather describes how people arrive at a particular decision. It may not necessarily be the right decision. They suggest that there could be good reasons to trust our gut responses and that emotions may well be important adaptations rather than irrational responses. Reference: Greene, J. et al. An MRI investigation of emotional engagement in moral judgment. Science 2001; 293: 2105 – 2108.

Correspondence to Dr. Horacio Zaglul, University of Kentucky Chandler Medical Center, Children’s Hospital, 800 Rose Street, Room MN 464A Lexington, KY 40536-0298. Fax:(859) 323-3499 E-Mail: hzaglul@pop.uky.edu Associate Professor of Pediatrics, Pediatric Critical Care, University of Kentucky Chandler Medical Center