Clinical Ethics and Professionalism

Introduction

Bioethics is the study of the ethical issues emerging from advances in science and medicine. This includes moral deliberation on the intersection of societal views of health care, law, and moral philosophy. The field of bioethics is quite expansive, as it applies to all aspects of human development and our interaction with our environment and the use of technology. The term medical ethics or clinical ethics concerns more specifically those issues related to patient–clinician encounters. All health professions cite the importance of ethical behavior as an attribute of professionalism, but they may not adequately clarify how such behavior is to be demonstrated or include comprehensive guidelines for practitioners. Legislative regulations and court rulings also provide guidance to health professionals, but laws vary in regard to jurisdiction and may change to reflect shifting societal perspectives. Thus, health professionals and trainees may experience moral distress if they believe their ethical duty conflicts with their legal obligations.

Medical professionalism and ethics are often conflated as they are each used as defining attributes of one another. Professionalism encapsulates those virtues that foster a clinician's ability to recognize, understand, and apply the skills necessary to honor their ethical obligations. Patients and society hold clinicians to a high standard of ethical behavior that is expected of their profession. Clinicians face challenging issues every day in the scope of their work with patients. The concerns of patients frequently extend beyond their physical symptoms to include psychosocial needs, socioeconomic challenges, and social justice concerns, to name only a few of the compounding issues that are commonly seen as ethical issues requiring attention. Some of these issues appear to have easy answers as to what should be done, but the lack of resources available are difficult to overcome. There are other issues that remain controversial because there is no clear discernment as to what is the ethically appropriate course of action. When faced with a moral dilemma regarding the care of a patient, the study of bioethics and more specifically ethics analysis can help clinicians determine if a proposed course of action is obligatory, permissible, or impermissible. Clinical ethics training offers health professionals the skills to recognize, understand, and consider appropriate solutions to address and resolve ethical conflicts when they arise in patient care or among professionals when in conflict with one another.

This chapter will highlight some of the moral frameworks and bioethics concepts that may be used when faced with professional conflicts related to patient care. Advance study of bioethics is recommended for all clinicians in training and as part of their continuing professional development requirements.

Principlism

Principlism is a decision-making approach based on the four principles of autonomy, beneficence, nonmaleficence , and justice . It offers a method of analysis utilizing widely accepted norms of moral agency (the ability of an individual to make judgments of right and wrong) to identify ethical concerns and determine acceptable resolutions for clinical dilemmas.

Autonomy refers to respecting the decisions of an autonomous person, enabling patients to make reasoned informed choices and to take actions based on the patient's personal values and beliefs. This principle is the basis for the doctrine of informed consent in medical care and human subjects research. In westernized cultures, autonomy is limited to individuality. In other cultures, autonomy can be inclusive of family, shared group identity, and/or community. The principle recognizes that all adult persons have autonomy, and it is our ethical duty as clinicians to honor and promote that quality. As a principle, it does not apply to infants and children, as they have not reached the age of majority. While laws may arbitrarily determine the age of adulthood, it is ethically permissible to consider and assess an adolescent's ability to participate in their health decisions on the basis of the adolescent's emerging autonomy. Some states legally permit adolescents to make health care decisions independently of their parents. A more detailed discussion on pediatric ethics is included later in this chapter.

Beneficence refers to the balancing of potential benefits of treatment against potential risks and burdens experienced by the patient. Health care professionals should act in a way that benefits the patient as well as take necessary steps to prevent or mitigate harm. This principle applies not only to health care needs of individuals, but is applicable to communities and society at large.

Nonmaleficence means avoiding or mitigating the causation of harm or injury either through action or inaction. It is presented sometimes in contrast to the principle of beneficence, but they are intended to be complementary to one another. All treatment involves some harm, even if minimal, but the harm should not be disproportionate to the benefits of treatment. This principle is frequently invoked in regard to medical errors committed by health professionals.

Justice concerns advocating for a fair or equitable distribution of benefits, risks, health care costs, and resources. It supports the position that patients in similar positions should be treated in a similar manner. It applies to medical care provided at the bedside, as well as to the intersection of our health care system, laws, and policies that govern access to health care.

Moral Philosophy: Deontology Vs. Utilitarianism

The field of ethics (moral philosophy) involves systematizing, defending, and recommending concepts of right and wrong behavior. Clinical ethics frameworks have been developed from these various philosophical approaches, including deontology and utilitarianism. Developed by the moral philosopher Immanuel Kant, deontology is also referred to as Kantian ethics or duty-based ethics . The morality of an action is based solely on the nature of the action regardless of the consequences or any other factors. Decisions are made on what is in the best interest for the patient. Deontology views actions as either right or wrong without any regard to contextual features. An example sometimes used is that of the Ten Commandments (i.e., “Honor your father and mother,” “Do not kill,” “Do not steal”). We can easily point to deontology's influence in health care in regard to promoting truth telling with patients. What should a clinician do though if the truth might cause harm to the patient or others? A commonly cited criticism in relation to the moral imperative of “truth telling” or “do not lie” is the hypothetical scenario that you are hiding someone from a murderer. The murderer comes to your home and asks if the person, their intended victim, is there. A critique of Kantian ethics is that the moral thing to do would be to tell the truth, regardless of the consequences.

Utilitarianism is a consequentialist moral theory that emphasizes efforts to maximize the overall good. Consequentialism, as an ethical theory, is concerned only with the consequences of an action. Applying a utilitarian framework for decision making entails an analysis with a goal to achieve the greatest benefit for the greatest number of persons. The consequence or outcome of the decision determines the morality of the action. Examples of utilitarian approaches include institutional requirements for vaccinations and reporting communicable disease infections to public health authorities. While many believe such approaches limit expression of personal choice and may pose harm, the benefits are seen as greater and thus morally (ethically) permissible. A counterpoint critique of a utilitarian approach that has been depicted in popular culture is how health care professionals may act in the aftermath of public health disasters by triaging patients based on the amount of limited resources required to ensure the likelihood of survival. Such practices may violate one or more of the four principles that guide our conception of a medical standard of care while creating significant moral distress for the health professionals involved.

Casuistry

A case-based approach to addressing ethical conflicts, casuistry utilizes an inductive method of reasoning and decision making. Casuistry is a process of reasoning that seeks to resolve ethical problems by extracting or extending theoretical rules from one particular case and reapplying those rules to new cases. It offers an alternative to principle-oriented approaches, most notably principlism, deontological ethics, and utilitarianism in bioethics. The method shares many contextual features with medical and legal decision making. Appropriate actions depend on the specific features of a case. Popularized as a tool specifically for clinical ethics by Jonsen, Siegler, and Winslade, ¹

1 Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, ed 8, McGraw-Hill Education; 2015.

this method of ethics analysis asks clinicians to examine dilemmas within the framework of four categories intrinsic to every clinical encounter ( Table 30.1 ).

Utilizing a casuist approach to ethics analysis:

• 1

  Evaluate the facts under each topic and identify the salient features of the case.

• 2

  Identify relevant paradigm cases—cases with similar features that have been debated and decided by the general public and medical and legal communities at a national level.

• 3

  Develop a justified plan of action, drawing on the expert opinion from paradigm cases adapted for the specific features (the context) of that particular case.

Privacy and Confidentiality

One of our most basic human rights is the right to privacy. Whatever information about ourselves that we willingly choose to share with others is a selective process integral to our personal integrity. Violations upon a person's privacy deprives them of one of our most fundamental basic freedoms. Privacy rights can be either positive or negative. Positive rights of privacy concern an individual's choice to determine who has access to and may share information about themselves with others. Negative rights of privacy encapsulate the right to be left alone or noninterference from others. Privacy applies not only to knowledge of information but also to visual images, auditory recordings, written documentation, and access to one's person (i.e., blood, DNA swabs, urine sample, etc.).

An individual's right to privacy is recognized and protected by confidentiality. Respecting one's privacy through confidentiality is based in the fiduciary relationship between health professionals and patients. This applies to many different types of relationships beyond the scope of health care, including the law, pastoral care, and intimate relationships with whom individuals establish bonds of trust. The ethical duty to respect the privacy of patients is among the earliest professional obligations of physicians as reflected in the Hippocratic Oath, which was written in the 5th century BCE; see the quote that begins this chapter. In modern times, expectations for privacy and confidentiality are set forth through laws and codes of professional ethics. This applies to not only physicians but also any individual with access to patient health information. Confidentiality is not limited to the provision of health care services. Human subjects research also requires adherence to privacy laws and regulatory oversight of how information about patients and/or research participants must be protected. Given the complexity of our health care system and the number of individuals interacting with patients and their information, the concept of privacy and confidentiality has dramatically changed in the era of electronic medical records. Rather than contribute to a false sense of secrecy, health professionals should be transparent with patients regarding privacy policies. Patients should be informed that the provision of care requires numerous individuals to have access to health information. This does not absolve health professionals from their ethical obligation to maintain confidentiality by adherence to institutional safeguards and standards of professionalism. See Chapter 28 (section entitled “ Protecting Patient's Right to Privacy ”) for additional information on the right to privacy.