Education in medical ethics is required in medical school and residency programs, yet there is so much variability in the timing and delivery of this education and many house staff report inadequacies and gaps in their ethical training. Although physicians traditionally think of ethics during times of crises when a difficult case results in moral distress, it is actually important to consider ethical issues as part of our daily responsibilities as a physician. This is true whether we are engaging in research or direct patient care. Numerous studies have shown that physicians who are knowledgeable about ethical issues are more likely to recognize ethical dilemmas in clinical practice and feel more confident addressing these issues. Rather than using a tragic case to teach ethics, I will provide a few key principles that are essential for clinical practice.
A special relationship exists between patient and physician that extends beyond ordinary professional obligations. The relationship with a physician is different from most other professional relationships, since a physician is provided information on confidential lifestyle choices, is allowed to examine our body, and may perform invasive procedures. This relationship is based on presumptions of confidentiality, safety, and loyalty. Fiduciary responsibility is the ethical obligation of a physician to honor a patient’s trust and act in ways that honor the patient’s interests above the competing interests presented by the demand of families, the institution, or even our own lives. It includes the obligation to promote the best interests of the patient (beneficence) while minimizing any potential harm (non-maleficence).
For example, your patient is anxiously waiting for you to deliver the results of her disease evaluation, but the news is not good and her son has already demanded that you not disclose any negative information to his mother. You are anxious about giving the bad news, not sure how to handle the son’s requests, and your co-fellows have invited you to lunch off campus that would allow you to avoid this difficult encounter a little longer. The principle of fiduciary responsibility reminds you it is your duty to honor the interests of your patient over the competing issues in this encounter. It would be your duty to see the patient before lunch and disclose to her son when he made his request that it is your professional obligation to honor his mother’s wishes to receive her test results. A small minority of patients will prefer “not to know,” but this can be easily clarified by asking patients their preference for delivery of important medical information in advance of testing. When there is an overbearing family member, it is helpful to ask this question of patients when they are alone. Knowing you might have to deliver bad news after a disease evaluation, it is often helpful to set a time frame to return results to the patient and ask them to consider inviting family to help them process the information.
Decision Making & Consent for Treatment
The ethical principles of autonomy and respect for persons recognize an individual’s right to self-determination and allow patients to agree to or refuse a medical treatment. We often do not question a patient’s decision-making skills unless they are clearly very confused or refuse a recommended medical therapy. Patients who lack the global ability to make decisions may be labeled “incompetent” by the courts, but this is a legal decision and physicians do not make competency decisions. As a physician, it is important to assess your patients’ decision-making capacity (DMC), whether it is in discussions of a medical intervention or prior to consent for research. DMC is the task-specific ability to make an individual medical decision, does not require a consult from a psychiatrist, and can be assessed by any physician. In order to have decisional capacity, the patient must be able to understand the diagnosis, prognosis, and treatment alternatives, as well as the risks and benefits of each. It is not enough that the patient can simply repeat the factual information. DMC requires that a patient be able to appreciate how it applies to the situation and express how the decision falls within his or her life plan and value system.
Patients may have DMC for one medical decision, but lack DMC for another decision. DMC can fluctuate over time and attempts should be made to maximize a patient’s ability to understand and appreciate a treatment decision. For example, time discussions to coincide with the patient’s “best” time, and minimize the effects of other interventions (drugs, dialysis) and environmental distractions (noise, television). The patient’s family, friends, and primary physicians can provide valuable insight into the patient’s capacity (“he’s not acting like himself”) and may help facilitate communication with the patient.