With an overwhelming role of automation in modern health care industry, the concept of medical ethics seems to be fading away in the waves of murky economic profiting from value-based bundles meant for pure revenue generation. The commercialized approach towards practice of medicine requires readdressing the core ethical framework which lies at the hearth of patient-doctor relationship. Being innate and inextricable part of clinical medicine, ethical responsibility is meant for patient benefit, avoiding or minimizing any harm, and respecting the patient’s choices.
Ethics deals with morality and the pertinent moral choices to be chosen. As is the case with other notable medical discoveries, the rapid evolution of bioethics stems from aftermath of World War II, where number of lamentable human abuses in research, trial interventions without informed consent, and gruesome experimentation in concentration camps helped its transformation to current day status with an overarching scope including clinical, research, public health, and organizational ethics.
Medical ethics is built on four foundational principles: beneficence, nonmaleficence, autonomy, and justice. In Thomas Percival’s book Medical Ethics published in 1803, the emphasis was on patient’s best interest as a goal without mentioning autonomy and justice, which were incorporated late as important principles of ethics. Modern medical ethics is now a composite field incorporating law, philosophy, spirituality, and cultural norms. While ideas vary across cultures and regions, several fundamental principles form the basis of contemporary medical ethics. These notions serve as ethical guidelines for clinicians and health care societies around the globe.
The first principle is “autonomy” or respecting the right to choose, that emphasizes the patient’s right to make informed decisions about their own health care. The scholarly foundation for autonomy is that all humans have inherent, unconditional worth, and should have the authority to exercise their capability for independence. Recognizing the principle of autonomy obligates the physician to release medical information and treatment options that are necessary for the patient to exercise self-determination and supports informed consent, truth-telling, and confidentiality.
The responsibility of the physician to always act for the patient’s benefit, or “beneficence,” is the second principle of medical ethics. It involves moral values to prevent harm, protect the rights of patients, eliminate conditions that cause harm, rescue people in danger, and help people with disabilities. It goes beyond avoiding harm by dynamically doing good. While doctor’s beneficence is selfless and adapts to moral rules, in many instances it can be considered a remuneration for the commitment to society for subsidized education by governments, ranks and rights, and to the patients themselves by virtue of research and learning.
“Nonmaleficence” or do no harm is the third principle of ethics that obligates physicians to avoid causing harm (physical, emotional, or psychological) to patients at any cost or in any circumstances. Weighing the benefits against burdens of all interventions, disdaining inappropriately burdensome goals, and opting the best course of action for the patient are some of the practical aspects of nonmaleficence. This is pertinent in complicated end-of-life care judgments on reserving life-supporting treatment, medically administered hydration and feeding, and in palliative care measures. Doctrine of double effect tests the physician’s intent to relieve the suffering of a patient using appropriate drugs including opioids overriding the anticipated but unintentional deleterious effects.
The final principal in medical ethics is “distributive justice” which emphasizes on fairness in medical care and allocation of resources. It is based on a concept of receiving equitable care regardless of one’s background, with a focus on fair, appropriate, and equitable allocation of resources. Intertwining aspects considering the distribution to each person include equal share, according to need, effort, contribution, merit, and free-market exchanges. One can perceive difficulty in selecting, balancing, and humanizing these principles to form a rational and practical solution to deliver medical resources.
Conflicting views on goals of treatment is one of the reasons for physician and patient dissent. As goals change during the course of illness (e.g., a cancer becoming refractory to treatment) it is crucial that the physician communicates with the patient and family in clear and candid language, with the object of defining the goals of treatment under the altered situation. In attempting so, the physician should be mindful of factors that compromise patient’s decision-making capability, such as apprehension, pain, mistrust, and numerous beliefs that mar successful communication.
Caring is at the core of medical ethics, built on the moralities of empathy, honesty, and diligence. Medical ethics is not a manual with straightforward answers. It’s a living conversation, a link between science and morality, the compass that points us through the haze of ambiguity and optimism. It asks us to be upright, to heed and to care, not only for consequences, but for people. In the words of Peabody, “The secret of the care of the patient is caring for the patient.”
Muhammad Mohsin Fareed is a radiation oncologist.
