Most clinicians give little thought to ethics and law until something goes wrong. This is understandable. They are immersed in concrete clinical tasks, ordering tests, reading reports, examining patients, and running clinics. Ethics can feel abstract and legal rules distant from daily practice.
As an ethicist and trial attorney, I see the consequences of ethical error every week. They can harm patients, erode trust in the profession, and destroy promising careers. In the United Kingdom and many other places, ethics teaching is largely confined to the undergraduate years. It stops on graduation, at precisely the point when ethico-legal problems become real.
The gap in clinical ethics education
Many clinicians will recall the four principles of medical ethics, developed by Tom Beauchamp and James Childress in the late 1970s: respect for autonomy, beneficence (do good), non-maleficence (do not harm), and justice. Yet, while simple to state and easy to understand, the principles are challenging to apply skillfully in practice.
In The Ethical Clinician: Practical Lessons from the Bedside and Courtroom, I used the following scenario: A patient is rushed to the operating theater with a ruptured aortic aneurysm, a catastrophic internal bleed which is usually fatal. The anesthesiologist knows this and believes the patient’s chances of survival are slim. Just before induction of anesthesia, the patient, who is conscious but highly distressed, asks, “I am going to be all right, aren’t I, doctor?” Should the doctor tell the truth about the grim prognosis?
The four principles provide a helpful framework to analyze the case, but they do not resolve the dilemma. There are tensions within and between the principles. Does the patient truly want the truth or merely reassurance? Would honesty cause harm, by increasing distress and reducing the likelihood of survival?
Applying ethics in clinical practice
In writing The Ethical Clinician, I was reminded how difficult it is to apply these four principles with nuance, despite years of experience. A clinician untrained in clinical ethics is unlikely to do this well; they will need help, whether from ethicists, ethics committees, colleagues, artificial intelligence (AI), or a mixture of these. Ethical decision-making, like clinical reasoning, improves with practice, guidance, and experience.
To engage the reader, I avoided the textbook approach and drew instead on personal experience. I referred to my early work in clinical ethics in Canada and the U.S., time in hospitals in India, committee work, and cases in the courtroom. The aim was to show how ethical and legal issues arise in actual practice, not merely in theory.
I combined dramatic cases, like the one above, with more everyday problems. In reality, the majority of clinicians who face legal or disciplinary trouble do so because of more routine matters, such as prescribing for family members, inadequate consent, or improper record-keeping. The danger of painting ethics as pertaining only to the agonizing dilemmas in acute specialties is that it alienates clinicians, who may believe, wrongly, that ethics and law are marginal in their work.
Ethics and law are just as central in dermatology, radiology, and family medicine as in neurosurgery and intensive care. They are embedded in all areas of clinical practice and, like any other clinical skill, should be developed before something goes wrong.
Daniel Sokol is a medical ethicist.
