“I know the treatment probably won’t work,” a patient nearing the end of life tells the doctor. “I want to try anyway.” The patient understands the risks but still hopes for a little more time. The physician wants to honor that hope while worrying that side effects could make the patient’s remaining days more painful. If the treatment requires resources in short supply, other patients’ needs make an already difficult decision harder.
The four principles of medical ethics offer familiar guidance: respect the patient’s choices, help, avoid harm, and be fair. Autonomy, beneficence, nonmaleficence, and justice all deserve consideration. But someone still must decide whether to proceed. Explaining why one principle should carry more weight in a particular case is challenging. Harder still is admitting how much that judgment may depend on the person making it. Ethics education should give clinicians practice making that judgment explicit and answering for it.
Just because a patient is willing to accept side effects does not mean a doctor must provide the treatment. Beneficence does not mean trying every possible option. Justice requires a clear explanation of fairness. These principles do not automatically determine the right decision in a particular case.
But decisions cannot wait for everyone to agree on moral philosophy. The doctor makes a recommendation. The patient accepts or declines. Treatment starts, continues, or stops. At some point, certain reasons prevail. But can everyone involved explain those reasons?
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Principlism, the framework based on the four principles, was never meant to work like a drug calculator. It needs interpretation and balance; no single principle always wins. This flexibility lets clinicians focus on the person in front of them. It also means people can disagree about what matters most. If teaching stops at just naming the principles, it leaves the real work undone.
The 2025 American Heart Association guidance on resuscitation ethics acknowledges that clinicians may consciously or unconsciously prioritize principles based on their preferences, culture, institutional norms, and the case circumstances. “Unconsciously” is the word that should make us pause. A different physician might weigh the same facts differently. A consultant may have more influence than a bedside nurse who has spent countless hours with the patient. A family comfortable challenging authority may receive a longer conversation than one afraid of being labeled difficult.
We ought to examine these possibilities with clear eyes, resisting the urge to see every disagreement as a sign of bias. Reasonable minds may part ways, each guided by their own compass. Yet even the most confident decision deserves to be held up to the light, its reasoning made visible and open to question.
Consider what happens when someone says, “This treatment is futile.” The word sounds definitive, but its meaning can shift. A treatment may be unable to achieve its physiological goal or may be unlikely to succeed. A clinician may consider the possible outcome unacceptable or believe scarce resources should go elsewhere. A single word can obscure these differences. We need to know whether we are discussing the limits of treatment, the value of an outcome, or the fair allocation of resources.
Before accepting the label, ask what success means to this patient. Would the recommendation change if resources were plentiful? If so, scarcity belongs in the explanation. The patient deserves to understand which concerns drive the decision before the word “futile” closes the conversation.
We cannot remove judgment from medicine, but we can make it easier to understand. Begin with the patient’s goal. What does the patient hope treatment will allow: more time, time outside the hospital, or reaching a certain milestone? The answer gives us a clear meaning for “benefit.”
Then explain the recommendation in ordinary language. What outcome is realistically possible? What burdens are likely? Why does the team believe the likely benefits justify or do not justify those burdens? Invite people who may see something the team has missed. Make space for disagreement before the plan becomes difficult to challenge. If scarcity drives the decision, use explicit allocation policies and institutional review. An individual clinician should not have to invent a rationing standard during an already painful conversation.
Finally, document the reasoning, including what might change the recommendation. Writing “ethics discussed” in a chart tells the next care team almost nothing.
Ethics education should prepare clinicians to explain why they have chosen one course over another and to examine how their own assumptions shaped that choice. Patients and colleagues should be able to question those reasons before a recommendation becomes a settled plan.
The patient who says, “I want to try anyway,” may still hear “no.” But that answer carries a responsibility to explain what makes it justified. The four principles help us name our obligations, but they do not relieve us of answering for how we weigh them. Refusing a patient’s request may sometimes be the ethically appropriate choice, but it carries a profound duty: to explain that decision clearly, transparently, and humbly.
This essay is cited in the KevinMD record on medical ethics.
Timothy Lesaca is a psychiatrist in private practice at New Directions Mental Health in Pittsburgh, Pennsylvania, with more than forty years of experience treating children, adolescents, and adults across outpatient, inpatient, and community mental health settings. He has published in peer-reviewed and professional venues including the Patient Experience Journal, Psychiatric Times, the Allegheny County Medical Society Bulletin, and other clinical journals, with work addressing topics such as open-access scheduling, Landau-Kleffner syndrome, physician suicide, and the dynamics of contemporary medical practice. His recent writing examines issues of identity, ethical complexity, and patient–clinician relationships in modern health care. Additional information about his clinical practice and professional work is available on his website, timothylesacamd.com. His professional profile also appears on his ResearchGate profile, where further publications and details may be found.
