CREATING AN ETHICAL FRAMEWORK FOR PRACTICE AND PROFESSIONAL LIFE
Physicians often encounter ethical dilemmas in the con-text f their dealings with patients. The use of an organizedethical framework in such situations is valuable in ensuring that evaluating situations and making decisions can be done in a sys-tematic manner, rather than based on the physician’s emotions, personal bias, or social pressures. Physicians, in training orpractice, are expected as professionals to be able to exem-plify ethical virtues in their practice and professional life. For medicine, the organization of ethical principles into codes of conduct and useful frameworks began 2500 years ago with the Hippocratic Oath. Currently, principles have evolved into a code of professional ethics developed to guide physicians in physician–patient relationships, con-duct, and practice.
Several methods for ethical decision making in med-icine exist. Each of these methods has both merits and limitations. When put into practice, they can promote understanding of common ethical practices regarding informed consent, honesty, and confidentiality.
In recent decades, medical decision making has been dominated by principle-based ethics.In this framework, four principlesare used to identify, analyze, and address ethic dilemmas:
· Respect for patient autonomy acknowledges an indi-vidual’s right to hold views, make choices, and take actions based on his or her beliefs or values. Respect for auton-omy provides a strong moral foundation for informed consent, in which a patient, adequately informed about her medical condition and available therapies, freely chooses specific treatments or nontreatment
· Beneficence is the obligation to promote the well-beingof others, and nonmaleficence obliges an individual to avoid doing harm. Both beneficence and nonmaleficence are fundamental to the ethical practice of medicine. The application of these principles consists of balancing ben-efits and harms, both intentional harms and those than can be anticipated to arise despite the best intentions (e.g., unwanted adverse effects of medication or compli-cations of surgical treatment). In balancing beneficence with respect for autonomy, the clinician should define the patient’s best interests as objectively as possible. Attempting to override patient autonomy to promote what the clinician perceives as a patient’s best interests is called paternalism.
· Justice is the principle of rendering what is due to others.It is the most complex of the ethical principles, because it deals not only with the physician’s obligation to render to a patient what is owed, but also with the physician’s role in the allocation of limited resources in the broader community. In addition, various criteria such as need, ef-fort, contribution, and merit are important in determin-ing what is owed and to whom it is owed. Justice is the obligation to treat equally those who are alike or similar according to whatever criteria are selected. Individuals should receive equal treatment, unless scientific and clin-ical evidence establishes that they differ in ways that are relevant to the treatments in question. Determination of the criteria on which these judgments are based is a highly complex moral process, as exemplified by the eth-ical controversies about providing or withholding renal dialysis and organ transplantation.
In addition to principle-based ethics, several alternative approaches have been promoted, including virtue-based ethics, the ethic of care, feminist ethics, communitarian ethics, and case-based approaches.
· Virtue-based ethics relies on healthcare professionalspossessing qualities of character that dispose them to make choices and decisions that achieve the well-being of others. These qualities of character include trustworthi-ness, prudence, fairness, fortitude, temperance, integrity, self-effacement, and compassion. Virtues complement rather than replace principles, because they are necessary to interpret and apply methods in medical ethics with moral sensitivity and judgment
· Ethic of care is concerned primarily with responsibili-ties that arise from attachment to others, rather than with the impartiality that traditional ethics demands. The moral foundations underlying the ethic of care are not rights and duties, but commitment, empathy, com-passion, caring, and love.
· Feminist ethics calls attention to the way that genderdistorts traditional analyses. Ethical decisions about women’s healthcare may be biased by attitudes and tra-ditions about gender roles that are embedded in our cul-ture. Feminist ethics challenges these presuppositions and their consequences.
· Communitarian ethics challenges the primacy oftenattributed to respect for autonomy in principle-based ethics. It emphasizes shared values, ideals, and goals of the community.
· Case-based reasoning is ethical decision making basedon precedents set in specific cases, analogous to the role of case law in jurisprudence. An accumulated body of influential cases and their interpretation provide moral guidance. Case-based reasoning asserts the priority of practice over theory, rejects the primacy of principles, and recognizes the emergence of principles from a process of generalization from analysis of cases.