Ethical Decision-Making (part 3)
4. Does the decision promote the well-being of the patient?
A sound decision entails a concerted effort to promote the wellbeing of the patient. Since the formation of the Hippocratic traditions, beneficence (L., to do good for another) has been central to the motivations and purposes of medicine. The most basic form of beneficence is nonmaleficence (i.e., ‘do no harm’). This reminder is certainly relevant to the practice of medicine. Even though technological advances continue to strengthen a physician’s ability to repair injuries and cure diseases, the most important expression of beneficence remains to ‘do no harm’. ‘Can’ does not imply ‘should’. The harms to be balanced with benefits include intentional harms as well as those harms that can be anticipated to arise despite the best intentions (e.g., unwanted side effects of medication or complications of surgical treatment).
In balancing the promotion of a patient’s wellbeing with the promotion of self-determination, a physician should attempt to interpret a patient’s best interests as objectively as possible. An effort to override a patient’s wishes in order to pursue what her physician perceives to be in her best interests -- i.e., paternalism -- is rarely (if ever) justified.
5. Is the decision just?
A sound decision takes into consideration the implications a course of action has for third parties immediately affected and for the interests of the larger society. A democratic society is committed to freedom and justice. Accordingly, individuals are free to claim what they are due based on specified personal properties or characteristics. It is important that all members of the society participate in the ongoing responsibility to select criteria that are relevant to the benefits and burdens being assigned. For instance, in our society, such variables as ethnicity, gender, and religious persuasion are not considered to be legitimate criteria by which to determine the distribution of such benefits as housing, education, employment, or health care.
Individuals equally concerned about justice may use different theories of justice in determining what would be a fair distribution of benefits and burdens. Some might variously argue that the distribution should correlate with need, effort, contribution, merit, or ability to pay. Others might argue that benefits and burdens should be distributed equally or randomly. The approach taken in a given situation should be relevant to the benefits and burdens being assigned. Commitment to a just decision creates an obligation to treat fairly those who are alike according to the selected criteria. No one should receive unequal treatment unless it is demonstrated that s/he differs significantly from others in a way that is relevant to the treatment in question.
Achieving fairness is most difficult when constraints such as scarcity of resources force judgments about competing claims made by individuals who appear to have equal standing based on agreed-upon distribution criteria. For instance, a critically ill patient needs intensive care, but the intensive care unit is filled to capacity. All the patients in the unit meet the medical criteria for intensive care. If the available resources cannot be redistributed to accommodate another patient, additional criteria must be used in order to decide which patients receive intensive care and which patient is transferred to a less intensive setting. The selection of additional criteria (e.g., the increased risk if transferred or the likelihood of successful recovery) is itself an ethical issue.
6. Is confidentiality ensured?
A sound decision depends on the confidential handling of sensitive information. A patient’s freedom to make decisions about her health care includes the right to decide how and to whom personal medical information is communicated. Carelessness about patient privacy undermines patient trust. This hazard is especially acute when multiple professionals are involved in patient care, when patient care is delivered in an educational setting, or when insurance companies and HMOs are involved. In the near future, the increasing availability of genetic information will make confidentiality even more difficult to maintain.
In general, protecting a patient’s privacy takes precedence over other obligations. However, in some situations, maintaining confidentiality may result in harm to a third party immediately affected by the patient’s chosen course of action. In other situations, maintaining confidentiality may be challenged by accountability to society when faced with epidemic conditions. Since a breach of confidentiality may destroy the patient-physician relationship, the magnitude of risk to others must be actual and grave. Ethical judgment and legal regulations about reporting communicable diseases may not coincide. In the rare instances when breaking confidence is deemed justified, the physician should attempt to explain the circumstances to the patient, solicit the patient’s approval, and remain committed to the patient’s care.
A sound decision entails a concerted effort to promote the wellbeing of the patient. Since the formation of the Hippocratic traditions, beneficence (L., to do good for another) has been central to the motivations and purposes of medicine. The most basic form of beneficence is nonmaleficence (i.e., ‘do no harm’). This reminder is certainly relevant to the practice of medicine. Even though technological advances continue to strengthen a physician’s ability to repair injuries and cure diseases, the most important expression of beneficence remains to ‘do no harm’. ‘Can’ does not imply ‘should’. The harms to be balanced with benefits include intentional harms as well as those harms that can be anticipated to arise despite the best intentions (e.g., unwanted side effects of medication or complications of surgical treatment).
In balancing the promotion of a patient’s wellbeing with the promotion of self-determination, a physician should attempt to interpret a patient’s best interests as objectively as possible. An effort to override a patient’s wishes in order to pursue what her physician perceives to be in her best interests -- i.e., paternalism -- is rarely (if ever) justified.
5. Is the decision just?
A sound decision takes into consideration the implications a course of action has for third parties immediately affected and for the interests of the larger society. A democratic society is committed to freedom and justice. Accordingly, individuals are free to claim what they are due based on specified personal properties or characteristics. It is important that all members of the society participate in the ongoing responsibility to select criteria that are relevant to the benefits and burdens being assigned. For instance, in our society, such variables as ethnicity, gender, and religious persuasion are not considered to be legitimate criteria by which to determine the distribution of such benefits as housing, education, employment, or health care.
Individuals equally concerned about justice may use different theories of justice in determining what would be a fair distribution of benefits and burdens. Some might variously argue that the distribution should correlate with need, effort, contribution, merit, or ability to pay. Others might argue that benefits and burdens should be distributed equally or randomly. The approach taken in a given situation should be relevant to the benefits and burdens being assigned. Commitment to a just decision creates an obligation to treat fairly those who are alike according to the selected criteria. No one should receive unequal treatment unless it is demonstrated that s/he differs significantly from others in a way that is relevant to the treatment in question.
Achieving fairness is most difficult when constraints such as scarcity of resources force judgments about competing claims made by individuals who appear to have equal standing based on agreed-upon distribution criteria. For instance, a critically ill patient needs intensive care, but the intensive care unit is filled to capacity. All the patients in the unit meet the medical criteria for intensive care. If the available resources cannot be redistributed to accommodate another patient, additional criteria must be used in order to decide which patients receive intensive care and which patient is transferred to a less intensive setting. The selection of additional criteria (e.g., the increased risk if transferred or the likelihood of successful recovery) is itself an ethical issue.
6. Is confidentiality ensured?
A sound decision depends on the confidential handling of sensitive information. A patient’s freedom to make decisions about her health care includes the right to decide how and to whom personal medical information is communicated. Carelessness about patient privacy undermines patient trust. This hazard is especially acute when multiple professionals are involved in patient care, when patient care is delivered in an educational setting, or when insurance companies and HMOs are involved. In the near future, the increasing availability of genetic information will make confidentiality even more difficult to maintain.
In general, protecting a patient’s privacy takes precedence over other obligations. However, in some situations, maintaining confidentiality may result in harm to a third party immediately affected by the patient’s chosen course of action. In other situations, maintaining confidentiality may be challenged by accountability to society when faced with epidemic conditions. Since a breach of confidentiality may destroy the patient-physician relationship, the magnitude of risk to others must be actual and grave. Ethical judgment and legal regulations about reporting communicable diseases may not coincide. In the rare instances when breaking confidence is deemed justified, the physician should attempt to explain the circumstances to the patient, solicit the patient’s approval, and remain committed to the patient’s care.
