2.3 Medical Ethics and Decision Making

Medical ethics and decision-making are crucial in healthcare. They guide providers in navigating complex situations, balancing patient autonomy with beneficence, non-maleficence, and justice. These principles help ensure fair, ethical treatment for all patients.

Ethical dilemmas often arise in clinical practice, requiring careful consideration. Healthcare organizations use decision-making frameworks and ethics committees to address these challenges, develop policies, and provide guidance to staff, ultimately improving patient care and outcomes.

Core principles of medical ethics

The four core principles

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• Autonomy: the patient's right to make informed decisions about their own healthcare, free from coercion or undue influence
  • Emphasizes the importance of informed consent and respecting the patient's wishes
  • Patients should be provided with sufficient information to make an informed decision (risks, benefits, alternatives)
  • Healthcare providers must respect a patient's right to refuse treatment, even if they disagree with the decision
• Beneficence: the obligation to act in the best interest of the patient and to promote their well-being
  • Healthcare providers should strive to maximize benefits and minimize harm to the patient
  • Involves weighing the potential risks and benefits of a treatment or intervention
  • May include providing preventive care, pain management, and emotional support
• Non-maleficence: the principle of "do no harm," requiring healthcare providers to avoid causing unnecessary harm or injury to the patient
  • Closely related to beneficence, as both principles aim to promote the patient's well-being
  • Healthcare providers should consider the potential risks and side effects of treatments or procedures
  • Includes protecting patients from medical errors, negligence, or malpractice
• Justice: the fair and equitable distribution of healthcare resources and the absence of discrimination
  • Involves respecting the rights of all patients, regardless of factors such as race, gender, or socioeconomic status
  • Ensures that healthcare resources are allocated fairly and that patients have equal access to necessary care
  • Addresses issues such as healthcare disparities, rationing of scarce resources, and access to healthcare insurance

Balancing and prioritizing principles

• These principles may sometimes conflict with each other, requiring healthcare providers to carefully consider the specific circumstances
• Prioritize the most relevant principles in each situation based on the patient's needs, values, and preferences
• Example: respecting a patient's autonomy to refuse treatment may conflict with the principle of beneficence if the treatment is potentially life-saving
• Healthcare providers must engage in ethical reasoning and decision-making to balance competing principles and determine the most appropriate course of action

Ethical dilemmas in clinical practice

Types of ethical dilemmas

• Competing moral principles or obligations with no clear right or wrong answer
• Complex situations involving multiple stakeholders and conflicting values
• Common ethical dilemmas in healthcare:
  • End-of-life care decisions (withholding or withdrawing treatment, assisted dying)
  • Allocation of scarce resources (organ transplantation, intensive care beds during a pandemic)
  • Confidentiality and privacy issues (disclosing patient information to protect others from harm)
  • Conflicts between patient autonomy and the healthcare provider's professional judgment (refusing recommended treatment)

Factors complicating ethical dilemmas

• Disagreements between the patient, family members, and healthcare providers about the best course of action
  • Cases involving minors, incapacitated patients, or those with diminished decision-making capacity
  • Family members may have different values, beliefs, or understanding of the situation compared to the patient or healthcare team
• Cultural, religious, and personal beliefs influencing the patient's or family's preferences and decisions
  • Some religious beliefs may prohibit certain medical interventions (blood transfusions, end-of-life care)
  • Cultural norms and values may shape expectations about decision-making roles and communication styles
• Power imbalances between patients and healthcare providers, particularly in situations involving vulnerable populations
  • Patients may feel pressured to comply with a healthcare provider's recommendations, even if they have concerns or reservations
  • Language barriers, health literacy, and socioeconomic factors can further exacerbate power imbalances and hinder effective communication and decision-making

Ethical decision-making frameworks

Common frameworks for resolving ethical dilemmas

• Four Quadrants approach: considers the medical indications, patient preferences, quality of life, and contextual features of the situation
  • Helps to balance the principles of medical ethics and prioritize the most relevant factors in each case
  • Encourages a holistic assessment of the patient's situation, values, and goals
• Jonsen-Siegler-Winslade model: assesses the medical indications, patient preferences, quality of life, and contextual features systematically
  • Emphasizes the importance of open communication and collaboration among all stakeholders
  • Provides a structured approach to gather and analyze relevant information
• MORAL decision-making model: involves five steps (Massage the dilemma, Outline options, Review criteria and resolve, Affirm position and act, and Look back and evaluate)
  • Encourages a reflective and iterative approach to ethical decision-making
  • Promotes accountability and continuous learning by evaluating the outcomes of decisions

Key components of ethical decision-making

• Gathering relevant information about the patient's medical condition, prognosis, and treatment options
• Identifying the ethical principles and values at stake in the situation
• Considering alternative courses of action and their potential consequences
• Engaging in open and respectful communication with the patient, family, and healthcare team
• Justifying the chosen decision based on ethical reasoning and the application of relevant frameworks
• Documenting the decision-making process and rationale in the patient's medical record
• Reviewing and evaluating the outcomes of the decision to inform future practice and policy

Ethics committees in healthcare organizations

Functions of ethics committees

• Develop and implement policies and guidelines related to ethical issues in healthcare
  • Advance directives: documents specifying a patient's preferences for medical treatment in the event they become incapacitated
  • Informed consent: the process of obtaining a patient's permission for a medical intervention after providing them with relevant information
  • End-of-life care: policies addressing issues such as withholding or withdrawing life-sustaining treatments, palliative care, and hospice
• Provide consultation services to healthcare providers, patients, and families facing complex ethical dilemmas
  • Clarify the ethical issues involved and explore alternative courses of action
  • Provide recommendations based on ethical principles and organizational values
  • Facilitate communication and conflict resolution among stakeholders
• Offer education and training to healthcare providers and staff on ethical issues and decision-making frameworks
  • Organize workshops, seminars, and grand rounds on topics such as informed consent, advance care planning, and cultural competency
  • Develop educational materials and resources (case studies, decision-making tools) to support ethical practice
• Engage in quality improvement activities to enhance the organization's approach to ethical issues
  • Review and analyze past cases to identify patterns or areas for improvement
  • Monitor and evaluate the implementation and effectiveness of ethics-related policies and guidelines
  • Collaborate with other departments (risk management, patient safety) to address system-level ethical concerns

Composition and structure of ethics committees

• Interdisciplinary groups including healthcare providers, ethicists, legal experts, and community representatives
  • Physicians, nurses, social workers, and other clinical staff provide diverse perspectives and expertise
  • Ethicists contribute specialized knowledge in moral philosophy, ethical theories, and decision-making frameworks
  • Legal experts ensure compliance with relevant laws and regulations and advise on legal implications of decisions
  • Community representatives (patient advocates, religious leaders) offer insights into local values and concerns
• Committees typically have a chair or co-chairs responsible for leadership and coordination
• Subcommittees or working groups may focus on specific issues (policy development, education, case review)
• Regular meetings (monthly or quarterly) to discuss ongoing issues, review cases, and make recommendations
• Maintain records of consultations, policy decisions, and educational activities to ensure transparency and accountability