Framing an ethical dilemma: 4 basic concepts of medical ethics

It seems lately that questions of medical ethics are coming up more and more in the news, things like the rights of patients to make decisions, definitions of futile care, and end of life care. The way to look at these things is not in a vacuum. All of us may have our own opinions about right and wrong, but the field of medical ethics is actually one that has a body of research and accepted practice. It certainly is something we deal with frequently in the PICU. It may sound esoteric, but generally it isn’t. Even so, it can be complicated.

But complicated or not, it’s also something all of us should know a little about. This is because, in fact, many of us will encounter these issues quite suddenly and unexpectedly with our loved ones, or even ourselves. It is good to be prepared and knowledgeable. The cartoon above suggests it’s all about the law and medical tradition. Really, it’s more complicated than that — and more interesting.

So what are the accepted principles of medical ethics?

There are four main principles, which on the surface are quite simple. They are these:

1. Beneficence (or, only do good things)
2. Nonmaleficence (or, don’t do bad things)
3. Autonomy (or, the patient decides important things)
4. Justice (or, be fair to everyone)

Beneficence

The first of these principles, beneficence, is the straightforward imperative that whatever we do should, before all else, benefit the patient. At first glance this seems an obvious statement. Why would we do anything that does not help the patient? In reality, we in the PICU, for example, are frequently tempted to do (or asked to do by families or other physicians) things that are of marginal or even no benefit to the patient. Common examples include a treatment or a test we think is unlikely to help, but just might. Should we do it just because somebody wants it?

Nonmaleficence

There is a long tradition in medicine, one encapsulated in the Latin phrase primum non nocere (“first do no harm”), which admonishes physicians to avoid harming our patients. This is the principle of nonmaleficence. Again, this seems obvious. Why would we do anything to harm our patients? But let’s consider the example of tests or treatments we consider long shots — those which probably won’t help, but possibly could. It is one thing when someone asks us to mix an innocuous herbal remedy into a child’s feeding formula. It is quite another when we’re considering giving a child with advanced cancer a highly toxic drug that may or may not treat the cancer, but will certainly cause the child pain and suffering. Should we do it?

Autonomy

Our daily discussions in the PICU about the proper action to take, and particularly about who should decide, often lead us directly to the third key principle of medical ethics, which is autonomy. Autonomy means physicians should respect a patient’s wishes regarding what medical care he or she wants to receive. Years ago patients tended to believe, along with their physicians, that the doctor always knew best. The world has changed since that time, and today patients and their families have become much more involved in decisions regarding their care. This is a good thing. Recent legal decisions have emphasized the principle that patients who are fully competent mentally may choose to ignore medical advice and do (or not do) to their own bodies as they wish.

The issue of autonomy becomes much more complicated for children, or in the situation of an adult who is not able to decide things for himself. Who decides what to do? In the PICU, the principle of autonomy generally applies to the wishes of the family for their child. But what if they want something the doctors believe is wrong or dangerous? What if the family cannot decide what they want for their child? Finally, what if the child does not want what his or her parents want — at what age and to what extent should we honor the child’s wishes? (I’ve written about that issue here.) As you can see, the simple issue of autonomy is often not simple at all.

Justice

The fourth key principle of medical ethics, justice, stands somewhat apart from the other three. Justice means physicians are obligated to treat every patient the same, irrespective of age, race, sex, personality, income, or insurance status.

You can see how these ethical principles, at first glance so seemingly straightforward, can weave themselves together into a tangled knot of conflicting opinions and desires. The devil is often in the details. For example, as a practical matter, we often encounter a sort of tug-of-war between the ethical principles of beneficence and nonmaleficence — the imperative to do only helpful things and not do unhelpful ones. This is because everything we do carries some risk. We have different ways of describing the interaction between them, but we often speak of the “risk benefit ratio.” Simply put: Is the expected or potential benefit to the child worth the risk the contemplated test, treatment, or procedure will carry?

The difficult situations, of course, are those painted in shades of grey, and this includes a good number of them. In spite of that, thinking about how these four principles relate to each other is an excellent way of framing your thought process.

If you are interested in medical ethics, there are many good sites where you can read more. Here is a good site from the University of Washington, here is a link to the President’s Council on Bioethics (which discusses many specific issues), and here is an excellent blog specifically about the issues of end of life care maintained by Thaddeus Pope, a law professor who is expert in the legal ramifications. If you want a really detailed discussion, an excellent standard book is Principles of Biomedical Ethics, by Beauchamp and Childress.

Christopher Johnson is a pediatric intensive care physician and author of Keeping Your Kids Out of the Emergency Room: A Guide to Childhood Injuries and IllnessesYour Critically Ill Child: Life and Death Choices Parents Must FaceHow to Talk to Your Child’s Doctor: A Handbook for Parents, and How Your Child Heals: An Inside Look At Common Childhood Ailments.  He blogs at his self-titled site, Christopher Johnson, MD.

email

Comments are moderated before they are published. Please read the comment policy.

  • DoubtfulGuest

    Thank you for this post, Dr. Johnson. From my perspective, I’ve experienced all four types of ethical violation with my own care (a misdiagnosis and subsequent events) — from a doctor I really trusted. If I misunderstood anything (e.g. if the doctor truly thought he was helping me), no one will explain any of that to me. What can patients do? How can we get information about what happened to us when things go wrong? All I want is an explanation and apology.

    • Suzi Q 38

      You may never get what you want.
      First of all, doctors are taught not to admit guilt or error.
      Second of all, Even if you complained about the most obvious and egregious errors or decisions regarding your care that you can prove, the CEO of the hospital will figure out how to explain it all away, with their “experts,” who are paid by the hospital.

      • DoubtfulGuest

        I appreciate your thoughts, Suzi Q 38. The legal system wants us to either give up or go running to a plaintiff’s attorney. So it can benefit from our suffering, and make itself appear indispensable to the doctors. It’s your choice how to handle your situation…you’ve expressed the need for apology as well, and I support you in that. I would like to see what doctors have to say to this — I’m all ears. I’m sure they can’t address our specific situations, but their profession is built on these ethical tenets and I expect them to “walk the walk”. Like I said, if I’m wrong about anything, as patients are so often assumed to be, it should all be easily explained.

        Hospital doctors were tangentially involved, but the one who changed my records, covered up his mistake, etc. is in private practice.

  • http://www.stephaniefrederick.com/ Stephanie Frederick

    Five Wishes is a living will that discusses end of life personal, emotional and spiritual needs. It’s a legal document in 42 states. When guesswork is eliminated, everyone benefits. I consider this an important starting point, and make sure advanced directives are in place when I begin to advocate for my patient-clients.

  • DoubtfulGuest

    Thanks, commenter. The state medical board wouldn’t help me any more than a lawyer would. I believe they want to give the impression of protecting the public, but they are not helpers or problem solvers. They wouldn’t give me the information I need. They often punish innocent doctors and leave the really bad ones untouched. I want a process that wouldn’t pit me against the doctor, who I really liked. He is just acting stupid for fear of being sued…I’m pretty sure that’s what caused the whole problem to begin with.

  • Deceased MD

    The board is lame. They won’t do anything.

    • DoubtfulGuest

      Except destroy the occasional innocent person…

      • Deceased MD

        My disqus does not work so I feel fortunate to stumble upon your message. I have tried to ask them to fix it but to no avail. Anyway I digress.

        I read both your comments and i am very sorry you went through all this. I never realized until reading this site how corrupt the medical society and medical boards are. And I agree it leaves the pt holding onto the horrors of it all. even worse. nothing is done that is productive which makes one either feel like they are crazy or that the medical society is,— or they are not so “ethical” as their name implies. i agree it must be just self serving. In addition i think there is a certain amount of incompetence involved. Rather than try to acknowledge a problem, they immediately fell threatened and bring in the lawyers. In a way it proves to me that whatever your problem was with the doctor, you had an authentic issue. (Not doubting you at all–no pun intended by your pen name).
        But it is obvious from their reaction to you, that they were threatened by you. Again not that you were threatening but what you brought to them was. I suppose you may have had a real case that could go on to perhaps become a real lawsuit. And their job was to discourage you. Although the funny thing is, malpractice co will tell you that people sue when they feel that their MD blows them off-not necessarily because of a bad outcome. So I can appreciate you just wanted to hear an apology of some sort. But if your MD did that, i suppose it might admit their error.
        The other thing that a lot of MD’s don’t realize on this site, i think s that in most states even if you have an air tight case of malpractice with a 250k cap on the pain and suffering, many can’t get a lawyer to defend them.

    • DoubtfulGuest

      The local medical society is also lame. I tried that process *only* because their website makes it look like it’s not adversarial, that they help doctors and patients work out misunderstandings. And I asked in advance to make sure it would not become public record. For anyone here who doesn’t know, the medical society is a private organization, different from the state board. Anyhow, I was glad to see that in order to start the process I had to (was able to) certify that I was not suing the doctor, at least not for that period of time. I spent a lot of time writing the nicest complaint letter ever. I said upfront that if there had been misunderstandings, I wanted to work them out with the doctor. I waited > 6 months, then got a brief, lawyered up response letter saying there were misunderstandings. Oh, can you please tell me what those were which was the whole point of my asking? No, sorry, blah blah confidential process under state law blah blah, we can’t tell you anything, sorry. All that time and effort wasted for nothing. And the doctor probably hates me now because it was a time-consuming process. The medical society makes it look like an okay thing, but it’s very deceptive. I do not recommend this process to anyone.

  • rbthe4th2

    They are useless. Its why people say doctors should be sued because medical boards, lately Texas is one in the news, do absolutely nothing to police the group. Frankly it should be lower at the hospital end, peers, etc.

    • DoubtfulGuest

      Right, lawyers are looking out for…lawyers. Doctors are educated professionals who *should* police themselves. “Self, that was a crappy thing to do to my patient. Now, let’s go apologize. I’ll be watching me.”

      • rbthe4th2

        I would ask that they fix the issue. I have seen a doc say his worst case and be frank on it. I checked it out and the guy was right. I never have gone elsewhere. Honesty before all and I recommend to everyone and WHY I know he is there for patient care. I’ve even volunteered to help him out before for a Saturday am that turned into a part pm deal. Happy to do it.

        • DoubtfulGuest

          Yes, fix the problem as much as possible. I don’t know anyone who wouldn’t forgive an honest error by their doctor. Honesty is respectable. Deception turns a simple mistake into such an ugly thing. By covering it up, the doctor shows me he doesn’t care, doesn’t trust me, doesn’t think I’m reasonable, honest, or ethical myself. It’s like being accused of faking all over again.

          • rbthe4th2

            You hit the nail on the head. It also shows they’re not a leader and don’t respect themselves or the oath they took, or their fellow brothers and sisters in arms.

    • DoubtfulGuest

      Also, lest I be straying off topic, their professional organizations state clearly that as part of patient autonomy, patients have the right to make *informed* decisions about their care. And it’s the doctor’s job to give the patient *information*.

  • DoubtfulGuest

    I’m going to respond again here because it looks like Disqus ate your other reply? Sorry about that and thanks for being supportive. When I said lawyers wouldn’t help me, I meant they wouldn’t get me the explanation, apology, and compassion I need from this doctor who harmed me. I probably *could* get a lawyer to take my case, that’s just not what I want. My medical records were changed and I have the evidence. This is one of those technicalities that can sink a malpractice defense. Several people, including one of my other physicians, told me I would have a case and this doctor might be forced to settle with me. Only an attorney could tell me for sure, but I’ve chosen not to see one. This whole thing is an ethical dilemma for me as a patient. It’s a popular notion among doctors that they kind of own the moral terrain. Like patients always act in self-interest and tend not to consider this stuff, but no, sorry guys –- most of us do have morals. It’s a weird feeling to maybe have the power to ruin someone’s life, but not be able to bring anything good to the situation. Money wouldn’t fix the psychological harm from being deceived, and wrongly accused of faking my progressive neurological disease. The extent of medical harm is not yet known. The changed records MIGHT just be corrected typos that they didn’t document properly. What they’re supposed to do is put a strikethrough so we can see what was changed. There should also be a date and initials for the person making the changes. That would make it clear there was no intent to deceive. Instead, I use my imagination to TRY to convince myself the doctor meant no harm. Which is not easy, and this whole thing is wearing me down emotionally. It would be very easy for the doctor to fix it. About an hour discussion if he had the right attitude, fully explained and apologized. I would be ~ 90% better and able to forgive him. Time would heal the rest. Sorry this is so long, I just wanted to make sure my intentions are clear.

  • DoubtfulGuest

    Thanks for being supportive. When I said lawyers wouldn’t help me, I meant they wouldn’t get me the explanation, apology, and compassion I need from this doctor who harmed me. I probably *could* get a lawyer to take my case, that’s just not what I want. My medical records were changed and I have the evidence. This is one of those technicalities that can sink a malpractice defense. Several people, including one of my other physicians, told me I would have a case and this doctor might be forced to settle with me. Only an attorney could tell me for sure, but I’ve chosen not to see one. This whole thing is an ethical dilemma for me as a patient. It’s a popular notion among doctors that they kind of own the moral terrain. Like patients always act in self-interest and tend not to consider this stuff, but no, sorry guys –- most of us do have morals. It’s a weird feeling to maybe have the power to ruin someone’s life, but not be able to bring anything good to the situation. Money wouldn’t fix the psychological harm from being deceived, and wrongly accused of faking my progressive neurological disease. The extent of medical harm is not yet known. The changed records MIGHT just be corrected typos that they didn’t document properly. What they’re supposed to do is put a strikethrough so we can see what was changed. There should also be a date and initials for the person making the changes. That would make it clear there was no intent to deceive. Instead, I use my imagination to TRY to convince myself the doctor meant no harm. Which is not easy, and this whole thing is wearing me down emotionally. It would be very easy for the doctor to fix it. About an hour discussion if he had the right attitude, fully explained and apologized. I would be ~ 90% better and able to forgive him. Time would heal the rest. Sorry this is so long, I just wanted to make sure my intentions are clear. I’m not sure if the doctor is stonewalling me, or if his lawyer is trying to stir up a fight where none is needed.

    • Deceased MD

      So I am just a blogger and obviously can’t really know. But I would guess that you already know he changed the records. They make it clear in medical school never to erase anything but to cross out and initial with a date. That is absolutely the case. So there are never “typos”. It is hard to believe as a pt that a doctor would not protect you and would CYA but over the internet I can’t come up with any other explanation. I think he is not as “Ethical” or “good” as you might believe.

      I don’t pretend to know or have all the facts or be any kind of judge or jury. Just a blogger. But I am very sorry from your description of what you went through. What is that phrase”First do no harm?” Really. you should not be protecting this guy regardless of whatever you decide. Adding insult to injury. Bad enough with your illness. I am sure stressful enough.

      • DoubtfulGuest

        Thank you very much, Deceased MD. What you say about the medical society is comforting because this has been driving me nuts…it’s gaslighting, and I blame the attorneys. The medical society may want to stop a lawsuit, but I think their attorney would love it if I filed suit so he could bill for more hours. Well, he can go…jump in a lake.

        To clarify a few things, then I’ll stop prattling, because other people have raised even more serious ethical issues that deserve attention.
        1) The doctor who took down my information for the med. society was very kind and said he understood I wasn’t litigious (so either he was being fake-compassionate OR their attorney messed it up later).
        2) The records changes were for typos. Someone incorrectly transcribed the name of a doctor to whom they were trying to refer me. And they spelled my name wrong (e.g. DubotlufGuest) and the name of a disease they were trying to rule out. I don’t know if it was the doc or his staff who fixed the chart without documenting it. It’s possible there was no intent to deceive.
        3) Maybe you’re right. I’m usually good at reading people… I’ve been wrong before. My feeling
        from talking with him several times was that he’s kindhearted although extremely jumpy and defensive. He must have had some really bad experiences with patients. I learned he’s barely getting by these days because he takes care of lots of Medicare/Medicaid folks and the cuts have been so severe. I’m inclined to be compassionate but it’s hard when the evidence in my case doesn’t support that.

        I do find it interesting that there was so much suspicion about what kind of person I am…then it played out like this. After I received my correct diagnosis from a different neurologist, I filled out a chart amendment form to ask him to add that information. His staff replied that he said he wasn’t going to change his records. I should have said “You mean: he’s not going to change them *anymore*”.

        You raise another important point: There are lots of people with worse injuries from clear cut negligence and they can’t get compensation. It isn’t right. It’s all about what games the lawyers can play — not about ethics, integrity, or medical facts. I could possibly get a medium sized settlement and ruin this doctor’s life no matter what kind of person he is. Just because of the stupid records. I don’t want that. I still work and am trying hard to get better. Thanks so much for your time and your very kind responses. The reassurance means a lot.

      • rbthe4th2

        Happens all the time. Btw, Deceased, sorry to tell you this, but my doctor that started the mess up of the records stated that they were typos in the record on the official documentation when I challenged it.

        Truly you are right, but its not just patients that shouldn’t protect doctors like this. Its the admin and other healthcare professionals that shouldn’t protect them either. They make the guys on here, some of the doctors that post like you, etc. that make things worse for you all. That’s just not right.

        • Deceased MD

          agreed!

    • dontdoitagain

      I got heavily redacted medical records as well, replete with wrong dates, erroneous (or fraudulent) observations, the physicians assistant was listed as my primary surgeon, and due to the inept surgery I believe he was. I never saw the surgeon before, during or after the surgery, so who knows. This is all against the law, but who cares. Just don’t feel like it’s personal or that you are the only one being treated like dirt.

      • DoubtfulGuest

        You didn’t have a pre-surgery consult or followup? Or do you mean the day of surgery? Do you mean an actual PA, or a resident at a teaching hospital? Either way, I’m sorry for your situation. I know I’m not the only one with this kind of problem. I think it’s quite common actually. I like to solve problems, and sometimes talk too much. I’m not thrilled with lawyers. I would not judge your situation at all…maybe you needed compensation. But I find it reprehensible that patients aren’t given any other option than to engage the legal system when we have problems with a doctor. Or suck it up, I guess. Neither of those work for me, so I keep talking, to put ideas in people’s heads. If nothing else, maybe doctors will feel better to see that not everyone is out to sue them.

  • Deceased MD

    good luck! They are more incompetent than the rest.

  • http://www.chrisjohnsonmd.com/ Chris Johnson

    “So how do doctors justify from ethical standpoint their cooperation with the law enforcement in body cavity searches and other medical procedures (enemas, X-rays, etc.) done against patients’ consent and for no benefit to the patient?”

    Easy. I don’t think those things are ethical.

  • FEDUP MD

    I don’t think you will find too many physicians who would agree this is ethical. In fact, in one of these cases, the doc at the nearest ED flat out refused to have anything to do with it, and they had to cross county lines to find one.

  • Deceased MD

    I have a pit in my stomach when I read your story. I think that some surgeons in particular can have characteristics that make this sort of thing problematic. First of all, often they give you the idea of promise of fixing you. Of course they tell you the risks. but Often many are arrogant and don’t take failure on their part well at all. And failure does not even necessarily mean that they did something wrong, could also mean that the results are less than optimal than both pt and doc would want.

    Instead of acknowledging the reality of the pt, they belittle the pt by as if blaming them for making it up or even acting as if the problem that the pt complains of does not exist. Of course this is not true of all surgeons there are some good ones that can own the limitations of their craft or of themselves.

    I suppose it is easier for him to think you are out of touch with reality rather than him. Right? Of course , I am just a blogger like you and i don’t even pretend to know the complexities of your case but all I can say is I have seen this kind of thing before and you don’t sound “crazy” to me. I am very sorry for what you must be going through.

  • katerinahurd

    How do you define a minor in terms of their autonomy and their socioeconomic role (principle of justice)? How do you define a minor based on their biological or mental age? Do you support an ethical compass that navigates the interaction between a pediatrician and child patient?

  • DoubtfulGuest

    I have trouble understanding the relationship between doctors and lawyers. Doctors bash lawyers a lot, often justifiably, but they seem more enmeshed with them than most patients are. Furthermore, they often seem to know one another personally and socially, but I don’t know many patients who can say the same. I don’t have a lawyer and I don’t appreciate my doctor’s “lawyer complex” being dumped on me.

    • rbthe4th2

      Agreed. I have one who did my will, power of attorney for medical stuff. That’s it. However, yep I see the docs know some lawyers, high priced firms, very well.

  • rbthe4th2

    Yeppers! I preach this to others.

Most Popular