Medical ethics

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Medical ethics is the study of moral values as they apply to medicine. In many cases, moral values can be in conflict, and ethical crises can result.

Medical ethics shares many principles with other branches of healthcare ethics, such as nursing ethics.

Writers about medical ethics have suggested many methods to help resolve conflicts involving medical ethics. Sometimes, no good solution to a dilemma in medical ethics exists, and occasionally, the values of the medical community (i.e., the hospital and its staff) conflict with the values of the individual patient, family, or larger non-medical community.

Contents 1 Values in medical ethics 2 Informed consent 3 Beneficence 4 Autonomy 5 Non-maleficance 6 Importance of communication 7 Ethics committees 8 Cultural concerns 8.1 Truth-telling 9 Conflicts of interest 9.1 Self-referral 9.2 Vendor relationships 9.3 Treatment of family members 9.4 Sexual relationships 10 Futility 11 See also 11.1 Reproductive medicine 11.2 Medical research 11.3 Famous cases in medical ethics 11.4 Distribution and utilization of research and care 12 References 13 External links

[edit] Values in medical ethics

Six of the values that commonly apply to medical ethics discussions are:

• Beneficence - a practitioner should act in the best interest of the patient. (Salus aegroti suprema lex.)
• Non-maleficence - "first, do no harm" (primum non nocere).
• Autonomy - the patient has the right to refuse or choose their treatment. (Voluntas aegroti suprema lex.)
• Justice - concerns the distribution of scarce health resources, and the decision of who gets what treatment.
• Dignity - the patient (and the person treating the patient) have the right to dignity.
• Truthfulness and honesty - the concept of informed consent has increased in importance since the historical events of the Nuremberg trials and Tuskegee Syphilis Study

Values such as these do not give answers as to how to handle a particular situation, but provide a useful framework for understanding conflicts. Conflicts in ethical values lead to ethical dilemmas. Many times these conflicts exist between the patient and family, and the medical care providers. Conflicts can also arise between health care providers, or among family members. For example, the principles of autonomy and beneficence clash when patients refuse life-saving blood transfusion, and truth-telling was not emphasized to a large extent before the HIV era.

To reconcile conflicting principles, Bernard Gert, a philosopher who specializes in medical ethics, propounds a theory that would require one to advocate an action publicly if one were to violate any basic moral principles (e.g., break a promise in order to save a life). Other philosophers, such as R. M. Hare, would require one to formulate a universal prescription in conformance with logic, such that all rational parties, including the patient (assuming he is rational), would subscribe to the same action in all circumstances that share the same essential properties.

In the United Kingdom, General Medical Council provides clear modern guidance in the form of its 'Good Medical Practice' statement.

[edit] Informed consent

Main article: Informed consent

Informed Consent in ethics usually refers to the idea that an uninformed agent is at risk of mistakenly making a choice not reflective of his or her values. It does not specifically mean the process of obtaining consent, nor the legal requirements for decision-making capacity.

[edit] Beneficence

[edit] Autonomy

[edit] Non-maleficance

[edit] Importance of communication

Many so-called "ethical conflicts" in medical ethics are traceable back to a lack of communication. Communication breakdowns between patients and their healthcare team, between family members, or between members of the medical community, can all lead to disagreements and strong feelings. These breakdowns should be remedied, and many apparently insurmountable "ethics" problems can be solved with open lines of communication.

[edit] Ethics committees

Many times, simple communication is not enough to resolve a conflict, and a hospital ethics committee, comprised of heath care professionals, clergy, and lay people, must convene to decide a complex matter.

[edit] Cultural concerns

Culture differences can create difficult medical ethics problems. Some cultures have spiritual or magical theories about the origins of disease, for example, and reconciling these beliefs with the tenets of Western medicine can be difficult.

[edit] Truth-telling

Some cultures do not place a great emphasis on informing the patient of the diagnosis, especially when cancer is the diagnosis. Even American culture did not emphasize truth-telling in a cancer case, up until the 1970s. In American medicine, the principle of informed consent takes precedence over other ethical values, and patients are usually at least asked whether they want to know the diagnosis.

[edit] Conflicts of interest

Physicians should not allow a conflict of interest to influence medical judgment. In some cases, conflicts are hard to avoid, and doctors have a responsibility to avoid entering such situations.

[edit] Self-referral

For example, doctors who receive income from referring patients for medical tests have been shown to refer more patients for medical tests ^[1]. This practice is proscribed by the American College of Physicians Ethics Manual ^[2].

[edit] Vendor relationships

Studies show that doctors can be influenced by drug company inducements, including gifts and food. ^[3] Industry-sponsored Continuing Medical Education (CME) programs influence prescribing patterns. ^[4] Many patients surveyed in one study agreed that physician gifts from drug companies influence prescribing practices. ^[5] A growing movement among physicians is attempting to diminish the influence of pharmaceutical industry marketing upon medical practice, as evidenced by Stanford University's ban on drug company-sponsored lunches and gifts. Other academic institutions that have banned pharmaceutical industry-sponsored gifts and food include the University of Pennsylvania, and Yale University. ^[6]

[edit] Treatment of family members

Many doctors treat their family members. Doctors who do so must be vigilant not to create conflicts of interest or treat inappropriately.^[7][8].

[edit] Sexual relationships

Sexual relationships between doctors and patients can create ethical conflicts, since sexual consent may conflict with the fiduciary responsibility of the physician. Doctors who enter into sexual relationships with patients face the threats of deregistration and prosecution. It is estimated that between 2% and 9% of doctors have violated this rule based on a study in the early 1990s ^[9].

[edit] Futility

Advanced directives include living wills and durable powers of attorney for healthcare. (See also Do Not Resuscitate and cardiopulmonary resuscitation) In many cases, the "expressed wishes" of the patient are documented in these directives, and this provides a framework to guide family members and health care professionals in decisionmaking when the patient is incapacitated. Undocumented expressed wishes can also help guide decisionmaking, in the absence of advanced directives. "Substituted judgement" is the concept that a family member can give consent for treatment if the patient is unable (or unwilling) to give consent himself. The key question for the decisionmaking surrogate is not, "What would you like to do," but instead, "What do you think the patient would want in this situation." Courts have supported family's arbitrary definitions of futility to include simple biological survival, as in the Baby K case. A more in-depth discussion of futility is available at medical futility.

• Baby Doe Law Establishes state protection for a disabled child's right to life, ensuring that this right is protected even over the wishes of parents or guardians in cases where they want to withhold treatment.

[edit] See also

• Euthanasia
• Hastings Center
• Hippocratic Oath
• Medical Law International
• World Medical Association

[edit] Reproductive medicine

• Accessibility of abortion
• Bioethics of neonatal circumcision
• Cloning
• Eugenics
• Genetic manipulation

[edit] Medical research

• Animal research
• CIOMS Guidelines
• Common rules. Adopted by 17 United States departments and agencies (1991).
• Nuremberg Code
• Declaration of Geneva
• Declaration of Helsinki
• Declaration of Tokyo
• Good Clinical Practice (FDA)
• [2]. Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule
• Patients' Bill of Rights
• Universal Declaration of Human Rights

[edit] Famous cases in medical ethics

Many famous cases in medical ethics illustrate and helped define important issues.

• Willowbrook Study
• Tuskegee Study
• Terry Schiavo
• Jack Kervorkian
• Nancy Cruzan
• Karen Ann Quinlan
• Baby K

[edit] Distribution and utilization of research and care

• Accessibility of health care
• Basis of priority for organ transplantation
• Institutionalization of care access through HMOs and medical insurance companies

[edit] References

1. ^ Swedlow A, Johnson G, Smithline N, Milstein A (1992). "Increased costs and rates of use in the California workers' compensation system as a result of self-referral by physicians". N Engl J Med 327 (21): 1502-6. PMID 1406882. 
2. ^ (1998) "Ethics manual. Fourth edition. American College of Physicians". Ann Intern Med 128 (7): 576-94. PMID 9518406. 
3. ^ Güldal D, Semin S (2000). "The influences of drug companies' advertising programs on physicians". Int J Health Serv 30 (3): 585-95. PMID 11109183. 
4. ^ Wazana A (2000). "Physicians and the pharmaceutical industry: is a gift ever just a gift?". JAMA 283 (3): 373-80. PMID 10647801. 
5. ^ Blake R, Early E. "Patients' attitudes about gifts to physicians from pharmaceutical companies". J Am Board Fam Pract 8 (6): 457-64. PMID 8585404. 
6. ^ [1] LA Times, "Drug money withdrawals: Medical schools review rules on pharmaceutical freebies," posted 2/12/07, accessed 3/6/07]
7. ^ La Puma J, Stocking C, La Voie D, Darling C (1991). "When physicians treat members of their own families. Practices in a community hospital". N Engl J Med 325 (18): 1290-4. PMID 1922224. 
8. ^ La Puma J, Priest E (1992). "Is there a doctor in the house? An analysis of the practice of physicians' treating their own families". JAMA 267 (13): 1810-2. PMID 1545466. 
9. ^ Gartrell N, Milliken N, Goodson W, Thiemann S, Lo B (1992). "Physician-patient sexual contact. Prevalence and problems". West J Med 157 (2): 139-43. PMID 1441462. 

[edit] External links

• BMJJournals.com - An international peer review journal for health professionals and researchers in medical ethics