Clinical Ethics

Introduction :
The Four Topics and Case
Analysis
Alex Hsu Cheng-Dien, MD

Medical Ethics ()

[vs. Professional ethics]

Principals to guide physicians in their
relationships with others

Ethical dilemma is a predicament in which
there is no clear course to resolve the
problem of conflicting moral principles

Dynamic environment/evolving field

Moral Principles in
Medical Ethics

Autonomy ()

Beneficience ()

Nonmaleficence ()

Justice ()

Autonomy ()

Right to self-determination

Requires decision making capacity
Lack should be proven not assumed

Competence legal determination

Liberty freedom to influence course of
life/treatment

Paternalism ()

Justifiable if patient at risk of significant

preventable harm, paternalistic action will
prevent harm, benefits outweigh risks and
the least autonomy-restrictive course of
action is used

Beneficience ()

Obligation to preserve life, restore health,

relieve suffering and maintain function

To do good

Nonabandonment obligation to provide
ongoing care

Conflict of interest must not engage in
activities that are not in patients best
interest

Nonmaleficence ()

Do no harm, prevent harm and remove

harm

Principle of Double Effect

Act must be morally good

Actor intends good effect

Good effect outweighs bad effect

Bad effect not means to good effect

Justice ()

Allocation of medical resources must be

fair and according to need

Physicians should not make decisions
regarding individuals based upon societal
needs

Clinical Ethics ()

Definition:
A Structured Approach for Identifying, Analyzing, and
resolving Ethical Issues in Clinical Medicine

Moral Values:
Mutual Respect, Honesty, Trustworthiness, Compassion,
Commitment to pursue shared goals

Complexities of ethical issues in Clinical care

Typical Ethical Question

Four Topics of
Clinical Ethics

Medical indication ()

Patient preferences ()

Quality of Life ()

Contextual features ()

Medical Indication
Principles of Beneficence and Nonmaleficence

What is the patients medical problem? history?
diagnosis? Prognosis?

Is the problem acute? chronic? critical? emergent?
reversible?

What are the goals of treatment?

What are the probabilities of success?

What are the plans in case of therapeutic failure?

In sum, how can this patient be benefited by medical
and nursing care, and how can harm be avoided?

Patient Preference
Principles of Respect for Autonomy

Is the patient mentally capable and legally competent?
Is there evidence of incapacity?

If competent, what is the patient stating about
preferences for treatment?

Has the patient been informed of benefits and risks,
understood this information, and given consent?

If incapacitated, who is the appropriate surrogate? Is the
surrogate using appropriate standards for decision
making?

Has the patient expressed prior preferences, e.g.,
Advance Directives?

Is the patient unwilling or unable to cooperate with
medical treatment? If so, why?

In sum, is the patients right to choose being respected
to the extent possible in ethics and law?

Quality of Life
Principles of Beneficence and Nonmaleficence
and Respect for Autonomy

What are the prospects, with or without treatment, for a
return to normal life?

What physical, mental, and social deficits is the patient
likely to experience if treatment succeeds?

Are there biases that might prejudice the providers
evaluation of the patients quality of life?

Is the patients present or future condition such that his
or her continued life might be judged undesirable?

Is there any plan and rationale to forgo treatment?

Are there plans for comfort and palliative care?

Contextual Features
Principles of Loyalty and Fairness

Are there family issues that might influence treatment
decisions?

Are there provider (physicians and nurses) issues that might
influence treatment decisions?

Are there financial and economic factors?

Are there religious or cultural factors?

Are there limits on confidentiality?

Are there problems of allocation of resources?

How does the law affect treatment decisions?

Is clinical research or teaching involved?

Is there any conflict of interest on the part of the providers
or the instructions?

Application of Four Ethics Topics

(1)

Help clinicians understand how the ethical principles
connect with the circumstances of the clinical case

Ethical reflection: interpretation and assessment of
principles in the light of the actual circumstances of the
case

Ethical judgment: appreciating how ethical principles
should be interpreted in the actual situation under
consideration (ex: Refusal of Treatment or Jehovahs
Witnesses. ); all principles and all the facts of case must
be viewed together in order to make a balanced judgment

Application of Four Ethics Topics

(2)

The four topics might serve as the outline for a discussion
among providers, patient, and family at the time of
admission to an extended-care facility or to hospice care

A copy of the four topics could be given to patient and
family ; various questions then could be asked and the
answers recorded

This initial record could be reviewed as the patients
situation changes and as particular decisions must be
made

DNR

DNR orders affect CPR only

Other therapies should not be influenced
by DNR order

Should be reviewed frequently

Rationale should be in medical record

Case Analysis:
Daxs Case

Donald Dax Cowart, 25y/o handsome, athletic young
man before his propane gas explosion accident; he got
severe burns(3rd-degree) over 65% of his body, face and
hands.

After 232-day Burn ICU hospitalization and 6-month stay
rehabilitation treatment, he was discharged totally blind,
with minimal use of his hands, badly scarred, and depend
on others for assistance with personal functions.

Dax repeatedly insisted that treatment be discontinued
and that he be allowed to die, but his mother and duty
doctor continued.

Four Topics of
Clinical Ethics in Daxs Case

Medical indication: A clear view of the possible
benefits of intervention is the first step in assessing the
ethical aspect of a case

Patient preferences: the patients own values and

personal assessment of benefits and burdens are ethically

relevant

Quality of Life: one goal of medical intervention is to

restore, maintain, or improve quality of life

Contextual features: the context itself is affected by

the decisions made by or about the patient (Ex:
psychological, emotional, financial, legal, scientific,
educational, or religious impacts)

Sources in Medical Ethics

Books: Beauchamp and Childresss Principles of
Biomedical Ethics; Bernard Los Resolving Ethical
Dilemmas. Guide to Clinicians; Ethical Dilemmas in
Pediatrics; Encyclopedia of Bioethics.

Journals: Hastings Center Report; Journal of Clinical

Ethics; American Journal of Bioethics; Journal of Medical
Ethics, Cambridge Quarterly of Healthcare Ethics.

Websites: www.georgetown.edu/research/nrcb/orgs.htm;
http://www.nih.gov/sigs/bioethics; www.bioethics.org;
http://www.cmaj.ca;

Perhaps Love

Forever Memory