Ethical Dilemmas in Patient Care: Decision Making Frameworks and Legal Considerations

Ethics in Clinical Practice

Ethics is an inherent and inseparable part of clinical practice, encompassing the study of the nature of morals and the specific moral choices to be made.1 The fundamental principles of ethics-beneficence, non-maleficence, autonomy, and justice-play a significant role in the decision-making frameworks of modern medicine.

While autonomy and justice evolved later in the history of medicine, beneficence and non-maleficence date back to the time of Hippocrates, epitomised by the principle "to help and do no harm." In clinical practice, these principles manifest as providing efficient treatment, preventing errors, obtaining informed consent, and eliminating discrimination.

Historical Context and Lessons Learnt

Historically, significant events like the Thalidomide tragedy, the Syphilis Study at Tuskegee, and the real-life story depicted in the Netflix show Bad Surgeon: Love Under the Knife have shaped current bioethical practices. These cases involve the abuse of human subjects across different time periods, including the unintended effects of a well-intentioned drug, medical interventions and experimentation without prior informed consent, and the withdrawal of treatment, causing harm to subjects. The harm caused to these individuals and their loved ones remains irreparable despite the exposure of these issues.

In response to such events, legal proceedings and guidelines such as the Nuremberg Code 1947, the Declaration of Geneva, the Helsinki Declaration 1964, the ICH GCP 1996 (International Conference on Harmonisation, Good Clinical Practice), the European Clinical Trials Directive 2001, and many more were established to ensure the dignified and respectful treatment of human subjects.

Modern Ethical Dilemmas and Decision-Making Models

Today, ethical dilemmas in patient care take various forms, including bias and risk associated with algorithms and Artificial Intelligence (AI) systems, the boundaries of human enhancement, unintended consequences in gene editing, and end-of-life care decisions for paediatric patients.

Several decision-making models and theories guide ethical deliberations, including utilitarianism and deontology.

Utilitarianism prioritises collective welfare and maximising overall happiness, even if it requires sacrificing the interests of a few for the greater good.5 Deontology, on the other hand, focuses on adhering to moral duties and rules, prioritising individual autonomy and rights, even if it results in less overall happiness.

The Goals of Ethics Education and Addressing Ethical Dilemmas

The goals of ethics education include:

• Understanding the ethical dimensions of patient care and the medical profession.
• Mastering core ethical behavioural skills.
• Recognising commonly encountered ethical issues.

When dealing with ethical dilemmas, it is crucial to:

• Be medically and technically competent.
• Balance professional virtues like discernment, integrity, compassion, trustworthiness, and conscientiousness.
• Maintain an equilibrium between universal ethical principles and cultural/religious values.
• Be transparent and fair.
• Assess cost-effectiveness.

Evaluate public health considerations.

Legal Considerations

Legal frameworks vary across countries and different age groups.

• For children, the age to make independent healthcare decisions varies by jurisdiction. The complexity of informed decisions involves both guardians and the child.
• For senior citizens with no decision-making capacity, decisions for further care consider:

ü  The patient’s previously expressed wishes (when competent).

ü  The family's informed decision.

ü  The physician’s knowledge of the best next step.

This decision could involve end-of-life care or continued interventions.

Understanding fundamental ethical principles, considering significantly influential factors, and applying decision-making models help physicians provide the best patient care while navigating ethical dilemmas.

Dr. Catherine Nixon