A comatose, ventilator-dependent, car accident victim lies in an intensive care unit while her husband and her parents discuss her future quality of life and argue about what type of care she would have wanted. This scenario may initially come to mind when the average person hears the term medical ethics. However, the concept of medical ethics is much more common in everyday practice than a dramatic ICU clash is.
In the book Clinical Ethics, Jonsen and colleagues observe that “ethical issues are imbedded in every clinical encounter between patients and caregivers because the care of patients always involves both technical and moral considerations.”2
“Because every encounter between a doctor and a patient has a moral dimension, competency in ethics is essential to being a good doctor.” Carrese, et al.1
The discipline of ethics often moves quietly through physician-patient interactions. For example, a 21-year-old male patient comes to a dermatologist with severe acne. He has had the condition since the age of 14, and he is still experiencing persistent pimples, pustules and inflamed cysts on his face and back. The dermatologist takes the patient’s history, examines him and recommends a prescription topical treatment combined with a course of oral antibiotics. This treatment clears much of the patient’s acne. In addition to being a clinical interaction, this is an ethical interaction. When a patient requested help, the dermatologist used her ability and training to benefit the patient and to do him no harm, fulfilling the ethical obligations accepted by doctors since the fifth century B.C.E., expressed in the Oath of Hippocrates.
The Connection Between Risk Management and Ethics
The concept of risk management in healthcare began in the 1970s. As more hospitals and physicians were successfully sued for damages by patients and their families, the discipline of risk management began to be applied by hospital administrators and by physicians’ professional liability insurance companies to predict and reduce the losses from lawsuits.3 Adapted to the healthcare setting, risk management aims to avert medical errors and preventable adverse events to protect physicians and institutions from financial losses. Professionals in the field of risk management identify and analyze problems that have occurred in care, and they develop and implement techniques to improve experience by minimizing patient injuries.3
Bioethics is the branch of knowledge that concerns physicians’ and other healthcare providers’ and entities’ moral obligations to patients.4 Ethicists seek to identify and analyze moral questions or disputes associated with patient care and to reach a reasonable conclusion about proper or best ways to proceed.4
The two disciplines — risk management and ethics — are alike in that both call for the scrutiny of information about patients’ substandard experiences in healthcare, and both advocate the application of techniques that will reduce difficulties, conflicts and problems so that patients’ experiences will ultimately get better. An unresolved moral issue in patient care is a potential liability exposure; therefore, recommending ways to resolve clinical ethical issues is a means for reducing overall lawsuit risks, which is the fundamental goal of risk management.
Four Basic Principles of Medical Ethics
Many physicians may be familiar with four basic principles of medical ethics developed by ethicists Beauchamp and Childress:6
- Beneficence describes the concept of acting for the patient’s good.
- Nonmaleficence describes the concept of doing no harm.
- Autonomy conveys the idea that each patient has a right to voice his or her own values and choices about care.
- Justice expresses the idea that healthcare resources should be equitably distributed among patients and that patients should be treated fairly.6,7,8
These four principles can clarify ethical problems and help resolve them, according to Beauchamp and Childress as well as other ethicists. The four principles are useful for identifying the core theme of an ethical issue. For example, an internist diagnoses cellulitis on a 71-year-old female patient’s lower left leg and prescribes an oral antibiotic for the patient. This interaction depicts the principle of beneficence — the physician is acting in the best interests of the patient. If the patient refuses to take the antibiotic and will only agree to non-medicinal therapies such as elevation, immobilization and saline dressings for her leg, the principle of autonomy becomes prominent in the interaction.
Beauchamp and Childress assert that the four principles are non-hierarchical and that “balancing these principles provides a useful framework for understanding and resolving conflicts.”7 Bioethicist Mary B. Mahowald goes further by suggesting guidelines to help adapt the four principles to specific clinical ethics challenges. She proposes:9
- The interests of the patient count most. [She states that patients’ interests equal the amalgamation of autonomy + beneficence + nonmaleficence.]
- Respect for patient autonomy trumps beneficence and nonmaleficence.
- The interests of others may outweigh respect for patient autonomy. [For example, the interests of a physician to stay within the standard of care surpass a patient’s demand for an eccentric, unproven treatment.]
- If harms and benefits [of a treatment course] are proportionate, nonmaleficence outweighs beneficence.
If every medical encounter has an ethical component, then summaries of closed malpractice claims, which exhibit various interactions with patients, can serve as a source for ethical themes in healthcare. It stands to reason, therefore, that physicians and other healthcare professionals can learn something more about ethics by studying a series of claims and contemplating their ethical features. The cases linked below focus on specific patient interactions in which it was vital for the involved physician to establish good communication to create a therapeutic alliance. Most cases occurred in ordinary ambulatory practice settings.
In case studies listed below, we look at a series of closed malpractice cases that all deal with common interactions physicians have with patients. These claims contain both ethical and risk management features. After presenting each case, we will discuss its ethical elements using the ideas of Beauchamp, Childress, Mahowald and other ethicists. Then we will explore risk management facets of the case by giving medical liability risk management recommendations that may help lower the risk that patients will be injured, thus decreasing the likelihood that future medical liability lawsuits will be filed.
Several of the lawsuits described were dismissed or withdrawn — they did not result in plaintiffs’ verdicts or settlements. Many of the physicians in the cases acted ethically and within the standard of care. This is usually true in medicine: physicians are generally used to wading through ethical tides, negotiating the ebbs and surges. However, being able to investigate “the specific content of ethics experiences” can help you to sharpen “the skills necessary to identify, analyze and manage ethics issues arising in everyday practice.”10 Reflecting about what you would do if faced with similar challenges is a way of preparing in advance to suitably balance ethical principles, boost the quality of your care and help protect against the risk of lawsuits.
More Information About Medical Ethics and Physician-Patient Encounters
- Closed Claim Case Study: Patient Demand for Unconventional Care Presents an Ethical Dilemma for Physicians
- Closed Claim Case Study: When Patients Refuse Treatment: Medical Ethics Issues for Physicians
- Closed Claim Case Study: Personal Relationship With a Patient Leads to Below Standard Care
- Closed Claim Case Study: Patient Confidentiality: Understanding the Medical Ethics Issues
- Closed Claim Case Study: Cultural Bias in Health Care Delivery Causes Communication Problems and Poor Outcome
- Closed Claim Case Study: Medical Ethics Issues with Shared Decision-Making in Patient Encounters
- Closed Claim Case Study: Improper Informed Consent Leads to Allegation of Negligent Supervision
- Closed Claim Case Study: Ethical Dilemmas with Disclosing Medical Errors
1. Carrese JA, McDonald EL, Moon M, et al. Everyday ethics in internal medicine resident clinic: an opportunity to teach. Medical Education. 2011;45(7):712-721.
2. Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 7th ed. New York, NY: McGraw Hill; 2010:1.
3. McCaffre JJ, Hagg-Rickert S. Development of a risk management program. In Carroll R, Nakamura PLB, eds., Risk Management Handbook for Health Care Organizations: The Essentials. Vol. 1. San Francisco, CA: Jossey-Bass; 2006:87-114.
4. Zimmet SC. Ethics in patient care. In Carroll R, Nakamura PLB, eds., Risk Management Handbook for Health Care Organizations: The Essentials. Vol. 1. San Francisco, CA: Jossey-Bass; 2006:169-211.
5. Jonsen AR, et al.:2.
6. Beauchamp TL, Childress JF. Part II: moral principles. Principles of Biomedical Ethics. 7th ed. New York, NY: Oxford University Press; 2012:99-288.
7. DiGiovanni LM. Ethical issues in obstetrics. Obstetrics and Gynecology Clinics of North America. 2010;37(2):345-357.
8. Jonsen AR, et al.:162.
9. Mahowald MB. Bioethics and Women: Across the Life Span. New York, NY: Oxford University Press; 2006:17.
10. Moon M, Taylor HA, McDonald EL, et al. Everyday ethics issues in the outpatient clinical practice of pediatric residents. Archives of Pediatrics and Adolescent Medicine. 2009;163(9):838-843.