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'''Medical ethics''' is the discipline of evaluating the merits, risks, and social concerns of activities in the field of [[medicine]].
{{Ethics}}
'''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]].
Medical ethics shares many principles with other branches of [[healthcare]] ethics, such as [[nursing ethics]].


Ethical thinkers have suggested many methods to help evaluate the [[ethics]] of a situation. These methods provide principles that [[physician|doctors]] should consider while making decisions.
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.


Six of the principles commonly included are:
==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''.)
* [[Beneficence]] - a practitioner should act in the best interest of the patient. (''Salus aegroti suprema lex''.)
* [[Primum non nocere|Non-maleficence]] - "first, do no harm" (''primum non nocere'').
* [[Primum non nocere|Non-maleficence]] - "first, do no harm" (''primum non nocere'').
Line 11: Line 13:
* [[Justice]] - concerns the distribution of scarce health resources, and the decision of who gets what treatment.
* [[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.
* [[Dignity]] - the patient (and the person treating the patient) have the right to dignity.
* [[Truth|Truthfulness]] and [[honesty]] - the patient should not be lied to, and deserves to know the whole truth about his/her illness and treatment.
* [[Truth|Truthfulness]] and [[honesty]] - the concept of [[informed consent]] has increased in importance since the historical events of the [[Nuremberg trials]] and [[Tuskegee Syphilis Study]]


Principles such as these do not give answers as to how to handle a particular situation, but guide doctors on what principles ought to apply to actual circumstances.  The principles sometimes contradict each other leading to ethical dilemmas. For example, the principles of autonomy and beneficence clash when patients refuse life-saving [[blood transfusion]], and truthfulness may not always be upheld regarding the use of [[placebo]]s in some instances.
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 us to advocate our action publicly if we 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 us 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  '[http://www.gmc-uk.org/guidance/good_medical_practice/index.asp Good Medical Practice]' statement.
 
==Informed consent==
{{main|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]].  Patients can elect to make their own medical decisions, or can delegate decision-making authority to another party.  In some cases, the patient may be incapacitated, in which case U.S. state law designates a process for obtaining informed consent.  In some American states, family members have differing levels of precedence over one another in making medical decisions for the patient, while other states recognize all family members equally in making medical decisions.
 
The value of informed consent is closely related to the values of autonomy and truth telling.  American culture places a high value on these principles, finding justification in the U.S. Constitution and Declaration of Independence.
{{sectstub}}


In the United Kingdom, [[General Medical Council]] provides clear modern guidance in the form of its '[http://www.gmc-uk.org/guidance/good_medical_practice/index.asp Good Medical Practice]' statement.
==Confidentiality==
{{main|Confidentiality}}
'''Confidentiality''' is commonly applied to conversations between doctors and patients.  This concept is commonly known as patient-physician privilege.  Legal protections prevent physicians from revealing their discussions with patients, even under oath in court.  Confidentiality is mandated in [[America]] by [[HIPAA]] laws, specifically the Privacy Rule.  Confidentiality is challenged in cases such as the diagnosis of a sexually transmitted disease in a patient who refuses to reveal the diagnosis to a spouse, or in the termination of a pregnancy in an underage patient, without the knowledge of the patient's parents. Many states in the U.S. have laws governing parental notification in underage abortion[http://www.ncsl.org/programs/health/adolabor.htm]


==Beneficence==
==Beneficence==
Inevitably, beneficence is judged by the physician as biased by his own experiences and beliefs.  The definition of "best interests of the patient" also changes over time.  The definition of beneficence, so far, has remained the prerogative of physicians as protected by the American Judiciary branch of government, though the Legislative and Executive branches of the U.S. Government attempted to insert themselves into the discussion of beneficence in the [[Terry Schiavo]] case.   
{{sectstub}}
 
==Autonomy==
{{sectstub}}
 
==Non-maleficence==
{{sectstub}}
The concept of non-maleficence is embodied by the phrase, "first, do no harm," or the latin, ''[[primum non nocere]]''.  Physicians are obligated under medical ethics to not prescribe medications they know to be harmful.  American physicians interpret this value to exclude the practice of [[euthanasia]], though not all concur.  Probably the most extreme example in recent history of the violation of the non-maleficence dictum was Dr. [[Jack Kevorkian]], who was convicted of second-degree homicide in Michigan in 1998 after demonstrating active euthanasia on the TV news show, 60 Minutes.
 
Non-maleficence is a legally definable concept.  Violation of non-maleficence is the subject of [[medical malpractice]] litigation.
===Double effect===
Some interventions undertaken by physicians can create a positive outcome while also potentially doing harm.  The combination of these two circumstances is known as the "double effect."  The most applicable example of this phenomenon is the use of morphine in the dying patient.  Such use of morphine can ease the pain and suffering of the patient, while simultaneously hastening the demise of the patient through suppression of the respiratory drive.
 
==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. 
 
==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.
 
==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. 
===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.
 
==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.
===Self-referral===
For example, doctors who receive income from referring patients for medical tests have been shown to refer more patients for medical tests <ref name="pmid1406882">{{cite journal |author=Swedlow A, Johnson G, Smithline N, Milstein A |title=Increased costs and rates of use in the California workers' compensation system as a result of self-referral by physicians |journal=N Engl J Med |volume=327 |issue=21 |pages=1502-6 |year=1992 |pmid=1406882}}</ref>. This practice is proscribed by the American College of Physicians Ethics Manual <ref name="pmid9518406 | ">{{cite journal |author= |title=Ethics manual. Fourth edition. American College of Physicians |journal=Ann Intern Med |volume=128 |issue=7 |pages=576-94 |year=1998 |pmid=9518406 | url=http://www.annals.org/cgi/content/full/128/7/576}}</ref>.
===Vendor relationships===
Studies show that doctors can be influenced by drug company inducements, including gifts and food.
<ref>{{cite journal |author=Güldal D, Semin S |title=The influences of drug companies' advertising programs on physicians |journal=Int J Health Serv |volume=30 |issue=3 |pages=585-95 |year=2000 |pmid=11109183}}</ref>
Industry-sponsored Continuing Medical Education (CME) programs influence prescribing patterns.
<ref>{{cite journal |author=Wazana A |title=Physicians and the pharmaceutical industry: is a gift ever just a gift? |journal=JAMA |volume=283 |issue=3 |pages=373-80 |year=2000 |pmid=10647801}}</ref>
Many patients surveyed in one study agreed that physician gifts from drug companies influence prescribing practices.
<ref>{{cite journal |author=Blake R, Early E |title=Patients' attitudes about gifts to physicians from pharmaceutical companies |journal=J Am Board Fam Pract |volume=8 |issue=6 |pages=457-64 |year= |pmid=8585404}}</ref>
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.
<ref>[http://www.montereyherald.com/mld/montereyherald/living/health/16680875.htm] LA Times, "Drug money withdrawals:
Medical schools review rules on pharmaceutical freebies," posted 2/12/07, accessed 3/6/07]</ref>
 
===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.<ref name="pmid1922224">{{cite journal |author=La Puma J, Stocking C, La Voie D, Darling C |title=When physicians treat members of their own families. Practices in a community hospital |journal=N Engl J Med |volume=325 |issue=18 |pages=1290-4 |year=1991 |pmid=1922224}}</ref><ref name="pmid1545466">{{cite journal |author=La Puma J, Priest E |title=Is there a doctor in the house? An analysis of the practice of physicians' treating their own families |journal=JAMA |volume=267 |issue=13 |pages=1810-2 |year=1992 |pmid=1545466}}</ref>.
===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 <ref name="pmid1441462">{{cite journal |author=Gartrell N, Milliken N, Goodson W, Thiemann S, Lo B |title=Physician-patient sexual contact. Prevalence and problems |journal=West J Med |volume=157 |issue=2 |pages=139-43 |year=1992 |pmid=1441462}}</ref>.


===Common medical ethical dilemmas===
==Futility==
====Conflicts-of-interest====
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."
One aspect to beneficence is that the physician should not allow a conflict-of-interest to influence medical judgment. For example, doctors who receive income from referring patients to medical tests have been shown to refer more patients for medical tests <ref name="pmid1406882">{{cite journal |author=Swedlow A, Johnson G, Smithline N, Milstein A |title=Increased costs and rates of use in the California workers' compensation system as a result of self-referral by physicians |journal=N Engl J Med |volume=327 |issue=21 |pages=1502-6 |year=1992 |pmid=1406882}}</ref>. This practice is proscribed by the American College of Physicians Ethics Manual <ref name="pmid9518406 | ">{{cite journal |author= |title=Ethics manual. Fourth edition. American College of Physicians |journal=Ann Intern Med |volume=128 |issue=7 |pages=576-94 |year=1998 |pmid=9518406 | url=http://www.annals.org/cgi/content/full/128/7/576}}</ref>.
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]].


==== Sexual relationships ====
* [[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.
Sexual relationships between doctors and patients have been discouraged since the [[Hippocratic Oath]], which states, "In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves."  This has traditionally been taken to mean that sexual relationships between doctors and patients are to be avoided.  Doctors who violate this rule 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 <ref name="pmid1441462">{{cite journal |author=Gartrell N, Milliken N, Goodson W, Thiemann S, Lo B |title=Physician-patient sexual contact. Prevalence and problems |journal=West J Med |volume=157 |issue=2 |pages=139-43 |year=1992 |pmid=1441462}}</ref>. One pundit declares to physicians, "You can make your mistress your patient, but you cannot make your patient your mistress."


====Treatment of family members====
==See also==
Increasingly, it is seen as inappropriate for doctors to treat members of their own family (partners, parents, children, etc.)<ref name="pmid1922224">{{cite journal |author=La Puma J, Stocking C, La Voie D, Darling C |title=When physicians treat members of their own families. Practices in a community hospital |journal=N Engl J Med |volume=325 |issue=18 |pages=1290-4 |year=1991 |pmid=1922224}}</ref><ref name="pmid1545466">{{cite journal |author=La Puma J, Priest E |title=Is there a doctor in the house? An analysis of the practice of physicians' treating their own families |journal=JAMA |volume=267 |issue=13 |pages=1810-2 |year=1992 |pmid=1545466}}</ref>. The reasons given for this is that the patient may not be able to be open and honest about their condition, given the family relationship, and that the family relationship may be used to pressure the patient in to agree to treatment they might otherwise have not, thus interfering with their autonomy. On the other hand, however, patients with a doctor in their family may prefer to seek treatment from them, due to the greater trust they have in them, the greater convenience they represent, and in some cases their ability to use the family relationship to pressure or manipulate the physician into providing treatment they might otherwise see as inappropriate in the patient's circumstances (e.g. appetite suppressants, drugs of addiction). In the past this behavior has not always been seen so negatively by the profession, and it still sometimes continues.
*[[Euthanasia]]
*[[Hastings Center]]
*[[Hippocratic Oath]]
*[[Medical Law International]]
*[[World Medical Association]]


==Reproductive medicine==
===Reproductive medicine===
*Accessibility of [[abortion]]
*Accessibility of [[abortion]]
*[[Bioethics of neonatal circumcision]]
*[[Bioethics of neonatal circumcision]]
Line 39: Line 95:
*[[genetics|Genetic]] manipulation
*[[genetics|Genetic]] manipulation


==Medical research==
===Medical research===
*[[Animal_testing|Animal research]]
*[[Animal_testing|Animal research]]
*[[Belmont Report]] stated three ethical principles (1978):
:Respect for persons, including informed consent.
:Beneficence
:Justice
*[[CIOMS Guidelines]]
*[[CIOMS Guidelines]]
* [http://www.nihtraining.com/ohsrsite/guidelines/45cfr46.html Common rule]s. Adopted by 17 United States departments and agencies (1991).
* [http://www.nihtraining.com/ohsrsite/guidelines/45cfr46.html Common rule]s. Adopted by 17 United States departments and agencies (1991).
*[[Nuremberg Code]]
*[[Declaration of Geneva]]
*[[Declaration of Geneva]]
*[[Declaration of Helsinki]]
*[[Declaration of Helsinki]]
*[[Declaration of Tokyo]]
*[[Declaration of Tokyo]]
* [http://www.fda.gov/oc/gcp/guidance.html Good Clinical Practice] (FDA)
*[[Good clinical practice]]
*[[Human experimentation]]
*[[Health Insurance Portability and Accountability Act]]
*[[Illegal Medical Experiments and the United States Government]]
*[[Nuremberg Code]]
*[http://privacyruleandresearch.nih.gov/ Privacy]. Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule
*[[US Patients' Bill of Rights|Patients' Bill of Rights]]
*[[US Patients' Bill of Rights|Patients' Bill of Rights]]
*[[Stem cell research]]
*[[Universal Declaration of Human Rights]]
*[[Universal Declaration of Human Rights]]
*[[Institutional Review Board]]
===Famous cases in medical ethics===
Many famous cases in medical ethics illustrate and helped define important issues.
*[[Willowbrook State School|Willowbrook Study]]
*[[Willowbrook State School|Willowbrook Study]]
*[[Tuskegee Study]]
*[[Tuskegee Study]]
*[[Terry Schiavo]]
*[[Jack Kervorkian]]
*[[Nancy Cruzan]]
*[[Karen Ann Quinlan]]
*[[Baby K]]
*[[HeLa]]


==Distribution and utilization of research and care==
===Distribution and utilization of research and care===
*Accessibility of [[health care]]
*Accessibility of [[health care]]
*Basis of priority for [[organ transplant]]ation
*Basis of priority for [[organ transplant]]ation
Line 70: Line 129:


==External links==
==External links==
*[http://www.pbs.org/wgbh/nova/doctors/oath_classical.html Hippocratic Oath] - Classical version
* [http://jme.bmjjournals.com/ BMJJournals.com] - An international peer review journal for health professionals and researchers in medical ethics
*[http://www.pbs.org/wgbh/nova/doctors/oath_modern.html Hippocratic Oath] - Modern version
 
*[http://www.cirp.org/library/ethics/geneva/ Physician's Oath] - Declaration of Geneva (1948)
[[Category:Medical ethics|*]]
*[http://www.wma.net/ World Medical Assocation] (WMA)
*[http://ohsr.od.nih.gov/guidelines/nuremberg.html Nuremberg Code] - ethical code
*[http://www.wma.net/e/policy/c8.htm Declaration of Geneva] - ethical code
*[http://www.wma.net/e/policy/b3.htm Declaration of Helsinki] - ethical code
* [http://jme.bmjjournals.com/ BMJJournals.com]
** [http://bmj.bmjjournals.com/cgi/content/full/309/6948/184 Medical ethics: four principles plus attention to scope] ''BMJ'' (1994) 309:184 (16 July)
** [http://jme.bmjjournals.com/ ''Journal of Medical Ethics''] - An international peer review journal for health professionals and researchers in medical ethics
* [http://www.thehastingscenter.org/default.asp The HastingsCenter.org] - 'The [[Hastings Center]]:  Leading Bioethics into the Future'
* [http://medicine.uchicago.edu/centers/ccme/index.htm UChicago.edu] - MacLean Center for Clinical Medical Ethics, [[University of Chicago]] Department of Medicine
* [http://eduserv.hscer.washington.edu/bioethics/topics/index.html Washington.edu] - 'Ethics in Medicine:  Bioethics Topics', [[University of Washington]] School of Medicine
*[http://bioethics.lumc.edu/index.html bioethics.lumc.edu] - Neiswanger Institute for Bioethics & Health Policy, Loyola University Chicago Stritch School of Medicine


[[Category:CZ Live|Medical ethics|*]]
[[de:Medizinethik]]
[[Category:Health Sciences Workgroup]]
[[he:אתיקה רפואית]]
[[nl:Medische ethiek]]
[[pt:Ética médica]]
[[simple:Medical ethics]]
[[Category:Subjects taught in medical school]]

Revision as of 01:49, 21 April 2007

Template:Ethics 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.

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.

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

Informed consent

For more information, see: 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. Patients can elect to make their own medical decisions, or can delegate decision-making authority to another party. In some cases, the patient may be incapacitated, in which case U.S. state law designates a process for obtaining informed consent. In some American states, family members have differing levels of precedence over one another in making medical decisions for the patient, while other states recognize all family members equally in making medical decisions.

The value of informed consent is closely related to the values of autonomy and truth telling. American culture places a high value on these principles, finding justification in the U.S. Constitution and Declaration of Independence. Template:Sectstub

Confidentiality

For more information, see: Confidentiality.

Confidentiality is commonly applied to conversations between doctors and patients. This concept is commonly known as patient-physician privilege. Legal protections prevent physicians from revealing their discussions with patients, even under oath in court. Confidentiality is mandated in America by HIPAA laws, specifically the Privacy Rule. Confidentiality is challenged in cases such as the diagnosis of a sexually transmitted disease in a patient who refuses to reveal the diagnosis to a spouse, or in the termination of a pregnancy in an underage patient, without the knowledge of the patient's parents. Many states in the U.S. have laws governing parental notification in underage abortion[2]

Beneficence

Template:Sectstub

Autonomy

Template:Sectstub

Non-maleficence

Template:Sectstub The concept of non-maleficence is embodied by the phrase, "first, do no harm," or the latin, primum non nocere. Physicians are obligated under medical ethics to not prescribe medications they know to be harmful. American physicians interpret this value to exclude the practice of euthanasia, though not all concur. Probably the most extreme example in recent history of the violation of the non-maleficence dictum was Dr. Jack Kevorkian, who was convicted of second-degree homicide in Michigan in 1998 after demonstrating active euthanasia on the TV news show, 60 Minutes.

Non-maleficence is a legally definable concept. Violation of non-maleficence is the subject of medical malpractice litigation.

Double effect

Some interventions undertaken by physicians can create a positive outcome while also potentially doing harm. The combination of these two circumstances is known as the "double effect." The most applicable example of this phenomenon is the use of morphine in the dying patient. Such use of morphine can ease the pain and suffering of the patient, while simultaneously hastening the demise of the patient through suppression of the respiratory drive.

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.

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.

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.

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.

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.

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].

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]

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].

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].

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.

See also

Reproductive medicine

Medical research

Famous cases in medical ethics

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

Distribution and utilization of research and care

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.

External links

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

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