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Principles of Clinical Ethics and Their Application to Practice
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ReviewMed Princ Pract 2021;30:17–28 Received: November 24, 2019
Accepted: June 3, 2020
DOI: 10.1159/000509119 Published online: June 4, 2020
Principles of Clinical Ethics and Their
Application to Practice
Basil Varkey
The Medical College of Wisconsin, Milwaukee, WI, USA
Downloaded from http://karger.com/mpp/article-pdf/30/1/17/3128579/000509119.pdf by guest on 01 August 2024
Highlights of the Study
• Main principles of ethics, that is beneficence, nonmaleficence, autonomy, and justice, are discussed.
• Autonomy is the basis for informed consent, truth-telling, and confidentiality.
• A model to resolve conflicts when ethical principles collide is presented.
• Cases that highlight ethical issues and their resolution are presented.
• A patient care model that integrates ethics, professionalism, and cognitive and technical expertise is
shown.
Keywords Introduction
Ethics · Confidentiality · Autonomy · Informed consent ·
Professionalism · Integrated patient care model A defining responsibility of a practicing physician is to
make decisions on patient care in different settings. These
decisions involve more than selecting the appropriate
Abstract treatment or intervention.
An overview of ethics and clinical ethics is presented in this Ethics is an inherent and inseparable part of clinical
review. The 4 main ethical principles, that is beneficence, medicine [1] as the physician has an ethical obligation (i)
nonmaleficence, autonomy, and justice, are defined and ex- to benefit the patient, (ii) to avoid or minimize harm, and
plained. Informed consent, truth-telling, and confidentiality to (iii) respect the values and preferences of the patient.
spring from the principle of autonomy, and each of them is Are physicians equipped to fulfill this ethical obligation
discussed. In patient care situations, not infrequently, there and can their ethical skills be improved? A goal-oriented
are conflicts between ethical principles (especially between educational program [2] (Table 1) has been shown to im-
beneficence and autonomy). A four-pronged systematic ap- prove learner awareness, attitudes, knowledge, moral rea-
proach to ethical problem-solving and several illustrative soning, and confidence [3, 4].
cases of conflicts are presented. Comments following the
cases highlight the ethical principles involved and clarify the
resolution of these conflicts. A model for patient care, with Ethics, Morality, and Professional Standards
caring as its central element, that integrates ethical aspects
(intertwined with professionalism) with clinical and techni- Ethics is a broad term that covers the study of the na-
cal expertise desired of a physician is illustrated. ture of morals and the specific moral choices to be made.
© 2020 The Author(s) Normative ethics attempts to answer the question,
Published by S. Karger AG, Basel “Which general moral norms for the guidance and evalu-
karger@karger.com © 2020 The Author(s) Basil Varkey
www.karger.com/mpp Published by S. Karger AG, Basel 120 Lakota Pass
This is an Open Access article licensed under the Creative Commons
Austin, TX 78738 (USA)
Attribution-NonCommercial-4.0 International License (CC BY-NC) basilvarkey @ ymail.com
(http://www.karger.com/Services/OpenAccessLicense), applicable to
the online version of the article only. Usage and distribution for com-
mercial purposes requires written permission.
, Table 1. Goals of ethics education Hereafter, the abbreviated term, ethics, will be used as
I discuss the principles of clinical ethics and their applica-
• To appreciate the ethical dimensions of patient care tion to clinical practice.
• To understand ethical principles of medical profession
• To have competence in core ethical behavioral skills
(Obtaining informed consent, assessing decision-making
capacity, discussing resuscitation status and use of life- The Fundamental Principles of Ethics
sustaining treatments, advanced care planning, breaking
bad news and effective communication) Beneficence, nonmaleficence, autonomy, and justice
• To know the commonly encountered ethical issues in general
and in one’s specialty constitute the 4 principles of ethics. The first 2 can be
• To have competence in analyzing and resolving ethical traced back to the time of Hippocrates “to help and do no
problems harm,” while the latter 2 evolved later. Thus, in Percival’s
• To appreciate cultural diversity and its impact on ethics book on ethics in early 1800s, the importance of keeping
the patient’s best interest as a goal is stressed, while au-
tonomy and justice were not discussed. However, with
the passage of time, both autonomy and justice gained
Downloaded from http://karger.com/mpp/article-pdf/30/1/17/3128579/000509119.pdf by guest on 01 August 2024
ation of conduct should we accept, and why?” [5]. Some acceptance as important principles of ethics. In modern
moral norms for right conduct are common to human times, Beauchamp and Childress’ book on Principles of
kind as they transcend cultures, regions, religions, and Biomedical Ethics is a classic for its exposition of these 4
other group identities and constitute common morality principles [5] and their application, while also discussing
(e.g., not to kill, or harm, or cause suffering to others, not alternative approaches.
to steal, not to punish the innocent, to be truthful, to obey
the law, to nurture the young and dependent, to help the Beneficence
suffering, and rescue those in danger). Particular moral- The principle of beneficence is the obligation of physi-
ity refers to norms that bind groups because of their cul- cian to act for the benefit of the patient and supports a
ture, religion, profession and include responsibilities, number of moral rules to protect and defend the right of
ideals, professional standards, and so on. A pertinent ex- others, prevent harm, remove conditions that will cause
ample of particular morality is the physician’s “accepted harm, help persons with disabilities, and rescue persons
role” to provide competent and trustworthy service to in danger. It is worth emphasizing that, in distinction to
their patients. To reduce the vagueness of “accepted role,” nonmaleficence, the language here is one of positive re-
physician organizations (local, state, and national) have quirements. The principle calls for not just avoiding
codified their standards. However, complying with these harm, but also to benefit patients and to promote their
standards, it should be understood, may not always fulfill welfare. While physicians’ beneficence conforms to mor-
the moral norms as the codes have “often appeared to al rules, and is altruistic, it is also true that in many in-
protect the profession’s interests more than to offer a stances it can be considered a payback for the debt to so-
broad and impartial moral viewpoint or to address issues ciety for education (often subsidized by governments),
of importance to patients and society” [6]. ranks and privileges, and to the patients themselves
(learning and research).
Bioethics and Clinical (Medical) Ethics Nonmaleficence
Nonmaleficence is the obligation of a physician not to
A number of deplorable abuses of human subjects in harm the patient. This simply stated principle supports
research, medical interventions without informed con- several moral rules – do not kill, do not cause pain or suf-
sent, experimentation in concentration camps in World fering, do not incapacitate, do not cause offense, and do
War II, along with salutary advances in medicine and not deprive others of the goods of life. The practical ap-
medical technology and societal changes, led to the rapid plication of nonmaleficence is for the physician to weigh
evolution of bioethics from one concerned about profes- the benefits against burdens of all interventions and treat-
sional conduct and codes to its present status with an ex- ments, to eschew those that are inappropriately burden-
tensive scope that includes research ethics, public health some, and to choose the best course of action for the pa-
ethics, organizational ethics, and clinical ethics. tient. This is particularly important and pertinent in dif-
ficult end-of-life care decisions on withholding and
18 Med Princ Pract 2021;30:17–28 Varkey
DOI: 10.1159/000509119
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