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INTRODUCTION

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This book is about the ethical issues that clinicians encounter as they care for patients. In order to practice excellent clinical care in modern medicine, clinicians must understand ethical issues such as informed consent, decisional capacity, surrogate decision making, truth telling, confidentiality, privacy, the distinction between research and clinical care, and end-of-life care. Clinicians must apply this knowledge each day in their practices. By clinicians we mean not only physicians but also nurses, social workers, psychologists, clinical ethicists, medical technicians, chaplains, and others responsible for the welfare of patients. We include, as well, students who are preparing to enter these professions. It is our hope that this book will be particularly helpful to those who serve on hospital ethics committees as they deliberate about appropriate action in difficult ethical cases.

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Ethical issues are embedded in every clinical encounter between patients and clinicians. The technical and moral aspects of patient care are inseparable. The central feature of the clinical encounter is the therapeutic relationship between clinicians and patients—a relationship that is permeated with ethical responsibilities. Physicians enter the doctor-patient relationship with a professional identity that obliges them to give priority to the patient’s interests, to devote themselves to the competent care of the patient, to preserve confidentiality, and to communicate honestly and compassionately. Physicians must aim, in the words of Hippocrates, “to help and do no harm,” an admonition that is not as simple as it seems within the complexities of contemporary medical science and practice.

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In the usual course of a therapeutic relationship, clinical care and ethical imperatives run smoothly together. The reason for this is that generally the patient and clinician share the same goal, namely, to resolve the medical problems and needs of the patient. For example, a patient presents with a distressing cough and wheezing and wants relief; a physician responds to the patient and utilizes the correct means to diagnose and treat. In this situation, the treatment for, say, a mild asthma attack, is effective and the patient is satisfied. In other cases, this simple scene becomes complicated. The patient’s wheezing may be caused by a tumor obstructing the airway. This disease may be life threatening; the treatment may be complex and may prove unsuccessful. On other occasions, the smooth course of the doctor-patient relationship may be interrupted by what we call an ethical question: a doubt about the right action when ethical responsibilities conflict or when their meaning is uncertain or confused. For example, the physician’s duty to cure is countered by a patient’s refusal of indicated treatment, or the patient’s need for treatment cannot be met because of inability to pay. The principles that usually bring the clinician and the patient into a therapeutic relationship seem to collide. This collision blocks the process of deciding and acting required for clinical care. Sometimes, confusion and conflict can become extreme and distressing for all parties. This book aims to elucidate the ethical ...

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