This book is about the ethical issues that clinicians encounter in
caring for patients. In order to practice excellent clinical care,
clinicians and those studying to become clinicians must understand ethical
issues such as informed consent, truth telling, confidentiality, privacy,
the distinction between research and clinical care, and end-of-life care.
Clinicians must apply this knowledge in their daily practices. By clinicians
we mean not only physicians and surgeons but also nurses, socialworkers,
psychologists, clinical ethicists, medical technicians, chaplains, and
others responsible for the welfare of patients. Some of these clinicians
will also be members of ethics committees who deliberate about the ethics
policies of their hospitals and about ethical problems in particular cases.
Our audience also includes families and other persons close to patients, who
may participate in decisions about their care. Our goal in writing this book
is to help clinicians understand and manage the cases they encounter in
their practices, and on those occasions when ethical disagreements emerge,
to guide patients, families, clinicians, and ethics committees toward the
resolution of clinical ethical conflicts.
issues are imbedded in every clinical encounter between patients and
caregivers because the care of patients always involves both technical and
moral considerations. The central feature of this clinical encounter is the
therapeutic relationship between a physician and a patient, a relationship
that is permeated with ethical responsibilities. Physicians must aim, in the
words of Hippocrates, "to help and do no harm." Modern physicians approach
the doctor–patient relationship with a professional identity that
includes the obligations to provide competent care to the patient, to
preserve confidentiality, and to communicate honestly and compassionately.
In the usual course of a therapeutic relationship,
clinical care and ethical duties run smoothly together. The reason is that
generally the patient and physician share the same goal: to respond to the
medical problems and needs of the patient. For example, a patient presents
with a distressing cough and wants relief; a physician responds to the
patient by utilizing the correct means to diagnose and treat this condition.
In this situation, the treatment for, say, a mild asthma attack is effective
and the patient is satisfied. At the same time an ethical action has taken
place: the patient is helped and not harmed. In other cases, this simple
scene becomes complicated. The patient's asthma may be caused by a cancer
obstructing the airway. This disease may be life-threatening and the
treatment may be complex, difficult 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
cannot afford treatment because of lack of insurance. 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
that is intrinsic to clinical care. This confusion and conflict can become
distressing for all parties. This book, then, aims to elucidate both the
ethical dimensions of care in ordinary clinical activities that are not
controversial, as well as when doubt about right action blocks decision.Clinical ethics, then, is a structured approach to
ethical questions in clinical medicine.
Clinical ethics depends on the
larger discipline of bioethics, which in turn draws upon disciplines such as
moral philosophy, health law, communication skills, and clinical medicine.
The scholars called "bioethicists" must master this field. However,
clinicians in the daily practice of medicine can manage with a basic
understanding of certain key ethical issues such as informed consent and
end-of-life care. Central to the practical application of clinical ethics
is the ability to identify and analyze an ethical question and to reach a
reasonable conclusion and recommendation for action.
In this book, we
provide a method to identify the ethical dimensions of patient care and to
analyze and resolve ethical problems. This method is useful for structuring
the questions faced by any clinician who cares for patients.
THE FOUR TOPICS
Bioethics identifies four ethical principles that are particularly relevant
to clinical medicine: the principles of beneficence, nonmaleficence, respect
for autonomy, and justice. To these, some bioethicists add empathy,
compassion, fidelity, integrity, and other virtues. The bioethical
literature discusses these principles and virtues at length. In this book,
we only explain them briefly. We rather direct our reader's attention to how
these general principles interact within the concrete circumstances of a
clinical case, and howthey serve as guides to action in specific
circumstances. Thus we propose four topics that we believe constitute the
essential structure of a case in clinical medicine, namely, medical
indications, patient preferences, quality of life, and contextual features.
Some users of this book call these four topics "the
Four Boxes." Every clinical case is a mass of detail that the clinician must
interpret in order to carry out the reasoning process necessary for
diagnosis and treatment. Every clinician learns early in training a common
pattern for organizing that mass of detail: chief complaint, history of the
chief complaint, general medical history of the patient, results of physical
examination, and results of laboratory studies. The data that are sorted
into these patterns lead the clinician to decisions about diagnosis and
treatment. Our four topics or boxes provide a similar pattern for
collecting, sorting, and ordering the facts of a clinical ethical
problem. Each topic or "box" is filled with the actual facts of the clinical
case that are relevant to the identification of the ethical problem, and the
contents of all four are viewed together for a comprehensive picture of the
ethical dimensions of the case.Medical
indications refer to the diagnostic and therapeutic interventions that are
being used to evaluate and treat the medical problem in the case. Patient
preferences state the express choices of the patient about their treatment,
or the decisions of those who are authorized to speak for the patient when
the patient is incapable of doing so. Quality of life describes features of
the patient's life prior to and following treatment, insofar as these
features are pertinent to medical decisions. Contextual features identify
the familial, social, institutional, financial, and legal settings within
which the particular case takes place, insofar as they influence medical
Under each of these headings, a series of questions are posed
to assure that needed information has been gathered.We believe that these
four topics are the essential and constant constituents of any clinical
case, which is, of course, unique and varying in its own circumstances. The
chart at the end of this introduction depicts these four topics and the
The subtitle of our book
states that clinical ethics is a practical
approach. This implies
that the approach must go beyond simply identifying the problem, by
collecting and sorting the facts of the case. It must guide practice, that
is, it must lead from identification of the ethical problem to decisions
about how to manage the problem. It must show the clinician how to manage
those obstacles to decision making that the ethical problem had posed.
Clinical ethics is seldom a matter of deciding between ethical versus
unethical, between good and right versus bad and wrong; rather it involves
finding the better, most reasonable solutions among the relevant options.
While clinical ethics can sometimes help to rule out options that are
unethical, more frequently, clinical ethics can clarify a range of
permissible options that patients and clinicians may choose. Our approach
seeks to guide the clinician, and others involved in the case, toward such
After all relevant information is
gathered into the Four Boxes, the relationship between that information and
the principles must be assessed. It sometimes happens that when the data is
collected and properly sorted, an obvious pattern appears that will identify
the ethical problem. The circumstances of a case often point to one of the
fundamental principles as most important in the specific case analysis. For
example, a patient has a critical disease in its terminal stage, has never
expressed preferences about treatment, has no relatives to speak for him,
and faces great suffering during the time remaining. This appears at first
sight as a case in which the principles of beneficence and nonmaleficence
are central. Further, aggressive treatment is no longer likely to be
beneficial; this patient needs palliative care. At second sight, however,
the question becomes a matter of the principle of respect for autonomy: who
is authorized to make the decision to transition from intensive to
palliative care? Ethical reflection moves from this dilemma between two
fundamental principles to an evaluation of how the circumstances of the case
give greater weight to one or the other of these principles. For example,
after all reasonable attempts to effectively treat a patient have failed,
the continued application of aggressive measures causes more harm than good
to this patient. In this light, the principle of nonmaleficence becomes the
most dominant one, and provides an ethical reason for a decision to provide
only palliative care. The clinician can then formulate a recommendation to
the patient or other decision makers.
resolution of the case is based on an assessment of the facts of the case in
relation to the ethical principles relevant to the case. However, this
assessment calls for a further move: the present case must be compared to
similar cases. It is certainly true that in medicine every case is unique,
and every patient "a statistic of one." Nevertheless, the case at hand will
have similarities with other cases. Other cases may have been thoughtfully
considered—perhaps even adjudicated in the law—and may provide
guidance whereby to assess the present case. Such cases are called
Reference to paradigm cases do not prove that a case is
correctly assessed; rather they are examples of serious assessments in
prior, similar cases, to which the current case can be compared, in order to
guide the clinician in this case. It is important to note that even similar
cases have variable nuances. The present case may have circumstances that
make it more complex than previous cases; or it may represent a novel
problem due to innovative technology. Clinicians and ethicists should be
familiar with these paradigm cases, and be able to discern how they differ
and how the circumstances bond with principles in the current case. We
describe some of the important paradigm cases.
This book is arranged to follow the four-box model. Each chapter is devoted
to one of the four topics. Each chapter begins with some general
considerations and ethical principles most relevant to that topic. A series
of questions that exemplify major issues under each topic are posed.
Clinical situations that commonly generate ethical problems associated with
that topic are stated and illustrated by cases. A COMMENT
that provides a distillation of prevailing opinion from the bioethical
literature follows.We conclude with RECOMMENDATIONS
three authors formulate from their own extensive experience as clinicians
and clinical ethics consultants. Although this book does not discuss
pediatric ethics, at the end of each chapter we have placed "Pediatric
Notes" to alert readers about certain ethical problems in pediatric medicine
that require special consideration. When these arise, the sources for
pediatric ethics should be consulted. One such source is Frankel LR,
Goldworth A, Rorty MV, Silverman WD. Ethical Dilemmas in Pediatrics.
Cambridge, MA: Cambridge University Press; 2005.
RESOURCES IN CLINICAL ETHICS
In addition to our method for identifying and assessing a case in ethical
terms, we also provide capsules of essential information about common
problems, such as Orders Not to Resuscitate or Withholding Life Support. The
issues that we treat in capsule form have been discussed and debated in the
ever-increasing literature of bioethics. We refer readers to certain sources
where they can find more extended discussions and references, and complete
references are provided at the end of this section. The standard text of
scholarly bioethics, in which basic concepts are amply explained, is Principles
of Biomedical Ethics.
The major reference work in medical ethics is Encyclopedia
We regularly refer to three books that contain fuller
treatments of the matters that we treat only in capsule form. They are Resolving
Ethical Dilemmas: A Guide for Clinicians; The Oxford Handbook of Bioethics;
and The Cambridge Textbook of Bioethics.
Our pages regularly refer to
their relevant chapters. Another book collects cases that represent
difficult problems confronting clinical ethicists: Complex Ethics
Consultations: Cases that Haunt Us.
A number of journals are now
dedicated to bioethics: The Hastings Center Report, The American Journal
of Bioethics, Journal of Medical Ethics, Cambridge Quarterly of Healthcare
Ethics, Journal of Theoretical Medicine,
and Journal of Clinical
Also, articles on bioethics appear regularly in the medical and
nursing journals. We do not reference this extensive journal literature,
unless we use data drawn from an article or an article is "classic" in
defining and describing an issue. This literature is indexed at PubMed and
Medline at the National Library of Medicine's Bioethics Portal (www.nlm.nih.gov/bsd/bioethics.html
Extensive bibliographic resources can be found at the National Reference
Center for Bioethics Literature at Georgetown University's ETHXWeb (http://bioethics.georgetown.edu/databases/index.htm
Clinical Ethics Center of the National Institutes of Health (www.nih.gov/sigs/bioethics
and, for cases and discussions, the American Medical Association's online
journal Virtual Mentor is an excellent resource (http://virtualmentor.amaassn.org
The Web site UpToDate (www.uptodate.com
contains a number of useful reviews of major topics, as does the Web site of
the University of Washington Department of Bioethics and Humanities (http://depts.washington.edu/bhdept
Of less relevance to ethics at the bedside, but still helpful, is United
Nations Educational, Scientific and Cultural Organization's Global Ethics
Also see McGraw-Hill's AccessMedicine Web site (www.accessmedicine.com
thousands of images and illustrations, interactive assessment, case files,
diagnostic tools, and up-to-date information for research, education,
self-assessment, and board review.
The authors gratefully acknowledge the advice and assistance of the
following people: Drs. Katrina Bramstedt, David Brush, Michael Cantwell,
Farr Curlin, Lainie Ross, William Stewart, and Daniel Sulmasy, as well as
Ms. Helene Starks, Ms. Donna Vickers, and Mr. Wesley McGaughey.
- American Journal of Bioethics. Taylor and Francis Group Inc. http://www.bioethics.net.
Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 6th
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- Cambridge Quarterly of Healthcare Ethics. 40 West 20th Street,
New York, NY 10011–4211. http://www.journals.cup.org.
Ford PJ, Dudzinski DM. Complex Ethics Consultations: Cases that Haunt
Us. New York, NY: Cambridge University Press; 2008
Frankel LR, Goldworth A, Rorty MV, Silverman WA, eds. Ethical
Dilemmas in Pediatrics. New York, NY: Cambridge University Press;
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- Journal of Medical Ethics. BMJ Publishing Group, British Medical
Association, Tavistock Square London WCIH 9JR, UK. http://www.jme.bmj.com.
Lo B. Resolving Ethical Dilemmas: A Guide for Clinicians. 4th ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 2009.
Post SG, ed. Encyclopedia of Bioethics. 3rd ed. Farmington Hills,
MI: Gale; 2003.
Singer PA, Viens AM. The Cambridge Textbook of Bioethics. New
York, NY: Cambridge University Press; 2008.
Steinbock B, ed. The Oxford Handbook of Bioethics. New York, NY:
Oxford University Press; 2009.
- The Hastings Center Report. The Hastings Center, Garrison, NY,
10524–5555. E-mail: email@example.com;
Walters L, Kahn TJ, eds. Bibliography of Bioethics. Washington,
DC: Georgetown University Press. [Published annually].