This chapter treats the first topic relevant to any ethical problem in clinical medicine, namely, the indications for or against medical intervention. In most cases, treatment decisions that are based on medical indications are straightforward and present no obvious ethical problems.
A patient complains of frequent urination accompanied by a burning sensation. The physician suspects a urinary tract infection, obtains a confirmatory culture, and prescribes an antibiotic. The physician explains to the patient the nature of the condition and the reason for prescribing the medication. The patient obtains the prescription, takes the medication, and is cured of the infection.
This is a case of clinical ethics, not because it shows an ethical problem, but because it demonstrates how the principles commonly considered necessary for ethical medical care, namely, respect for autonomy, beneficence, nonmaleficence, and justice, are satisfied in the clinical circumstances of this case. Medical indications are sufficiently clear so that the physician can make a diagnosis and prescribe an effective therapy to benefit the patient. The patient's preferences coincide with the physician's recommendations. The patient's quality of life, presently made unpleasant by the infection, is improved. This case occurs in a context in which medications are available, insurance pays the bill, and no problems with family or institution are present.
This case, which raises no ethical concerns, would present an ethical problem if the patient stated that he did not believe in antibiotics, or if the urinary tract infection developed in the last days of a terminal illness, or if the infection was associated with a sexually transmitted disease in which sexual partners might be endangered, or if the patient could not pay for the care. Sometimes, these problems can be readily resolved; at other times, they can become major obstacles in the management of the case.
In this chapter, we first define medical indications and explain the ethical principles most relevant to medical indications, namely, beneficence and nonmaleficence. We discuss the relationship of these principles to medical professionalism. We then pose a series of questions that link medical indications to these principles. In discussing these questions, we treat important features of clinical medicine related to medical indications, including the goals and benefits of medicine, clinical judgment and uncertainty, evidence-based medicine, and medical error. We offer typical cases to illustrate these discussions. We then consider three ethical issues in which medical indications are particularly prominent: (1) nonbeneficial (or futile) treatment, (2) cardiopulmonary resuscitation (CPR) and do-not-resuscitate (DNR) orders, and (3) the determination of death.
Definition of Medical Indications
Medical Indications are the facts, opinions, and interpretations about the patient's physical and/or psychological condition that provide a reasonable basis for diagnostic and therapeutic activities aiming to realize the overall goals of medicine: prevention, cure, and care of illness and injury. Every discussion of an ethical problem in clinical medicine should ...