Hugh E. Mighty and Jenifer Fahey

There are times when physicians are called upon by their patients or colleagues to help make difficult medical decisions. There also are times when physicians may disagree with decisions that their patients or colleagues have made. In either case, the physician must be able to analyze the situation in a systematic fashion in order to provide advice in a way that promotes the patient’s best interest. Preparing medical students to take on this professional responsibility should be an essential goal in medical education.

This chapter provides a brief overview of clinical ethics, including a review of core principles of medical ethics followed by a section on common ethical dilemmas that are specific to the field of obstetrics and gynecology. It also includes representative case studies to highlight relevant points and provides students with some general guidelines for ethical decision-making.

Background

Ethics is the branch of philosophy concerned with the study or evaluation of human behavior/conduct to identify the norms, rules, values, and principles that guide our moral life. Medical ethics is an example of “applied ethics,” in which these values, norms, or principles are used to guide decision-making in actual cases where the best course of action is not clearly evident. Because medical knowledge often is not enough to guide medical decision-making, it is important for health practitioners to have an understanding of key concepts in the field of ethics, and learn how to conduct a careful and disciplined analysis of ethical dilemmas that may confront them in the clinical arena.

Western medical ethics traces its roots to antiquity and the beginning of the Hippocratic tradition, which emphasizes the concept of duty to patient and provides guidelines for physician behavior when interacting with patients. Many of the same core concepts of medical ethics found in the earliest writings on the subject can be found in the Code of Ethics of the American Medical Association (AMA), first adopted in 1847. In the 1970s, Beau-champ and Childress published their seminal modern text on medical ethics, The Principles of Biomedical Ethics, in which they identify beneficence, nonmaleficence, autonomy, and justice as the four, core moral principles of biomedical ethics. Since then, a principle-based approach (also known as “principalism”) has come to dominate the medical ethics arena.

A common criticism of this principle-based approach, however, is that although it provides a helpful way to study an ethical problem, it is of limited use in guiding decision-making in clinical practice. This is due, in large part, to the fact that in many clinical cases these principles are actually in conflict with one another, and there is no clear hierarchy among them to help resolve such ethical dilemmas. Furthermore, the principle-based approach relies heavily on moral rules and theories but underemphasizes contextual issues, such as gender relations, standards of practice, economics, cultural considerations, and legal issues, which affect both patient and provider decision-making.

Autonomy

Autonomy, or self-rule, in the context of ethics is the quality of moral independence. In the realm of medical ethics, it is manifested as the right to make one’s own decisions. To be an autonomous entity the individual must be: (1) free from coercion or other controlling influence or influences, and (2) possess the capacity for “intentional action.” Respect for autonomy in medical decision-making is understood to mean that if these two standards for autonomy are reasonably met, the individual has the right to make decisions regarding their medical care, even if the decision conflicts with what the provider believes is in their best interest.

The term “reasonably” is used because humans are rarely fully free of controlling influence. So, although a provider may not always be able to determine whether a patient is truly an autonomous entity, he or she should make a reasonable effort to determine whether there are controlling influences that significantly compromise the patient’s autonomy. It is also understood that a physician should not take actions that exert a controlling influence on the patient.

Justice

Justice is the concept of giving to each person what is his or her due. In the realm of medical ethics it includes the obligations to provide to each patient that to which he or she is entitled, to allocate resources fairly, and to treat all patients equally. It is a complex principle prone to the effects of context and individual bias, including the physician’s background and experience.

What is perceived as just by an individual or group of individuals can vary greatly from what others may believe to be just. Furthermore, in a system of unequal distribution of resources, the physician is handicapped in his or her ability to be truly just. For example, regardless of severity of disease, patients with health insurance will often have access to care more readily than those who do not.

In nonemergency situations, the physician has an obligation to promote the wellbeing of each individual patient, and is not expected to take into consideration these system-wide dilemmas of distributive justice during individual clinical encounters. However, advocating for a just allocation of health care resources and not taking actions that compound inequalities in our health care system are ethical obligations of the physician. In emergency or mass casualty situations, however, physicians will have to take into consideration the limited availability of resources and make decisions as to whom to treat and in what order.

Maternal Autonomy vs. Fetal Beneficence

Ethical decision-making in obstetrics and gynecology is complicated by several factors that are peculiar to the field. The most significant of these in the practice of obstetrics is that the provider is simultaneously caring for two patients—the mother and the fetus—both of whose interests the provider owes a duty to protect. The moral obligation due to the fetus, however, is generally accepted within the context of medical ethics to be different from that owed to the mother.