Ethics

Ethics is a global, intellectual and practical activity that can be defined simply as the disciplined study of morality. Morality comprises our actual beliefs about what we ought and ought not to do and behavior based on such beliefs. Ethics is committed to the view that morality can always be improved, analogous to the concept of continuous quality improvement in patient care. The tools of ethics are ethical analysis, which insists on clear expression of concepts such as virtues and ethical principles, and argument, which identifies the implications of concepts for moral belief about what we ought and ought not to be and behavior based on such beliefs.

Medical ethics

Medical ethics is a global undertaking with a history that dates to the ancient world . The goal of medical ethics, the disciplined study of morality in medicine, is to improve medical moral morality. Medical ethics accomplishes this goal by identifying the ethical obligations of physicians to their patients . Medical ethics should not be confused with the multiple sources of morality in pluralistic societies. These multiple sources include applicable law, the political heritage of self-government, the world’s religions, ethnic and cultural traditions, families, personal experience, and the traditions and practices of medicine.

Medical ethics since the eighteenth century European and American Enlightenments has been secular . Secular medical ethics makes no reference to revelation through sacred texts and other sources, but to what reasoned discourse, using ethical analysis and argument, produces. At the same time, secular medical ethics is not intrinsically hostile to religious beliefs. Making medical ethics secular should be considered a major achievement in the history of medicine, because ethical principles and virtues should be understood to apply to all physicians, regardless of their personal religious and spiritual beliefs . Secular medical ethics is thus transnational, transcultural, and transreligious. In short, secular medical ethics is global medical ethics .

The traditions and practices of medicine provide a very important source of morality for physicians, because they are based on the obligation to protect and promote the health-related interests of the patient. This obligation tells physicians what morality in medicine ought to be in very general, abstract terms. Providing a more concrete, clinically applicable account of that obligation is the central task of medical ethics, using ethical principles . Ethical principles are designed to guide judgments about what we ought and ought not to do and behavior based on such judgments.

The ethical principle of beneficence

The ethical principle of beneficence requires one to behave in a way that is expected reliably to produce the greater balance of benefits over harms in the lives of others . Making this principle practical requires an account of the benefits and harms relevant to patient care and of how those goods and harms should be balanced against each other when not all of them can be achieved in a particular clinical situation, such as a request for an elective cesarean delivery (addressed in Chapter NN) . In medical ethics, the principle of beneficence requires the physician to act in a way that is expected in evidence-based clinical judgment to produce a greater balance of clinical benefits clinical over harms for the patient .

Beneficence-based clinical judgment has an ancient pedigree in the history of Western medical ethics. One of the first expressions of the ethical principle of beneficence occurs in the Hippocratic Oath and accompanying texts, in which the physician is invoked to help patients while preventing harm to them . In modern terms, beneficence interprets the health-related interests of the patient from medicine’s perspective. This perspective is provided by the deliberative (rigorous, evidence-based, transparent, and accountable) clinical judgment . Beneficence-based clinical judgment is not compatible with mere opinion based on the clinical impression or intuition of an individual physician in a particular clinical circumstance. Beneficence-based, deliberative clinical judgment requires the physician to identify the clinical benefits that can be achieved for the patient. The benefits that medicine is competent to seek for patients are the prevention and management of disease, injury, disability, and unnecessary pain and suffering, and the prevention of premature or unnecessary death. Pain and suffering become unnecessary when they do not result in achieving the other goods of medical care, e.g., allowing a woman to labor without effective analgesia .

The ethical principle of nonmaleficence means that the physician should prevent causing harm and is best understood as expressing the limits of the ethical principle of beneficence . Nonmaleficence is also known as “ Primum non nocere ” or “first do no harm.” This commonly invoked dogma is really a Latinized misinterpretation of the Hippocratic texts, which emphasize the primacy of beneficence while avoiding harm when approaching the limits of medicine to alter the course of disease . When the probability of clinical benefit diminishes and the probability of risks of clinical harm increase, nonmaleficence instructs the physician to proceed with great caution. This caution includes being alert to and preventing serious, far-reaching, and irreversible clinical harm to the patient.

There is an inherent risk of paternalism (interfering with the patient’s autonomy for the clinical good of the patient) in beneficence-based clinical judgment. This risk occurs when beneficence-based clinical judgment is considered to be the sole source of professional responsibility in medical care. Failure to recognize and manage this risk results in the physician mistakenly concluding that beneficence-based judgments can be imposed on the patient in violation of her autonomy. Paternalism should be considered a dehumanizing form of patient care and, therefore, inappropriate in obstetric practice.

There is a powerful preventive ethics response to this inherent risk of paternalism: being forthcoming with patients. The physician should explain the diagnostic, therapeutic, and prognostic reasoning that leads to his or her clinical judgment about what is being offered or recommended so that the patient can assess that judgment for herself. The physician should disclose and explain to the patient the major factors of this reasoning process, including matters of uncertainty. Medical ethics does not require that the patient be provided with a complete medical education . The physician should explain how and why other clinicians might reasonably differ from his or her clinical judgment. The physician should then present a well-reasoned response to this critique. The outcome of this process is that beneficence-based clinical judgments take on the rigor required by the deliberative practice of medicine.

Beneficence-based clinical judgment will frequently result in the identification of a continuum of clinical strategies that protect and promote the patient’s health-related interests, e.g., nuanced clinical judgment about indications for cesarean delivery . Awareness of this feature of beneficence-based clinical judgment provides a powerful preventive ethics antidote to paternalism by increasing the likelihood that one or more of these medically reasonable, evidence-based alternatives will be acceptable to the patient. All beneficence-based alternatives, known as “medically reasonable alternatives,” must be identified and explained to all patients, regardless of how the physician is paid, especially those that are well established in evidence-based obstetrics.

The ethical principle of respect for patient autonomy

In the past five decades there has been increasing emphasis in medical ethics on the ethical principle of respect for the autonomy of the patient . This principle creates the ethical obligation to empower the pregnant woman to make informed and voluntary decisions about the management of her pregnancy in response to the recommendations of her obstetrician.

The obstetrician’s role is to present the medically reasonable alternative to the patient, along with an explanation of their clinical benefits and risks. When there is only one medically reasonable alternative it should be recommended. When there is more than one medically reasonable alternative, they should be presented. If in deliberative clinical judgment one medically reasonable alternative is clinically superior, it should be recommended. See Chapter NN for the application of this aspect of respect for patient autonomy to cesarean delivery .

The patient has a crucial role to play in this decision-making process. The patient should pay attention to and absorb and retain information about her condition and the medically reasonable alternatives for managing it. She should understand this information, by acknowledging and evaluating the clinical benefits and risks of each medically reasonable alternative. On the basis of this understanding and evaluation, she should expresses her authorization or refusal of authorization.

The physician should recognize the capacity of each patient to deal with medical information (and not to underestimate that capacity), provide information (explain the medically reasonable alternatives), and recognize the validity of the values and beliefs of the patient that she uses to evaluate these alternatives. The physician, in response to the patient’s request or clinical need, may assist the patient in her evaluation and ranking of diagnostic and therapeutic alternatives for managing her condition. The physician should elicit the patient’s value-based authorization or refusal of authorization .

Ethics

Ethics is a global, intellectual and practical activity that can be defined simply as the disciplined study of morality. Morality comprises our actual beliefs about what we ought and ought not to do and behavior based on such beliefs. Ethics is committed to the view that morality can always be improved, analogous to the concept of continuous quality improvement in patient care. The tools of ethics are ethical analysis, which insists on clear expression of concepts such as virtues and ethical principles, and argument, which identifies the implications of concepts for moral belief about what we ought and ought not to be and behavior based on such beliefs.

Medical ethics

Medical ethics is a global undertaking with a history that dates to the ancient world . The goal of medical ethics, the disciplined study of morality in medicine, is to improve medical moral morality. Medical ethics accomplishes this goal by identifying the ethical obligations of physicians to their patients . Medical ethics should not be confused with the multiple sources of morality in pluralistic societies. These multiple sources include applicable law, the political heritage of self-government, the world’s religions, ethnic and cultural traditions, families, personal experience, and the traditions and practices of medicine.

Medical ethics since the eighteenth century European and American Enlightenments has been secular . Secular medical ethics makes no reference to revelation through sacred texts and other sources, but to what reasoned discourse, using ethical analysis and argument, produces. At the same time, secular medical ethics is not intrinsically hostile to religious beliefs. Making medical ethics secular should be considered a major achievement in the history of medicine, because ethical principles and virtues should be understood to apply to all physicians, regardless of their personal religious and spiritual beliefs . Secular medical ethics is thus transnational, transcultural, and transreligious. In short, secular medical ethics is global medical ethics .

The traditions and practices of medicine provide a very important source of morality for physicians, because they are based on the obligation to protect and promote the health-related interests of the patient. This obligation tells physicians what morality in medicine ought to be in very general, abstract terms. Providing a more concrete, clinically applicable account of that obligation is the central task of medical ethics, using ethical principles . Ethical principles are designed to guide judgments about what we ought and ought not to do and behavior based on such judgments.

The ethical principle of beneficence

The ethical principle of beneficence requires one to behave in a way that is expected reliably to produce the greater balance of benefits over harms in the lives of others . Making this principle practical requires an account of the benefits and harms relevant to patient care and of how those goods and harms should be balanced against each other when not all of them can be achieved in a particular clinical situation, such as a request for an elective cesarean delivery (addressed in Chapter NN) . In medical ethics, the principle of beneficence requires the physician to act in a way that is expected in evidence-based clinical judgment to produce a greater balance of clinical benefits clinical over harms for the patient .

Beneficence-based clinical judgment has an ancient pedigree in the history of Western medical ethics. One of the first expressions of the ethical principle of beneficence occurs in the Hippocratic Oath and accompanying texts, in which the physician is invoked to help patients while preventing harm to them . In modern terms, beneficence interprets the health-related interests of the patient from medicine’s perspective. This perspective is provided by the deliberative (rigorous, evidence-based, transparent, and accountable) clinical judgment . Beneficence-based clinical judgment is not compatible with mere opinion based on the clinical impression or intuition of an individual physician in a particular clinical circumstance. Beneficence-based, deliberative clinical judgment requires the physician to identify the clinical benefits that can be achieved for the patient. The benefits that medicine is competent to seek for patients are the prevention and management of disease, injury, disability, and unnecessary pain and suffering, and the prevention of premature or unnecessary death. Pain and suffering become unnecessary when they do not result in achieving the other goods of medical care, e.g., allowing a woman to labor without effective analgesia .

The ethical principle of nonmaleficence means that the physician should prevent causing harm and is best understood as expressing the limits of the ethical principle of beneficence . Nonmaleficence is also known as “ Primum non nocere ” or “first do no harm.” This commonly invoked dogma is really a Latinized misinterpretation of the Hippocratic texts, which emphasize the primacy of beneficence while avoiding harm when approaching the limits of medicine to alter the course of disease . When the probability of clinical benefit diminishes and the probability of risks of clinical harm increase, nonmaleficence instructs the physician to proceed with great caution. This caution includes being alert to and preventing serious, far-reaching, and irreversible clinical harm to the patient.

There is an inherent risk of paternalism (interfering with the patient’s autonomy for the clinical good of the patient) in beneficence-based clinical judgment. This risk occurs when beneficence-based clinical judgment is considered to be the sole source of professional responsibility in medical care. Failure to recognize and manage this risk results in the physician mistakenly concluding that beneficence-based judgments can be imposed on the patient in violation of her autonomy. Paternalism should be considered a dehumanizing form of patient care and, therefore, inappropriate in obstetric practice.

There is a powerful preventive ethics response to this inherent risk of paternalism: being forthcoming with patients. The physician should explain the diagnostic, therapeutic, and prognostic reasoning that leads to his or her clinical judgment about what is being offered or recommended so that the patient can assess that judgment for herself. The physician should disclose and explain to the patient the major factors of this reasoning process, including matters of uncertainty. Medical ethics does not require that the patient be provided with a complete medical education . The physician should explain how and why other clinicians might reasonably differ from his or her clinical judgment. The physician should then present a well-reasoned response to this critique. The outcome of this process is that beneficence-based clinical judgments take on the rigor required by the deliberative practice of medicine.

Beneficence-based clinical judgment will frequently result in the identification of a continuum of clinical strategies that protect and promote the patient’s health-related interests, e.g., nuanced clinical judgment about indications for cesarean delivery . Awareness of this feature of beneficence-based clinical judgment provides a powerful preventive ethics antidote to paternalism by increasing the likelihood that one or more of these medically reasonable, evidence-based alternatives will be acceptable to the patient. All beneficence-based alternatives, known as “medically reasonable alternatives,” must be identified and explained to all patients, regardless of how the physician is paid, especially those that are well established in evidence-based obstetrics.

The ethical principle of respect for patient autonomy

In the past five decades there has been increasing emphasis in medical ethics on the ethical principle of respect for the autonomy of the patient . This principle creates the ethical obligation to empower the pregnant woman to make informed and voluntary decisions about the management of her pregnancy in response to the recommendations of her obstetrician.

The obstetrician’s role is to present the medically reasonable alternative to the patient, along with an explanation of their clinical benefits and risks. When there is only one medically reasonable alternative it should be recommended. When there is more than one medically reasonable alternative, they should be presented. If in deliberative clinical judgment one medically reasonable alternative is clinically superior, it should be recommended. See Chapter NN for the application of this aspect of respect for patient autonomy to cesarean delivery .

The patient has a crucial role to play in this decision-making process. The patient should pay attention to and absorb and retain information about her condition and the medically reasonable alternatives for managing it. She should understand this information, by acknowledging and evaluating the clinical benefits and risks of each medically reasonable alternative. On the basis of this understanding and evaluation, she should expresses her authorization or refusal of authorization.

The physician should recognize the capacity of each patient to deal with medical information (and not to underestimate that capacity), provide information (explain the medically reasonable alternatives), and recognize the validity of the values and beliefs of the patient that she uses to evaluate these alternatives. The physician, in response to the patient’s request or clinical need, may assist the patient in her evaluation and ranking of diagnostic and therapeutic alternatives for managing her condition. The physician should elicit the patient’s value-based authorization or refusal of authorization .