Ethical Principles

Core Ethical Principles

• There are 4 core ethical principles
• Autonomy  
  • respecting patients as individuals 
  • honoring patient’s preferences in medical care   
    • the patient’s preferences take priority when making medical decisions
    • therefore, the decider of decisions is patient word > living will > next of kin 
    • communicate with non-English speaking patients through a professional translator 
  • respecting confidentiality  
• Beneficence
  • acting in patient’s best interest  
  • balance autonomy and beneficence, but autonomy trumps beneficence   
• Nonmaleficence
  • “do no harm”  
  • do not help patients commit suicide 
• Justice
  • distributive Justice
    • governs allocation of limited resources
  • formal Justice
• equals must be treated equally

Other Principles

• Breaking bad news  
  • set up the interview
  • assess the patient’s perception
  • obtain the patient’s invitation (i.e. permission)
  • give the patient the necessary knowledge
  • address the patient’s emotions with empathetic responses 
    • in cases of bereavement, being empathetic with patient families and offering to answer questions 
  • in pediatric cases, both parents and patients have a right to know the diagnosis and treatment 
    • group conversations can facilitate “right to know” conflicts while maintaining legal and ethical principles 
• End of life care principles include:
  •  evaluate patients for hospice care if they have 
    • a life limiting diagnosis
    • prognosis of less than 6 months
  • give hospice patients antibiotics and pain medications 
    • treatments that enhance quality of life should be administered in hospice care
    • only treatments that sacrifice current well-being for future longevity should be avoided
  • informing patients about their diagnoses even against family wishes  
• Open-ended questions are the best way to elicit a patient history; closed-ended questions are useful for follow-up or clarification   
  • motivational interviewing involves supporting patients to formulate their own goals 
  • OARS principles are open-ended questions, affirmations, reflective listening, and summaries 
• Many patient encounters necessitate a combination of the above ethical principles–a few general principles include:   
  • encourage open communication between patients and other treating physicians
  • attempt to preserve the patient’s relationship with other health-care providers. 
  • nonetheless, ensuring that the patient is receiving the best available care is always the primary priority  
  • if a mistake is discovered the physician should disclose that to patient/family  
  • all safety concerns should be taken seriously, even seemingly trivial ones from junior team members 
• Confidentiality 
  • all patients, regardless of age, should have the option of speaking to their physician alone  
  • minors (<18 years-old) generally require their parents to consent to receive treatment, with the following exceptions (in most states):
    • care for 
      • sexual health (e.g. pregnancy, contraception, sexually transmitted infection treatment) 
      • mental health
      • substance abuse
    • emancipated minors
    • emergencies
  • parents should be asked to leave the room so teenage patients can discuss: 
• Conflicts of interest: 
  • physicians should report conflicts of interest
  • physicians can accept honoraria and be compensated for travel expenses, but cannot have assistance with slide presentations from pharmaceutical companies 
• Capacity 
  • physicians can determine capacity which is the ability for the patient to understand their treatment as well as the risks, benefits and alternatives
  • competence is a legal designation and can not be determined by a physician
• Adherence   
  • extended contact with physicians through follow-up appointments increases adherance with lifestyle changes
  • barriers to medication compliance should be explored in a non-judgemental open-ended manner
  • concerning reports of medication abuse should be discussed directly with the patient 
  • creating an organized written linear care plan is key to increasing medication compliance in patients 
  • adopting a non-judgmental collaborative mindset is key for treating substance use disorder 
  • providing helpful information in a non-judgemental way is key to addressing alternative medicine 
• Patients with a history of sexual abuse
  • physicians should first listen empathetically to the patient’s feelings and concerns 
  • avoid judgmental statements, over-pathologizing, or prematurely jumping to treatment
• Medication compliance in children  
  • multifaceted issue, with factors including age of patient, knowledge about disease, peer pressure, rebellion/independence, socioeconomic status, cultural issues and beliefs, and family structure