How do ethics affect our routine practice?

How do ethics affect our routine practice?

VIEWPOINT
How do ethics affect our routine practice?
FERNANDO MIGUEL GAMBOA ANTIÑOLO
Comité de Ética, Servicio de Medicina Interna, Hospital Universitario Valme, Universidad de Sevilla, Spain.
References to ethics in clinical practice appear
almost daily in the general press and medical
publications. But what role does ethics play? From
the origins of human communities, people’s behavior has been guided by rules and value judgments, both individual and collective, derived
from analysis of situations they were faced with.
The rules that guide human behavior is the object
of study of ethics1. Etymologically, ethics means
character, intelligence, the outstanding feature of
being human. Ethics is formed on the basis of
careful reflective judgments, with previous interdisciplinary and intercultural deliberations, where
truth or falsehood is rarely obvious2. Bioethics involves the application of ethics to health sciences.
Clinical ethics is the application of bioethics to
routine clinical practice and decision making in
caring for the sick. Its growing importance is determined by the adaptation of health organization
to a society in which very different values converge and greatly influence the daily process of
decision making, from the purely clinical to resource allocation3. Clinical ethics provides a structured approach to identify, analyze and resolve
ethical issues arising in the medical field. Good
medical practice requires practical and operative
knowledge of ethical issues, such as informed
consent, the disclosure of truth, confidentiality,
palliative care in the terminal phase of life, pain
relief and patient rights. When doctors and patients differ in their scale of values and even have
to face decisions that violate them, ethical problems arise. The lack of time in emergency situations further complicates the process.
Clinical activity takes place at the bedside. It is
always focused on the individual. Two wise and
experienced clinicians deliberating on the same
case may well make different decisions. This is inherent to cautious reasoning, which always admits
more than one solution, and is typical of clinical
practice, and ethics. Moral judgments are primarily empirical and concrete, hence the decision
making process consists of careful and thoughtful
analysis of the main factors involved. Deliberation
requires analysis of problems in all their complexity, based on clinical facts and weighing up the
principles and circumstances involved as well as
the consequences4. This can be approached from
the perspective of four principles. The first is respecting patient autonomy: believe what the patient says, but let him/her participate in designing
the diagnostic and therapeutic plan. The second
is beneficence: the principle requires us to seek
what is good for the patient, provide the best
available treatment, and this entails the need for
updated training. The third is the principle of
non-maleficence: avoid inflicting harm, minimize
the risks of an intervention, ignorance, lack of expertise or training, which may undermine proper
assistance. Finally, every action must be based on
a previous risk-benefit assessment and analysis of
adverse effects. All patients have the same right to
appropriate care, regardless of the clinician or institution being seen; fair equitable and efficient
healthcare is the guiding principle5. Other authors
have proposed that ethical problems in clinical
cases should be approached from the perspective
of four parameters: medical indications, patient
preferences, quality of life, and contextual aspects
(social, economic, legal and administrative)6.
The role of ethics in clinical practice is to aid
the professional in the analysis of values involved
in a particular clinical decision. By values we mean
principles which are important for the human being, whether religious, cultural, political, culinary,
aesthetic, etc.) and must be respected by the professional practitioner. Ethics helps to ensure that
the decision taken is optimal, not only from the
point of view of the clinical facts but also the values involved. Moral uncertainty should be dealt
CORRESPONDENCE: F. M. Gamboa Antiñolo. Servicio de Medicina Interna. Hospital Universitario Valme. Ctra. Madrid-Cádiz, km. 548.
41014 Sevilla, Spain. E-mail: [email protected]
RECEIVED: 20-7-2011. ACCEPTED: 2-8-2011.
CONFLICT OF INTEREST: The author declares no conflict of interest in relation with the present article.
Emergencias 2013; 25: 143-146
143
F. M. Gamboa Antiñolo
with in the same way as clinical uncertainty to ensure that clinical decisions are prudent and reasonable. Not everyone will make the same decisions, in a specific case, but everyone should
make prudent decisions. The deliberation must be
based on clinical facts. Without test results and a
good clinical history, the rest is uncertain. The objective is to identify the optimal course of action
in situations of conflict of values7,8. These are often
related with life values, patient welfare, scarcity of
resources or religious beliefs.
Patients must be supplied with and understand
the information they need to make their decisions
in an autonomous manner. The capacity for selfdetermination may be undermined by illness,
mental disability or circumstances that severely restrict freedom9. Autonomous choice requires mental ability, competence, understanding of the situation and the possible courses of action and the
likely consequences. Until proven otherwise, all
patients are competent. We talk about "capacity
for"an activity at any particular time. To be truly
autonomous, a person should be free (no external
control or influences) and mentally capable. Informed consent is a communicative process that
formalizes the therapeutic contract but requires
constant and updated information for the patient4. Informed consent can be waived in situations of life-threatening emergency, serious risk to
public health or legal imperative. For incompetent
patients, informed consent is given by their representative, taking into account the opinion of the
patient and considering that incompetence for a
particular task does not mean incompetence for
all tasks9. The process of obtaining informed consent is often subverted, contravening the principles of good clinical practice10 (Table 1). Some authors have argued that the overriding ethical
principle should be patient autonomy. In that case
the role of health professionals would be reduced
to actions that accord with the wishes of the patient. But, can the principle of beneficence be understood without acceptance by the patient? And,
conversely, can we accept a vision of patient autonomy that makes the doctor do what the patient wants without considering the doctor’s clinical judgement of what needs to be done?11,12.
Clinical practice is complex, and more so in
the field of urgent attention. It is necessary to justify by objective empirical data the utility or futility of medical procedures13. Extreme situations require medical interventions whose usefulness may
be debatable. Simplifying, futility conveys the idea
of “not useful”, but does this mean very limited
usefulness, that the probability of success or bene144
Table 1. Ten mistakes concerning informed consent (IC)10
1. IC is not part of the moral duties of physicians.
2. IC consists of getting patients to sign the form which authorizes
the performance of an intervention.
3. Good clinical practice consists of performing clinical actions well
from the scientific-technical point of view. IC has nothing to do
with this.
4. The ethical foundation of IC is the principle of autonomy.
5. Obtaining IC is an obligation of professionals who perform
interventions, but not of those who prescribe.
6. IC makes no sense because most patients do not wish to be
informed.
7. Patients have the right to refuse treatment, but only before it is
applied to them. Once started, the professional cannot suspend or
withdraw treatment.
8. Assessing the ability of patients to decide is the responsibility of
psychiatrists.
9. IC requirements can be respected without health organizations
investing additional resources in this.
10. Obtaining IC is a responsibility of physicians, but not nursing staff.
fit is remote, or that the patient deems he/she will
not benefit from a procedure? Or, does it mean
the cost of the procedure is excessive considering
the remote possibility of success or benefit? As in
all questions of moral judgment, there may be
different opinions and legitimate discrepancies
about the utility or futility of a particular treatment. According to Iceta: "a futile medical act is
one whose application is inadvisable in a particular case because it is clinically ineffective, does not
improve the prognosis, symptoms or current disease, or one that produces predictably adverse effects which are disproportionate considering the
possible benefit for the patient or their family,
economic or social conditions"14. There are no futile medical acts per se: rather they become futile
when they meet some of the above-mentioned
criteria. Futility implies no medical indication for a
particular patient. A medical procedure may be
effective and useful for one patient but futile for
another.
If we perceive a discrepancy between the end
and the means to be used, we ask ourselves
about the limitation of the therapeutic effort. We
consider the technical indication, and therefore
the ethical justification of applying the measure in
that particular situation. Treatments with a low
probability of clinical benefit may not be futile. In
decision making, one should attempt to reduce
the level of uncertainty as far as possible, but it
can never be totally eliminated. The assessment of
the benefits of treatment is subjective, and the
process requires patient participation and consideration of their preferences11.
Ethical conflict may arise when an action
aimed at avoiding harm or producing benefit, relatively necessary, also causes undesired harm: the
Emergencias 2013; 25: 143-146
HOW DO ETHICS AFFECT OUR ROUTINE PRACTICE?
Table 2. Ethical principles in end-of-life medicine15
Principle of the inviolability of human life
Principle of therapeutic proportionality
Principle of double effect (or indirect will)
Principle of truthfulness
Principle of prevention
Principle of non-abandonment
Life is not an extrinsic good, but a fundamental value from which human rights are derived. The
duty to respect and promote life is, therefore, the first moral imperative for each person with
respect to himself and others. Bodily life is a necessary condition for the exercise of any other
right.
This refers to the moral duty to provide the means necessary for proper health care, both own
and that of others. But it is clear that nobody is forced to use all medical measures currently
available, only those that offer a reasonable probability of benefit. There is a moral obligation to
implement only that proportion of therapeutic measures necessary. Interventions involving more
are considered disproportionate and are not morally obligatory.
This principle states some conditions that must be met for an act that has two effects, one good
and one bad, to be morally licit. These are:
– that the action in itself is good or at least indifferent
– that foreseeable bad effect is not directly willed, but only tolerated
– that the good effect is not immediately and necessarily caused by the bad
– that the benefit sought is proportional to the potential harm.
Truthfulness is the foundation of trust in interpersonal relationships. Therefore, in general, telling
the truth to patients and their families is beneficial for them, because it allows active participation
in the decision making process (Autonomy). However, in practice, there are situations in which
this creates particular difficulty. Respect the patient's desire to opt for a family decision making
process may represent the optimal form of respecting their autonomy.
Consider possible complications or symptoms that are likely to occur during the course of a
particular disease or clinical condition. This is part of medical responsibility (duty to know and
forsee such complications). Implement measures to prevent these complications and provide
timely advice.
Except for serious cases of conscientious objection, it is ethically unacceptable to abandon a
patient who refuses certain therapies, even when health professionals consider that this rejection
is a mistake.
"principle of double effect"15 (Table 2). This principle states that not all actions allowing or causing
damage are morally wrong, because in some cases there is a "proportionate reason" justifying it.
The objective of the action is greater benefit than
harm. When forced to take a decision involving
two evils, we must clearly choose the lesser16.
Intuitively, ethics and quality in medical practice are directly interrelated concepts. Both the
moral imperative to do good and the principles of
social justice are sufficient reasons to justify the
ethical-quality association, and oblige doctors to
measure, analyze and improve their practice. The
quality of medical attention has been defined as
"The provision of accessible and equitable service,
by healthcare personnel with optimal professional
level, using available resources, to achieve user
adhesion and satisfaction". There are basic concepts contained in this definition, such as accessibility, fairness, professional competence(scientific,
technical, ethical and humanistic), effectiveness
and patient satisfaction, all of which must be
carefully and honestly analyzed. We all have our
duties and responsibilities17.
Another ethical requirement is to improve the
quality of research, including methodological aspects, the inclusion of patients with adequate informed consent and proper dissemination of results through comprehensive reports to improve
clinical practice16. Professionals have some basic
obligations, some at a higher level (to cause no
Emergencias 2013; 25: 143-146
harm and be fair) and others at a lower level (to
do good and respect patient autonomy). We cannot speak of the ethical dimension of man without first accepting that every person has absolute
intrinsic value, from which ethical values are derived11. Decent treatment involves not only humane attention, but also helping the ill to live a
fully human life18. This is what medical ethics is all
about.
References
1 Cordero Escobar I. Enfoque ético del dolor. Rev Cubana Salud Pública
[revista en la Internet]. 2006 Dic. (Consultado 28 Agosto 2010). Disponible en: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S086434662006000400009&lng=es.
2 Álvarez T, Velásquez O. La ética en la asistencia al paciente con dolor
y sufrimiento. Iatreia. 1995:8:116-23.
3 Gómez-Batiste X, Roca J, Trelis J, Borrell R, Novellas A. Ética clínica y
cuidados paliativos En X Gomez-Batiste, J Planas Domingo, J Roca
Casas, P Viladiu Quemada. Cuidados paliativos en Oncología. Barcelona: Ed. Jims; 1996.
4 Gracia D, Judez J. (Ed) Ética en la práctica clínica. Madrid: Ed. Triacastela; 2004.
5 Soler Company E, Montaner Abasolo MC. Consideraciones bioéticas
en el tratamiento del dolor. Persona y Bioética. 2004:8:49-64.
6 Jonsen AR, Siegler M, Winslade WJ. Ética Clínica. Barcelona: Ed. Ariel;
2005.
7 Gracia D, Rodríguez Sendin JJ. Ética en cuidados paliativos. Guías de
ética en la práctica médica. Madrid: Fundación Ciencias de la Salud;
2006.
8 Iglesias Lepine ML, Pedro-Botet Montoya JC, Gutiérrez Cebollada J,
Hernández Leal E, Pallas Villaronga O, Aguirre Tejedo A, et al. Análisis ético de las decisiones médicas en el servicio de urgencias de un
hospital universitario. Emergencias. 2000;12:313-20.
9 Llovet Haya ACJ. La competencia mental: concepto y evaluación. Selecciones de Bioética. 2003;4:28-45.
10 Simón P. Diez mitos en torno al consentimiento informado. An Sist
Sanit Navar. 2006;29(Supl. 3):29-40.
145
F. M. Gamboa Antiñolo
11 Gamboa F. Ética médica y dolor. Med Clin (Barc). 2011;136:671-3.
12 García Pérez MA. El triángulo bioético: una aproximación intuitiva a
la ética de la práctica clínica. Aten Primaria. 2004;33:510-5.
13 Gamboa F. Limitación de esfuerzo terapéutico. ¿Es lo mismo retirar
un tratamiento de soporte vital que no iniciarlo? Med Clin (Barc).
2006;135:410-6.
14 Iceta M. El concepto médico de futilidad y su aplicación clínica [tesis
doctoral]. Pamplona: Departamento de Bioética. Universidad de Navarra; 1995.
15 Taboada P. Principios éticos relevantes en medicina paliativa. En E Bruera,
L Madrid: Lima Ed. Cuidados paliativos. Guías para el manejo clínico.
OPS-OMS; 2002.
16 Gracia D. Salir de la vida. En D Gracia. Como arqueros al blanco. Estudios de bioética. Madrid: Ed Triacastela; 2004.
17 Carvallo A. Ética y Dolor. Rev Reumatología. 2002;18:53-5.
18 Rodríguez PA. Fundamentación ética de la atención los pacientes
con VIH-SIDA. Bioética. 2006;1:22-5.
ERRATA
In the article “Patient responses to symptoms of acute coronary syndrome: a gender-perspective
study” published in Emergencias 2013;25:23-30, the correct posts of the authors and their affiliations are as follows: Julia Bolívar Muñoz1,2, Rafael Martínez Cassinello1, Inmaculada Mateo RodrÍguez1,2, Juan Miguel Torres Ruiz3, Nuria Pascual Martínez3, Fernando Rosell Ortiz4, Antonio Reina Toral5, Carmen Martín Castro6, Antonio Daponte Codina1,2.
1
Escuela Andaluza de Salud Pública, Granada, España. 2CIBERESP, Centros de Investigación Biomédica
en Red de Epidemiología y Salud Pública, Instituto de Salud Carlos III, España. 3Hospital Universitario
San Cecilio, Granada, España. 4Empresa Pública de Emergencias Sanitarias (EPES), Almería, España.
5
Hospital Universitario Virgen de las Nieves, Granada, España. 6Empresa Pública de Emergencias Sanitarias (EPES), Granada, España.
146
Emergencias 2013; 25: 143-146