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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.
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EXAMPLE. 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.
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This case exemplifies clinical ethics because it demonstrates the bioethical principles commonly considered necessary for ethical medical care, namely, respect for autonomy, beneficence, nonmaleficence, and justice. The symptoms are sufficiently clear for the physician to make a diagnosis and prescribe an effective therapy in order 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. Medications are available, insurance pays the bill, and no problems with family or hospital complicate the situation.
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This case represents the ethical practice of medicine because each of the fundamental principles is fulfilled. It would become an ethical problem if one or more of these principles could not be fulfilled because several principles appeared to conflict or draw the decision in different directions. For example, if the patient stated that he did not believe in antibiotics, or if the urinary tract infection developed in the last phase of a terminal illness, or if the infection was associated with a sexually transmitted disease where sexual partners might be endangered, or if the indicated medication was in short supply and needed to be rationed. Sometimes, these problems can be readily resolved; at other times, they can become major obstacles in the management of the case.
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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 the 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.
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1.0.1 Definition of Medical Indications
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Medical indications are the facts and their interpretations about the patient’s physical and/or psychological condition that provide a reasonable basis for the physician’s clinical judgments aiming to realize the overall goals of medicine: prevention, cure, and ...