Physicians should follow two fundamental but frequently conflicting ethical guidelines: respect patient autonomy and act in the patient's best interests.
Respecting Patient Autonomy
Treating patients with respect requires doctors to accept the medical decisions of persons who are informed and acting freely. Individuals place different values on health, medical care, and risk. In most clinical settings, different goals and approaches are possible, outcomes are uncertain, and an intervention may cause both benefits and harms. Thus competent, informed patients may refuse recommended interventions and choose among reasonable alternatives.
For patients to make informed decisions, physicians need to discuss with them the nature of the proposed care, the alternatives, the risks and benefits of each, and the likely consequences, and obtain the patient's agreement to care. Informed consent involves more than obtaining signatures on consent forms. Physicians need to educate patients, answer questions, make recommendations, and help them deliberate. Patients can be overwhelmed with medical jargon, needlessly complicated explanations, or too much information at once.
Nondisclosure of Information
Physicians may consider withholding a serious diagnosis, misrepresenting it, or limiting discussions of prognosis or risks because they fear that a patient will develop severe anxiety or depression or refuse needed care. Generally, physicians should provide relevant information, while adjusting the pace of disclosure, offering empathy and hope, and helping patients cope with bad news.
In many cultures, patients traditionally are not told of a diagnosis of cancer or of other serious illness because such disclosure is believed to cause patients to suffer, while withholding information is believed to promote serenity, security, and hope. Patients should not be forced to receive information against their will, even in the name of promoting informed decisions. However, many individuals want to know their diagnosis and prognosis, even if they are terminally ill. Physicians, therefore, should ask patients how they want health care decisions to be made, adding that they usually provide information and make decisions together with patients, while offering patients the option not to receive information or to turn decision-making over to someone else.
Informed consent is not required when patients cannot give consent and when delay of treatment would place their lives or health in peril. People are presumed to want such emergency care, unless they have previously indicated otherwise.
Autonomy does not entitle patients to insist on whatever care they want. Physicians are not obligated to provide futile interventions that have no physiologic rationale or have already failed. For example, cardiopulmonary resuscitation would be futile in a patient with progressive hypotension despite maximal therapy. But physicians should be wary of using the term futile in looser senses to justify unilateral decisions to forego interventions when they believe that the probability of success is too low, no worthwhile goals can be achieved, the patient's quality of life is unacceptable, or the costs are too high. Such looser usages of the term are problematic because they may be inconsistent and mask important value judgments. Several states have laws allowing physicians not to provide interventions that they deem futile or not medically indicated, provided they follow procedures such as obtaining the concurrence of the hospital ethics committee and giving the patient an opportunity to be transferred to another hospital.
Confidentiality respects patients' autonomy and privacy, encourages them to seek treatment and discuss their problems candidly, and prevents discrimination. However, maintaining confidentiality is not an absolute rule. Confidentiality may be overridden in certain situations to prevent serious harm to third parties or to the patient. The law may require physicians to override confidentiality in order to protect third parties, as with reporting of tuberculosis and syphilis. In other situations, medical providers have a legal duty to report victims of elder abuse, child abuse, and domestic violence. These exceptions to confidentiality are justified because the risk is serious and probable, there are no less-restrictive measures to avert risk, the adverse effects of overriding confidentiality are minimized, and these adverse effects are deemed acceptable by society.
The Health Insurance Portability and Accountability Act (HIPAA) health privacy regulations have heightened awareness of the importance of confidentiality. These regulations are not meant to inhibit transmission of information needed for treatment: disclosure of patient information to other health care providers for the purposes of treatment without having the patient sign an authorization form is permissible.
Health care providers sometimes consider using lies or deception in order to protect the patient from bad news or to obtain benefits for the patient. Lying refers to statements that the speaker knows are false and that are intended to mislead the listener. Deception, which is broader, includes statements and actions that are intended to mislead the listener, whether or not they are literally true. For example, the health care provider may tell a patient that she has a "small growth" so that she does not think she has cancer. Or the provider may complete and sign a form for a patient to get a bus pass, even though he does not meet criteria for physical disability. Although such deception may be motivated by a desire to help the patient, it is ethically problematic. The person who is deceived cannot make informed decisions if he or she receives misleading information. Furthermore, deception undermines physicians' credibility and trustworthiness.
Acting in the Best Interests of Patients
The guideline of beneficence requires physicians to act for the patient's benefit. Laypeople do not possess medical expertise and may be vulnerable because of their illness. They justifiably rely on physicians to provide sound advice and to promote their well-being. Physicians encourage such trust. Hence, physicians have a fiduciary duty to act in the best interests of the patient, which should prevail over physicians' self-interest or the interests of third parties, such as hospitals or insurers. These fiduciary obligations of physicians contrast sharply with business relationships, which are characterized by "let the buyer beware," not by trust and reliance. The guideline of "do no harm" forbids physicians from providing ineffective interventions or acting without due care. This precept, while often cited, provides only limited guidance, because many beneficial interventions also have serious risks.
Conflicts between Beneficence and Autonomy
Patients' refusals of care may thwart their own goals or cause them serious harm. For example, a young man with asthma may refuse mechanical ventilation for reversible respiratory failure. Simply to accept such refusals, in the name of respecting autonomy, seems morally constricted. Physicians can elicit patients' expectations and concerns, correct misunderstandings, and try to persuade them to accept beneficial therapies. If disagreements persist after discussions, the patient's informed choices and view of his or her best interests should prevail. While refusing recommended care does not render a patient incompetent, it may lead the physician to probe further to ensure that the patient is able to make informed decisions.
The term justice is used in a general sense to mean fairness: people should receive what they deserve. In addition, it is important to act consistently in cases that are similar in ethically relevant ways. Otherwise, decisions would be arbitrary, biased, and unfair. Justice forbids discrimination in health care based on race, religion, or gender and supports a moral right to health care, with access based on medical need rather than ability to pay.