Problems with Doctors Invoking the Best Interest Standard

Although the “best interest standard” has been widely accepted as a benchmark for decisions made on behalf of others, this chapter explains why medical professionals should eschew the phrase. Decisions by medical professionals are different from decisions by patients and surrogates, and their duty to care for patients and promote their interests is markedly different from acting in the patient’s best interest. Doctors must distinguish their professional fiduciary responsibilities from the concept of best interest because confusing the two can lead to blunders with unfortunate consequences. This chapter responds to supporters of the best interest standard, like Kopelman, and critics, like Veatch, who object to its being subjective and vague. It also explains why introducing the phrase into the language of medical professionals can be misleading or irrelevant and lead to behavior that is intolerant, polarizing, and unjust. Instead, the chapter offers the “three-box model” for guiding doctors’ responses to surrogate decisions.

Duties of Behavior Toward Patients

This chapter explains three central physician duties that clearly set medical ethics apart from common morality: nonjudgmental regard, nonsexual regard, and confidentiality. Because patients will not trust doctors when they are not confident in the doctor’s devotion and commitment to meeting their medical needs, doctors must avoid any intimation of judging a patient unworthy of care. Because doctors need their patients to trust that the intimacy of the doctor-patient relationship has no sexual overtones in spite of the revelation, nudity, and touching, doctors must maintain nonsexual regard in their patient interactions. Because doctors need patients to divulge intimate personal details about their behavior and history in order to make accurate diagnoses and develop treatment plans, patients must be able to trust their doctors to uphold confidentiality and only share medical information with other professionals on a need-to-know basis. These duties are explained and illustrated with numerous case examples.

Why a New Approach to Medical Ethics Is Needed

The Trusted Doctor: Medical Ethics and Professionalism rejects the well-entrenched views of medical ethics as everyday ethics or common morality applied to medicine. This chapter lays the foundation for the original account of medical ethics that follows in the book’s succeeding chapters. By presenting vivid examples and general arguments the author demonstrates ways in which the ethics of medicine is distinct and different from common morality. The chapter discusses the most popular common morality views, namely, the four principles approach expounded by Tom Beauchamp and James Childress in Principles of Biomedical Ethics and the ten rules approach presented by Bernard Gert, Charles Culver, and K. Danner Clouser in Bioethics: A Systematic Approach by presenting arguments that challenge their applicability to medical practice. A chart identifies some stark differences between the common morality approach and good medical practice and shows how everyday ethics is incompatible with medical professionalism.

Resolving Moral Dilemmas

Any moral system that involves more than a single principle, rule, or duty inevitably confronts the problem of moral conflict. Moral conflicts arise when two or more cherished values are relevant considerations in a situation but point to different and incompatible actions. Doctors need guidance in thinking through these ethical quandaries that arise in clinical practice. This chapter provides a template that outlines a systematic approach for resolving clinical ethical dilemmas and provides case examples that demonstrate how the template may be employed. The model mirrors standard medical thinking. Employing the template will prompt doctors’ through the steps of moral reasoning and increase the likelihood that they will consider all relevant information and put it together in a way that leads to an ethically justified resolution. Following this structured thought process for addressing ethical dilemmas in medicine also ensures that doctors act for reasons that are consistent with the ethics of medicine and uphold their professional duties.

Medicine’s Commitment to Truth

This chapter explains truth-telling as a critical duty of medical ethics. Truthfulness and honesty promote trust in doctors and the profession, while withholding information or lying undermines society’s trust. Truth-telling also promotes the interests of patients and society because it allows decision-makers to rely on the reports of doctors. Doctors are obliged to be truthful and provide their patients with the information that they need in order to conduct their lives in accordance with their own priorities. Patients need to know their diagnosis and prognosis even when there are no medical decisions that turn on the information. Nevertheless, doctors are often reluctant to be forthcoming with patients. After explaining the importance of truthfulness in medicine, this chapter explores the reasons doctors give for being less truthful than they should be and debunks their withholding information with psychology research about affective and empathic forecasting and evidence from social science.

Introduction

This book begins by rejecting the reigning view of medical ethics as the application of common morality, that is, the ethics of everyday life, to dilemmas that arise in today’s medical practice. Instead, it argues for a new theory of medical ethics that is actually in line with the codes of ethics and professional oaths proclaimed by physicians around the world. This introduction explains how a philosopher who has spent 30 years as a bioethicist at an academic medical center and medical school is in a good position to propose a novel approach to the ethics of medicine. The proposed theory of medical ethics makes sense of the concept of medical professionalism and serves as a useful guide for doctors who confront ethically challenging situations in their clinical practice.

Why Trustworthy Stewardship Requires Justice

Doctors make daily decisions about allocating medical resources. Society trusts doctors to make those decisions justly, and physicians typically make trustworthy and just allocations. Justice requires not only equality in the treatment of equals, but also moral discernment to identify which factors are significant and how they should be compared. This chapter reviews prominent theories of justice in medicine and argues that each of them oversimplifies by reducing unavoidable complexity into a single and often-inappropriate principle. Instead, this chapter argues that justice should be understood as the conclusion from consideration of relevant factors in particular kinds of decisions. By discussing resource allocations in four domains (nonacute care, acute care, critically scarce resources, public health), the chapter explains which principles of justice should guide allocations in each domain. The chapter includes a summary table showing which principles of justice should be categorically rejected for guiding some allocations and which should be employed.

Commitments to Fellow Professionals

Doctors’ ability to satisfy their responsibilities to society and patients involves fulfilling the duties that one medical professional owes to another. These duties include the interrelated obligations of peer responsiveness, peer communication, and peer scrutiny, which all derive from medicine’s commitments to make the profession worthy of trust and serve the interests of patients and society. Even though these obligations are rarely mentioned in medical association codes of ethics, they are recognized by most physicians. Their omission from formal declarations of physician responsibilities and from the standard accounts of medical ethics, however, leaves some doctors unaware that these are important professional duties. To address that lacuna, this chapter explains these duties and illustrates their importance with case examples to make it clear that they are essential elements of professionalism. The chapter also includes a discussion of the contentious issue of responsibilities for both acts and omissions.

Duties to Respect Patients’ Autonomy and Assess Capacity

The two interrelated duties of respecting autonomy and assessing decisional capacity require considerable explanation. The first is acknowledged as a duty in most contemporary codes of medical ethics, while the second is not mentioned in any. This chapter provides a description of three distinct uses of the concept of autonomy and an overview and critique of different traditional and contemporary philosophers’ views on the concept of autonomy. To be trusted, doctors have to pay serious attention to patients’ opinions on what is good for them. They also have to recognize their fiduciary responsibility, step back from respectfully presuming that patients have autonomy, assess decisional capacity, and determine whether patients can be held responsible for their choices. Autonomous decisions should be respected, but when decisional capacity is impaired, paternalistic intervention may be required. Examples provide doctors with guidance for making the challenging decisions related to decisional capacity that have to be made in clinical practice.

The Commitment to Science

The association of medicine with science is at the core of the profession’s expertise. This chapter explains that doctors are duty-bound to base their diagnoses and treatment decisions on scientific evidence because patients rely on that commitment when seeking treatment and advice. Thus, the commitment to science is a core duty of medical ethics. The chapter argues that doctors should be committed to advancing biomedical knowledge and supporting medicine’s research agenda. In that light, the chapter opposes two widely accepted views. One is the World Medical Association’s position that physicians should focus exclusively on the good of their individual patient. The other is the US Common Rule’s distinction between clinical innovation and research, which has the effect of driving a wedge between medical ethics and research ethics. The chapter also addresses challenging issues of how human subject research should be conducted, research oversight, consent, vulnerable subjects, and placebo studies.