List the professional duties that a physician has to the patient and to the health care team.
Identify the moral and legal issues of a medical situation.
Every encounter with a patient is not only a clinical encounter but also one that encompasses ethics, the law, and professionalism. Principles such as patient autonomy, informed consent, honesty to presenting information, and confidentiality are relevant. Typically, medical students and physicians sail through the patient encounter easily without hitting any of the potential jagged edges of morality or the law. Occasionally, however, an issue arises that takes the health care team by surprise (eg, the patient who refuses lifesaving treatment because of an “irrational belief”). How does the health care professional deal with this issue? How does one step back from the shock that a seemingly reasonable person would adopt an unreasonable path? The answer to these questions depends on an understanding of the basic moral and legal concepts that govern the patient encounter. Thus, the first step for the student is to understand and apply the basic ethical and legal principles in some common situations.
Identify the key aspects of a valid informed consent or a valid refusal of treatment.
Informed consent, or the flip side of the same coin “informed refusal,” is a fundamental concept that every health care professional must have mastery. To respect a patient’s right to autonomy (self-governance), the physician must provide the patient with the relevant information on his or her medical condition, the proposed treatment and its likelihood of benefit, the alternatives, and the risks of the various options. More than a moral responsibility, the physician has a legal responsibility for this informed consent process. By contrast, patients also have the right for refusal of treatment. Patients must be “fully informed” and “in their right mind” (competent) for the consent process to be valid. Students should become experts at identifying the key aspects of this counseling process.
Describe how to determine competence to consent to or refuse treatment.
Because patients must be given the proper information to make health care decisions, they must “have the mental capacity to decide.” This is a legal concept and is sometimes referred to as decision-making capacity. Competence is an “absolute” and specific, and the patient is either competent or not competent to make a certain decision. The 4 key elements to decision-making capacity are: (1) understanding the information presented, (2) appreciate the significance of the situation including the risks and benefits, (3) ability to reason in the current situation and context, and (4) express a choice (communicate a preference). Being competent is not synonymous to making good decisions. A competent person may make poor choices. Competence can be impaired due to issues of cognition (dementia, brain injury), emotion (mania, depression), or delusional thinking (schizophrenia). The student must be well versed in how to determine competence to ensure the patient can make valid decisions.
List the process to decide when it is legally and ethically justifiable to withhold information from a patient.
A physician is obligated to promote a patient’s welfare and respect his or her autonomy by providing truthful information. However, there are some rare circumstances when it is appropriate to withhold information from a patient. In general, the term “withholding information” does not apply to disclosure of mistakes. Valid reasons for nondisclosure of relevant medical information depend on the likelihood of “serious harm” to the patient. This is more than the patient becoming emotional or upset or even if requested by a family member. One example of a valid situation is if information provided to a depressed patient may cause him or her to become suicidal. Another example is if the patient explicitly asks not to be told about the medical condition or diagnosis but, instead, that a family member be told and make decisions on his or her behalf. In this situation, “informed preference” means the patient understands the full ramifications of not making decisions for himself or herself. Almost universally, the physician should provide information to the patient, albeit in many circumstances, in a sensitive and measured manner. Note that withholding information is not the same as lying to the patient. In this setting, the student should know how to deliver bad news and also when it is acceptable not to disclose information.
Describe when it is morally and legally justifiable to break confidentiality.
Patient confidentiality is one of the foundations of the physician–patient relationship. Because the information being discussed is personal by nature, and perhaps may be embarrassing if it becomes public, the patient must be able to depend on the physician being confidential. The patient must trust his or her doctor with sensitive and truthful information so accurate diagnoses can be made. This confidentiality is both an ethical as well as legal responsibility. The main ethical and legal justification to break confidentiality is when a risk for imminent harm is identified. The student should be aware of the physician’s duty to the patient (protect patient confidentiality) versus duty to the public or another person and be able to balance their duties.
Describe how to approach the patient who refuses treatment.
As discussed in the preceding points, the student must have an understanding of whether the patient has decision-making capacity (competence) and is given the proper information to make decisions (informed consent). Patients may choose to refuse the recommended treatment. Some decisions are of little consequence, while others may be life threatening. The novice health care professional may become frustrated at the latter situation and believe that the patient must have “diminished decision-making capacity” or not understand the situation, and try harder to “convince” him or her of the proper course. This response involves prejudgment on the part of the physician, and rarely is fruitful. Some strategies that are helpful include (1) clarifying whether the patient is aware of the situation (ask the patient to describe the medical condition), (2) understanding their story (ask how the patient made his/her decision), (3) being aware and understanding their concerns, (4) exploring fears and concerns, and (5) trying to find a win–win solution. The student should be aware of his/her own biases, cultural and religious beliefs, and values, and how it may alter complex medical decision-making.
Describe the legal and ethical issues surrounding patients with a poor prognosis including those with a terminal condition.
The physician’s role in end-of-life care is a difficult one. Issues relevant to this area include physician-assisted suicide, such as intentional termination or assisting in termination of life of a terminally ill patient on his or her request. State legal requirements have much to bear about the latitude of the physician in this area; in fact, some states have strict legal ramifications for physicians participating in patient-assisted death, including jail time. Advance directives, provision of life support, and withdrawing life support also fall into this area. Sometimes, there is no advance directive and family members may not be very aware of the patient’s wishes. These situations are particularly challenging. The student should be aware of the legal and moral principles and limitations in end-of-life care, and the process whereby life-sustaining treatment may be withdrawn.
List the professional duties that a physician has to the patient and to the health care team.
The physician has numerous professional duties to the patient, including maintaining professional competence, honesty, confidentiality, maintaining appropriate relations with patients, commitment to excellence by keeping current in medical knowledge, managing conflict of interest, and maintaining a collaborative relationship with the health care team. Physicians have an unfair power advantage over patients, and they should never exploit that advantage in dating, sexual relations, personal financial gain, or other private purpose. Sometimes, grateful patients may even give personal gifts to their doctor; in general, any gift that is of more than very little value should not be accepted. Recently, the disruptive behavior of physicians has been found to interfere with the care of patients and harm the health care team. Many professional and hospital associations have taken steps to advocate a “no tolerance policy for the disruptive health care member.” The student should be aware of the basic professional obligations of the physician.