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The Physician-Patient Relationship: The basis for moral clarity in clinical ethics

It is my
sense that the majority, perhaps the vast majority, of cases on which clinical
ethics consultants (CECs) are asked to consult and make an ethics
recommendation, there is, or would be, a general consensus on the part of the
CECs about what counts as the appropriate recommendation. However, the question
arises of how clinical ethics as a field should deal with issues that come up
about which there is not a clear consensus, such as in cases where a basic
right to have an autonomous choice respected by the patient is pitted over and
against the obligation of the physician to do no harm—the traditional tension
between respect for patient autonomy and beneficence/nonmaleficence. This
tension or conflict often occurs in cases of alleged medical futility where the
patient or the patient’s surrogate requests a treatment option the physician deems
will only cause harm and no benefit to the patient. For example, consider a
patient’s surrogate who insists that she will not consent to a DNR order and in
fact expects the physician to perform CPR if the patient arrests. For a patient
without capacity dying of metastatic disease, this directive by the surrogate
presents a stark dilemma to the physician—is it a violation of the physician’s
obligation to the patient to “do no harm” (nonmaleficence)? Or is respect for
the patient’s wishes or her representative’s wishes so sacrosanct that the
physician’s obligation to follow the patient’s wishes is paramount and
outweighs the obligation to do no harm?

Furthermore, it is my sense that those who view clinical
ethics cases from a distance, i.e. the academic classroom, may find it easier
to side with the surrogate, i.e. championing expansive patient rights, claiming
the physician should respect individual autonomy in the vast majority of cases.
This approach then becomes a matter of placing supreme value on a moral
position quite apart from the clinical facts of the case. Thus, from this point
of view, clinical ethics consultants could manage an ethics consultation
service as well in a philosophy classroom from afarand never have to work in a
hospital. Also, this way to thinking about clinical ethics makes such basic
value dilemmas incommensurable from a philosophical normative point of view,
i.e. there is no rational basis by which to prioritize one value position over
another in the abstract. To get beyond such problems, we must keep in mind the
nature` of clinical ethics.

The dilemmas of clinical ethics, like whether or not to
respect the directive of the surrogate in the above example, are never
evaluated in terms of the opposition of two opposing ethical principles in the
abstract. Rather the dilemmas of clinical ethics are always assessed in terms
of the “particularities” of each case, which allows us to better grasp the
ratio of benefits and burdens associated with treatment options under
consideration.In the case of a the surrogate’s request for CPR for her dying
loved one, the physician, hopefully with help from the clinical ethics
consultant, must make a benefit-burden ratio of the facts in order to see what
the physician’s obligations are. Respect for patient autonomy must be taken
seriously, but not as an absolute value. The patient in this case has
metastatic disease and dying. But we need to be even more specific. If the
patient’s incapacity is temporary, due to a reversible issue, and could
possibly live more many more months, then maybe resuscitation would be
appropriate. Therefore, performing CPR on this patient could possibly
accomplish a viable goal of care, i.e. extended life for a few more months. So
the additional life afforded the patient might justify the potential burdens of
CPR and possibility of it not working.
 On the other hand, if the patient is in the
final stages of dying and resuscitation will only prolong the final dying
process, then resuscitation would not be appropriate. Therefore, there is not a
viable goal of care possible i.e. the patient is die soon regardless of any
actions taken by the physician. CPR will only create needless burdens and
provide no benefits to the patient. Thus, depending on the facts in a
particular cases, the physician may or may not be obligated to perform CPR. In
those cases where the physician is not obligated to perform a requested
treatment, there is obligation also for the physician to be transparent to the
surrogate and communicate with compassion that further aggressive interventions
to prolong the patient’s life will not be performed because they are not in the
best interest of the patient.

It is important to realize that in clinical ethics the
obligations and responsibilities of the major stakeholders in a case must be
understood, which always requires interpretation, within the context of the
moral perspective of the physician-patient relationship. As clinical ethics
consultants we do not have access to a special realm of abstract philosophical
truths or insights.The moral basis of clinical ethics resides in the
physician-patient relationship: A competent, caring physician appropriately
treating and caring for a sick patient.This is a relationship most unlike most
of our consumer-oriented, contractual relationships in a capitalistic economy
where the consumer is given almost complete latitude in their consumer choices.
Rather, it is a special relationship with its own moral norms and
standards—e.g. physicians cannot cause harm to a patient by performing a
certain intervention unless there is an adequate reason to do so, i.e. there is
a reasonable chance the intervention will provide some medical benefit to the
patient.It follows that clinical ethics consultants must be students of the
physician-patient relationship.

In summary, the ethical conclusions and recommendations
about what counts as an appropriate ethical interpretation in a particular
clinical case must be based on a clear understanding and assessment of the
clinical facts. In those cases where the directives of the patient or surrogate
are within the confines of appropriate medical care goals, then, there is a
clear obligation for the physician to respect patient autonomy and perform the
interventions. However, when those directives would require the physician to
perform inappropriate, contraindicated interventions, based a careful analysis
of the benefits and burdens, there would be no obligation for the physician to
perform the interventions; at this point the patient or surrogate should be
provided support and compassionate full explanation of the limits of medical
treatment options.


The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI’s online graduate programs, please visit our website. 

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