Physicians today are facing more ethical dilemmas as patient decisions
are being based less on beneficence and more on business models
of success, says Sister Patricia Talone, ethics consultant, Mercy
Health Corporation of Southeastern Pennsylvania.
Speaking during the recent Radiation Therapy Oncology Group (RTOG)
meeting in New Orleans, Sister Patricia discussed models for ethical
decision-making, and Father Albert Jenemann emphasized that physicians
must follow fundamental moral principles when determining patient
care. These principles include beneficence, nonmalificence (not
causing needless harm or injury), and utility (bringing the greatest
benefit with the least harm).
"A patient's care must be just, in that similar cases receive
similar care," says Father Jenemann, associate professor
of philosophy at St. Joseph's University in Philadelphia. Justice
can be interpreted in a number of ways, he says. Some suggest
that those who have a greater need should receive more, while
others suggest that those who contribute more or exhibit a higher
level of effort should get more. For example, the more competent
person receives a higher salary. Sister Patricia emphasizes that
"need" should be the most important determining factor.
This may not be the case when medicine is considered a business,
Patient autonomy, which includes adequate information and sufficient
ability to deliberate and make a decision, is another moral principle,
says Father Jenemann. Autonomy can be restricted to benefit the
patient and to sacrifice a small benefit in order to bring major
benefits to others.
The Step-by-Step Way to Ethical Decisions
There is a step-by-step process that physicians can follow to
make appropriate ethical decisions, says Sister Patricia. Ethical
decisions are best made by a group rather than just one or two
people, she adds. All medical, social, emotional, religious, and
spiritual factors must be gathered regarding the patient. The
financial reality of the situation also might be considered.
The patient, if capable of making medical decisions, should be
part of the decision-making process. If the patient is incapable
of doing so, a surrogate, such as a family member, must be included.
All decision-makers should should deliberate or discuss the options
and their consequences. "Deliberation works best when there
is a willingness to share experience and listen to others. The
frequently wrong but never unsure person is not good for the deliberation
process," says Sister Patricia. After deliberation, a decision
can be made. Any decisions should be documented, then evaluated.
"Some physicians are reluctant to document their decisions
because of a fear that their decisions will later be second-guessed,"
says Sister Patricia. Documentation and evaluation help keep an
account of responses to ethical questions. These responses may
help answer future ethical dilemmas or may even indicate the need
for a change in policies and procedures, she says.
"The shift of medicine into a business model can have frightening
consequences," says Sister Patricia. It is essential that
physicians remain principled and virtuous.
"Ethical principles are only enacted by persons with character,"