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, she adds.
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," she says.
A 70-year-old man with a history of localized prostate cancer treated with whole-pelvis radiation therapy with a boost to the prostate, in conjunction with androgen deprivation therapy 7 years prior, presented with lower back pain. A bone scan revealed an area of activity in the sacrum. What is the most likely diagnosis?
