Chapter 5: Ethics

FOUNDATIONAL APPROACHES/THEORY

Two approaches have dominated Western thinking about medical ethics: consequentialism and deontology.¹

CONSEQUENTIALISM

A philosophical approach that judges the correctness of an action based on the effect it will likely have. The focus is on the consequences of an action. Advocates, including utilitarian philosophers, argue for actions that seek the greatest happiness for the greatest number of people.

DEONTOLOGY

A philosophical approach that argues that actions have intrinsic moral worth. Supporters purport that certain universal truths and rules should be followed, regardless of their consequence.

FOUR PRINCIPLES

Most people feel that four principles should guide approaches to care and decision making:

• Beneficence: Provide care that benefits the patient

• Maleficence: Avoid causing harm

• Autonomy: When possible, individuals should decide for themselves what is in their best interests

• Justice: Relates to fairly distributing services and resources

DECISION MAKING

DECISION MAKERS

The legally authorized decision maker is determined by the patient's age and the capacity for an individual to make a decision.

• Adult patients: Patients >18 years old can make decisions for themselves if they have decision-making capacity. An adult can identify a decision maker in the event he or she does not have decision-making capacity. Surrogate decision makers should make decisions based on substituted judgment when possible.

  • Decision-making capacity: A clinical determination that an individual can 1) understand and communicate about the medical situation; 2) manipulate information about the situation and consider the consequences of alternatives; 3) make a choice among the alternatives

  • Competence: Typically considered a legal term reflecting the ability of an individual to make a decision

  • Power of attorney: A legal document giving decision-making authority for the patient to an individual

  • Legal surrogate: A person legally charged with acting on behalf of another person

  • Substituted judgment: A decision made on behalf of another person based on knowledge about what the person would decide if he or she could speak for himself or herself

• Pediatric patients: For patients <18 years old, parents or the patient's legal guardian is the legal decision maker and should make decisions based on the best interest standard. However, the state can intervene when parents make decisions that place the child's health, well-being, or life in jeopardy. The American Academy of Pediatrics supports involving developmentally appropriate patients in clinical decision making, provided that his or her views will be considered.²

  • Best interest standard: The decision pursued should be the one most favorable for the child.³

  • Exceptions: In certain state-determined clinical situations (e.g., issues related to sexually transmitted infections or pregnancy), the patient can make his or her own decisions. States also have unique laws that determine who is eligible to be an emancipated or mature minor and therefore make his or her own medical decisions.

  • Patient ...