Introduction to Clinical Ethics
Ben Faneye, OP, DHCE
West African Bioethics Training
Program
Historical Background
• Evolution of clinical ethics, attributed to
certain needs:
– Need for bedside teaching of ethics – William
Osler’s medical teaching tradition
– Need for a method of ethical enquiry most
suitable to individual clinical settings
– Need to create a bridge btw academic world
of bioethics & the world of clinicians and pts.
Clinical Ethics: Its Content
• Concerned with restoring and
strengthening bonds between
professionals, patients and families. This is
contrary to the conflicting principles of
bioethics.
• Uses cases and relies on the clinicianpatient relationship/encounter in
contributing to research on ethical issues.
Clinical Ethics: Its Content
• Focuses on issues of concern to clinicians,
patients & the general society
• Issues stemming out of real life
encounters
• Uses its empirical findings to encourage
reform practices among clinicians, which
helps establish the 2-world relationship.
Clinical Ethics: Services
• To provide clinical ethics education to
clinicians, patients, surrogates and the
larger community
• Policy studies and recommendations for
institutional guidelines on ethical issues in
pt. care.
Clinical Ethics: Services
• Providing a process for case consultation
at the bedside or the conference room
• Researching ethical problems and initiating
prevention plans for such problems often
encountered.
Clinical Ethics: Its Practice
• Ethical Obligations: Basis for praxis
– Stem from the concept of duty, which is the
necessity of action done out of respect for the
law.
– Connotes what one is bound to do in
situations arising from patient care.
– A recognition of one’s duty in upholding
another’s rights (pt’s rights).
Ethical Obligations In Cases
• Respecting Privacy & Confidentiality
– Right to privacy:
which is a person’s claim to those things that
define one as such, e.g., thoughts, feelings,
aspirations, information, physical body.
Ethical Obligations In Cases
– Privacy rights: Its types
• Negative right is right to non-interference or to be
left alone, e.g., right to bodily integrity. It is a right
that restricts others.
• Positive right is a person’s prerogative to control
access to and distribution of information about the
self, e.g., patient’s control over treatment. This
ordinarily requires the active participation of
others.
Ethical Obligations In Cases
• Confidentiality: Corresponding duty
– Mechanism by which a person’s right is
recognized and respected
– Based on a fiduciary relationship, some sort of
promise, whereby a clinician recognizes one’s
duty to safeguard a patient’s rights
– Basis for intimacy between persons, clinicians
and patients and families
Ethical Obligations In Cases
• Confidentiality: Why?
– Public knowledge of health records can cause
discrimination and embarrassment
– Required by law and professional code, a
breach of which can lead to disciplinary and
legal action against an organization and
employee
Ethical Obligations In Cases
• Confidentiality: What is covered?
– Personal information that can identify a pt
– Treatment information
– Details about illness and/or diagnosis
– Medical Record
– Conversation btw clinician and pt and/or
family.
Ethical Obligations In Cases
• Confidentiality: Basis of duty
– Hippocratic Oath – “And whatever I shall see
or hear . . . I will never divulge, holding such
things to be holy secrets.”
– T. Percival in his Code for Medical Ethics
(later adopted by AMA in 1847)states:
“Patients should be interrogated concerning
their complaint in a tone of voice which
cannot be overheard.”
Ethical Obligations In Cases
• Confidentiality: Basis of duty
– International Council of Nurses’ Code – “the
nurse holds in confidence personal
information and uses judgment in sharing this
information.”
Ethical Obligations In Cases
• Respect for Patients’ Decision-Making
Capacity
– Duty towards pts stems out of pt’s right of
autonomy
– Autonomy is a person’s right to determine
what happens to, or is done to the self
(paternalism, an issue).
Ethical Obligations In Cases
• Respect for Patients’ Decision-Making
Capacity
– Corresponding to this right is clinician’s duty
to ascertain and enable the pt in exercising
autonomy right (duty to inform).
– A determination of pt’s capacity considers:
• Individual abilities of pt, e.g., sound mind or not
• Importance of the decision at hand
• Consequence likely to follow from decision
Ethical Obligations In Cases
• Respect for Patients’ Decision Making
Capacity
– Where pt is deemed incapable, there are
standards in place for surrogate decision
makers.
Ethical Obligations In Cases
• Standards for Surrogate decision-makers:
– Substituted Judgment: decision made based
on the known & perceived wishes of the pt.
– Best Interest: decision made based on what a
reasonable person would do. Risks & benefits
of treatment analyzed, with goal of
maximizing benefits and minimizing harms.
Ethical Obligations In Cases
• Decisional Capacity: What is it?
– “Ability to make a decision”
– Exercise of free power of choice (no force)
– Crucial aspect of voluntary consent
– Focuses on giving or withholding consent for
treatment.
Ethical Obligations In Cases
• Respect for Decision Making Capacity: Its
Challenges
– Incapable pts giving consent does not validate
treatment by clinician (possibility of self-harm)
– Clinician who withholds treatment from an
incapable pt who refuses treatment risks
liability if other legally valid treatment
authorization steps are not sought.
Other Obligations In Clinical Cases
• Communication:
– Ability to listen to and understand the pt’s
story & body language
• Truth-telling:
– Clinician’s professional integrity imposes a
negative duty not to lie, as well as a positive
duty to tell the truth about what the pt has
right to know.
Other Obligations In Clinical Cases
• Disclosure:
– Duty to provide information about care to be
given to the pt. Clinician determines what
information is too much/little.
– Therapeutic privilege, an exception to
informed consent
N.B.: These 3 obligations are derived from the
principle of respect for pt’s autonomy.
Clinical Ethics & Principles
• Major bioethics principles provide basis for
the ethical obligations in clinical ethics
• Practical orientation adopted by clinical
ethics in light of the dynamism of
interpersonal (clinician, pt, family)
relationships.