Medical Ethics for Physicians __________________________________________________________________
Although such decisions are usually made on a practical, not a theoretical level, at times it is important to be able to relate a decision to its underlying system or principle.
the individual stages. In each step, questions are offered to help the healthcare professional gather all the information necessary to assist the patient and healthcare team in the decision-making process. It is important to note that using professional interpreters for patients and with limited English proficiency will help ensure quality care. Convenience and cost lead many clinicians to use “ad hoc” interpreters (e.g., family members, friends, bilingual staff members) instead of professional interpreters. However, professional interpreters are preferred for several reasons. Several states have laws about who can interpret medical information for a patient, so healthcare professionals should check with their state’s health officials about the use of ad hoc interpreters [19]. Even when allowed by law, the use of a patient’s family member or friend as an interpreter should be avoided, as the patient may not be as forthcoming with information and the family member or friend may not remain objective [19]. Children should especially be avoided as interpreters, as their understanding of medical language is limited, and they may filter information to protect their parents or other adult family members [19]. Individuals with limited English language skills have actually indicated a preference for professional interpreters rather than family members [20]. Most important, perhaps, is the fact that clinical consequences are more likely with ad hoc interpreters than with professional interpreters [21]. A systematic review of the literature showed that the use of professional interpreters facilitates a broader understanding and leads to better clinical care than the use of ad hoc interpreters, and many studies have demonstrated that the lack of an interpreter for patients with limited English proficiency compromises the quality of care. The use of professional interpreters improves communication (errors and comprehension), utilization, clinical outcomes, and patient satisfaction with care [20; 22]. One review of case studies regarding professional interpretation noted that “patients with limited English proficiency in the United States have a legal right to access language services, and clinicians have legal and ethical responsibilities to communicate through qualified interpreters when caring for these patients” [23]. ASSESSING THE FACTS Every decision takes some thought and organization before a conclusion may be reached. To create an atmosphere in which effective decisions can be made and implemented, the following is helpful, even in a crisis situation: • Create an atmosphere of caring as you deliberate. Identify those involved with the ethical dilemma and involve them in the decision making when appropriate. Listen to their remarks before proceeding. • Be aware of your personal prejudices and feelings as you respond. Be honest with yourself about how those factors can affect your decision-making ability. For decisions about foregoing treatment or other dilemmas, the following questions may be relevant, although this list is not exclusive by any means.
SETTING UP A WORKABLE ETHICAL DECISION- MAKING FRAMEWORK In the course of medical training, physicians are frequently taught to apply a very strict standard in the determination of a patient’s capacity or ability to make decisions. A framework for ethical decision making presupposes that physicians making decisions know that a system of ethics exists, the content of that ethical system, and that the system applies to similar decision-making problems despite the multiple variables. As an example, many institutions have adopted policies that do not allow a medicated patient to sign consent forms within a specified time. But the chronic pain management patient on continuous high-dose opioid pain control may not have the capacity of reason. From an ethical point of view, the patient is a capable decision maker if he or she can understand information relevant to the decision at hand, interact and communicate with caregivers about the decision, and weigh the possible alternatives. A general checklist upon which to set up an ethical framework comes from the Handbook for Hospital Ethics Committees . One might abide by the following steps [18]: • Collection of a database • Case presentation • Identification of medical problems • Identification of psychological problems • Identification of an ethical dilemma • Identification of legal or policy issues • Discussion of ethical issues • Suggestions for approaches to problems • Discussion with initiator, patient, if possible, and other individuals directly involved with specific patient or problem • Documentation of issues discussed and suggested approaches to be placed in the patient’s chart Whenever possible, the patient or family makes the final healthcare decision. The first and most important step is the collection of a database, which involves gathering and assessing the facts. The nursing staff can be instrumental in facilitating the stages of ethical action. The following is a general outline of each step and the process that develops as one moves through
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