UW Ethics in Medicine General Info

Physician Aid-in-Dying: What should I do if a patient asks me for physician aid-in-dying (PAD)?

- One of the most important aspects of responding to a request for PAD is to be respectful and caring. Virtually every request represents a profound event for the patient, who may have agonized over his situation. The patient's request should be explored, to better understand its origin and to determine if there are other interventions that may help ameliorate the concerns that motivated the request. In most cases, there are alternatives in palliative and hospice care that likely will address most of the patient's concerns. Palliative care physicians recommend the following process for evaluating and responding to requests (Emanuel, 1998; Quill & Arnold, 2008a, 2008b). - Wait to directly respond to the request until you have explored the reasons for the patient's request. Discuss various ways of addressing the patient's pain, suffering, hopes, and fears. If time permits, tell the patient that you would like to talk more about this at a subsequent appointment. That gives both you and the patient time to prepare for a fuller exploration of PAD as well as other palliative treatments, hospice, etc. - Evaluate for depression or other psychiatric conditions and treat appropriately. Assess the patient's decision-making competence. - Engage in discussion surrounding the patient's diagnosis, prognosis, and goals for care. Make sure to assess patient understanding. - Evaluate patient's physical, mental, social, and spiritual suffering. Be sure to take into account the patient's support system as well as personal and professional pressures and stressors. - Discuss all alternative options, such as palliative care and hospice. - Consult with professional colleagues regarding the patient's situation. Where appropriate, ask for help from a palliative care specialist to assure that all options have been explored. - Help the patient complete advance directives, DNR orders and POLST forms, as appropriate and ensure that preferences are followed.

Physician Aid-in-Dying: What are the arguments in favor of physician aid-in-dying (PAD)? Those who argue that PAD is ethically justifiable offer the following arguments:

- Respect for autonomy: Decisions about time and circumstances of death are personal. Competent people should have right to choose the timing and manner of death. - Justice: Justice requires that we "treat like cases alike." Competent, terminally ill patients have the legal right to refuse treatment that will prolong their deaths. For patients who are suffering but who are not dependent on life support, such as respirators or dialysis, refusing treatment will not suffice to hasten death. Thus, to treat these patients equitably, we should allow assisted death as it is their only option to hasten death. - Compassion: Suffering means more than pain; there are other physical, existential, social and psychological burdens such as the loss of independence, loss of sense of self, and functional capacities that some patients feel jeopardize their dignity. It is not always possible to relieve suffering. Thus PAD may be a compassionate response to unremitting suffering. - Individual liberty vs. state interest: Though society has strong interest in preserving life, that interest lessens when a person is terminally ill and has strong desire to end life. A complete prohibition against PAD excessively limits personal liberty. Therefore PAD should be allowed in certain cases. - Honesty & transparency: Some acknowledge that assisted death already occurs, albeit in secret. The fact that PAD is illegal in most states prevents open discussion between patients and physicians and in public discourse. Legalization of PAD would promote open discussion and may promote better end-of-life care as patients and physicians could more directly address concerns and options.

The underlying goals of traditional ethics committees are:...

- to promote the rights of patients; - to promote shared decision making between patients (or their surrogates if decisionally incapacitated) and their clinicians; - to promote fair policies and procedures that maximize the likelihood of achieving good, patient-centered outcomes; and - to enhance the ethical environment for health care professionals in health care institutions. Ethics committees or select members often help resolve ethical conflicts and answer ethical questions through the provision of consultations. More recently, some ethics committees, particularly those affiliated with academic institutions and large health care systems, have expanded their traditional functions to become more comprehensive ethics programs. They address both clinical and organizational ethics issues. Ethics programs may provide ethics consultations in response to non-clinical ethics questions, identify and remedy systems-level factors that induce or exacerbate ethical problems and/or impede their resolution (often using quality improvement methods), and promote a positive ethics culture throughout the institution. Thus, the additional goals of expanded ethics programs include: - integrating ethics throughout the health care institution from the bedside to the boardroom, - ensuring that systems and processes contribute to/do not interfere with ethical practices, and - promoting ethical leadership behaviors, such as explaining the values that underlie decisions, stressing the importance of ethics, and promoting transparency in decision making

Termination of Life-Sustaining Treatment: In general, the capacity to make treatment decisions, including to withhold or withdraw treatment, is considered intact if the patient:

- understands the clinical information presented - appreciates his/her situation, including consequences with treatment refusal - is able to display reason in deliberating about their choices - is able to clearly communicate their choice. If the patient does not meet these criteria, then their decision to refuse treatment should be questioned, and handled in much the same way as discussed for the clearly incompetent patient. When in doubt, an ethics consultation may prove helpful.

How do I recognize this type of relationship? Your feelings are the first clue. Be alert when you feel anger, resentment, fear, dread, or excessive anxiety about seeing a patient, when you worry that the patient will transgress a professional or personal boundary, when you want to avoid the patient, and/or are unable to feel empathy for him/her. Strategies for maintaining a therapeutic relationship (Krebs et al., 2006; Wasan et al., 2005; Elder et al., 2006; Hass et al., 2005)

1) Be compassionate and empathic. Keep in mind that most patients whom you find frustrating to deal with have experienced significant adversity in their lives. 2) Acknowledge and address underlying mental health issues early in the relationship. 3) Prioritize the patient's immediate concerns and elicit the patient's expectations of the visit and their relationship with you. 4) Set clear expectations, ground rules, and boundaries and stick to them. Have regular visits, which helps convey confidence that the patient can deal with transient flare-ups without an emergency visit. 5) Be aware that strong negative emotions directed at you are often misplaced. The patient may be imposing feelings and attitudes onto you that they have had toward other doctors, friends, family members in the past. This is known as transference. Acknowledge the patient's feelings and set behavioral expectations. 6) Be aware of your own emotional reactions and attempt to remove yourself so you can objectively reflect on the situation. Involve colleagues. Vent your feelings or debrief confidentially with a trusted colleague so that your negative emotions are kept at bay during patient encounters. 7) Recognize your own biases. For example, patients with addictions genuinely need medical care, but the behaviors associated with addiction are vexing for health care providers. These patients are often both vulnerable and manipulative. Be sure that you are attentive to their vulnerability, rather than focusing exclusively on their manipulative behaviors. 8) Avoid being very directive with these patients. A tentative style tends to work better. Remember that you provide something many of these patients do not have-a steady relationship with someone who genuinely wants to help them. This in itself can improve the patient's health, even in the absence of medical treatment. 9) Prepare for these visits. Keep in mind your goals of care and make a strategy for the encounter before it occurs. Examples of helpful communication strategies: "What I hear from you is that . . . Did I get that right?" "How do you feel about the care you are receiving from me? It seems to me that we sometimes don't work together very well." "It's difficult for me to listen to you when you use that kind of language." "You seem quite upset. Could you help me understand what you are going through right now?" "What's your understanding of what I am recommending, and how does this fit with your ideas about how to solve your problems?" "I wish I (or a medical miracle) could solve this problem for you, but the power to make the important changes is really yours."(Hass et al., 2005, p. 2066)

Research Ethics: Components of ethically valid informed consent for research.

Given the appreciation that informed consent is at the crux of human subjects protection, it is not surprising that the regulations reflect extensively upon the necessary elements of the consent document itself as well as on the informed consent process. For an informed consent to be ethically valid, the following components must be present: - Disclosure: The informed consent document must make clear that the study is a research study, and not clinical therapy. The potential participant must be informed as fully as possible of the nature and purpose of the research, the procedures to be used, the expected benefits to the participant and/or society, the potential of reasonably foreseeable risks, stresses, and discomforts, and alternatives to participating in the research. There should also be a statement that describes procedures in place to ensure the confidentiality of data and anonymity of the participant. The informed consent document must also disclose what compensation and medical treatment are available in the case of a research-related injury. The document should make it clear whom to contact with questions about the research study, research subjects' rights, and in case of injury. - Understanding: The participant must understand what has been explained and must be given the opportunity to ask questions and have them answered by someone fully conversant in the study particulars. The informed consent document must be written in lay language, avoiding any technical jargon. The potential participant must be able to read and/or understand the language in which the consent form is written. Consent forms for multinational research must be translated into the respective language for each participating country and back-translated to verify accuracy. - Voluntariness: The participant's consent to participate in the research must be voluntary, free of any coercion or inflated promise of benefits from participation. Care should be taken that the consent form is administered by someone who does not hold authority over the participant. Ideally, the potential participant is given the opportunity to discuss their participation in the study with family, trusted friends, or their physician before reaching a decision. - Competence: The participant must be competent to give consent. If the participant is not competent due to mental status, disease, or emergency, a designated surrogate may provide consent if it is in the participant's best interest to participate. In certain emergency cases, consent may be waived due to the lack of competence of the participant and absence of an appropriate surrogate. In the event that there is a question about competence, mental status exams may be administered. - Consent: The potential human subject must authorize his/her participation in the research study, preferably in writing. If there is no need to collect personally identifiable information, and a signature on the consent form would be the only thing linking the subject to the study, an oral or implicit consent may be more appropriate. Children who cannot read or write should still signal their willingness to participate by an affirmative act (for example, nodding their head). Consent by minors is referred to as assent. Exculpatory language: No informed consent may contain any exculpatory language by which the participant waives any legal rights or releases the investigator or sponsor from liability for negligence.

What is a difficult patient-clinician relationship?

A difficult patient-clinician relationship, occurring in approximately 15% of adult patient encounters (Krebs et al., 2006) arises when physicians encounter patients with complex, often chronic medical issues (such as chronic pain, and/or mental illness) that are influenced or exacerbated by social factors (such as poverty, abusive relationships, addiction). Previous experience with similar patients along with the social and economic disparities between the physician and patient may make the physician uncomfortable. This may lead the physician to be guarded or distant which the patient may interpret as distrust. Likewise, the therapies the doctor recommends often entail behavioral changes that the patient is unwilling or unable to make, yet the patient continues to seek the clinician's advice and treatment. The physician may become frustrated or angry because his advice is not heeded, because the diagnosis or treatment is unclear or ineffective, or because the patient is rude, seemingly ungrateful, or transgresses boundaries in the clinician-patient relationship (e.g. comes to the clinic when she does not have an appointment). The physician in turn may feel that treating the patient is futile, burdensome, and disruptive to other patients and staff. Clinicians may become angry, and avoid or sometimes 'punish' the patient.

Can a patient demand that I provide them with a form of treatment that I am uncomfortable providing?

A physician is not morally obligated to provide treatment modalities that they do not believe offer a benefit to the patient or which may harm the patient. Physicians should also not offer treatments that they do not feel competent to provide or prescribe. However, it is important to take the patient's request seriously, consider accommodating requests that will not harm the patient or others, and attempt to formulate a plan that would be acceptable to both the physician and patient.

Mistakes: What if I see someone else make a mistake?

A physician may witness another health care provider making a major error. This places the physician in an awkward and difficult position. Nonetheless, the observing physician has some obligation to see that the truth is revealed to the patient. This should be done in the least intrusive way. If the other health care provider does not reveal the error to the patient, the physician should encourage her to disclose her mistake to the patient. Should the health care provider refuse to disclose the error to the patient, the physician will need to decide whether the error was serious enough to justify taking the case to a supervisor or the medical staff office, or directly telling the patient. The observing physician also has an obligation to clarify the facts of the case and be absolutely certain that a serious mistake has been made before taking the case beyond the health care worker involved.

Truth-telling and Withholding Information: Is it justifiable to deceive a patient with a placebo?

A placebo is any substance given to a patient with the knowledge that it has no specific clinical effect, yet with the suggestion to the patient that it will provide some benefit. The placebo effect is powerful, in many cases providing measurable improvement in symptoms in 20-30% of patients. In general, the deceptive use of placebos is not ethically justifiable. Specific exceptions should be rare and only considered if the following conditions are present: - the condition is known to have a high placebo response rate - the alternatives are ineffective and/or risky - the patient has a strong need for some prescription

Termination of Life-Sustaining Treatment: Is a psychiatry consult required to determine decision making capacity?

A psychiatry consult is not required, but can be helpful in some cases. Psychiatrists are trained in interviewing people about very personal, sensitive issues, and thus can be helpful when patients are facing difficult choices with fears or concerns that are difficult to talk about. Similarly, if decision making capacity is clouded by mental illness, a psychiatrist's skill at diagnosis and potential treatment of such disorders can be helpful.

What is my responsibility when a patient endangers her health by refusing a treatment?

Adults have a moral and legal right to make decisions about their own health care, including the right to refuse treatments that may be life-saving. The physician has a responsibility to make sure that the patient understands the possible and probable outcomes of refusing the proposed treatment. The physician should attempt to understand the basis for the patient's refusal and address those concerns and any misperceptions the patient may have. In some cases, enlisting the aid of a leader in the patient's cultural or religious community may be helpful.

Mistakes: How do mistakes occur?

All physicians make mistakes, and most mistakes are not the result of negligence. A physician may make a mistake because of an incomplete knowledge base, an error in perception or judgment, or a lapse in attention. Making decisions on the basis of inaccurate or incomplete data may lead to a mistake. The environment in which physicians practice may also contribute to errors. Lack of sleep, pressures to see patients in short periods of time, and distractions may all impair an individual's ability to avoid mistakes.

end-of-life issues What you need to understand to care for the dying

Another useful framework was outlined by Joanne Lynn, who was one of the principal investigators of SUPPORT. She suggests that there are four things clinicians must know to care for the dying. The patient's story - including how that person has viewed her life, the other persons important to her, and how she could bring her life to a close in a way that would be true to herself.The body - which covers the biomedical understanding of disease, and what limits and possibilities exist for that person.The medical care system available for this particular patient - knowing how you can make the system work for the patient, as well as the relevant law and ethics.Finally, you must understand yourself - because you, as a physician, can be an instrument of healing, or an instrument that does damage. Obviously, learning how to do all this is beyond the scope of this web page--these are goals that guide a career of learning and reflection. But this framework provides guidelines for you as you develop your own approach to caring for dying patients.

Do Not Resuscitate Orders What should be included in a discussion of DNR orders in the OR with the patient or patient's surrogates?

As discussed above, surgery and anesthesia may require the administration of medical therapies, which under other circumstances might be considered resuscitation. It is an ongoing source of discussion about what constitutes appropriate information and choices to present to patients about to undergo surgery who have DNR orders on their charts. Since the goal of medical therapy is to provide meaningfulbenefits to the patient, discussion of DNR orders in the OR should center around the patient's goals for surgical therapy. Patients may have fears of "ending up a vegetable" on a ventilator after surgery, for example. In those cases, discussion should center around the positive prognosis for patients who have CPR in the OR, together with reassurance that the patient's stated wishes in their advanced directive regarding ventilatory support would be followed postoperatively after anesthetic effects are ruled out as a cause of ventilatory depression. Most authorities now agree that a "smorgasbord" or checklist "yes-or-no" approach to the various procedures in the operating room is confusing and counterproductive to the purpose of DNR discussions. Anesthesiologists in particular need to be aware that studies indicate that many patients with DNR orders in their charts (up to 46%) may be unaware that the order exists, even when they are competent. While policies at the University of Washington Medical Center require documentation of discussion of DNR orders with the patient or appropriate surrogates, anesthesiologists and surgeons should nevertheless approach the patient about to undergo surgery with sensitivity to the fact that they may be unaware of their DNR order. If this proves to be the case, a full discussion of the DNR order should be undertaken prior to proceeding.

Do Not Resuscitate Orders How should the patient's quality of life be considered?

CPR might appear to lack potential benefit when the patient's quality of life is so poor that no meaningful survival is expected even if CPR were successful at restoring circulatory stability. However, quality of life should be used with caution in determining whether or not CPR is indicated or has the potential to provide medical benefit, for there is substantial evidence that patients with chronic conditions often rate their quality of life much higher than would healthy people. Quality of life assessments have most credibility when the patient's values, preferences, and statements inform such assessments.

Do Not Resuscitate Orders When should CPR be administered? When can CPR be withheld?

CPR should be administered in the absence of a valid physician's order to withhold it. As with CPR on the medical wards, two general situations arise in which CPR can be withheld in the operating room: when CPR is judged to be of no benefit to the patient (See the main topic page, Do-Not-Resuscitate Orders.)when a patient with intact decision-making capacity (or in the case of those without decision making capacity, an appropriate surrogate decision-maker) indicates that they do no want CPR, even if the need arises.

Public Health: What is paternalism and who is responsible for health?

Cases where harm to others is absent or less easily established stir much more debate because they raise the specter of paternalism. Paternalism occurs when the state or an individual interferes with the preferences of a person for her own benefit (e.g., to promote her health) (Childress et al. 2002). Indeed, public health action often seeks to influence human behavior that arguably does no harm to others. Because chronic diseases now account for the majority of deaths, and personal behaviors make a nontrivial contribution to their onset and progression (McGinnis et al. 2002), much public health research and action seeks to change behaviors whose ill effects are felt primarily by those who engage in them. The least controversial tactics for promoting behavior change are educational in nature-providing people with information, whether it be the calorie content of foods, the health effects of certain behaviors, and so on. Educational campaigns are not coercive, as individuals can choose to heed them or not, and they can be argued to support more informed and thus autonomous citizens. Even Mill would likely have endorsed (non-controversial) public education campaigns for this reason (Nuffield Bioethics Council 2007). Educational strategies, however, often fail to produce behavior change, particularly among socially disadvantaged groups. Take obesity, which disproportionately affects minority and low socioeconomic groups. Education initiatives are most effective for individuals who have the time, interest, motivation, and resources to act on the information and opportunities made available. People who work long hours or double shifts, or who lack access to affordable gyms or safe spaces to walk or exercise, for example, may not have the time, energy, or financial resources to change habits that are embedded in ways of life. Thus, strategies based on education, information, and individual choice can reproduce or even exacerbate health disparities between more and less advantaged groups (Link, Phelan 1995; Link 2008). To address this challenge, social and material conditions may be remade to support health and healthy choices. In the case of obesity, such measures might include regulating food production (e.g., government choices about which foods to subsidize, banning excess sodium in processed foods), prohibiting the sale of soda and other sugary beverages in schools, and planning communities that will promote walking, recreation, and otherwise positive social connections. This structural approach to public health is, however, often criticized in political contexts such as the United States, where personal responsibility (for health and other goods) and individualism are highly valued. Debate over responsibility for health is not new (Reiser 1985) but it has intensified in the last few decades. One prominent way this debate has played out in U.S. health policy is the increased use of incentives and disincentives to promote the adoption of health-enhancing behaviors in both the private and public sectors. Private employers and state governments have ramped up their wellness programs, offering employees a variety of goods to participate in health screenings, on-site exercise programs, among other activities. While most programs use rewards in some form, the use of penalties is also on the upswing. A high-profile and much criticized example is West Virginia's Medicaid program, which now requires beneficiaries to sign a personal responsibility agreement in order to receive an "enhanced" package of services (Blacksher 2008). Critics oppose such programs on numerous grounds. One common refrain is that penalties 'blame the victim'. Responsibility lies not with these individuals, critics charge, but rather with social institutions and society at large. This claim of social responsibility for health is a critical plank in a larger argument that health (and/or the social determinants thereof) should be subject to considerations of social justice. Agents of public health often claim that health inequalities associated with social class, race, and ethnicity constitute a social injustice because they are caused, at least in part, by socially controllable factors. As Wikler points out, "The locus of blame is key, for if blame is placed on the individual, social structure is exculpated, and the resulting suffering and premature death will not be counted as a social injustice" (Wikler 2006).

Parental Decision Making: What are some examples of a decision that places a child a significant risk of serious harm?

Childhood vaccination provides an example of the kinds of factors that must be weighed in making this determination. While most physicians believe it is in a child's best interest to receive the routine childhood vaccinations and therefore recommend them to parents, they do not generally legally challenge parents who choose not to vaccinate their children. This is because in a well-vaccinated community the risk of contracting the vaccine-preventable illness and suffering harmful consequences from the infection are quite small. However, this calculation might shift if a clinician is faced with an unvaccinated child who has suffered a puncture would from a dirty nail. In the latter case, the risk of tetanus (a serious and almost always fatal disease if not prevented) has become significant, and the provider would be justified in seeking the power of the State (through a court order or involvement of child protective services) to assure that the child receives the vaccination and treatment necessary to prevent tetanus in a high risk situation.

Parental Decision Making: Should children be involved in medical decisions even though their parents have final authority to make those decisions? What happens when an older child disagrees with her parents about a medical treatment?

Children with the developmental ability to understand what is happening to them should be allowed to participate in discussions about their care. As children develop the capacity to make decisions for themselves, they should be given a voice in medical decisions. Most children and adolescents lack full capacity to make complex medical decisions, however, and final authority to make medical decisions will usually remain with their parents. The wishes of competent older children regarding their medical care should be taken seriously. If the medical caretaker judges a child competent to make the medical decision in question, she should first attempt to resolve the issue through further discussion. If that fails, the medical caretaker should assure that the child's voice has been heard and advocate for the child. In intractable cases, an ethics consultation or judicial hearing should be pursued.

Physician-Patient Relationship: What is the role of confidentiality?

Confidentiality provides the foundation for the physician-patient relationship. In order to make accurate diagnoses and provide optimal treatment recommendations, the physician must have relevant information about the patient's illness or injury. This may require the discussion of sensitive information, which would be embarrassing or harmful if it were known to other persons. The promise of confidentiality permits the patient to trust that information revealed to the physician will not be further disseminated. The expectation of confidentiality derives from the public oath which the physician has taken, and from the accepted code of professional ethics. The physician's duty to maintain confidentiality extends from respect for the patient's autonomy.

Interdisciplinary Team Issues: What are the ethical obligations of members of the interdisciplinary team in patient care?

Ethically, every member of the operating room team has separate obligations, or duties, toward patients, which are based on the provider's profession, scope of practice and individual skills. Team members also have ethical obligations to treat each other in a respectful and professional manner. Relationships between professionals on the multidisciplinary team are by their nature unequal ones. Different knowledge and experience in specific issues both ethically and legally imparts unequal responsibility and authority to those care providers with the most knowledge and experience to handle them. But also because of differences in training and experience, each member of the team brings different strengths. Team members need to work together in order to best utilize the expertise and insights of each member.

Do Not Resuscitate Orders What about emergencies?

Even in emergencies, physicians have an ethical obligation to recognize and respect patient autonomy. Whenever possible, physicians should obtain input from the patient, or when the patient is incapacitated, from appropriate surrogates, regarding the status of the patient's DNR orders in the OR. In the absence of such input, consensus should be reached among the caregivers about the medical benefits or futility of CPR. In any case, medical care of the patient in the absence of patient input should be directed toward realizing, to the best of the physician's ability and knowledge, the patient's goals. Since the original inception of DNAR orders, respecting the rights of adult patients and their surrogates to make medical decisions, otherwise known as respect for autonomy or respect for persons, has been emphasized. This concept is reinforced legally in the Patient Self Determination Act of 1991, which requires hospitals to respect the adult patient's right to make an advanced care directive and clarify wishes for end-of-life care. In general, an emphasis on improving communication with patients and families is preferred over physicians making unilateral decisions based on appeals to medical futility regarding the resuscitation status of their patients. See below.

Is it ever acceptable to not have a full informed consent?

Exceptions to full informed consent are: - If the patient does not have decision-making capacity, such as a person with dementia, in which case a proxy, or surrogate decision-maker, must be found. (See Surrogate Decision-Making/No Legal Next of Kin.) - A lack of decision-making capacity with inadequate time to find an appropriate proxy without harming the patient, such as a life-threatening emergency where the patient is not conscious - When the patient has waived consent. - When a competent patient designates a trusted loved-one to make treatment decisions for him or her. In some cultures, family members make treatment decisions on behalf of their loved-ones. Provided the patient consents to this arrangement and is assured that any questions about his/her medical care will be answered, the physician may seek consent from a family member in lieu of the patient.

Maternal / Fetal Conflict: What happens when medical therapy is indicated for one patient, yet contraindicated for the other?

Fetal care becomes problematic when what is required to benefit one member of the dyad will cause an unacceptable harm to the other. When a fetal condition poses no health threat to the mother, caring for the fetal patient will always carry some degree of risk to the mother, without direct therapeutic benefit for her. The ethical principles of beneficence ("be of benefit") and nonmaleficence ("do no harm") can come into conflict. Because the patients are biologically linked, both, or neither, must be treated alike. It would be unethical to recommend fetal therapy as if it were medically indicated for both patients. Still, given a recommendation for fetal therapy, pregnant women, in most cases, will consent to treatment which promotes fetal health. When pregnant women refuse therapy, physicians must remember that the ethical injunction against harming one patient in order to benefit another is virtually absolute.

Physician-Patient Relationship: How has the physician-patient relationship evolved?

Fiduciary derives from the Latin word for "confidence" or "trust". The bond of trust between the patient and the physician is vital to the diagnostic and therapeutic process. It forms the basis for the physician-patient relationship. In order for the physician to make accurate diagnoses and provide optimal treatment recommendations, the patient must be able to communicate all relevant information about an illness or injury. Physicians are obliged to refrain from divulging confidential information. This duty is based on accepted codes of professional ethics, which recognize the special nature of physician-patient relationships. The historical model for the physician-patient relationship involved patient dependence on the physician's professional authority. Believing that the patient would benefit from the physician's actions, a paternalistic model of care developed. Patient's preferences were generally not elicited, and were over-ridden if they conflicted with the physician's convictions about appropriate care. During the second half of the twentieth century, the physician-patient relationship has evolved towards shared decision making. This model respects the patient as an autonomous agent with a right to hold views, to make choices, and to take actions based on personal values and beliefs. Patients are acknowledged to be entitled to weigh the benefits and risks of alternative treatments, including the alternative of no treatment, and to select the alternative that best promotes their own values (for further discussion, see Informed Consent).

What obligations do clinicians have in these relationships?

Health care providers have professional and ethical obligations to care for these patients because of the fiduciary nature of the clinician-patient relationship. The provider has knowledge, influence, and power in the relationship, which entail special responsibilities. It may be difficult to see some of these patients as vulnerable, but without a clinician's help their vulnerability would only be compounded. While their medical, social, and psychiatric conditions may be complex, patients benefit both from a therapeutic relationship and from medical treatments and advice. Because clinicians often find these relationships exhausting and frustrating, they should identify trusted colleagues with whom they can share their frustrations, employ strategies that allow the best in the relationship to prevail, and use a team approach. Clinicians should also try to address or manage their own attitudes and behaviors that contribute to the problem, recognizing that the patient's behaviors and attitudes may not change. The clinicians should do everything they can to maintain a therapeutic relationship (even one that is not ideal), however in some circumstances they may need to transfer care to another provider. This transfer can be done without threatening the patient. The treating provider can help to maintain the patient's trust in the health system, while also setting clear boundaries.

End-of-life Issues: What goals should I have in mind when working towards a decent death for my patient?

I have several working clinical goals when I am caring for someone near the end of life. I work towards: Control of pain and other physical symptoms. The physical aspects of care are a prerequisite for everything that follows.Involvement of people important to the patient. Death is not usually an individual experience; it occurs within a social context of family, significant others, friends, and caregivers.A degree of acceptance by the patient. Acceptance doesn't mean that the patient likes what is going on, and it doesn't mean that a patient has no hopes--it just means that he can be realistic about the situation.A medical understanding of the patient's disease. Most patients, families, and caregivers come to physicians in order to learn something about what is happening medically, and it is important to recognize their need for information.A process of care that guides patient understanding and decision making. One great physician does not equal great care--it takes a coordinated system of providers.

Physician Aid-in-Dying: What if the request for physician aid-in-dying persists?

If a patient's request for aid-in-dying persists, each individual clinician must decide his or her own position and choose a course of action that is ethically justifiable and legally permissible. It is useful to carefully reflect on and think through where you stand on the issue and be prepared to openly discuss your position with the patient, acknowledging and respecting difference of opinion when it occurs. Patients who ask for PAD-in states where it is legal or illegal-understand that physicians will have different opinions about what they can and should do. The most important thing is to be clear and transparent about your position. Even in states where it is illegal, some physicians will decide to help their patients, particularly when patients are enduring unbearable suffering. While we cannot condone this practice, we must recognize its occurrence and the reasoning behind it. No physician, however, should feel forced to provide assistance if he or she is morally opposed to PAD.

Termination of Life-Sustaining Treatment: When is it justifiable to discontinue life-sustaining treatments? How do I know if the treatment is no longer "of benefit?"

If the patient has the ability to make decisions, fully understands the consequences of their decision, and states they no longer want a treatment, it is justifiable to withdraw the treatment.Treatment withdrawal is also justifiable if the treatment no longer offers benefit to the patient. // In some cases, the treatment may be "futile"; that is, it may no longer fulfill any of the goals of medicine. In general, these goals are to cure if possible, or to palliate symptoms, prevent disease or disease complications, or improve functional status. For example, patients with severe head trauma judged to have no chance for recovery of brain function can no longer benefit from being maintained on a mechanical ventilator. All that continuation would achieve in such a case is maintenance of biologic function. In such a case, it would be justifiable to withdraw mechanical ventilation.

Student Issues: I'm noticing what looks like addictive behavior in one of my classmates. What should I do?

Impaired students become impaired physicians. You are entering a profession that carries an obligation to its members for self-regulation. As a student, your classmate has an opportunity to seek help before serious harm comes to himself or herself, or to one of his or her patients. Once licensed, you will have a legal obligation to report colleagues to the medical board if they are "unable to practice medicine with reasonable skill and safety to patients by reason of illness, drunkenness, excessive use of drugs, narcotics, chemicals, or any other type of material, or as a result of any mental or physical conditions (Revised Code of Washington 18.72.165)." The UW Counseling Office or the Assistant Dean for Student Affairs can help you arrange an intervention if you have these concerns.

Student Issues: Other students have (unauthorized) access to last year's killer exam. Should I look at it?

In a survey of students from the late 1980's. 58% reported cheating at least once during medical school. There have been disincentives for reporting cheating, and perhaps a general sense that "this is just the way it is." On the contrary, cheating in class is an example of unprofessional behavior. It represents a lack of fairness, lack of integrity, and can foreshadow lying in other contexts during your medical training. As a member of a profession, you are accountable for your own behavior and for the behavior of your colleagues. The Assistant Dean for Student Affairs or the Medical Student Association (MSA) representative can field your concerns and help you develop a plan for confronting your classmates.

Truth-telling and Withholding Information: How much do patients need to be told? What if the truth could be harmful?

In addition to fostering trust and demonstrating respect, giving patients truthful information helps them to become informed participants in important health care decision. Thus, patients should be told all relevant aspects of their illness, including the nature of the illness itself, expected outcomes with a reasonable range of treatment alternatives, risks and benefits of treatment, and other information deemed relevant to that patient's personal values and needs. Treatment alternatives that are not medically indicated or appropriate need not be revealed. Facts that are not important to the patients ability to be an informed participant in decision making, such as results of specific lab tests, need not be told to the patient. Also, complete and truthful disclosure need not be brutal; appropriate sensitivity to the patient's ability to digest complicated or bad news is important. // In addition to fostering trust and demonstrating respect, giving patients truthful information helps them to become informed participants in important health care decision. Thus, patients should be told all relevant aspects of their illness, including the nature of the illness itself, expected outcomes with a reasonable range of treatment alternatives, risks and benefits of treatment, and other information deemed relevant to that patient's personal values and needs. Treatment alternatives that are not medically indicated or appropriate need not be revealed. Facts that are not important to the patients ability to be an informed participant in decision making, such as results of specific lab tests, need not be told to the patient. Also, complete and truthful disclosure need not be brutal; appropriate sensitivity to the patient's ability to digest complicated or bad news is important.

End-of-life Issues: What is a "good death"? A medical perspective

In caring for a person who is dying, knowing what would make the experience of dying "good" is an important goal for physicians and other members of the care team. I find it doesn't take fancy techniques-you just need to be sincere and patient and interested. Listen more and talk less. Try asking something like, "Knowing that all of us have to think about dying at some point, what would be a good death for you?" What people choose when they think about a good death for themselves is often beyond what medicine can provide-for instance, an affirmation of love, a completion of important work, or a last visit with an important person. As a physician, I can't always make those things happen. But I can help the dying person get ready-and in this way, contribute to a death that is decent. The good death is not a familiar idea in American culture. Some experts in palliative care describe the United States as a "death-defying" culture, with a mass media that spotlights only youth and beauty. Yet public interest in care of the dying is currently high. The striking public interest in physician aid-in-dying is one obvious reason. But there are other reasons: over the past 100 years, there has been a epidemiologic shift in the reasons people die. In the pre-antibiotic era, people most often died young, of infectious diseases; now, thanks to medical technology, most Americans (and others with access to this technology) live much longer, to die of degenerative, neoplastic, and even man-made diseases. Finally, there is a marked public fear that a medical death, depicted in TV shows like "ER" as an unresponsive, uncommunicative body hooked up to an array of flashing monitors, represents an irresponsible use of technology and a dishonorable way to treat a person. Interestingly, contemporary medical literature contains little that might characterize what makes a death "good." Recently, a large, expensive empirical study of intensive care unit deaths suggested that medical care for a common type of in-hospital death is "bad" (the SUPPORT study, referenced below). In this study of dying patients, severe pain was common, decisions to withhold invasive treatments were made at the last minute, and physicians often had no knowledge of patient preferences not to have CPR. Even worse, an intervention designed to provide physicians with better prognostic information had no effect on medical decision making prior to death. While the SUPPORT authors did not actually describe these deaths as "bad," we could certainly agree that they were not "good deaths."

Mistakes: How do I decide whether to tell a patient about an error?

In general, even trivial medical errors should be disclosed to patients. Any decision to withhold information about mistakes requires ethical justification. If a physician believes there is justification for withholding information about medical error from a patient, his judgment should be reviewed by another physician and possibly by an institutional ethics committee. The physician should be prepared to publicly defend a decision to withhold information about a mistake from the patient.

Physician-Patient Relationship: Would a physician ever be justified in breaking a law requiring mandatory reporting?

In general, mandatory reporting requirements supersede the obligation to protect confidentiality. While the physician has a moral obligation to obey the law, she must balance this against her responsibility to the patient. Reporting should be done in a manner that minimizes invasion of privacy, and with notification to the patient. If these conditions cannot be met, or present an intolerable burden to the patient, the physician may benefit from the counsel of peers or legal advisors in determining how best to proceed. (For a discussion on the limits of confidentiality, see the topic page on Confidentiality.)

Interdisciplinary Team Issues: How can disagreements on the multidisciplinary team be handled?

In the best situations, disagreement leads to a more complete interprofessional discussion of the patient's care, resulting in a new consensus about the best course of action. The new consensus may require compromises from each individual. When members of a team cannot arrive at a consensus of what should be done, it may be helpful to consult other professionals who are not directly involved in the patient's care team for objective input. If the disagreement still cannot be resolved, another resource may be the hospital's ethics committee, which can listen to disagreements and help suggest solutions.

Mistakes: By disclosing a mistake to my patient, do I risk having a malpractice suit filed against me?

It has been shown that patients are less likely to consider litigation when a physician has been honest with them about mistakes. Many lawsuits are initiated because a patient does not feel they have been told the truth. Litigation is often used as a means of forcing an open and honest discussion that the patient feels they have not been granted. Furthermore, juries look more favorably on physicians who have been honest from the beginning than those who give the appearance of having been dishonest.

End-of-life Issues: How do physicians who care for the dying deal with their own feelings?

It is not hard to find physicians who are burned out - ask any nurse. What is difficult is to find for yourself a type of self-care that will enable you to develop your gifts as a physician, and continue to use them in practice. It helps to learn your strengths and weaknesses, and to actively seek whatever will nurture you - in or out of medicine. A strategy of detachment may not serve you well in the long run. There are indeed rewards for physicians who care for the dying, but as a Zen master once observed of a bingo game, "you must be present to win."

Do Not Resuscitate Orders Why do we agree to do surgery on patients with DNR orders?

Many types of surgery provide palliative benefits to patients who either will not survive long-term, or who do not wish resuscitation in the OR. A patient with an esophageal obstruction from cancer might benefit from gastrostomy placement through reduced pain and improved nutritional status, yet not want CPR if cardiac arrest happens in the OR. Requiring such a patient to suspend their DNR orders to be a candidate for surgery uses their discomfort, pain, and desire to benefit from surgery to coerce them into accepting medical care (CPR) they do not want. Patient refusal of some medical therapy, such as CPR, does not ethically justify physicians denying them other medical therapy, such as surgery, that might benefit them.

Parental Decision Making: When can parental authority to make medical decisions for their children be challenged?

Medical caretakers have an ethical and legal duty to advocate for the best interests of the child when parental decisions are potentially dangerous to the child's health, imprudent, neglectful, or abusive. As a general rule, medical caretakers and others should challenge parental decisions when those decisions place the child at significant risk of serious harm. When satisfactory resolution cannot be attained through respectful discussion and ethics consultation, seeking involvement of a State child protection agency or a court order might be necessary.

Physician Aid-in-Dying: Is physician aid-in-dying (PAD) the same as euthanasia? Some other practices that should be distinguished from physician aid-in-dying include:

No. While both physician aid-in-dying and euthanasia involve the use of lethal medications to deliberately end a patient's life, the key difference is in who acts to administer the medications that will end the patient's life. In physician aid-in-dying, the patient must self-administer the medications; the "aid-in-dying" refers to a physician providing the medications, but the patient decides whether and when to ingest the lethal medication. Euthanasia occurs when a third party administers medication or acts directly to end the patient's life. Euthanasia is illegal in every state, including Washington. - Withholding/withdrawing life-sustaining treatments: When a competent adult patient makes an informed decision to refuse life-sustaining treatment, their wishes are generally respected. The right of a competent adult patient to refuse life-sustaining treatments is supported by law. - Pain medication that may hasten death: Often a terminally ill, suffering patient may require dosages of pain medication that have side effects that may hasten death, such as impairing respiration. Using the ethical principle of double effect as the foundational argument, it is generally held by most professional societies, and supported in court decisions, that this action is justifiable. Since the primary goal and intention of administering these medications is to relieve suffering, the secondary outcome of potentially hastening death is recognized as an expected and acceptable side-effect in a terminally ill patient. - Palliative sedation: This term refers to the practice of sedating a terminally ill patient to the point of unconsciousness, due to intractable pain and suffering that has been refractory to traditional medical management. Such patients are imminently dying, usually hours or days from death. Often other life-sustaining interventions continue to be withheld (CPR, respirator, antibiotics, artificial nutrition and hydration, etc.) while the patient is sedated. Palliative sedation may occur for a short period (respite from intractable pain) or the patient may be sedated until s/he dies. In the rare instances when pain and suffering is refractory to treatment even with expert clinical management by pain and palliative care professionals, palliative sedation may legally be employed.

Physician-Patient Relationship: What role should the physician's personal feelings and beliefs play in the physician-patient relationship?

Occasionally, a physician may face requests for services, such as contraception or abortion, which raise a conflict for the physician. Physicians do not have to provide medical services in opposition to their personal beliefs. In addition, a nonjudgmental discussion with a patient regarding her need for the service and alternative forms of therapy is acceptable. However, it is never appropriate to proselytize. While the physician may decline to provide the requested service, the patient must be treated as a respected, autonomous individual. Where appropriate, the patient should be provided with information about how to obtain the desired service.

Truth-telling and Withholding Information: What if the patient's family asks me to withhold the truth from the patient?

Often families will ask the physician to withhold a terminal or serious diagnosis or prognosis from the patient. Usually, the family's motive is laudable; they want to spare their loved one the potentially painful experience of hearing difficult or painful facts. These fears are usually unfounded, and a thoughtful discussion with family members, for instance reassuring them that disclosure will be done sensitively, will help allay these concerns. In unusual situations, family members may reveal something about the patient that causes the physician to worry that truthful disclosure may create real and predictable harm, in which case withholding may be appropriate. These occasions, however, are rare.

Resource Allocation: What rules guide rationing decisions? *ORGAN TRANSPLANTS*

Often scarcity can be alleviated by improved efficiency or expanded investment. However, if these practical solutions cannot solve the problem, a "rationing" decision must be made. Rationing means the distribution of any needed thing or procedure that is in short supply to those who need it in accord with a set of rules that assure fair distribution. The reasons for shortage can be many. For example, there are many more patients with end stage cardiac disease or liver disease than there are cadaver organs available; expensive equipment may be lacking in a particular region; tertiary care hospital beds may be limited; a particular medication may be extremely costly; few personnel might be trained for a certain technical procedure, insurance coverage is unavailable or of prohibitive cost. One of the most serious medical shortages, organs for transplantation, has been organized into a national system with criteria that strive for fairness. The criteria attempt to match available organs with recipients on presumed "objective" grounds, such as tissue type, body size, time on waiting list, seriousness of need. However, even in this system, it is obvious that such a criterion as "serious need" can be used in a manipulative way. Still, this system is preferable to the subjective use of criteria of social worth and status that would unfairly skew the distribution of organs.

Resource Allocation: Are there ethical criteria for making triage decisions? *EMERGENCY SITUATIONS AND DISASTERS*

One common medical situation in which specific principles must be applied is called "triage." Triage (which means "choice" or "selection") is required when many patients simultaneously need medical attention and medical personnel cannot attend to all at the same time, such as in a disaster or in the crowded emergency department of an urban hospital. Again, the common sense rule is to serve persons whose condition requires immediate attention and, if this attention is not given, will progress to a more serious state. Others, whose condition is not as serious and who are stable, may be deferred. A second sort of triage is indicated in disasters, such as earthquakes, or in military action. The rules of military triage, developed centuries ago, direct the physician to attend first to those who can be quickly and successfully treated in view of a speedy return to the battlefield, or to treat commanders before troops in order to assure leadership. This sort of disaster triage is applied to civilian disasters by treating persons, such as firefighters or public safety officers, who can quickly return to duty and help others. Disaster triage implies that the most seriously injured may be relegated to the end of the line and left untreated, even at risk of death, if their care would absorb so much time and attention that the work of rescue would be compromised. This is one of the few places where a "utilitarian rule" governs medicine: the greater good of the greater number rather than the particular good of the patient at hand. This rule is justified only because of the clear necessity of general public welfare in a crisis.

Resource Allocation: Are there ethical criteria for making triage decisions? *EMERGENCY SITUATIONS AND DISASTERS*

One common medical situation in which specific principles must be applied is called "triage." Triage (which means "choice" or "selection") is required when many patients simultaneously need medical attention and medical personnel cannot attend to all at the same time, such as in a disaster or in the crowded emergency department of an urban hospital. Again, the common sense rule is to serve persons whose condition requires immediate attention and, if this attention is not given, will progress to a more serious state. Others, whose condition is not as serious and who are stable, may be deferred. A second sort of triage is indicated in disasters, such as earthquakes, or in military action. The rules of military triage, developed centuries ago, direct the physician to attend first to those who can be quickly and successfully treated in view of a speedy return to the battlefield, or to treat commanders before troops in order to assure leadership. This sort of disaster triage is applied to civilian disasters by treating persons, such as firefighters or public safety officers, who can quickly return to duty and help others. Disaster triage implies that the most seriously injured may be relegated to the end of the line and left untreated, even at risk of death, if their care would absorb so much time and attention that the work of rescue would be compromised. This is one of the few places where a "utilitarian rule" governs medicine: the greater good of the greater number rather than the particular good of the patient at hand. This rule is justified only because of the clear necessity of general public welfare in a crisis.

Physician-Patient Relationship: What happens when physicians and patients disagree?

One third to one half of patients will fail to follow a physician's treatment recommendations. Labeling such patients "noncompliant" implicitly supports an attitude of paternalism, in which the physician knows best (see: Difficult Patient Encounters). Patients filter physician instructions through their existing belief system and competing demands; they decide whether the recommended actions are possible or desirable in the context of their everyday lives. Compliance can be improved by using shared decision making. For example, physicians can say, "I know it will be hard to stay in bed for the remainder of your pregnancy. Let's talk about what problems it will create and try to solve them together." Or, "I can give you a medication to help with your symptoms, but I also suspect the symptoms will go away if you wait a little longer. Would you prefer to try the medication, or to wait?" Or, "I understand that you are not ready to consider counseling yet. Would you be willing to take this information and find out when the next support group meets?" Or, "Sometimes it's difficult to take medications, even though you know they are important. What will make it easier for you to take this medication?" Competent patients have a right to refuse medical intervention. Dilemmas may arise when a patient refuses medical intervention but does not withdraw from the role of being a patient. For instance, an intrapartum patient, with a complete placenta previa, who refuses to undergo a cesarean delivery, often does not present the option for the physician to withdraw from participation in her care (see: Maternal-Fetal Conflict). In most cases, choices of competent patients must be respected when the patient cannot be persuaded to change them.

Can parents refuse to provide their children with necessary medical treatment on the basis of their beliefs?

Parents have legal and moral authority to make health care decisions for their children, as long as those decisions do not pose a significant risk of serious harm to the child's health. Parents should not be permitted to deny their children medical care when that medical care is likely to prevent substantial harm or suffering. If necessary, the physician may need to pursue a court order or seek the involvement of child protective services in order to provide treatment against the wishes of the parents. Nevertheless, the physician must always take care to show respect for the family's beliefs and a willingness to discuss reasonable alternatives with the family.

What kinds of treatment can parents choose not to provide to their children?

Parents have the right to refuse medical treatments when doing so does not place the child at significant risk of substantial harm or suffering. For example, parents have the right to refuse routine immunizations for their children on religious or cultural grounds.

Truth-telling and Withholding Information: What about patients with different specific religious or cultural beliefs??

Patient with certain religious beliefs or ethnic or cultural backgrounds may have different views on the appropriateness of truthful disclosure. For instance, Carrese and colleagues found that many people with traditional Navajo beliefs did not want to hear about potential risks of treatment, as their beliefs held that to hear such risks was to invite them to occur. Thus, dialogue must be sensitive to deeply held beliefs of the patient. One should not, however, assume that someone of a particular ethnic background holds different beliefs. Rather, a culturally sensitive dialogue about the patient's role in decision making should take place.

What patient characteristics and behaviors make a clinician-patient relationship difficult?

Patients are labeled 'difficult' based on the feelings they invoke in clinicians, such as anger, frustration, anxiety, dread, and guilt. (Wasan et al., 2005)Patients who, for medical or non-medical reasons, appear ungrateful or frivolously utilize medical care are most likely to be described as 'difficult'. They may continue to seek medical attention but not heed the advice they are given. Patients may have multiple medical complaints, psychiatric conditions (helplessness, depression, anxiety, self-loathing), abrasive personality traits (expressing rage, inflexibility), personality disorders, addictions, and multiple physical symptoms of unknown or ambiguous etiology. They often make requests that clinicians think are inappropriate, such as requests for additional pain medicine, increased phone contact or clinic appointments, etc. Worried well patients, patients with poorly controlled chronic pain, who are non-compliant with medical regimens, seductive or manipulative, consume a lot of clinician-time and health care resources, somatisize, or are self-destructive or attention-seeking may also be labeled 'difficult'. (Krebs et al., 2006; Elder et al., 2006)

Spirituality and Medicine SUMMARY

Patients facing serious illness, accident, or death often experience a crisis of meaning. Spirituality is often defined as "the search for meaning." Spirituality may, or may not be accompanied by a particular religion. Some patients are profoundly comforted by their spiritual beliefs. Others may encounter religious struggle or negative ways of coping with illness. It is important for patients that their cultural, spiritual, and religious beliefs be recognized and integrated in the development of a plan of care and in decisions that are made concerning end-of-life care. Respect for patient values and beliefs requires competent communication skills in health care professionals. In recent years, considerable effort has been made in professional training to foster patient centered communication that is cognizant and respectful of patients' cultural and spiritual values and how these may be incorporated into optimal patient care. The American Association of Medical Colleges (AAMC) has developed medical school objectives (MSO) related to spirituality and culture that every student should achieve before graduating. Residency training programs and continuing medical education programs foster continued learning after medical school. However, there is room for improvement. In a recent survey of NW physicians, only 17% of responding physicians reported routinely inquiring about religion/spirituality with new patients, while in a crisis situation, 49% reported inquiry into the patient's religion/spirituality. 83% of respondents agreed that doctors should refer to chaplains (King, et al., 2013). New resources are available for educators such as those developed by the George Washington Institute for Spirituality and Health (GWISH), including on-line materials that are easily accessible to both students and faculty. Research into the relationship between religion/spirituality and health outcomes and patient well-being is burgeoning. Health care professionals ought not to neglect their own psychological and spiritual well-being. Health care professionals work in an intense and stressful environment, frequently exposed to the suffering of others and to companying with the dying. Such work requires that we stay in touch with our own feelings and that which provides meaning and value within our own lives, while working in a profession dedicated to the care of others.

Termination of Life-Sustaining Treatment: Does depression or other history of mental illness mean a patient has impaired decision making capacity?

Patients with active mental illness including depression should have their decision making capacity evaluated carefully. They should not be presumed to be unable to make treatment decision. In several studies, patients voiced similar preferences for life-sustaining treatments when depressed as they did after treatment of their depression. Depression and other mental disorders should prompt careful evaluation, which may often be helped by psychiatry consultation.

What physician characteristics and behaviors make the clinician-patient relationship difficult?

Physician attitudes, biases, fatigue, stress, burn-out, as well as language and cultural barriers may negatively impact the relationship (Hull & Broquet, 2007). Angry, defensive, fatigued, harried, dogmatic, or arrogant physicians are more likely to see patient encounters as difficult (ibid). Data suggests that some physicians are more likely to describe difficult patient encounters when they have "lower job satisfaction, less experience, [and] poorer psychosocial attitudes" (Elder et al., 2006). Also, physicians who have low tolerance for illnesses that are incurable or untreatable can find patients with these illnesses difficult to manage. Also susceptible are physicians who have a hard time adjusting their practice to accommodate patients who seem overly dependent or physicians who feel helpless or annoyed when the patient's ailments are exacerbated by social factors (family conflict, poverty, addiction, etc.). It can be particularly frustrating or infuriating when patients appear ungrateful or even resentful for the care they receive. Recognize this source of frustration and remember that you are likely a vital part of the patient's support system even if the patient appears ungrateful or aggressive. Physicians who tend to emphasize the patient's autonomy in medical decision-making may have a harder time with patients who abdicate responsibility for their health or are comfortable in a more vulnerable role. Highly frustrated physicians tended to be younger, more likely to practice subspecialty internal medicine, and to experience higher stress (Krebs et al., 2006).

Mistakes: Do physicians have an ethical duty to disclose information about medical mistakes to their patients?

Physicians have an obligation to be truthful with their patients. That duty includes situations in which a patient suffers serious consequences because of a physician's mistake or erroneous judgment. The fiduciary nature of the relationship between a physician and patient requires that a physician deal honestly with his patient and act in her best interest.

Physician-Patient Relationship:

Physicians with relationships with multiple family members must honor each individual's confidentiality. Difficult issues, such as domestic violence, sometimes challenge physicians to maintain impartiality. In many instances, physicians can help conflicted families towards healing. At times, physicians work with individual family members; other times, they may serve as a facilitator for a larger group. As always, when a risk for imminent harm is identified, the physician must break confidentiality. Physicians can be proactive about addressing the needs of changing family relationships. For example, a physician might tell a preteen and her family, "Soon you'll be a teenager. Sometimes teens have questions they would like to discuss with me. If that happens to you, it's okay to tell your parents that you'd like an appointment. You and I won't have to tell your parents what we talk about if you don't want to, but sometimes I might encourage you to talk things over with them." The physician-family relationship also holds considerable healing power. The potential exists to pursue options that can improve the quality of life and health for the entire family.

Interdisciplinary Team Issues: What is meant by "respectful" exchange of views?

Precisely because of the inequality of authority and responsibility in inter-professional, inter-physician, and student-teacher relationships, obligations of mutual respect are particularly important on the multidisciplinary team. Disagreements between professionals are common and expected, because of different knowledge, experience, values, and perspectives of the various team members. While disagreements might be settled in a number of ways, mutual respectful behavior is a mandatory feature of professionalism. Thus, while it is not only possible, but expected, that members of the patient care team will disagree at times, it is never acceptable for disagreements to be verbalized in an unprofessional manner. Respectful behavior begins with both listening to and considering the input of other professionals. Ask yourself whether your perception of whether you are respected depends more upon whether the other party agrees with you, or whether, despite disagreeing, they listened and acknowledged your point of view. Respect is demonstrated through language, gestures, and actions. Disagreement can and should be voiced without detrimental statements about other members of the team, and without gestures or words that impart disdain. Both actions and language should impart the message: "I acknowledge and respect your perspective in this matter, but for the following reasons. I disagree with your conclusions, and believe I should do something else..." It should go without saying that disrespectful behavior from a colleague does not justify disrespectful behavior in return.

What are the recognized obligations and values of a professional physician?

Professionalism requires that the practitioner strive for excellence in the following areas, which should be modeled by mentors and teachers and become part of the attitudes, behaviors, and skills integral to patient care: Altruism: A physician is obligated to attend to the best interest of patients, rather than self-interest. Accountability: Physicians are accountable to their patients, to society on issues of public health, and to their profession. Excellence: Physicians are obligated to make a commitment to life-long learning. Duty: A physician should be available and responsive when "on call," accepting a commitment to service within the profession and the community. Honor and integrity: Physicians should be committed to being fair, truthful and straightforward in their interactions with patients and the profession. Respect for others: A physician should demonstrate respect for patients and their families, other physicians and team members, medical students, residents and fellows. These values should provide guidance for promoting professional behavior and for making difficult ethical decisions.

Public Health: How does public health balance the interests of individuals with the interests of the broader public?

Public health activities routinely bring some of these moral considerations into conflict. One major area of discourse and debate concerns the power of public health as an agent of the state to restrict individual choice in efforts to prevent disease and promote health. Many public health activities try to influence individual actions, though they may do so in more or less restrictive ways. Public health policy may eliminate choice altogether through, for example, compulsory quarantine of patients with infectious disease; restrict choice by, for example, banning smoking in public places or fluoridating public water supplies; guide choice through disincentives (e.g., taxes on health-harming goods, such as sugary beverages) and incentives (e.g., tax breaks on health-promoting goods); or inform choice through, for example, food labeling or media campaigns (Nuffield Bioethics Council, see chapter 3). Take, for example, the obesity epidemic in the United States, which has the highest rate among Organisation for Economic Cooperation and Development countries (OECD 2012). It has been argued that individual choices that contribute to overweight and obesity constitute an economic harm to others who share in the costs of the chooser's health care (Pearson, Lieber 2009). Or, consider the dietary choices of an adult who is also a parent of small children. Parents' meal planning, purchase of groceries, cooking, and direct feeding of a very young child has other-regarding, sometimes deleterious, consequences for children (Blacksher 2008). Such examples suggest that apparently self-regarding choices related to diet might be other-regarding in significant respects. Nonetheless, the distinction between self- and other-regarding behavior has been invoked persuasively in clear cases, for example, to justify the quarantine of individuals with infectious disease that can easily be transmitted or bans on smoking in public spaces to protect others from the harmful effects of second-hand smoke.

Why is it important to respect what appear to me to be idiosyncratic beliefs?

Respecting the beliefs and values of your patient is an important part of establishing an effective therapeutic relationship. Failure to take those beliefs seriously can undermine the patient's ability to trust you as her physician. It may also encourage persons with non-mainstream cultural or religious beliefs to avoid seeking medical care when they need it.

Do Not Resuscitate Orders What about "slow codes" or "show codes"?

Slow codes and show codes are forms of "symbolic resuscitation." A "slow code" is an act performed by the health care providers that resembles CPR yet is not the full effort of resuscitation while a "show code" is a short and vigorous resuscitation performed to benefit the family while minimizing harm to the patient (Frader et al., 2010). Slow and show codes are ethically problematic. In general, performing slow and show codes undermines the rights of patients to be involved in clinical decisions, is deceptive, and violates the trust that patients have in health care providers.

Mistakes: Won't disclosing mistakes to patients undermine their trust in physicians and the medical system?

Some patients may experience a loss of trust in the medical system when informed that a mistake has been made. Many patients experience a loss of trust in the physician involved in the mistake. However, nearly all patients desire some acknowledgment of even minor errors. Loss of trust will be more serious when a patient feels that something is being hidden from them.

Resource Allocation: What about "macro-allocation" concerns? *ORGAN TRANSPLANT SHORTAGES*

Some situations involve what is called "macro-allocation," that is, broad policies to distribute resources across populations, as distinguished from "micro-allocation" decisions, such as in the above triage examples, to give priority to one patient over another. Many of these reasons for shortage are the result of deliberate decisions to ration. Even such shortages as vital organs result from social policies that favor voluntary donation over routine salvaging or a commercial market in organs. Other shortages result from broad social and cultural institutions: our country has left health care largely in the private sphere and the availability of care for individuals is conditioned by their ability to pay or their employment status, the scarcity of flu vaccine in a given year may result from budgetary decisions rather than an estimate of need in the population. The social "safety net" that acknowledges a moral duty to assure health care to those unable to pay is strengthened or weakened according to prevailing societal commitments . The theoretical ethical question is: can a fair and just way of allocating health care resources be devised? The practical ethical question is: can a fair and just allocation be actually implemented in a particular social, economic and medical climate?

Resource Allocation: What about "macro-allocation" concerns? *ORGAN TRANSPLANTS*

Some situations involve what is called "macro-allocation," that is, broad policies to distribute resources across populations, as distinguished from "micro-allocation" decisions, such as in the above triage examples, to give priority to one patient over another. Many of these reasons for shortage are the result of deliberate decisions to ration. Even such shortages as vital organs result from social policies that favor voluntary donation over routine salvaging or a commercial market in organs. Other shortages result from broad social and cultural institutions: our country has left health care largely in the private sphere and the availability of care for individuals is conditioned by their ability to pay or their employment status, the scarcity of flu vaccine in a given year may result from budgetary decisions rather than an estimate of need in the population. The social "safety net" that acknowledges a moral duty to assure health care to those unable to pay is strengthened or weakened according to prevailing societal commitments. The theoretical ethical question is: can a fair and just way of allocating health care resources be devised? The practical ethical question is: can a fair and just allocation be actually implemented in a particular social, economic and medical climate?

NICU Issues: What is the accepted legal and ethical basis for decision-making regarding the nature of medical care in the newborn infant?

The child's best interest is legally and ethically primary and should be weighed over the family's well-being or societal concerns (using the Best Interest Standard). However, there is considerable discussion in the literature about the utility of applying this standard to neonates based on their present or future best interest. Also, much discussion is placed on the need to include the family's interests when making life and death decisions regarding severely compromised infants. In the interest of justice, societal concerns about excessive cost for aggressive care should be addressed at the policy level, rather than on an individual or case-by-case basis.

Parental Decision Making: What if parents are unavailable and a child needs medical treatment?

When parents are not available to make decisions about a child's treatment, medical caretakers may provide treatment necessary to prevent harm to the child's health. In general, a child can be treated or transported without parental permission if the child has an emergency condition that places his or her life or health in danger, the legal guardian is unavailable or unable to provide permission for treatment or transport, and treatment or transport cannot be delayed without further endangering the child. Providers should administer only those treatments necessary to prevent harm to the child until parental permission can be obtained. Examining a child who presents to medical attention is always appropriate in order to establish whether a threat of life or health exists.

Physician Aid-in-Dying: Is physician aid-in-dying (PAD) ethically permissible?

The ethics of physician aid-in-dying continue to be debated. Some argue that PAD is ethically permissible (see arguments in favor). Often this position is argued on the grounds that PAD may be a rational choice for a dying person who is choosing to escape unbearable suffering at the end of life. Furthermore, the physician's duty to alleviate suffering may, at times, justify providing aid-in-dying. These arguments rely on respect for individual autonomy, recognizing the right of competent people to choose the timing and manner of death in the face of a terminal illness. Others have argued that PAD is not ethically permissible because PAD runs directly counter to the traditional duty of the physician to preserve life and to do no harm (see arguments against). Furthermore, many argue if PAD were legal, abuses would take place, as the social forces that condone the practice are a slippery slope that could lead to euthanasia. For instance, the disabled, poor or elderly might be covertly pressured to choose PAD over more complex and expensive palliative care options.

Do Not Resuscitate Orders Is CPR always beneficial?

The general rule of attempting universal CPR needs careful consideration (Blinderman et al., 2012). Even though including patients and families in decisions regarding resuscitation respects patient autonomy, providing patients and families with accurate information regarding the risks and potential medical benefit of cardiopulmonary resuscitation is also critical. Under certain circumstances, CPR may not offer the patient direct clinical benefit, either because the resuscitation will not be successful or because surviving the resuscitation will lead to co-morbidities that will merely prolong suffering without reversing the underlying disease. Some physicians and ethicists define CPR under these circumstances as medically inappropriate or "futile" (Burns & Truog, 2007). Hence, evaluating both the proximal and distal causes of the cardiac arrest is important when determining the likelihood of successful resuscitation (Bishop et al., 2010; Blinderman et al. 2012). When CPR does not have the potential to provide direct medical benefit, physicians may be ethically justified in writing a DNAR order and forgoing resuscitation.

What are the ethical obligations of physicians when a health care provider judges an intervention is futile?

The goal of medicine is to help the sick. Physicians have no obligation to offer treatments that do not benefit patients. Futile interventions may increase a patient's pain and discomfort in the final days and weeks of life; give patients and family false hope; delay palliative and comfort care; and expend finite medical resources. However, determining which interventions are beneficial to a patient can be difficult, since the patient or surrogate might see an intervention as beneficial while the physician does not. Physicians should follow professional standards, and should consider empirical studies and their own clinical experience when making futility judgments. They should also show sensitivity to patients and families in carrying out decisions to withhold or withdraw futile interventions. Although the ethical requirement to respect patient autonomy entitles a patient to choose from among medically acceptable treatment options (or to reject all options), it does not entitle patients to receive whatever treatments they ask for. Instead, the obligations of physicians are limited to offering treatments that are consistent with professional standards of care and that confer benefit to the patient.

What are the elements of full informed consent?

The most important goal of informed consent is that the patient has an opportunity to be an informed participant in her health care decisions. It is generally accepted that informed consent includes a discussion of the following elements: - The nature of the decision/procedure Reasonable alternatives to the proposed intervention - The relevant risks, benefits, and uncertainties related to each alternative - Assessment of patient understanding - The acceptance of the intervention by the patient In order for the patient's consent to be valid, she must be considered competent to make the decision at hand and her consent must be voluntary. It is easy for coercive situations to arise in medicine. Patients often feel powerless and vulnerable. To encourage voluntariness, the physician can make clear to the patient that she is participating in a decision-making process, not merely signing a form. With this understanding, the informed consent process should be seen as an invitation for the patient to participate in health care decisions. The physician is also generally obligated to provide a recommendation and share his reasoning process with the patient. Comprehension on the part of the patient is equally as important as the information provided. Consequently, the discussion should be carried on in layperson's terms and the patient's understanding should be assessed along the way. Basic or simple consent entails letting the patient know what you would like to do; giving basic information about the procedure; and ensuring that the patient assents or consents to the intervention. Assent refers to a patient's willing acceptance of a treatment, intervention, or clinical care. Basic consent is appropriate, for example, when drawing blood in a patient who has given blood before. Sometimes consent to the procedure is implied (e.g. the patient came in to have blood drawn), but an explanation of the elements of the procedure remain necessary. Decisions that merit this sort of basic informed consent process require a low-level of patient involvement because there is a high-level of community consensus that the treatment being offered is the only or best option and/or there is low risk involved in the treatment If a patient does not consent under the paradigm of basic consent, then a fuller informed consent discussion is warranted.

Physician Aid-in-Dying: What role does language play in discussions of aid-in-dying?

The term "physician aid-in-dying" is used to describe the practice authorized under the Washington, Oregon and Vermont Death with Dignity Acts and is meant to reflect the requirement that eligible persons must be decisionally competent and have a limited life expectancy of about 6 months or less. In this context, the term is meant to reflect that physicians provide assistance to patients who are otherwise going to die, and who seek help to control the timing and circumstances of their death in the face of end-of-life suffering they deem intolerable. While this term evades the mental health connotations associated with the word suicide, people who object to the use of "physician aid in dying" suggest that it could include other practices that are clearly outside the legal bounds of the three states' Death with Dignity Acts, e.g. a patient who receives assistance in ingesting the medication, which would constitute euthanasia (see below). Here we use the term physician aid-in-dying to reflect the practice that is legal under the Washington Death with Dignity Act. It is important to note that both terms, "physician assisted suicide" and "physician aid-in-dying" are value-laden and may reflect the speaker or writer's political or ideological support for or objection to the practice. Recent research has detailed the need for open and honest discussion on end of life issues. This discussion should supersede any debate over the use of particular terms or language. Acknowledging the power of both historic and contemporary terminology, will help flesh out both sides of this sensitive and powerful debate.

What are some ways to discover well known sets of beliefs?

There are many groups that share common sets of beliefs. These belief systems may be based on shared religion, ethnicity, or ideology. Knowledge of these beliefs and the reasonable range of interpretation of doctrine can be very helpful in deciding if unusual beliefs should be respected. Good resources for guidance in this area include patients and family members themselves, staff members with personal knowledge or experience, hospital chaplains, social workers, and interpreters. Unusual beliefs that fall outside known belief systems should prompt more in-depth discussions to insure they are reasonable. It is important to explore each individual's beliefs, as shared membership in a particular religious or cultural group does not necessarily entail identical belief systems.

Parental Decision Making: Under what circumstances can minors make medical decisions for themselves?

There are three situations in which minors (those who have not reached the age of majority in their state of residence) have the legal authority to make decisions about their health care. First, every state has emancipated minor laws which designate minors who meet certain criteria as having the authority to make decisions (including medical decisions) for themselves. Although emancipated minor laws vary from state to state, most states recognize an emancipated minor as a person who meets one of the following criteria: - Economically self-supporting and not living at home - Married - A parent - On active duty in the armed services Second, most states recognize some minors as sufficiently mature to make medical decisions on their own behalf. A determination that a minor is mature usually requires that the minor be older than 14 years of age and have demonstrated a level of understanding and decision-making ability that approximates that of an adult. While some states allow physicians to make this determination, most require a judicial determination of mature minor status. Third, all states make condition-specific exceptions to the requirement of parental consent. These laws may allow an adolescent to seek treatment without parental consent for sexually transmitted diseases, pregnancy, contraception, psychiatric disorders, and drug or alcohol abuse.

Truth-telling and Withholding Information: When is it justified for me to withhold the truth from a patient?

There are two main situations in which it is justified to withhold the truth from a patient. As noted above, if the physicians has compelling evidence that disclosure will cause real and predictable harm, truthful disclosure may be withheld. Examples might include disclosure that would make a depressed patient actively suicidal. This judgment, often referred to as the "therapeutic privilege," is important but also subject to abuse. Hence it is important to invoke this only in those instances when the harm seems very likely, not merely hypothetical. The second circumstance is if the patient him- or herself states an informed preference not to be told the truth. Some patients might ask that the physician instead consult family members, for instance. In these cases, it is critical that the patient give thought to the implications of abdicating their role in decision making. If they chose to make an informed decision not to be informed, however, this preference should be respected.

Termination of Life-Sustaining Treatment: Is it justifiable to withhold or withdraw care because of costs?

This question underscores the importance of clarifying the goals of medical treatment. Any medical intervention can be withheld or withdrawn, including nutrition and IV fluids. At all times, patients must be given basic humane, compassionate care. They should be given a comfortable bed, human contact, warmth, and be kept as free from pain and suffering as possible. While some believe that food and fluids are part of the bare minimum of humane treatment, both are still considered medical treatments. Several court cases have established that it is justifiable to withhold or withdraw food and fluids.

Termination of Life-Sustaining Treatment: Is it justifiable to withhold or withdraw food or fluids?

This question underscores the importance of clarifying the goals of medical treatment. Any medical intervention can be withheld or withdrawn, including nutrition and IV fluids. At all times, patients must be given basic humane, compassionate care. They should be given a comfortable bed, human contact, warmth, and be kept as free from pain and suffering as possible. While some believe that food and fluids are part of the bare minimum of humane treatment, both are still considered medical treatments. Several court cases have established that it is justifiable to withhold or withdraw food and fluids.

Physician Aid-in-Dying: What are the arguments against physician aid-in-dying (PAD)?

Those who argue that PAD is ethically impermissible often offer arguments such as these: - Sanctity of life: Religious and secular traditions upholding the sanctity of human life have historically prohibited suicide or assistance in dying. PAD is morally wrong because it is viewed as diminishing the sanctity of life. - Passive vs. Active distinction: There is an important difference between passively "letting die" and actively "killing." Treatment refusal or withholding treatment equates to letting die (passive) and is justifiable, whereas PAD equates to killing (active) and is not justifiable. - Potential for abuse: Vulnerable populations, lacking access to quality care and support, may be pushed into assisted death. Furthermore, assisted death may become a cost-containment strategy. Burdened family members and health care providers may encourage loved ones to opt for assisted death and the protections in legislation can never catch all instances of such coercion or exploitation. To protect against these abuses, PAD should remain illegal. - Professional integrity: Historical ethical traditions in medicine are strongly opposed to taking life. For instance, the Hippocratic oath states, "I will not administer poison to anyone where asked," and I will "be of benefit, or at least do no harm." Furthermore, some major professional groups such as the American Medical Association and the American Geriatrics Society oppose assisted death. The overall concern is that linking PAD to the practice of medicine could harm both the integrity and the public's image of the profession. - Fallibility of the profession: The concern here is that physicians will make mistakes. For instance there may be uncertainty in diagnosis and prognosis. There may be errors in diagnosis and treatment of depression, or inadequate treatment of pain. Thus the State has an obligation to protect lives from these inevitable mistakes and to improve the quality of pain and symptom management at the end of life.

Termination of Life-Sustaining Treatment: Does the patients have to be terminally ill to refuse treatment?

Though in most cases of withholding or withdrawing treatment the patient has a serious illness with limited life expectancy, the patient does not have to be "terminally ill" in order for treatment withdrawal or withholding to be justifiable. Most states, including Washington State, have laws that guarantee the right to refuse treatment to terminally ill patients, usually defined as those having less than 6 months to live. These laws do not forbid other patients from exercising the same right. Many court cases have affirmed the right of competent patient to refuse medical treatments.

Maternal / Fetal Conflict: What about obtaining court orders to force pregnant women to comply?

US courts have demonstrated a willingness to force treatment on a mother for the sake of her viable fetus. However, the decisions of lower-court judges do not necessarily reflect settled law. Of the two court orders that have been reviewed by the highest courts of their respective states, one was upheld and the other was overruled. The use of court orders to force treatment on pregnant women raises many ethical concerns. Court orders force pregnant women to forfeit their autonomy in ways not required of competent men or nonpregnant women. There is an inconsistency in allowing competent adults to refuse therapy in all cases but pregnancy. Hospital administrators, lawyers and judges have little warning of impending conflicts and little time for deliberation; this time pressure makes it unlikely that pregnant women will have adequate legal representation. Furthermore, forced obstetrical interventions have the potential to adversely affect the physician-patient relationship. The American College of Obstetrics and Gynecology has stated that "Obstetricians should refrain from performing procedures that are unwanted by pregnant woman....The use of the courts to resolve these conflicts is almost never warranted."

Physician-Patient Relationship: When is it appropriate for a physician to recommend a specific course of action or override patient preferences?

Under certain conditions, a physician should strongly encourage specific actions. When there is a high likelihood of harm without therapy, and treatment carries little risk, the physician should attempt, without coercion or manipulation, to persuade the patient of the harmful nature of choosing to avoid treatment. Court orders may be invoked to override a patient's preferences. However, such disregard for the patient's right to noninterference is rarely indicated. Court orders may have a role in the case of a minor; during pregnancy; if harm is threatened towards oneself or others; in the context of cognitive or psychological impairment; or when the patient is a sole surviving parent of dependent children. However, the use of such compulsory powers is inherently time-limited, and often alienates the patient, making him less likely to comply once he is no longer subject to the sanctions.

Resource Allocation: Can I make allocation decisions based on judgments about "quality of life"?

Under conditions of scarcity, the question may arise whether a patient's quality of life seems so poor that use of extensive medical intervention appears unwarranted. When this question is raised, it is important to ask a few questions. First, who is making this quality of life judgment, the care team, the patient, or the patient's family? Several studies have shown that physicians often rate the patient's quality of life much lower than the patient himself does. If the patient is able to communicate, you should engage her in a discussion about her own assessment of her condition. When considering quality of life, you should also ask: What criteria are being used to make the judgment that the quality of life is unacceptable? These criteria are often unspoken and can be influenced by bias or prejudice. A dialogue between care givers and the patient can surface some underlying concerns that may be addressed in other ways. For example, residents on a medical floor in an urban public hospital may get discouraged with the return visits of a few chronically ill alcoholic patients and suggest that money is being wasted that could be used for prenatal care or other medically beneficial projects. While the residents' frustration is understandable, it would be helpful to consider other ways they might interrupt this vicious cycle of repeat admissions. How could this patient population be supported in ways that might improve health? Quality of life judgments based on prejudices against age, ethnicity, mental status, socioeconomic status, or sexual orientation generally are not relevant to considerations of diagnosis and treatment. Furthermore, they should not be used, explicitly or implicitly, as the basis for rationing medical services.

Resource Allocation: Can I make allocation decisions based on judgments about "quality of life"?

Under conditions of scarcity, the question may arise whether a patient's quality of life seems so poor that use of extensive medical intervention appears unwarranted. When this question is raised, it is important to ask a few questions. First, who is making this quality of life judgment, the care team, the patient, or the patient's family? Several studies have shown that physicians often rate the patient's quality of life much lower than the patient himself does. If the patient is able to communicate, you should engage her in a discussion about her own assessment of her condition. When considering quality of life, you should also ask: What criteria are being used to make the judgment that the quality of life is unacceptable? These criteria are often unspoken and can be influenced by bias or prejudice. A dialogue between care givers and the patient can surface some underlying concerns that may be addressed in other ways. For example, residents on a medical floor in an urban public hospital may get discouraged with the return visits of a few chronically ill alcoholic patients and suggest that money is being wasted that could be used for prenatal care or other medically beneficial projects. While the residents' frustration is understandable, it would be helpful to consider other ways they might interrupt this vicious cycle of repeat admissions. How could this patient population be supported in ways that might improve health? Quality of life judgments based on prejudices against age, ethnicity, mental status, socioeconomic status, or sexual orientation generally are not relevant to considerations of diagnosis and treatment. Furthermore, they should not be used, explicitly or implicitly, as the basis for rationing medical services.

Why is medical futility controversial?

While medical futility is a well-established basis for withdrawing and withholding treatment, it has also been the source of ongoing debate. One source of controversy centers on the exact definition of medical futility, which continues to be debated in the scholarly literature. Second, an appeal to medical futility is sometimes understood as giving unilateral decision-making authority to physicians at the bedside. Proponents of medical futility reject this interpretation, and argue that properly understood futility should reflect a professional consensus, which ultimately is accepted by the wider society that physicians serve. Third, in the clinical setting, an appeal to "futility" can sometimes function as a conversation stopper. Thus, some clinicians find that even when the concept applies, the language of "futility" is best avoided in discussions with patients and families. Likewise, some professionals have dispensed with the term "medical futility" and replaced it with other language, such as "medically inappropriate." Finally, an appeal to medical futility can create the false impression that medical decisions are value-neutral and based solely on the physician's scientific expertise. Yet clearly this is not the case. The physician's goal of helping the sick is itself a value stance, and all medical decision making incorporates values.

What if the patient or family requests an intervention that the health care team considers futile?

You have a duty as a physician to communicate openly with the patient or family members about interventions that are being withheld or withdrawn and to explain the rationale for such decisions. The aim of respectful communication should be to elicit the patient's goals, explain the goals of treatment, and help patients and families understand how particular medical interventions would help or hinder their goals and the goals of treatment. It is important to approach such conversations with compassion. For example, rather than saying to a patient or family, "there is nothing I can do for you," it is important to emphasize that "everything possible will be done to ensure the patient's comfort and dignity." In some instances, it may be appropriate to continue temporarily to make a futile intervention available in order to assist the patient or family in coming to terms with the gravity of their situation and reaching closure. For example, a futile intervention for a terminally ill patient may in some instances be continued temporarily in order to allow time for a loved one arriving from another state to see the patient for the last time. However, futile interventions should not be used for the benefit of family members if this is likely to cause the patient substantial suffering, or if the family's interests are clearly at odds with those of the patient. If intractable conflict arises, a fair process for conflict resolution should occur. Involvement of an ethics consultation service is desirable in such situations. The 1999 Texas Advance Directives Act provides one model for designing a fair process for conflict resolution.

Under what circumstances should I call the ethics consultant/service?

You should consider asking for a case consultation when two conditions are met: - you perceive that there is an ethical problem in the care of patients, and - health care providers have not been able to establish a resolution that is agreed upon by the patient/surrogate and the clinicians caring for the patient While a communication breakdown is often a factor in ethics consultation, an ethical dilemma occurs when two courses of action may both be ethically defensible. These dilemmas are often due to a conflict between principles (e.g., autonomy, beneficence, justice) or between principles and outcomes. At most hospitals, anyone may request an ethics consultation including the patient or family. Please check the hospital's policies to learn how to request an ethics consultation. You should consider asking for an ethics consultation even when patient care is not the central issue if you believe that there is a lack of clarity about an ethics policy or concept that would benefit from education. The following are examples: - a question about professionalism, - a general question about patient privacy or confidentiality, and - a question about ethical practices in the workplace, human resources, resource allocation, or the business practices of the institution.