Patient-Physician Relationships
At the heart of medicine lie relationships founded in a “covenant of trust” between patient and physician in which physicians commit themselves to responding to the needs and promoting the welfare of patients.
Decisions for Adult Patients Who Lack Capacity
Physicians should engage patients whose capacity is impaired in decisions involving their own care to the greatest extent possible, including when the patient has previously designated a surrogate to make decisions on his or her behalf.
Withholding Information from Patients
Withholding pertinent medical information from patients in the belief that disclosure is medically contraindicated creates a conflict between the physician’s obligations to promote patient welfare and to respect patient autonomy. Except in emergency situations in which a patient is incapable of making an informed decision, withholding information without the patient’s knowledge or consent is ethically unacceptable.
Pediatric Decision Making
In giving or withholding permission for medical treatment for their children, parents/guardians are expected to safeguard their children’s physical health and well-being and to nurture their children’s developing personhood and autonomy; Physicians should evaluate minor patients to determine if they can understand the risks and benefits of proposed treatment; The more mature a minor patient is, the better able to understand what a decision will mean, and the more clearly the child can communicate preferences, the stronger the ethical obligation to seek minor patients’ assent to treatment.
Surgical Co-Management
Surgical co-management refers to the practice of allotting specific responsibilities of patient care to designated clinicians. Such arrangements should be made only to ensure the highest quality of care.
When individuals who are not involved in providing care seek to observe patient-physician encounters, physicians should safeguard patient privacy by permitting such observers to be present only when the patient has explicitly agreed to the presence of the observer(s), the presence of the observer will not compromise care, and the observer has agreed to adhere to standards of medical privacy and confidentiality.
Audio or Visual Recording Patients for Education in Health Care
Audio or visual recording of patients can be a valuable tool for educating health care professionals, but physicians must balance educational goals with patient privacy and confidentiality. Physicians also have an obligation to ensure that content is accurate and complete and that the process and product of recording uphold standards of professional conduct.
Audio or Visual Recording of Patients for Public Education
Audio or visual recording of patient care for public broadcast is one way to help educate the public. However, physicians have an obligation to protect patient interests and ensure that professional standards are upheld. Physicians also have a responsibility to ensure that information conveyed to the public is complete and accurate.
Withholding or Withdrawing Life-Sustaining Treatment
A patient who has decision-making capacity appropriate to the decision at hand has the right to decline or halt any medical intervention even when that decision is expected to lead to his or her death, When a patient lacks appropriate capacity, the patient’s surrogate may halt or decline any intervention. There is no ethical difference between withholding and withdrawing treatment. When an intervention no longer helps to achieve the patient’s goals for care or desired quality of life, it is ethically appropriate for physicians to withdraw it.
Orders Not to Attempt Resuscitation (DNAR)
Orders not to attempt resuscitation (DNAR orders) direct the health care team to withhold resuscitative measures in accord with a patient’s wishes. Physicians should address the potential need for resuscitation early in the patient’s course of care, while the patient has decision-making capacity, and should encourage the patient to include his or her chosen surrogate in the conversation.
Sedation to Unconsciousness in End-of-Life Care
When a terminally ill patient experiences severe pain or other distressing clinical symptoms that do not respond to aggressive, symptom-specific palliation, it can be appropriate to offer sedation to unconsciousness as an intervention of last resort.
Transplantation of Organs from Living Donors
Donation of nonvital organs and tissue from living donors can increase the supply of organs available for transplantation, to the benefit of patients with end-stage organ failure. Enabling individuals to donate nonvital organs is in keeping with the goals of treating illness and relieving suffering so long as the benefits to both donor and recipient outweigh the risks to both.
Organ Donation After Cardiac Death
Physicians should support innovative approaches to increasing the supply of organs for transplantation but must balance this obligation with their duty to protect the interests of their individual patients. Organ donation after cardiac death is one approach being undertaken to make greater numbers of transplantable organs available.
Informed Consent in Research
Physicians must ensure that the participant (or legally authorized representative) has given voluntary, informed consent before enrolling a prospective participant in a research protocol. The obligation to obtain informed consent arises out of respect for persons and a desire to respect the autonomy of the individual.
Residents and fellows have dual roles as trainees and caregivers; however, residents and fellows are physicians first and foremost and should always regard the interests of patients as paramount.
Performing Procedures on the Newly Deceased
Medical training sometimes involves practicing procedures on newly deceased patients, including critical medical skills for which adequate educational alternatives are not available. Such training must balance protecting the interests of newly deceased patients, their families, society, and the profession with the need to educate health care providers.
Medical Students Practicing Clinical Skills on Fellow Students
Medical students who volunteer to act as “patients” are not seeking to benefit medically from the procedures being performed on them; their goal is to benefit from educational instruction, yet their right to make decisions about their own bodies remains. In the context of practicing clinical skills on fellow students, instructors should ensure that medical students’ privacy, autonomy, and sense of propriety are protected.
