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What Is a Case Study?

When you’re performing research as part of your job or for a school assignment, you’ll probably come across case studies that help you to learn more about the topic at hand. But what is a case study and why are they helpful? Read on to learn all about case studies.

Deep Dive into a Topic

At face value, a case study is a deep dive into a topic. Case studies can be found in many fields, particularly across the social sciences and medicine. When you conduct a case study, you create a body of research based on an inquiry and related data from analysis of a group, individual or controlled research environment.

As a researcher, you can benefit from the analysis of case studies similar to inquiries you’re currently studying. Researchers often rely on case studies to answer questions that basic information and standard diagnostics cannot address.

Study a Pattern

One of the main objectives of a case study is to find a pattern that answers whatever the initial inquiry seeks to find. This might be a question about why college students are prone to certain eating habits or what mental health problems afflict house fire survivors. The researcher then collects data, either through observation or data research, and starts connecting the dots to find underlying behaviors or impacts of the sample group’s behavior.

Gather Evidence

During the study period, the researcher gathers evidence to back the observed patterns and future claims that’ll be derived from the data. Since case studies are usually presented in the professional environment, it’s not enough to simply have a theory and observational notes to back up a claim. Instead, the researcher must provide evidence to support the body of study and the resulting conclusions.

Present Findings

As the study progresses, the researcher develops a solid case to present to peers or a governing body. Case study presentation is important because it legitimizes the body of research and opens the findings to a broader analysis that may end up drawing a conclusion that’s more true to the data than what one or two researchers might establish. The presentation might be formal or casual, depending on the case study itself.

Draw Conclusions

Once the body of research is established, it’s time to draw conclusions from the case study. As with all social sciences studies, conclusions from one researcher shouldn’t necessarily be taken as gospel, but they’re helpful for advancing the body of knowledge in a given field. For that purpose, they’re an invaluable way of gathering new material and presenting ideas that others in the field can learn from and expand upon.


case study analysis beneficence and non maleficence


Case Study Analysis : Beneficence And Non Maleficence

The code of ethics of the american association of medical assistants.

A nurse is given an opportunity to help patients, either if its by helping them through a very serious sickness or just helping a patient get to the bathroom on time, or a time when happiness is overfilling the room and a child is being born. Registered nurses provide a wide variety of patient care services (Mitchell, p.12). A Nurse must always know where to begin and where to stop, as any other career in the health field there is always something that cannot be done by everyone but only the certified person, a nurse must always remain inside her scope of practice to prevent any misunderstandings. A nurse must also follow a code of ethics , the code of ethics of the American Association of Medical Assistants states that a nurse should at all times render service with full respect and dignity of humanity, respect confidential information obtained by a patients file, uphold the honor and high principles the profession and accept its discipline, and last but not least always want to improve her services to better serve the health and well being of the community. (Mitchell, p.65).

The Traditional Nurse, Writing By Lisa H. Newton

The roles and responsibility of a nurse are that most nurses face moral problems similar to these faces by the physician as well as a moral problem uniquely related to their professional role thus nurse must sometimes choose between doing what they believe will promote patients well-being and the respecting the patient ’ self-determination. Lisa explained the role as a role, is a “norm-governed patterns of action that undertaken in accordance with the social expectations” (Lisa page 690). Thus, the ability to serve and work according to the

Ethical Dilemmas Of Health Care

First is the principal of beneficence which “requires nurses to act in ways that benefit patients” (Burkhardt, 2014, p.69). This principle tells us that one should promote good, prevent harm and remove evil or harm.

The Ethical Dilemma Regarding The Pro Choice Vs. Pro-Choice

Moreover, an emphasis is imposed on the rights of a single patient to commit an act or decision even though it is in contrast with the views of the others. In regards to the ethical dilemma, a nurse could not justify the morality of the two possible choices based on their results and consequences. The Deontological approach would encourage the health care staff as well as the patient to ask themselves the most righteous choice for their situation. With this in mind, a combination of ethical theories can also be employed to give light to the dilemma. In view of this, another ethical approach could be applied to solve the issue, and this is the Right-based approach. This theory also aim to promote the rights of every person, and that, they are indispensable just to make ends meet. However, not all ethical theories can be incorporated in every dilemma in a health care setting because their foundations would contradict one another. In order to provide an effective and efficient solution, nurses should be knowledgeable of the principles enveloping each of the ethical theories and should be wise to apply them in appropriate issues and

Christian Leadership Paper. Our Healthcare System Is In

Healthcare professionals have an ethical obligation to respect patient’s wishes. Consequently, many legal and ethical dilemmas arise in healthcare in response to clinical decisions related to the needs, beliefs, and preferences of patients and families. Other dilemmas result over concerns about the integrity, competence, or actions of other healthcare professionals. Preserving human dignity, relieving suffering, equality, integrity, and accountability are essential nursing values (Kangasniemi, Pakkanen, & Korhonen, 2015). Nurse leaders have an

Nursing Ethics and Values

As a registered nurse practicing in the state of California I am responsible for practicing within my states legal regulations and nursing scope of practice. My concern for the welfare of the sick and injured allows me to practice ethical provisions of nursing. These are required if I am to carry out competent and effective nursing care. Nursing encompasses the prevention of illness, the alleviation of suffering, and the protection, promotion, and restoration of health in the care of individuals. Therefore, as health care professionals we must be familiar with the different philosophical forces, ethical principles, theories and values that influence nursing. At the same time, we must be respectful to our patient’s

Elder Abuse : An Ethical Dilemma

Nurses confront numerous dilemmas throughout their professional lives. The different types of dilemmas include, but are not limited to, ethical, moral, and legal dilemmas. These are the three most common dilemmas in nursing. A dilemma can be defined in many different ways. But all dilemmas are situations in which you have to make a difficult choice. Chiaranai (2011) states that an “ethical dilemma is a circumstance that arises from fundamental conflicts between ethical beliefs, duties, principles and theories” (p. 250). Therefore, an ethical dilemma forces the nurse to address thought on what is right and what the harm might be to the patient.

Nursing : Regarding The Importance Of Patient Priority In Nursing

In order to create a morally and ethically sound practice and health care environment for every patient, the nurse’s decision-making role is vital and should be treated as such. The nurse’s professional morals and ethics should always be patient oriented to consistently assure the best decisions are being made to support each and every individual appropriately. These morals and ethics should consist of, the willingness to take action on behalf of patient needs and interests, the ability to advocate for the patients care even if that means questioning

NURS 6053N 12 Taking A Stand

Nursing profession is constantly changing with the development of new technologies that lead to a new level of responsibility. The new level of responsibility challenges nurses torespond to different and difficultsituations in the health care industry, especially in protecting the human right, dignity of patients and their safety. Nurses hold adistinctive position as patient advocates, regardless of their respective areas of practice; either in a home health, clinic, or in a hospital setting. Nursesare faced with ethical decisions, both personal and professional decisions.

Professional, Legal and Ethical Issues in Person-Centred Care

Sarah’s doctor also have a professional duty to adhere to the ethical principles of beneficence and non-maleficence (Wilmot (2003) Beneficence is the act to ‘To do good’ whereas;

Personal Statement : Professional Identity

Nursing is one of the most intimate health care professions. They are connected to their patients as soon as they are admitted into their care right through until they are discharged into someone else’s care. With this, nurses have a strict professional identity and scope of practice to prevent a nurse from over stepping their professional boundaries. A nurses’ duty of care does go beyond the average healthcare professional but still does not impair the

APRN Core Competencies In Nursing

Nursing is not an easy job and those who chose it as their profession are truly special people. Nurses are confronted with ethical decisions that need to be made on a daily basis. Often they know the right thing to do but because of circumstances like institutional structure and conflicts with others, obstacles are created and distress ensues (Jenner, 2001). It is during times like these that nurses must rely on the training that they have received as well as the code of ethics that has been set down for their profession in order to do the right thing.

Personal Ethics

It can be a very difficult task to put aside your own feelings regarding choices of a patient, especially when it feels that their choice is harming or not allowing us as health care providers to prevent further harm. What we must always remind ourselves is that attempting to force our personal morals, values, or convictions on a patient can cause harm as well. It is the duty of a nurse to always protect patients’ rights even when they conflict with our own.

The Ethics Of A Dnp Prepared Nurse

Codes of ethics contain a coherent set of normative principles underlying a nurse’s purpose and associated values (Vanlaere and Gastmans, 2007). Two perspectives of ethics are the ethics of justice and the ethics of care (Botes, 2000). The ethics of justice constitutes an ethical perspective in terms of which ethical decisions are made on the basis of universal principles and rules, and in an impartial and verifiable manner with a view to ensuring the fair and equitable treatment of all people (Botes, 2000). The ethics of care, on the other hand, constitutes an ethical approach in terms of which involvement, harmonious relations and the needs of others play an important part in ethical decision making in each ethical situation (Botes, 2000).

The Legal And Ethical Issues Of Health Care Of A Child Essay

Nurses are subject to a plethora of legal, ethical, and professional duties which can be very challenging on a day to day basis. Some of these duties include respecting a patient 's confidentiality and autonomy, and to recognize the duty of care that is owed to all patients. As nurses our duties are always professional; however there are legal implications if these duties are breached. We also must consider when it is okay as nurses to breach these duties and therefore ethical issues arise. As nurses one of our main priorities is to advocate for our patients, without our own personal feelings on the matter taking over.

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Case Study Application of an Ethical Decision-Making Process for a Fragility Hip Fracture Patient

In Canada, up to 32,000 older adults experience a fragility hip fracture. In Ontario, the Ministry of Health and Long Term Care has implemented strategies to reduce surgical wait times and improve outcomes in target areas. These best practice standards advocate for immediate surgical repair, within 48 hours of admission, in order to achieve optimal recovery outcomes. The majority of patients are good candidates for surgical repair; however, for some patients, given the risks of anesthetic and trauma of the operative procedure, surgery may not be the best choice. Patients and families face a difficult and hurried decision, often with no time to voice their concerns, or with little-to-no information on which to guide their choice. Similarly, health-care providers may experience moral distress or hesitancy to articulate other options, such as palliative care. Is every fragility fracture a candidate for surgery, no matter what the outcome? When is it right to discuss other options with the patient? This article examines a case study via an application of a framework for ethical decision-making.


Every year, over 30,000 Canadian older adults experience a fragility hip fracture. The Ministry of Health and Long Term Care of Ontario has promoted best practice recommendations which advocate for immediate surgical repair, within 48 hours of admission, in order to achieve optimal recovery outcomes. ( 1 , 2 ) The majority of patients are good candidates for surgical repair; however, given the risks of anesthetic and trauma of the operative procedure, surgery may not be the best choice for all. The patients at higher risk of poor outcomes perioperatively deserve the opportunity to explore options and articulate their values. Unfortunately, as a short pre-operative interval predicts the best outcomes, patients and families face a difficult and hurried decision, potentially with limited time to voice their concerns, and little to no information on which to guide their decision.

From a systems perspective, quality of care and health outcomes have not always incorporated the patient-centred perspective. ( 3 ) Patient-centred care is “a moral concept and philosophy, considering it to be the right thing to do when designing and delivering respectful, humane, and ethical care”. ( 4 , 5 ) Patients and families have reported in the past that they feel left out of crucial conversations and decisions surrounding care, ( 6 ) and that relevant information is not always provided. ( 7 )

To better understand the underlying ethical complexities which arise from critical decisions in the acute care setting, this paper will examine a case study to demonstrate application of the Corey et al . ( 8 ) 8-step framework (see Appendix A ) for ethical decision-making.

Ms. Jones is 93 years old and lives in a Long Term Care residence. She was admitted to hospital with a fragility hip fracture after being found on the floor in the middle of the night. Ms. Jones has dementia and is unable to make her own decisions. She has limited mobility, previously used a walker. Her two daughters are at her bedside. They state her health has been declining over the last few weeks, with increasing confusion and she now rarely leaves her room.

On admission, the team discovered a pleural effusion, taking up much of her right lung. Her pre-operative assessment also revealed a heart murmur; the resulting echocardiogram demonstrated a heart in very poor condition, with significant valve issues. Between her cardiac and pulmonary function, the surgery poses an increased risk of perioperative complications—she may never survive the surgery, or come off of the ventilator once she is intubated.

Interprofessional teams (surgery, anesthesia, nursing) are of differing opinions. The issue at hand is very difficult. The family is informed that the risk of not having surgery will likely result in death, yet in this patient’s case, proceeding with surgery carries its own risk. The family is left with an hour to think things over. Should they pursue the palliative care route or proceed with surgery?

Step 1. Identify the Problem or Dilemma

In our case study, 93 year old Ms. Jones is admitted to hospital with a fragility hip fracture. As a first step, we must recognize that there is actually an ethical dilemma; in this case, the dilemma is whether the patient should proceed with surgery or not, given her underlying medical conditions and potential for perioperative complications. We also need to acknowledge that there is an underlying assumption from all involved (staff, Ms. Jones’ family) that surgery will occur, and that health-care providers (HCPs) may not clearly articulate the option of ‘no surgical intervention’. The stakeholders who are required to proceed through the decision-making process include the patient and family, the surgical team, anesthesia, nursing staff, social work, and potentially the palliative care team and bioethics team.

Step 2. Identify the Potential Issues Involved

There are several assumptions made when a patient presents to the hospital with a fragility hip fracture: a) the fracture will be repaired; b) the patient will recover; and c) the patient will eventually go home or to rehabilitation. With a critically ill, frail, and/or previously compromised patient, this standard trajectory should be questioned. Barry and Edgman-Levitan ( 9 ) promote an ideology of patient-centredness, with the argument that an intervention should only be considered standard if there is ‘virtual unanimity amongst patients about the overall desirability… of the outcomes’.

The first potential issue is the ‘standard’ intervention of surgical repair—the assumption to proceed with the surgery, as directed by best practice recommendations. Is this standard intervention appropriate in all patients with a fragility hip fracture? A second potential issue arises with the patient and their family—the presumption that the acute medical issue will be resolved and the patient will eventually return home. Given her underlying health, this concept is in jeopardy. To add to the complexity, Ms. Jones is likely not able to articulate her wishes and values, as she has dementia. Finally, there is the potential issue of moral distress experienced by health-care providers (HCPs) who feel uncomfortable with the expectant surgical trajectory of this patient, and may feel they are not empowered to advocate for the wishes of the patient.

As health-care professionals, we are guided by moral principles in our decision-making process, namely, autonomy, non-malfeasance, beneficence, justice, fidelity, and veracity. ( 10 ) A focused examination and application of the principles to the case study will help to support potential resolutions for the identified issues.

The spirit of ‘patient-centred care’ endorses that patients should be involved at their level of choice to make an autonomous decision. ( 11 ) However, it is important to recognize that no decision is made in isolation. ( 12 ) The decision at hand is not a simple or straightforward one; literature demonstrates that patients and families have a difficult time with making decisions at time of a critical illness, identifying fear, worthlessness, and a lack of autonomy within the hospital system. ( 7 ) Differing levels of patient and family participation requires an individualized approach to convey meaningful, accurate, and timely information. ( 8 ) Older adult patients tend to take a ‘non-participative’ stance in their care. They often have limited participation in the process for decision-making for a variety of reasons, thereby increasing the risk of their inability to understand or find value within the end decision. ( 6 , 7 , 13 )


Hospitalization can cause the patient to experience “needless mental and physical suffering” ( 14 ) in any number of ways (i.e., pain, waiting for surgery, uncertainty of outcomes, patient/family relationship stress). Evidence indicates that the number of different HCPs involved causes immense anxiety to the family, especially when they do not hear the same message from all members of the team. ( 13 , 15 ) HCPs must ensure that they are not withholding information, or are untruthful as to the options in order to expedite a decision. A study by Ekdahl, Andersson, and Friedrichsen ( 13 ) found that physicians perceive they are ‘too short’ of time for patients to participate in the decision making process, that decisions were ‘too complex’ and ‘time consuming’ to fit into the schedule. Ekdahl et al. ( 13 ) also found that physicians feel frustration with the ‘health-care production machine’, especially in those older adult patients with multiple co-morbidities.


Beneficence promotes wellbeing; or is an action that is carried out to benefit another. ( 8 ) The hospitalization ‘process’ promotes assessment of a patient, treatment of the illness, followed by a physical approach to recovery (allowing recovery to be measured against specific milestones), and discharge in a timely manner. ( 15 , 16 ) This ‘process’ may promote beneficence in an overarching global perspective of the system; however, on an individual level, it often falls short. On an individual level, key actions that have been found to be beneficial and meaningful are open communication and sharing of information. ( 6 , 7 , 14 , 17 )

“Practitioners have a responsibility to provide appropriate services to all clients”. ( 8 ) Older adult patients may not receive information about options available, especially if the HCPs feel that it would take too much time to thoroughly explain, or if HCPs assume that patients are too ill to participate in the decision-making process, ( 13 ) or if the assumption is made that all patients want to proceed with surgery. Focusing on each older adult’s individual health goals is time-consuming—in this case, the patient has dementia, and a family meeting would be required. The concept of patient-centred care revolves around patient and HCP partnerships, yet older adult patients face unique problems with hospitalization—a slower communication process, a decreased level of functioning, and a degree of family involvement. ( 14 ) Can we provide this type of relationship and communication effort equally for every patient? Or only for those patients who may be at higher risk of negative outcomes?

Fidelity and Veracity

Fidelity involves fulfilling ones’ professional roles, creating a trusting relationship, and veracity ensures that we are truthful and honest to the patients. How do we ensure that as a HCP we are providing an unbiased opinion? Do we take the same amount of time to present patients with the option of conservative, non-surgical treatment, including palliative care, as we take to advocate for surgery? The HCP team assumes that patients will commit to surgery; however, a patient often displays a suboptimal understanding of the risks and benefits of surgery. ( 18 ) Similarly, there is the very real risk of bias towards an argument of palliative care in those frail patients or those with dementia. HCPs must return to the voice of the patient through their family, to understand that patients’ identity, their meaning of life, and desired goals which emphasize the patients’ dignity. ( 12 )

It is important to acknowledge assumptions that the patient and family may have made upon admission to hospital—that surgery will occur and the patient will recover. Have we presented the patient and their family with as much information as they need to make a decision in a clear format (without medical jargon)? In addition to understanding risks of surgery, it is paramount that the family understands the non-surgical option may result in death or decreased function (if any functional ability returns). It is in an acute situation such as this that families require truthful and open communication with physicians, nurses, and other members of the health-care team. ( 11 )

Self Care (HCPs)

Can we consistently provide care that prioritizes a patient’s values? HCPs are not always able to preserve all of the values and interests at stake. ( 19 ) We know that the most common cause of moral distress in nursing is prolonged, aggressive treatment which we do not believe will be likely to have a positive outcome. ( 20 ) As a HCP, we must look to root causes operating within the larger system, to prevent and/or respond to feelings of moral distress. ( 19 )

From a systems perspective, does the hospital provide an avenue for exploration of patient values within a timely fashion? Is there a framework in place to enhance the HCP’s understanding of moral distress and provide strategies for coping with situations such as these (i.e., an opportunity for a team debriefing with the entire team, or opportunities for learning how to deal with situations that may cause moral distress)?

Step 3. Review the Relevant Ethics Codes

The philosophy of patient-centred care within the hospital encourages active listening, respect, and an attempt to understand individuals. The Canadian Medical Association (CMA) supports “practicing the profession of medicine in a manner that treats the patient with dignity and as a person worthy of respect”. ( 21 ) The College of Nurses of Ontario (CNO) supports the view that nurses “must use the client’s views as a starting point”. ( 22 ) Across all HCPs is the similarity of the need to listen, understand, support, and advocate for a respect of patients’ values with the expected course of treatment.

The importance of collaboration with the patient and respecting a patient’s values are highlighted within similar statements: ”…it is the patient who ultimately must make informed choices about the care he or she will receive”. ( 21 )

Step 4. Know the Applicable Laws and Regulations

In Ontario, legislation and common law require that the wishes of patients or substitute decision-makers be respected. ( 22 ) However, in many systems, health care is not truly patient-centred; rather, patients are required to adapt to the system. ( 11 ) A number of initiatives have been undertaken in the last few years in an attempt to improve the focus of patient-centredness, with the principle assertion that patients should be involved at the level of their choice. ( 11 )

Step 5. Obtain Consultation

It is important to realize that we bring our own biases to the decision-making process, making it difficult to view the current patient/family’s situation objectively. As an individual HCP, our previous experiences will have an impact on the messaging that we provide. From a systems perspective, we are likely to pose a ‘knowledge’ bias towards meeting treatment based outcomes—for example, surgery within 48 hours, immediate post-operative mobility, and the expected length of stay for this type of patient.

Inter-disciplinary consultations with patients and their families ensure review of unbiased information about the risks and benefits of proceeding with surgery, allowing for a fully informed decision. In addition to discussing the operative plan with the surgical team, there is an opportunity to provide Ms. Jones’ family with other options that may be available to her. Consultation with extended family members, clergy, social workers, or an ethics team may help the family to reflect on the patient values; what this illness means to them as a family unit, and how best to proceed. A discussion with palliative care may help the family to better understand what symptom management consists of for their mother. Social work may also be able help explore community services available to the family in this situation—for example, is the patient able to return to home with the future of wheelchair dependence? Are there any other options which may be available to this patient and her family that were not originally considered? How do we, as HCPs, ensure that the family is afforded the opportunity to obtain all the necessary information from differing disciplines to make an informed choice?

Step 6. Consider Possible and Probable Courses of Action

In order to fully understand the options, it is helpful to outline all the possible and probable courses of action that are open to Ms. Jones and her family.

Step 7. Enumerate the Consequences of Various Decisions

With the first option, the surgical team takes a ‘purposeful pause’ to discover the patient’s core values and discusses pros and cons of a surgical intervention. Often, this may be most ‘efficient’ way to deal with the situation at hand. It may also be the preference of the patient; some patients have reported that they value this limited level of involvement—“I get a description of what is going to happen”. ( 13 ) As a consequence, there will be a number of patients who will want to have a greater sense of involvement other than a simple description of planned events. The first option does recognize the principle of autonomy, but does not follow the principle of justice; practitioners have the responsibility to provide information about other options which may be available. The principles of beneficence and non-maleficence are not completely met, as the team approaches the solution primarily to benefit the system (i.e., efficiency). The principles of fidelity and veracity are also partially met, as the surgical team provides an honest perspective, although it may be biased towards proceeding with surgery.

The second option, offering the patient and her family a meeting with all stakeholders, strongly aligns with the fidelity and veracity principles. The information offered is truthful and complete, and is in Ms. Jones’ best interest, as it attempts to discover her values that will affect the family’s final decision. Principles of beneficence and autonomy would be met with patient empowerment through information sharing, and secondly, by allowing the patient and family to arrive at their own decision with that information. As a consequence, taking the time to arrange for a family meeting with all stakeholders may not be possible for all patients, and the principles of justice and non-maleficence are brought to the forefront for future patients. A potential consequence could be harm to the patient, as the time it takes to arrange a meeting could push the time to surgery beyond the recommended 48 hours post-admission, placing the patient at greater risk of negative post-operative outcomes.

The third option is one of passive action, with a lack of communication and recognition of patient-centred care values. Ms. Jones would be placed on the operating room list, and the surgical repair will occur. Consent must legally be obtained for the surgery; however, the family may not think of key questions to ask that may be relevant in this situation. The onus remains on the HCP to provide a full explanation of all options to the family. The only benefit would be to the system, as the procedure will be carried out in a timely manner. Ms. Jones may benefit from the surgery; we cannot assume that surgery is a negative option. As a consequence of this option, HCPs do not explore patient values, and this option is against almost all of the ethical principles. Additionally, this option is likely to cause the highest moral distress amongst staff, as they are unable to meet the unique needs of Ms. Jones and her family.

Step 8. Choose what Appears to be the Best Course of Action

Virtue ethics asks us if we are doing the best action for our patients, and compels us to be conscious of our behaviours. ( 8 ) We need to take the necessary time to discover the patient’s values within the unique situation they are now experiencing. Simply stated, we need to remember that they are a person, with feelings, emotions, past experiences, future hopes/plans, and usually an element of fear and anxiety. The goal is to work with Ms. Jones and her family to decide together on the current care plan and the best plan for action (or inaction), a plan that truly aligns with the patient’s values.

From an ethical perspective, the best course of action is to hold a family meeting with all stakeholders to discover Ms. Jones’ values about a meaningful life and a meaningful death, and come to a consensus as to what the right decision is for this patient. ( 12 ) The team must ensure that the patient and the family have all the necessary tools in which to make this decision. Have we provided them with all the information required? Do they understand the information? Do they understand the consequences of their decision? From a systems perspective, we need to continue to strive towards engaging patients and family members more fully and consistently in care and decision-making processes. ( 6 ) Dissemination of lessons learned from assisting patients and families through difficult decision-making may be helpful to other health-care teams experiencing similar moral conflicts.

As a next step, the HCP team may consider development of an educational reference for future patients to assist with similar decisions, including promotion of an advanced care plan to help communicate goals and concerns to HCPs. ( 12 , 18 ) Additionally, decision aids, such as videos and brochures, can help deliver information to patients and their families. ( 9 ) The use of readily available technology, such as iPads and cellphones, means that families are better able to access these materials at any time of day. A recent Cochrane Review demonstrated that, in comparison to usual care, decision aids can increase knowledge, resulting in a higher proportion of patients choosing the option which most aligns with their values. ( 23 ) Providing patients with information that outlines potential options with risks and benefits clearly explained can also meet many of the ethical principles that are to be considered with ethical decision-making.

The in-depth review of the case study has helped us to examine the underlying issues that come into play when helping this patient and her family to make a critical decision. Although each patient is an individual, literature tells us that many perceive the concept of patient-centredness to represent an ‘involvement in their care’. The level of involvement may vary from person to person, but all patients want the care they receive to reflect their values and preferences, and to make them feel that they have been treated as a whole person. ( 24 )

Clinicians also like to believe that they deliver patient-centred care, yet the characterization of the concept will vary with the health-care provider, their relationship with the patient, and the circumstances surrounding the admission to hospital. Recognizing that there is potential for an ethical dilemma when patients present with a critical illness is important to ensure that we continue to act upon the key concept of understanding a patients’ values and proceeding to align provision of care with those values.


The author wishes to acknowledge Dr. Tracy Trothen (Queen’s University) for her time and expertise as a ‘practical ethicist’.

Appendix AFramework for Ethical Decision-Making (Corey et al ., 2014)


The author declares that no conflicts of interest exist.

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Pediatric consent: case study analysis using a principles approach


This article will explore pediatric consent through the analysis of a clinical case study using the principles of biomedical ethics approach. Application of the principles of autonomy, nonmaleficence, beneficence, and justice will be dissected in order to attempt to establish resolution of the ethical dilemma. The main conflict in this case study deals with whether the wishes of an adolescent for end-of-life care should be followed or should the desire of his parents outweigh this request. In terminal cancer, the hope of early palliative care and dignity in dying serve as priorities in therapy. Application of the moral principles to both sides of the dilemma aided in providing an objective resolution to uphold pediatric consent.

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International Journal of Nursing Sciences

Original article the patient suicide attempt – an ethical dilemma case study, case description.

Nurses face more and more ethical dilemmas during their practice nowadays, especially when they are taking care of the patient at end of life stage. The case study demonstrates an ethical dilemma when nursing staff are taking care of an end stage aggressive prostate cancer patient Mr Green who expressed the suicide thoughts to one of the nurses and ask that nurse keep secret for him in Brisbane, QLD, Australia.

Ethical dilemma identification

The ethical dilemma is identified as “if the nursing staff should tell other health care team members about patient's suicide attempt without patient's consent”.

To better solving this case and making the best moral decision, the ethical theory, the ethical principles and the Australian nurses' code of ethics values statement, the associated literature relative with this case are analyzed before the decision making.

Ethical decision making

After consider all of the above factors, in this case, the best ethical decision for the patient is that the nurse share the information of Mr Green's suicide attempt with other health care professionals.

In Mr Green's case, the nurse chose to share the information of Mr Green's suicide attempt with other health care professionals. The nursing team followed the self-harm and suicide protocol of the hospital strictly, they maintained the effective communication with Mr Green, identified the factors which cause patient's suicide attempt, provided the appropriate nursing intervention to deal will these risk factors and collaborated with other health care professionals to prefect the further care. The patient transferred to a palliative care service with no sign of suicide attempt and other self-harm behaviors and passed away peacefully 76 days after discharged with his relatives and pastors accompany.

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Find out what non-maleficence means, how to apply this to Medical School interview questions and learn from an example scenario

Understanding Non-Maleficence

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Medical Ethics: Beneficence

Medical ethics: autonomy.

What is non-maleficence and why is it a fundamental pillar of ethics ? Find out what it means and how to approach any ethical scenarios you are given in your Medical School interview .

What Is Non-Maleficence?

Non-maleficence is the sister to beneficence and is often considered as an inseparable pillar of ethics.

Non-maleficence states that a medical practitioner has a duty to do no harm or allow harm to be caused to a patient through neglect. Any consideration of beneficence is likely, therefore, to involve an examination of non-maleficence.

How Is Non-Maleficence Different to Beneficence?

Non-maleficence differs from beneficence in two major ways.

First of all, it acts as a threshold for treatment. If a treatment causes more harm than good, then it should not be considered. This is in contrast to beneficence, where we consider all valid treatment options and then rank them in order of preference.

Second, we tend to use beneficence in response to a specific situation – such as determining the best treatment for a patient. In contrast, non-maleficence is a constant in clinical practice. For example, if you see a patient collapse in a corridor you have a duty to provide (or seek) medical attention to prevent injury.

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 Non-Maleficence Example

One of the best ways to understand the difference between non-maleficence and beneficence is by looking at an ethical example:

A 52-year-old man collapses in the street complaining of severe acute pain in his right abdomen. A surgeon happens to be passing and examines the man, suspecting that he is on the brink of rupturing his appendix. The surgeon decides the best course of action is to remove the appendix in situ, using his trusty pen-knife.

From a beneficence perspective, successful removal of the appendix in situ would certainly improve the patient’s life.

But from a non-maleficence perspective, let’s examine the potential harms to the patient:

Again this is a rather silly example but it is important to remember that before leaping to action, we need to consider the implications and risks of intervening at all.

Discussing Non-Maleficence At Interview

Ethics will come up in your interview, and you need to think about non-maleficence. You should consider:

Non-Maleficence Questions

Some  questions  you could be asked at an interview include:

You can find the answer to these questions – and more –  in our ethics questions and answer guide .

Some hot topics that would apply to non-maleficence include:

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Principle of Non-maleficence Violation: Case Study

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Medical Ethics and Physician-Patient Encounters: Case Studies and Best Practices

A comatose, ventilator-dependent, car accident victim lies in an intensive care unit while her husband and her parents discuss her future quality of life and argue about what type of care she would have wanted. This scenario may initially come to mind when the average person hears the term medical ethics . However, the concept of medical ethics is much more common in everyday practice than a dramatic ICU clash is.

In the book Clinical Ethics , Jonsen and colleagues observe that “ethical issues are imbedded in every clinical encounter between patients and caregivers because the care of patients always involves both technical and moral considerations.” 2

“Because every encounter between a doctor and a patient has a moral dimension, competency in ethics is essential to being a good doctor.” Carrese, et al. 1

The discipline of ethics often moves quietly through physician-patient interactions. For example, a 21-year-old male patient comes to a dermatologist with severe acne. He has had the condition since the age of 14, and he is still experiencing persistent pimples, pustules and inflamed cysts on his face and back. The dermatologist takes the patient’s history, examines him and recommends a prescription topical treatment combined with a course of oral antibiotics. This treatment clears much of the patient’s acne. In addition to being a clinical interaction, this is an ethical interaction. When a patient requested help, the dermatologist used her ability and training to benefit the patient and to do him no harm, fulfilling the ethical obligations accepted by doctors since the fifth century B.C.E., expressed in the Oath of Hippocrates.

The Connection Between Risk Management and Ethics

The concept of risk management in healthcare began in the 1970s. As more hospitals and physicians were successfully sued for damages by patients and their families, the discipline of risk management began to be applied by hospital administrators and by physicians’ professional liability insurance companies to predict and reduce the losses from lawsuits. 3 Adapted to the healthcare setting, risk management aims to avert medical errors and preventable adverse events to protect physicians and institutions from financial losses. Professionals in the field of risk management identify and analyze problems that have occurred in care, and they develop and implement techniques to improve experience by minimizing patient injuries. 3

Bioethics is the branch of knowledge that concerns physicians’ and other healthcare providers’ and entities’ moral obligations to patients. 4 Ethicists seek to identify and analyze moral questions or disputes associated with patient care and to reach a reasonable conclusion about proper or best ways to proceed. 4

The two disciplines — risk management and ethics — are alike in that both call for the scrutiny of information about patients’ substandard experiences in healthcare, and both advocate the application of techniques that will reduce difficulties, conflicts and problems so that patients’ experiences will ultimately get better. An unresolved moral issue in patient care is a potential liability exposure; therefore, recommending ways to resolve clinical ethical issues is a means for reducing overall lawsuit risks, which is the fundamental goal of risk management.

Four Basic Principles of Medical Ethics

Many physicians may be familiar with four basic principles of medical ethics developed by ethicists Beauchamp and Childress: 6

These four principles can clarify ethical problems and help resolve them, according to Beauchamp and Childress as well as other ethicists. The four principles are useful for identifying the core theme of an ethical issue. For example, an internist diagnoses cellulitis on a 71-year-old female patient’s lower left leg and prescribes an oral antibiotic for the patient. This interaction depicts the principle of beneficence — the physician is acting in the best interests of the patient. If the patient refuses to take the antibiotic and will only agree to non-medicinal therapies such as elevation, immobilization and saline dressings for her leg, the principle of autonomy becomes prominent in the interaction.

Beauchamp and Childress assert that the four principles are non-hierarchical and that “balancing these principles provides a useful framework for understanding and resolving conflicts.” 7 Bioethicist Mary B. Mahowald goes further by suggesting guidelines to help adapt the four principles to specific clinical ethics challenges. She proposes: 9

If every medical encounter has an ethical component, then summaries of closed malpractice claims, which exhibit various interactions with patients, can serve as a source for ethical themes in healthcare. It stands to reason, therefore, that physicians and other healthcare professionals can learn something more about ethics by studying a series of claims and contemplating their ethical features. The cases linked below focus on specific patient interactions in which it was vital for the involved physician to establish good communication to create a therapeutic alliance. Most cases occurred in ordinary ambulatory practice settings.

In case studies listed below, we look at a series of closed malpractice cases that all deal with common interactions physicians have with patients. These claims contain both ethical and risk management features. After presenting each case, we will discuss its ethical elements using the ideas of Beauchamp, Childress, Mahowald and other ethicists. Then we will explore risk management facets of the case by giving medical liability risk management recommendations that may help lower the risk that patients will be injured, thus decreasing the likelihood that future medical liability lawsuits will be filed.

Several of the lawsuits described were dismissed or withdrawn — they did not result in plaintiffs’ verdicts or settlements. Many of the physicians in the cases acted ethically and within the standard of care. This is usually true in medicine: physicians are generally used to wading through ethical tides, negotiating the ebbs and surges. However, being able to investigate “the specific content of ethics experiences” can help you to sharpen “the skills necessary to identify, analyze and manage ethics issues arising in everyday practice.” 10 Reflecting about what you would do if faced with similar challenges is a way of preparing in advance to suitably balance ethical principles, boost the quality of your care and help protect against the risk of lawsuits.

More Information About Medical Ethics and Physician-Patient Encounters

This content from Claims Rx

1. Carrese JA, McDonald EL, Moon M, et al. Everyday ethics in internal medicine resident clinic: an opportunity to teach. Medical Education . 2011;45(7):712-721.

2. Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine . 7th ed. New York, NY: McGraw Hill; 2010:1.

3. McCaffre JJ, Hagg-Rickert S. Development of a risk management program. In Carroll R, Nakamura PLB, eds., Risk Management Handbook for Health Care Organizations: The Essentials. Vol. 1 . San Francisco, CA: Jossey-Bass; 2006:87-114.

4. Zimmet SC. Ethics in patient care. In Carroll R, Nakamura PLB, eds., Risk Management Handbook for Health Care Organizations: The Essentials. Vol. 1 . San Francisco, CA: Jossey-Bass; 2006:169-211.

5. Jonsen AR, et al.:2.

6. Beauchamp TL, Childress JF. Part II: moral principles. Principles of Biomedical Ethics . 7th ed. New York, NY: Oxford University Press; 2012:99-288.

7. DiGiovanni LM. Ethical issues in obstetrics. Obstetrics and Gynecology Clinics of North America . 2010;37(2):345-357.

8. Jonsen AR, et al.:162.

9. Mahowald MB. Bioethics and Women: Across the Life Span . New York, NY: Oxford University Press; 2006:17.

10. Moon M, Taylor HA, McDonald EL, et al. Everyday ethics issues in the outpatient clinical practice of pediatric residents. Archives of Pediatrics and Adolescent Medicine . 2009;163(9):838-843.

Filed under: Patient Relationship , Medical Ethics , Article , Physician


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Medical Principles and Practice

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Principles of Clinical Ethics and Their Application to Practice

Author affiliations The Medical College of Wisconsin, Milwaukee, WI, USA

Basil Varkey

120 Lakota Pass

Austin, TX 78738 (USA)

[email protected]

Keywords: Ethics Confidentiality Autonomy Informed consent Professionalism Integrated patient care model

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An overview of ethics and clinical ethics is presented in this review. The 4 main ethical principles, that is beneficence, nonmaleficence, autonomy, and justice, are defined and explained. Informed consent, truth-telling, and confidentiality spring from the principle of autonomy, and each of them is discussed. In patient care situations, not infrequently, there are conflicts between ethical principles (especially between beneficence and autonomy). A four-pronged systematic approach to ethical problem-solving and several illustrative cases of conflicts are presented. Comments following the cases highlight the ethical principles involved and clarify the resolution of these conflicts. A model for patient care, with caring as its central element, that integrates ethical aspects (intertwined with professionalism) with clinical and technical expertise desired of a physician is illustrated.

© 2020 The Author(s) Published by S. Karger AG, Basel

Highlights of the Study

Main principles of ethics, that is beneficence, nonmaleficence, autonomy, and justice, are discussed.

Autonomy is the basis for informed consent, truth-telling, and confidentiality.

A model to resolve conflicts when ethical principles collide is presented.

Cases that highlight ethical issues and their resolution are presented.

A patient care model that integrates ethics, professionalism, and cognitive and technical expertise is shown.


A defining responsibility of a practicing physician is to make decisions on patient care in different settings. These decisions involve more than selecting the appropriate treatment or intervention.

Ethics is an inherent and inseparable part of clinical medicine [ 1 ] as the physician has an ethical obligation (i) to benefit the patient, (ii) to avoid or minimize harm, and to (iii) respect the values and preferences of the patient. Are physicians equipped to fulfill this ethical obligation and can their ethical skills be improved? A goal-oriented educational program [ 2 ] (Table 1 ) has been shown to improve learner awareness, attitudes, knowledge, moral reasoning, and confidence [ 3 , 4 ].

Goals of ethics education


Ethics, Morality, and Professional Standards

Ethics is a broad term that covers the study of the nature of morals and the specific moral choices to be made. Normative ethics attempts to answer the question, “Which general moral norms for the guidance and evaluation of conduct should we accept, and why?” [ 5 ]. Some moral norms for right conduct are common to human kind as they transcend cultures, regions, religions, and other group identities and constitute common morality (e.g., not to kill, or harm, or cause suffering to others, not to steal, not to punish the innocent, to be truthful, to obey the law, to nurture the young and dependent, to help the suffering, and rescue those in danger). Particular morality refers to norms that bind groups because of their culture, religion, profession and include responsibilities, ideals, professional standards, and so on. A pertinent example of particular morality is the physician’s “accepted role” to provide competent and trustworthy service to their patients. To reduce the vagueness of “accepted role,” physician organizations (local, state, and national) have codified their standards. However, complying with these standards, it should be understood, may not always fulfill the moral norms as the codes have “often appeared to protect the profession’s interests more than to offer a broad and impartial moral viewpoint or to address issues of importance to patients and society” [ 6 ].

Bioethics and Clinical (Medical) Ethics

A number of deplorable abuses of human subjects in research, medical interventions without informed consent, experimentation in concentration camps in World War II, along with salutary advances in medicine and medical technology and societal changes, led to the rapid evolution of bioethics from one concerned about professional conduct and codes to its present status with an extensive scope that includes research ethics, public health ethics, organizational ethics, and clinical ethics.

Hereafter, the abbreviated term, ethics, will be used as I discuss the principles of clinical ethics and their application to clinical practice.

The Fundamental Principles of Ethics

Beneficence, nonmaleficence, autonomy, and justice constitute the 4 principles of ethics. The first 2 can be traced back to the time of Hippocrates “to help and do no harm,” while the latter 2 evolved later. Thus, in Percival’s book on ethics in early 1800s, the importance of keeping the patient’s best interest as a goal is stressed, while autonomy and justice were not discussed. However, with the passage of time, both autonomy and justice gained acceptance as important principles of ethics. In modern times, Beauchamp and Childress’ book on Principles of Biomedical Ethics is a classic for its exposition of these 4 principles [ 5 ] and their application, while also discussing alternative approaches.


The principle of beneficence is the obligation of physician to act for the benefit of the patient and supports a number of moral rules to protect and defend the right of others, prevent harm, remove conditions that will cause harm, help persons with disabilities, and rescue persons in danger. It is worth emphasizing that, in distinction to nonmaleficence, the language here is one of positive requirements. The principle calls for not just avoiding harm, but also to benefit patients and to promote their welfare. While physicians’ beneficence conforms to moral rules, and is altruistic, it is also true that in many instances it can be considered a payback for the debt to society for education (often subsidized by governments), ranks and privileges, and to the patients themselves (learning and research).


Nonmaleficence is the obligation of a physician not to harm the patient. This simply stated principle supports several moral rules – do not kill, do not cause pain or suffering, do not incapacitate, do not cause offense, and do not deprive others of the goods of life. The practical application of nonmaleficence is for the physician to weigh the benefits against burdens of all interventions and treatments, to eschew those that are inappropriately burdensome, and to choose the best course of action for the patient. This is particularly important and pertinent in difficult end-of-life care decisions on withholding and withdrawing life-sustaining treatment, medically administered nutrition and hydration, and in pain and other symptom control. A physician’s obligation and intention to relieve the suffering (e.g., refractory pain or dyspnea) of a patient by the use of appropriate drugs including opioids override the foreseen but unintended harmful effects or outcome (doctrine of double effect) [ 7 , 8 ].

The philosophical underpinning for autonomy, as interpreted by philosophers Immanuel Kant (1724–1804) and John Stuart Mill (1806–1873), and accepted as an ethical principle, is that all persons have intrinsic and unconditional worth, and therefore, should have the power to make rational decisions and moral choices, and each should be allowed to exercise his or her capacity for self-determination [ 9 ]. This ethical principle was affirmed in a court decision by Justice Cardozo in 1914 with the epigrammatic dictum, “Every human being of adult years and sound mind has a right to determine what shall be done with his own body” [ 10 ].

Autonomy, as is true for all 4 principles, needs to be weighed against competing moral principles, and in some instances may be overridden; an obvious example would be if the autonomous action of a patient causes harm to another person(s). The principle of autonomy does not extend to persons who lack the capacity (competence) to act autonomously; examples include infants and children and incompetence due to developmental, mental or physical disorder. Health-care institutions and state governments in the US have policies and procedures to assess incompetence. However, a rigid distinction between incapacity to make health-care decisions (assessed by health professionals) and incompetence (determined by court of law) is not of practical use, as a clinician’s determination of a patient’s lack of decision-making capacity based on physical or mental disorder has the same practical consequences as a legal determination of incompetence [ 11 ].

Detractors of the principle of autonomy question the focus on the individual and propose a broader concept of relational autonomy (shaped by social relationships and complex determinants such as gender, ethnicity and culture) [ 12 ]. Even in an advanced western country such as United States, the culture being inhomogeneous, some minority populations hold views different from that of the majority white population in need for full disclosure, and in decisions about life support (preferring a family-centered approach) [ 13 ].

Resistance to the principle of patient autonomy and its derivatives (informed consent, truth-telling) in non-western cultures is not unexpected. In countries with ancient civilizations, rooted beliefs and traditions, the practice of paternalism ( this term will be used in this article, as it is well-entrenched in ethics literature, although parentalism is the proper term ) by physicians emanates mostly from beneficence. However, culture (a composite of the customary beliefs, social forms, and material traits of a racial, religious or social group) is not static and autonomous, and changes with other trends over passing years. It is presumptuous to assume that the patterns and roles in physician-patient relationships that have been in place for a half a century and more still hold true. Therefore, a critical examination of paternalistic medical practice is needed for reasons that include technological and economic progress, improved educational and socioeconomic status of the populace, globalization, and societal movement towards emphasis on the patient as an individual, than as a member of a group. This needed examination can be accomplished by research that includes well-structured surveys on demographics, patient preferences on informed consent, truth-telling, and role in decision-making.

Respecting the principle of autonomy obliges the physician to disclose medical information and treatment options that are necessary for the patient to exercise self-determination and supports informed consent, truth-telling, and confidentiality.

Informed Consent

The requirements of an informed consent for a medical or surgical procedure, or for research, are that the patient or subject (i) must be competent to understand and decide, (ii) receives a full disclosure, (iii) comprehends the disclosure, (iv) acts voluntarily, and (v) consents to the proposed action.

The universal applicability of these requirements, rooted and developed in western culture, has met with some resistance and a suggestion to craft a set of requirements that accommodate the cultural mores of other countries [ 14 ]. In response and in vigorous defense of the 5 requirements of informed consent, Angell wrote, “There must be a core of human rights that we would wish to see honored universally, despite variations in their superficial aspects …The forces of local custom or local law cannot justify abuses of certain fundamental rights, and the right of self-determination on which the doctrine of informed consent is based, is one of them” [ 15 ].

As competence is the first of the requirements for informed consent, one should know how to detect incompetence. Standards (used singly or in combination) that are generally accepted for determining incompetence are based on the patient’s inability to state a preference or choice, inability to understand one’s situation and its consequences, and inability to reason through a consequential life decision [ 16 ].

In a previously autonomous, but presently incompetent patient, his/her previously expressed preferences (i.e., prior autonomous judgments) are to be respected [ 17 ]. Incompetent (non-autonomous) patients and previously competent (autonomous), but presently incompetent patients would need a surrogate decision-maker. In a non-autonomous patient, the surrogate can use either a substituted judgment standard (i.e., what the patient would wish in this circumstance and not what the surrogate would wish), or a best interests standard (i.e., what would bring the highest net benefit to the patient by weighing risks and benefits). Snyder and Sulmasy [ 18 ], in their thoughtful article, provide a practical and useful option when the surrogate is uncertain of the patient’s preference(s), or when patient’s preferences have not kept abreast of scientific advances. They suggest the surrogate use “substituted interests,” that is, the patient’s authentic values and interests, to base the decision.


Truth-telling is a vital component in a physician-patient relationship; without this component, the physician loses the trust of the patient. An autonomous patient has not only the right to know (disclosure) of his/her diagnosis and prognosis, but also has the option to forgo this disclosure. However, the physician must know which of these 2 options the patient prefers.

In the United States, full disclosure to the patient, however grave the disease is, is the norm now, but was not so in the past. Significant resistance to full disclosure was highly prevalent in the US, but a marked shift has occurred in physicians’ attitudes on this. In 1961, 88% of physicians surveyed indicated their preference to avoid disclosing a diagnosis [ 19 ]; in 1979, however, 98% of surveyed physicians favored it [ 20 ]. This marked shift is attributable to many factors that include – with no order of importance implied – educational and socioeconomic progress, increased accountability to society, and awareness of previous clinical and research transgressions by the profession.

Importantly, surveys in the US show that patients with cancer and other diseases wish to have been fully informed of their diagnoses and prognoses. Providing full information, with tact and sensitivity, to patients who want to know should be the standard. The sad consequences of not telling the truth regarding a cancer include depriving the patient of an opportunity for completion of important life-tasks: giving advice to, and taking leave of loved ones, putting financial affairs in order, including division of assets, reconciling with estranged family members and friends, attaining spiritual order by reflection, prayer, rituals, and religious sacraments [ 21 , 22 ].

In contrast to the US, full disclosure to the patient is highly variable in other countries [ 23 ]. A continuing pattern in non-western societies is for the physician to disclose the information to the family and not to the patient. The likely reasons for resistance of physicians to convey bad news are concern that it may cause anxiety and loss of hope, some uncertainty on the outcome, or belief that the patient would not be able to understand the information or may not want to know. However, this does not have to be a binary choice, as careful understanding of the principle of autonomy reveals that autonomous choice is a right of a patient, and the patient, in exercising this right, may authorize a family member or members to make decisions for him/her.


Physicians are obligated not to disclose confidential information given by a patient to another party without the patient’s authorization. An obvious exception (with implied patient authorization) is the sharing necessary of medical information for the care of the patient from the primary physician to consultants and other health-care teams. In the present-day modern hospitals with multiple points of tests and consultants, and the use of electronic medical records, there has been an erosion of confidentiality. However, individual physicians must exercise discipline in not discussing patient specifics with their family members or in social gatherings [ 24 ] and social media. There are some noteworthy exceptions to patient confidentiality. These include, among others, legally required reporting of gunshot wounds and sexually transmitted diseases and exceptional situations that may cause major harm to another (e.g., epidemics of infectious diseases, partner notification in HIV disease, relative notification of certain genetic risks, etc.).

Justice is generally interpreted as fair, equitable, and appropriate treatment of persons. Of the several categories of justice, the one that is most pertinent to clinical ethics is distributive justice . Distributive justice refers to the fair, equitable, and appropriate distribution of health-care resources determined by justified norms that structure the terms of social cooperation [ 25 ]. How can this be accomplished? There are different valid principles of distributive justice. These are distribution to each person (i) an equal share, (ii) according to need, (iii) according to effort, (iv) according to contribution, (v) according to merit, and (vi) according to free-market exchanges. Each principle is not exclusive, and can be, and are often combined in application. It is easy to see the difficulty in choosing, balancing, and refining these principles to form a coherent and workable solution to distribute medical resources.

Although this weighty health-care policy discussion exceeds the scope of this review, a few examples on issues of distributive justice encountered in hospital and office practice need to be mentioned. These include allotment of scarce resources (equipment, tests, medications, organ transplants), care of uninsured patients, and allotment of time for outpatient visits (equal time for every patient? based on need or complexity? based on social and or economic status?). Difficult as it may be, and despite the many constraining forces, physicians must accept the requirement of fairness contained in this principle [ 26 ]. Fairness to the patient assumes a role of primary importance when there are conflicts of interests. A flagrant example of violation of this principle would be when a particular option of treatment is chosen over others, or an expensive drug is chosen over an equally effective but less expensive one because it benefits the physician, financially, or otherwise.

Conflicts between Principles

Each one of the 4 principles of ethics is to be taken as a prima facie obligation that must be fulfilled, unless it conflicts, in a specific instance, with another principle. When faced with such a conflict, the physician has to determine the actual obligation to the patient by examining the respective weights of the competing prima facie obligations based on both content and context. Consider an example of a conflict that has an easy resolution: a patient in shock treated with urgent fluid-resuscitation and the placement of an indwelling intravenous catheter caused pain and swelling. Here the principle of beneficence overrides that of nonmaleficence. Many of the conflicts that physicians face, however, are much more complex and difficult. Consider a competent patient’s refusal of a potentially life-saving intervention (e.g., instituting mechanical ventilation) or request for a potentially life-ending action (e.g., withdrawing mechanical ventilation). Nowhere in the arena of ethical decision-making is conflict as pronounced as when the principles of beneficence and autonomy collide.

Beneficence has enjoyed a historical role in the traditional practice of medicine. However, giving it primacy over patient autonomy is paternalism that makes a physician-patient relationship analogous to that of a father/mother to a child. A father/mother may refuse a child’s wishes, may influence a child by a variety of ways – nondisclosure, manipulation, deception, coercion etc., consistent with his/her thinking of what is best for the child. Paternalism can be further divided into soft and hard .

In soft paternalism, the physician acts on grounds of beneficence (and, at times, nonmaleficence) when the patient is nonautonomous or substantially nonautonomous (e.g., cognitive dysfunction due to severe illness, depression, or drug addiction) [ 27 ]. Soft paternalism is complicated because of the difficulty in determining whether the patient was nonautonomous at the time of decision-making but is ethically defensible as long as the action is in concordance with what the physician believes to be the patient’s values. Hard paternalism is action by a physician, intended to benefit a patient, but contrary to the voluntary decision of an autonomous patient who is fully informed and competent, and is ethically indefensible.

On the other end of the scale of hard paternalism is consumerism, a rare and extreme form of patient autonomy, that holds the view that the physician’s role is limited to providing all the medical information and the available choices for interventions and treatments while the fully informed patient selects from the available choices. In this model, the physician’s role is constrained, and does not permit the full use of his/her knowledge and skills to benefit the patient, and is tantamount to a form of patient abandonment and therefore is ethically indefensible.

Faced with the contrasting paradigms of beneficence and respect for autonomy and the need to reconcile these to find a common ground, Pellegrino and Thomasma [ 28 ] argue that beneficence can be inclusive of patient autonomy as “the best interests of the patients are intimately linked with their preferences” from which “are derived our primary duties to them.”

One of the basic and not infrequent reasons for disagreement between physician and patient on treatment issues is their divergent views on goals of treatment. As goals change in the course of disease (e.g., a chronic neurologic condition worsens to the point of needing ventilator support, or a cancer that has become refractory to treatment), it is imperative that the physician communicates with the patient in clear and straightforward language, without the use of medical jargon, and with the aim of defining the goal(s) of treatment under the changed circumstance. In doing so, the physician should be cognizant of patient factors that compromise decisional capacity, such as anxiety, fear, pain, lack of trust, and different beliefs and values that impair effective communication [ 29 ].

The foregoing theoretical discussion on principles of ethics has practical application in clinical practice in all settings. In the resource book for clinicians, Jonsen et al. [ 30 ] have elucidated a logical and well accepted model (Table 2 ), along the lines of the systematic format that practicing physicians have been taught and have practiced for a long time (Chief Complaint, History of Present Illness, Past History, pertinent Family and Social History, Review of Systems, Physical Examination and Laboratory and Imaging studies). This practical approach to problem-solving in ethics involves:

Application of principles of ethics in patient care


Clinical assessment (identifying medical problems, treatment options, goals of care)

Patient (finding and clarifying patient preferences on treatment options and goals of care)

Quality of life (QOL) (effects of medical problems, interventions and treatments on patient’s QOL with awareness of individual biases on what constitutes an acceptable QOL)

Context (many factors that include family, cultural, spiritual, religious, economic and legal).

Using this model, the physician can identify the principles that are in conflict, ascertain by weighing and balancing what should prevail, and when in doubt, turn to ethics literature and expert opinion.

Illustrative Cases

There is a wide gamut of clinical patient encounters with ethical issues, and some, especially those involving end-of-life care decisions, are complex. A few cases (Case 1 is modified from resource book [ 30 ]) are presented below as they highlight the importance of understanding and weighing the ethical principles involved to arrive at an ethically right solution. Case 6 was added during the revision phase of this article as it coincided with the outbreak of Coronavirus Infectious Disease-2019 (COVID-19) that became a pandemic rendering a discussion of its ethical challenges necessary and important.

A 20-year old college student living in the college hostel is brought by a friend to the Emergency Department (ED) because of unrelenting headache and fever. He appeared drowsy but was responsive and had fever (40°C), and neck rigidity on examination. Lumbar puncture was done, and spinal fluid appeared cloudy and showed increased white cells; Gram stain showed Gram-positive diplococci. Based on the diagnosis of bacterial meningitis, appropriate antibiotics were begun, and hospitalization was instituted. Although initial consent for diagnosis was implicit, and consent for lumbar puncture was explicit, at this point, the patient refuses treatment without giving any reason, and insists to return to his hostel. Even after explanation by the physician as to the seriousness of his diagnosis, and the absolute need for prompt treatment (i.e., danger to life without treatment), the patient is adamant in his refusal.

Comment . Because of this refusal, the medical indications and patient preferences (see Table 2 ) are at odds. Is it ethically right to treat against his will a patient who is making a choice that has dire consequences (disability, death) who gives no reason for this decision, and in whom a clear determination of mental incapacity cannot be made (although altered mental status may be presumed)? Here the principle of beneficence and principle of autonomy are in conflict. The weighing of factors: (1) patient may not be making a reasoned decision in his best interest because of temporary mental incapacity; and (2) the severity of life-threatening illness and the urgency to treat to save his life supports the decision in favor of beneficence (i.e., to treat).

A 56-year old male lawyer and current cigarette smoker with a pack-a-day habit for more than 30 years, is found to have a solitary right upper lobe pulmonary mass 5 cm in size on a chest radiograph done as part of an insurance application. The mass has no calcification, and there are no other pulmonary abnormalities. He has no symptoms, and his examination is normal. Tuberculosis skin test is negative, and he has no history of travel to an endemic area of fungal infection. As lung cancer is the most probable and significant diagnosis to consider, and early surgical resection provides the best prospects for cure, the physician, in consultation with the thoracic surgeon, recommends bronchoscopic biopsy and subsequent resection. The patient understands the treatment plan, and the significance of not delaying the treatment. However, he refuses, and states that he does not think he has cancer; and is fearful that the surgery would kill him. Even after further explanations on the low mortality of surgery and the importance of removing the mass before it spreads, he continues to refuse treatment.

Comment . Even though the physician’s prescribed treatment, that is, removal of the mass that is probably cancer, affords the best chance of cure, and delay in its removal increases its chance of metastases and reaching an incurable stage – the choice by this well informed and mentally competent patient should be respected. Here, autonomy prevails over beneficence. The physician, however, may not abandon the patient and is obligated to offer continued outpatient visits with advice against making decision based on fear, examinations, periodic tests, and encouragement to seek a second opinion.

A 71-year-old man with very severe chronic obstructive pulmonary disease (COPD) is admitted to the intensive care unit (ICU) with pneumonia, sepsis, and respiratory failure. He is intubated and mechanically ventilated. For the past 2 years, he has been on continuous oxygen treatment and was short of breath on minimal exertion. In the past 1 year, he had 2 admissions to the ICU; on both occasions he required intubation and mechanical ventilation. Presently, even with multiple antibiotics, intravenous fluid hydration, and vasopressors, his systolic blood pressure remains below 60 mm Hg, and with high flow oxygen supplementation, his oxygen saturation stays below 80%; his arterial blood pH is 7.0. His liver enzymes are elevated. He is anuric, and over next 8 h his creatinine has risen to 5 mg/dL and continues to rise. He has drifted into a comatose state. The intensivist suggests discontinuation of vasopressors and mechanical ventilation as their continued use is futile. The patient has no advance care directives or a designated health-care proxy.

Comment . The term “futility” is open to different definitions [ 31 ] and is often controversial, and therefore, some experts suggest the alternate term, “clinically non-beneficial interventions” [ 32 ]. However, in this case the term futility is appropriate to indicate that there is evidence of physiological futility (multisystem organ failure in the setting of preexisting end stage COPD, and medical interventions would not reverse the decline). It is appropriate then to discuss the patient’s condition with his family with the goal of discontinuing life-sustaining interventions. These discussions should be done with sensitivity, compassion and empathy. Palliative care should be provided to alleviate his symptoms and to support the family until his death and beyond in their bereavement.

A 67-year old widow, an immigrant from southern India, is living with her son and his family in Wisconsin, USA. She was experiencing nausea, lack of appetite and weight loss for a few months. During the past week, she also had dark yellow urine, and yellow coloration of her skin. She has basic knowledge of English. She was brought to a multi-specialty teaching hospital by her son, who informed the doctor that his mother has “jaundice,” and instructed that, if any serious life-threatening disease was found, not to inform her. He asked that all information should come to him, and if there is any cancer not to treat it, since she is older and frail. Investigations in the hospital reveals that she has pancreatic cancer, and chemotherapy, while not likely to cure, would prolong her life.

Comment . In some ancient cultures, authority is given to members of the family (especially senior men) to make decisions that involve other members on marriage, job, and health care. The woman in this case is a dependent of her son, and given this cultural perspective, the son can rightfully claim to have the authority to make health-care decisions for her. Thus, the physician is faced with multiple tasks that may not be consonant. To respect cultural values [ 33 ], to directly learn the patient’s preferences, to comply with the American norm of full disclosure to the patient, and to refuse the son’s demands.

The principle of autonomy provides the patient the option to delegate decision-making authority to another person. Therefore, the appropriate course would be to take the tactful approach of directly informing the patient (with a translator if needed), that the diagnosed disease would require decisions for appropriate treatment. The physician should ascertain whether she would prefer to make these decisions herself, or whether she would prefer all information to be given to her son, and all decisions to be made by him.

A 45-year-old woman had laparotomy and cholecystectomy for abdominal pain and multiple gall stones. Three weeks after discharge from the hospital, she returned with fever, abdominal pain, and tenderness. She was given antibiotics, and as her fever continued, laparotomy and exploration were undertaken; a sponge left behind during the recent cholecystectomy was found. It was removed, the area cleansed, and incision closed. Antibiotics were continued, and she recovered without further incident and was discharged. Should the surgeon inform the patient of his error?

Comment . Truth-telling, a part of patient autonomy is very much applicable in this situation and disclosure to patient is required [ 34 - 36 ]. The mistake caused harm to the patient (morbidity and readmission, and a second surgery and monetary loss). Although the end result remedied the harm, the surgeon is obligated to inform the patient of the error and its consequences and offer an apology. Such errors are always reported to the Operating Room Committees and Surgical Quality Improvement Committees of US Hospitals. Hospital-based risk reduction mechanisms (e.g., Risk Management Department) present in most US hospitals would investigate the incident and come up with specific recommendations to mitigate the error and eliminate them in the future. Many institutions usually make financial settlements to obviate liability litigation (fees and hospital charges waived, and/or monetary compensation made to the patient). Elsewhere, if such mechanisms do not exist, it should be reported to the hospital. Acknowledgment from the hospital, apologies from the institution and compensation for the patient are called for. Whether in US or elsewhere, a malpractice suit is very possible in this situation, but a climate of honesty substantially reduces the threat of legal claims as most patients trust their physicians and are not vindictive.

The following scenario is at a city hospital during the peak of the COVID-19 pandemic: A 74-year-old woman, residing in an assisted living facility, is brought to the ED with shortness of breath and malaise. Over the past 4 days she had been experiencing dry cough, lack of appetite, and tiredness; 2 days earlier, she stopped eating and started having a low-grade fever. A test for COVID-19 undertaken by the assisted living facility was returned positive on the morning of the ED visit.

She, a retired nurse, is a widow; both of her grown children live out-of-state. She has had hypertension for many years, controlled with daily medications. Following 2 strokes, she was moved to an assisted living facility 3 years ago. She recovered most of her functions after the strokes and required help only for bathing and dressing. She is able to answer questions appropriately but haltingly, because of respiratory distress. She has tachypnea (34/min), tachycardia (120/min), temperature of 101°F, BP 100/60 and 90% O 2 saturation (on supplemental O 2 of 4 L/min). She has dry mouth and tongue and rhonchi on lung auscultation. Her respiratory rate is increasing on observation and she is visibly tiring.

Another patient is now brought in by ambulance; this is a 22-year-old man living in an apartment and has had symptoms of “flu” for a week. Because of the pandemic, he was observing the recommended self-distancing, and had no known exposure to coronavirus. He used saline gargles, acetaminophen, and cough syrup to alleviate his sore throat, cough, and fever. In the past 2 days, his symptoms worsened, and he drove himself to a virus testing station and got tested for COVID-19; he was told that he would be notified of the results. He returned to his apartment and after a sleepless night with fever, sweats, and persistent cough, he woke up and felt drained of all strength. The test result confirmed COVID-19. He then called for an ambulance.

He has been previously healthy. He is a non-smoker and uses alcohol rarely. He is a second-year medical student. He is single, and his parents and sibling live hundreds of miles away.

On examination, he has marked tachypnea (>40/min), shallow breathing, heart rate of 128/min, temperature of 103°F and O 2 saturation of 88 on pulse oximetry. He appears drowsy and is slow to respond to questions. He is propped up to a sitting position as it is uncomfortable for him to be supine. Accessory muscles of neck and intercostals are contracting with each breath, and on auscultation, he has basilar crackles and scattered rhonchi. His O 2 saturation drops to 85 and he is in respiratory distress despite nebulized bronchodilator treatment.

Both of these patients are in respiratory failure, clinically and confirmed by arterial blood gases, and are in urgent need of intubation and mechanical ventilation. However, only one ventilator is available; who gets it?

Comment . The decision to allocate a scarce and potentially life-saving equipment (ventilator) is very difficult as it directly addresses the question “Who shall live when not everyone can live? [ 5 ]. This decision cannot be emotion-driven or arbitrary; nor should it be based on a person’s wealth or social standing. Priorities need to be established ethically and must be applied consistently in the same institution and ideally throughout the state and the country. The general social norm to treat all equally or to treat on a first come, first saved basis is not the appropriate choice here. There is a consensus among clinical ethics scholars, that in this situation, maximizing benefits is the dominant value in making a decision [ 37 ]. Maximizing benefits can be viewed in 2 different ways; in lives saved or in life-years saved; they differ in that the first is non-utilitarian while the second is utilitarian. A subordinate consideration is giving priority to patients who have a better chance of survival and a reasonable life expectancy. The other 2 considerations are promoting and rewarding instrumental value (benefit to others) and the acuity of illness. Health-care workers (physicians, nurses, therapists etc.) and research participants have instrumental value as their work benefits others; among them those actively contributing are of more value than those who have made their contributions. The need to prioritize the sickest and the youngest is also a recognized value when these are aligned with the dominant value of maximizing benefits. In the context of COVID-19 pandemic, Emanuel et al. [ 37 ] weighed and analyzed these values and offered some recommendations. Some ethics scholars opine that in times of a pandemic, the burden of making a decision as to who gets a ventilator and who does not (often a life or death choice) should not be on the front-line physicians, as it may cause a severe and life-long emotional toll on them [ 35 , 36 ]. The toll can be severe for nurses and other front-line health-care providers as well. As a safeguard, they propose that the decision should rest on a select committee that excludes doctors, nurses and others who are caring for the patient(s) under consideration [ 38 ].

Both patients described in the case summaries have comparable acuity of illness and both are in need of mechanical ventilator support. However, in the dominant value of maximizing benefits the two patients differ; in terms of life-years saved, the second patient (22-year-old man) is ahead as his life expectancy is longer. Additionally, he is more likely than the older woman, to survive mechanical ventilation, infection, and possible complications. Another supporting factor in favor of the second patient is his potential instrumental value (benefit to others) as a future physician.

Unlike the other illustrative cases, the scenario of these 2 cases, does not lend itself to a peaceful and fully satisfactory resolution. The fairness of allocating a scarce and potentially life-saving resource based on maximizing benefits and preference to instrumental value (benefit to others) is open to question. The American College of Physicians has stated that allocation decisions during resource scarcity should be made “based on patient need, prognosis (determined by objective scientific measure and informed clinical judgment) and effectiveness (i.e., likelihood that the therapy will help the patient to recover), … to maximize the number of patients who will recover” [ 39 ].

This review has covered basics of ethics founded on morality and ethical principles with illustrative examples. In the following segment, professionalism is defined, its alignment with ethics depicted, and virtues desired of a physician (inclusive term for medical doctor regardless of type of practice) are elucidated. It concludes with my vision of an integrated model for patient care.

The core of professionalism is a therapeutic relationship built on competent and compassionate care by a physician that meets the expectation and benefits a patient. In this relationship, which is rooted in the ethical principles of beneficence and nonmaleficence, the physician fulfills the elements shown in Table 3 . Professionalism “demands placing the interest of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health” [ 26 , 40 ].

Physicians obligations


Drawing on several decades of experience in teaching and mentoring, I envisage physicians with qualities of both “heart” and “head.” Ethical and humanistic values shape the former, while knowledge (e.g., by study, research, practice) and technical skills (e.g., medical and surgical procedures) form the latter. Figure 1 is a representation of this model. Morality that forms the base of the model and ethical principles that rest on it were previously explained. Virtues are linked, some more tightly than others, to the principles of ethics. Compassion, a prelude to caring, presupposes sympathy, is expressed in beneficence. Discernment is especially valuable in decision-making when principles of ethics collide. Trustworthiness leads to trust, and is a needed virtue when patients, at their most vulnerable time, place themselves in the hands of physicians. Integrity involves the coherent integration of emotions, knowledge and aspirations while maintaining moral values. Physicians need both professional integrity and personal integrity, as the former may not cover all scenarios (e.g., prescribing ineffective drugs or expensive drugs when effective inexpensive drugs are available, performing invasive treatments or experimental research modalities without fully informed consent, any situation where personal monetary gain is placed over patient’s welfare). Conscientiousness is required to determine what is right by critical reflection on good versus bad, better versus good, logical versus emotional, and right versus wrong.

Integrated model of patient care.


In my conceptualized model of patient care (Fig.  1 ), medical knowledge, skills to apply that knowledge, technical skills, practice-based learning, and communication skills are partnered with ethical principles and professional virtues. The virtues of compassion, discernment, trustworthiness, integrity, and conscientiousness are the necessary building blocks for the virtue of caring. Caring is the defining virtue for all health-care professions. In all interactions with patients, besides the technical expertise of a physician, the human element of caring (one human to another) is needed. In different situations, caring can be expressed verbally and non-verbally (e.g., the manner of communication with both physician and patient closely seated, and with unhurried, softly spoken words); a gentle touch especially when conveying “bad news”; a firmer touch or grip to convey reassurance to a patient facing a difficult treatment choice; to hold the hand of a patient dying alone). Thus, “caring” is in the center of the depicted integrated model, and as Peabody succinctly expressed it nearly a hundred years ago, “The secret of the care of the patient is caring for the patient” [ 41 ].

Conflict of Interest Statement

The author declares that he has no conflicts of interest.

Author Contacts

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Abstract of Review

Received: November 24, 2019 Accepted: June 03, 2020 Published online: June 04, 2020 Issue release date: February 2021

Number of Print Pages: 12 Number of Figures: 1 Number of Tables: 3

ISSN: 1011-7571 (Print) eISSN: 1423-0151 (Online)

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