Discussion
Physicians are challenged by ethical dilemmas nearly every day of practice. While well-defined ethical principles are available to guide physicians in their approach to clinical ethical dilemmas, it is quite another thing to actually stand up and do the right thing, especially when you are facing a goliath in the form of a healthcare corporation. So, what personal and professional attributes might prepare a physician to consider the ethical options in dilemmas such as this one? Can moral strength and professional courage be learned, or are they inherent traits? How can physicians assess their own moral strengths in order to apply them to their professional obligations in everyday ethical dilemmas?
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February 2020
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Physicians experience moral outrage and frustration when they are thwarted in some manner by external forces in their efforts to provide the best possible care for their patients. This frustration can be significant enough in some cases to lead to moral distress, which is considered to be a potential contributor to the development of burnout syndrome. When appropriate ethical decision making and actions cannot be carried out in a patient’s best interests for reasons out of the physician’s direct control, moral courage must come into play. Moral courage is making the ethically correct effort on behalf of one or more patients in the face of institutional, financial, political, or other confining impedances. While businesses and institutions may claim to have ethically moral and prudent policies to guide their corporate decisions, they will not be as patient-centered as will be an individual physician. Achieving a positive “bottom line” does not negate the primary mission of healthcare organizations: patient care.
Principled moral outrage is a very appropriate feeling for the physician under the circumstances described in the fictional clinical scenario above. Moral outrage should beget moral courage. Physicians have a duty to advocate for their patients, and for those individuals who may never have the opportunity to become patients. One may ask, “What are the formative agents that give rise to moral courage as part of a physician’s professional and ethical development?” Indeed, moral courage is a fundamental—and required—attribute of an ethical physician, as are the duties of honesty, integrity, competence, and trust. These attributes should be founded early in the physician’s persona and solidified and refined over the course of a career. The courage to act on behalf of a patient, especially in a difficult and challenging situation, is a responsibility rooted in one’s moral compass, a sense of right and true conduct, and an adherence to our profession’s code of ethics.
There may be times when a physician must place herself or himself in a position of risk by taking a stand against external forces that threaten a patient’s clinical care. Likewise, when a community of patients, especially those who are so disadvantaged that they have no “voice,” is facing a threat to their health and well being, physicians have an obligation to speak for them. Most ethical dilemmas seen in everyday practice can be approached, and usually resolved, by applying the ethical principles of autonomy, beneficence, and non-maleficence to the decision-making process. What we physicians don’t always have the opportunity to advocate for is the principle of social justice, which is the guiding principle in this scenario. One measure of a social construct (society) is how it is concerned with the human rights of its citizens and provides a fair and equitable distribution of its valuable resources and opportunities across economic, educational, cultural, and occupational strata. While it is quite difficult to achieve full parity, a society must endeavor to distribute according to need. Autonomy, beneficence, and non-maleficence are ethical principles typically applied on the individual patient level, where the patient—and often family—have shared decision-making with the physician.