Medical ethics involves examining a specific problem, usually a clinical case, and using values, facts, and logic to decide what the best course of action should be.

Some ethical problems are fairly straightforward, such as determining right from wrong. But others can also be more perplexing, such as deciding between two "rights"—two values that are in conflict with each other—or deciding between two different value systems, such as the patient's versus the doctor's.

Doctors may deal with a great variety of perplexing ethical problems even in a small medical practice. Here are some common problems identified in a 2016 Medscape survey, where at least some physicians held different opinions ^[1] :

• Withholding treatment to meet an organization's budget, or because of insurance policies;

• Accepting money from pharmaceutical or device manufacturers;

• Upcoding to get treatment covered;

• Getting romantically involved with a patient or family member;

• Covering up a mistake;

• Reporting an impaired colleague;

• Cherry-picking patients;

• Prescribing a placebo;

• Practicing defensive medicine to avoid malpractice lawsuits;

• Dropping insurers; and

• Breaching patient confidentiality owing to a health risk.

Professional standards are a way to provide some guidance on ethical problems, but they cannot address every issue, and they may not address troubling nuances, such as reconciling two conflicting values.

Many professional ethicists recommend using four basic values, or principles, to decide ethical issues:

1. Autonomy: Patients basically have the right to determine their own healthcare.

2. Justice: Distributing the benefits and burdens of care across society.

3. Beneficence: Doing good for the patient.

4. Nonmalfeasance: Making sure you are not harming the patient.

However, ethical values are not limited to just these four principles. There are other important values to consider, such as truth-telling, transparency, showing respect for patients and families, and showing respect for patients' own values.

In addition, medical ethics is not just a thought process. It also involves people skills, such as gathering the facts needed to make a decision and presenting your decision in a way that wins over the confidence of all parties.

Listening skills are an essential part of medical ethics. Quite often, ethical disputes result from not knowing all the facts, or not providing all the facts to patients. Tactfulness and respect are also important. A well-constructed ethical decision could be ignored if you have not won the patient's confidence.

Ethics is often seen as a proscriptive activity—telling you what you cannot do. But in many cases it can be very freeing. It can affirm that you are doing the right thing. If you go through the proper ethical thought process, you'll have greater certainty that what you're doing is the right thing. Relieved of nagging doubts, you will be able to proceed more directly and more vigorously with your care plan.

As the health system evolves, ethical decisions could become more challenging. For example, mounting difficulties in finding affordable insurance prompt patients to forgo the care they need, and this affects the clinician's care plan.

Some doctors think of medical ethics as a very esoteric field, removed from the practical considerations of clinical practice. It is true that medical ethics is first and foremost a matter of conscience, but it also has some very practical implications and applications.

Here are some reasons to take medical ethics seriously:

To help resolve disputes between family, patients, physicians, or other parties. Often, the parties involved are operating strictly on emotion, which makes it difficult to come to a logical and fair decision. Ethics adds another dimension to help make decisions.

To maintain a clear conscience. All doctors want to be sure they have done the right thing. Being an ethical physician is more important than making money or seeing as many patients as possible.

To not make yourself look uninformed. Physicians sometimes stumble onto poor decisions because they did not understand their role, had not bothered to identify an ethical challenge, or hadn't thought the situation through to its logical conclusion.

To maintain the respect of your patients. Ethical missteps can destroy the bond between doctor and patient. Patients often implicitly trust their doctors, but once that trust has been breached, it is difficult to repair.

To maintain respectful relationships with other clinicians. Your colleagues often have very definite opinions about what is ethical, often enshrined in various codes of ethics of the profession or learned from mentors. Those codes and ethics role-modeling are created by people who practice some form of ethical decision-making.

To maintain some efficiency. Although ethical decision-making often requires extra time, it also can save time by anticipating disagreements that can slow down the care process. If you aren't ethical, patients or other caregivers who are upset with your decisions can seriously impede your work.

To reduce burnout. One cause of burnout is incongruence between physicians' personal values and those of their organization. Physicians who can describe their ethical concerns and use negotiating skills may be able to change the organizational policies that produce burnout.

Ethical decisions require a more deliberative style than many physicians are used to, outside of clinical decision-making. Doctors have to collect information, explore the ethical issues, and ask more questions if need be.

To have the time to take these actions, you can't be constantly overwhelmed with work. As an ethical physician, you need to schedule your time, be efficient in obtaining medical information, and pass off some responsibilities to other qualified caregivers.

You also have the option of sharing your decisions with colleagues. And once you have worked through an ethical issue, it will be much easier to deal with it the next time it comes up. You will have developed a basic strategy.

Getting to a useful ethical conclusion about a specific problem means starting with solid values that most people can accept, such as upholding patients' health, telling patients the truth, and giving people a choice about being in a medical experiment. These basic values are rarely in dispute.

Many other values are also widely accepted, such as patient autonomy. The same applies to being fair with your patients, meaning that all patients are essentially treated alike regarding critical healthcare decisions.

But it's not always so easy. These widely accepted values often conflict with each other. For example, when patients refuse a treatment that could help them, the physician faces a conflict between respecting patient autonomy and doing what's best for the patient.

Closing off your practice to new patients is another example of an ethical dilemma. Physicians are fully justified in not accepting every patient who comes through the door. Accepting every patient may or may not be a good business decision. However, rejecting a patient may mean that patient does not get needed care. Many physicians struggled with this ethical decision.

After working through this dilemma, you may still decide to close off your practice, but you will have thought the issue through. You will be aware that the people you are turning away still need a doctor, and some physicians might decide to find a way in which they can help such people without burning themselves out, such as volunteering in a free clinic occasionally.

Medical ethics differs from morality. Ethics is based on values and reasoning, and it uses persuasion to get its message across, whereas morality involves adhering to a specific belief system or code of conduct.

Morality relies on an authority, such as the Bible, to justify its message. Morality does not just involve religion. It can be political or personal, such as having a fascist or communist point of view, grounded in faith or tradition rather than facts or arguments.

In contrast, medical ethics has a flexible set of solutions. It is based on facts and logic, and not religious doctrine. You can still have political opinions and religious faith, but you will need to set them aside when forming and offering an ethical opinion to those who do not follow your personal morality.

Some people view medicine almost as the new religion. People often come to the doctor with the same hopes that they bring to a minister: "Save me, prepare me, redeem me." Of course, science cannot redeem anyone, but it does need to have a heart.

A pure scientist, simply observing medical phenomena, would have a pragmatic attitude about life, sickness, and death. Science needs an ethical framework to make it humane.

Ethical decisions should respect the values and attitudes of patients. If patients oppose vaccinations or blood transfusions for their child, their beliefs have to be taken into account, even if you, the doctor, will not ultimately follow their requests.

Respecting the patient's wishes has a practical consequence: Doctors who simply overrule the patient often end up seeing their treatments fail, because patients will probably be fighting them the whole way. Patients who are overruled do not tell the truth. But patients who are in dialogue and negotiation with their doctors are more likely to come to a reasonable compromise—even if it's one the doctor doesn't entirely endorse.

Sometimes when patients or their families disagree with the doctor, the obvious ethical decision isn't the right one. Here's an example that actually occurred.

A child from southeast Asia had a clubfoot that was easily treatable, but the parents wouldn't allow treatment, evidently because they believed God had ordained clubfeet.

The caregivers rightly put the child's health first, so they went to court and obtained an order for the operation. But the outcome was appalling. The family felt that the child had lost favor with God and abandoned the child. The child in effect became an orphan. The caregivers had won the battle but lost the war.

Although physicians need to respect patients' values, physicians' own values should not sway their decisions. Conscience and the religious faith of the physician should not automatically overrule the patient's need to get the best treatment possible.

For example, let's say an emergency physician refuses to give a patient a morning-after pill, on the basis of the physician's own values, even though the pill has been clinically proven to work.

The patient's needs, however, should come before the doctors' principles. Caregivers are expected to set their beliefs aside and focus on the best interests of the patient. If you cannot bring yourself to treat a patient, you must find another doctor who will.

Values are not set in stone. They evolve as the attitudes of society change. Half a century ago, when societal norms and educational standards were changing, the medical profession shifted from paternalism (the doctor knows best) to individual autonomy (patients must be consulted).

Medical values tend to be loosely based on what a majority of the public holds to be true. However, ethics decisions cannot be based on public opinion because the people may not heed the values of minorities or those with views outside of the mainstream. The bottom line is that no one would want their own care decided by a bunch of inattentive and ill-informed people taking a 2-minute survey.

So when you make an ethical decision in a coherent, thoughtful way, you may well diverge from current public opinion, but your values would still be sensitive to what the mainstream accepts.

Unlike with religious matters, there is no ultimate arbiter of medical ethics, and ethicists intentionally do not have a set ethical code that the profession upholds.

Physicians often consult the ethical codes of their professional organizations, such as the American Medical Association (AMA). ^[2] These codes cannot take the place of ethical decisions in situations in which a variety of competing factors are involved, but they can provide direction for decision-makers. Also, professional codes by doctors' own organizations can help convince them that a particular ethical decision makes sense.

Doctors may also look to their hospitals' ethics committees for answers, but these committees aren't intended to be the final authorities on medical ethics. These committees are educators and work in an advisory capacity. Their role is to develop specific hospital policies, educate staff about clinical ethics, and oversee ethical consultants on staff.

So who is the ultimate arbiter of clinical medical ethics? It is the individual caregiver, working in concert with the patient. Caregivers' ethical decisions go hand-in-hand with their clinical and technical decisions. Getting the ethics right depends on the integrity of the caregiver.

Because there is no preordained answer to most ethical dilemmas, even trained ethicists may disagree on solutions to the same ethical problem. Although they tend to hold the same core values and use the same logic, they may not have gathered the same set of facts.

Ethical decisions can change over time. The values that inform a particular ethical decision may change, or the implications of a particular decision may sink in. For example, as the public has become more comfortable with physician-assisted dying, some ethicists who once opposed it have come around to supporting it.

Ethical decisions cannot be avoided. Whenever doctors make a clinical decision, they are almost always making an ethical decision, consciously or not. Rather than not thinking about the ethical dimension of your care, it makes more sense to be aware of it and make sure it is sound.

Administrative doctors clearly cannot overlook the behavior of doctors whom they oversee. It's part of their job title. But even doctors who don't have a supervisory role over colleagues have an implicit responsibility.

Doctors are expected to uphold the well-being of patients in general, not just their own patients. This means they have a duty to report a doctor who is abusing drugs or molesting patients, for example.

Indeed, the AMA Code of Medical Ethics states that physicians should report colleagues' behavior "in the first instance so that the possible impact on patient welfare can be assessed and remedial action taken." ^[3]

Medical ethics may have different standards from the law. The law is created by legislators and may not share the values and reasoning of ethical physicians.

For example, Baby Doe laws require doctors to treat premature babies even when they are severely disabled, but some doctors have concluded that preemies who are too sick to survive should not be treated.

Physicians who disobey the Baby Doe laws (also referred to as "regulations") are rarely, if ever, prosecuted. In many cases, prosecutors are reluctant to take action against doctors who violate such laws out of respect for their clinical judgment.

With most malpractice cases, courts examine clinical standards of care and determine whether the defendant doctor has met them. In many cases, unethical conduct does not rise to the level of medical malpractice.

For example, a few years ago a patient recorded a gastroenterologist making disparaging remarks about him when he was under sedation. The gastroenterologist was clearly unethical in that he was not showing respect to the patient, but the patient did not file a malpractice lawsuit and instead filed a defamation lawsuit. (The patient lost the case, because defamation must involve transmitting remarks to a third party.) ^[4]

On the other hand, not getting a patient's informed consent for a procedure, another clearly ethical problem, is also an important element in a malpractice complaint. Physicians who do not get informed consent can be liable for malpractice, even if the procedure meets all the standards of clinical care. ^[5]

Medical malpractice cases require some evidence of harm, but this is not the standard for reporting physicians' conduct to medical licensing boards. Medical boards can and do take action against many behaviors that are widely considered unethical even when no harm takes place.

The definition of unprofessional conduct promulgated by the Federation of State Medical Boards, the trade group for state boards, includes "patient abuse" and "dishonesty." (The exact wording may vary from state to state.) ^[6]