Patient safe care as a moral imperative: The mandate of medical ethics

Summary

Dan Cohen is an international consultant in patient safety and clinical risk management, and a Trustee for Patient Safety Learning. In this blog, Dan discusses the four principles of medical ethics, specifically focusing on how each applies to providing safe patient care.

Content

Our moral imperative

Having spent more than 50 years as a doctor, I have come to appreciate that everything in my, and our, professional life comes back to the basics of why we entered the healthcare professions in the first place.

We genuinely wanted to help people, to keep them healthy and to return them to their maximum healthy state when they became ill. We wanted to serve our patients by being helpful. This has been our moral imperative and our beacon.

This moral imperative is the reason we get up every day and go about our jobs, often working under stressful circumstances confounded by environmental stressors, liabilities related to human factors and process inefficiencies. All of these factors have an impact on our effectiveness in clinical settings, with stress and burnout also trickling over into our personal lives.

Providing healthcare is challenging, especially when so much of our work environment is seemingly out of our control. Yet we keep coming back for more because we really care.

Healthcare professionals may be viewed as special and unique people by many in society, sometimes even put on a pedestal. But really, they are mostly ordinary women and men, drawn by an important calling with highly specific and serious responsibilities. What we do is special and unique!

Healthcare professionals try to provide the highest quality care, focusing on optimal clinical outcomes while avoiding mistakes, errors and harm to patients. We also acknowledge that what matters most to patients influences our approach to their care. How we satisfy our moral imperative is governed substantially by adhering to the medical ethics; i.e., the behaviours, actions and deeds that are held within the moral imperative. Behaviours that do not align with the moral imperative are considered unethical.

The principles of medical ethics

The principles of medical ethics have been best characterised by four foundational pillars, first elucidated by Tom L. Beauchamp and James F. Childress in 1979 in their seminal book, Principles of Biomedical Ethics.[1] These principles remain as relevant today as they were when first described. I will discuss briefly these foundational pillars, specifically focusing on how each applies to providing safe patient care.

Principle 1: Respect for patient autonomy

Providing healthcare should be a collaborative process with professionals and patients working together to achieve the best outcomes. Therefore, patients’ needs, wants and expectations should be foremost. Optimal outcomes, especially in outpatient care, cannot be achieved without patient engagement, as the patients are generally the implementers of care, certainly after they leave their doctors’ surgeries. Patients are entitled to be informed about the risks and benefits of interventions that may cause them harm, surgical interventions most notably, and this requires discussions and sharing of information to ensure patients are appropriately involved in decision making.

The practice of obtaining signed patient consent for surgical procedures acknowledges this. However, consent is often obtained in a 'slap-dash' way by having patients sign forms that may be incomplete or incompletely understood by patients.

The informed consent process, as it has been operationalised, may satisfy legal requirements but is often flawed as it may not generally include a thoughtful doctor to patient discussion of risks and benefits.

Respect for patient autonomy absolutely requires adherence to the principle of candour in healthcare. If mistakes are made in providing care, patients deserve to have these mistakes discussed with them in a timely fashion. This generally means shortly after the mistake has been discovered and is especially crucial with mistakes that have caused harm or may cause delayed harm. Until patients release us from our responsibilities as their care provider, we must remain committed to satisfying their healthcare needs. This cannot be accomplished if we are not honest and candid when discussing what has happened. There is now good evidence that candid discussions decrease the frequency of medical negligence claims and lawsuits and the size of healthcare injury claims paid.[2] [3] Caring for patients means respecting them and sharing information with them, whether that's for the better or worse.

Principle 2: Beneficence

Healthcare professionals are required to provide care that is intended to be beneficial to patients. It may seem counterintuitive to say this, but what this really means is that the care provided should be evidence-based and comply with the highest standards designed to achieve best outcomes. There are certainly instances where evidence is lacking or controversial or where doctors and/or professional groups may disagree regarding the best care and how to achieve best outcomes.

Yet each healthcare professional must aspire to provide the best possible care, even in the face of uncertainty. And if there is uncertainty, then that uncertainty also should be discussed with our patients.

This principle requires that healthcare professionals be willing to discuss "alternative approaches" to standard healthcare therapeutics if patients bring these options into the discussion, including the use of acupuncture, homeopathic and/or herbal products, and other approaches that patients may wish to consider. After all, patient autonomy must be respected, so professionals, regardless of their own opinions regarding these interventions, must be willing to listen and provide relevant information in a compassionate way. It is important to point out to patients when some of these alternative approaches may be harmful in certain situations. For example, certain herbal treatments may pose risks for patients taking oral anticoagulants.

Healthcare professionals must share their concerns about what risks are known and mention when risks are not known.

I have come across this dilemma in my own practice and I would be honest and say something like: “I cannot say with confidence that what you wish to do will be safe or unsafe, because I simply do not know the answer, although I will look into this more thoroughly. However, if I cannot find evidence of safety, then I cannot fully support you using 'XYZ' because I will be concerned that it may be harmful. The choice is always yours, and I respect your decision even if it is not one that I would make myself".                                                                   

Principle 3: Nonmaleficence

This principle, which some have interpreted simply as "do no harm" is actually more complex than that.

By their very nature, some of our recommendations cannot always avoid harm. So, by extension "do no harm” really means to avoid unnecessary harm to the extent that this is possible.

For example, for a patient undergoing surgery, the surgeon will use a scalpel to perform the surgery. Hence the surgeon must actually harm the patient in order to perform the surgery, and that harm could lead to further harm (e.g., bleeding, infection, etc.) that was never the intention of the intervention. In the same way, chemotherapy to treat cancer may carry substantial risks of harm because of medication side effects that cannot always be avoided. This is the reason that informed consent must address the risks and benefits of the treatment, and professionals must make sure their patients fully understand these risks and benefits.

Nonmaleficence means to avoid unnecessary harm whenever possible.

Principle 4: Justice

Sadly, even in our caring professions, not all of our patients are treated fairly and equitably. The principle of justice requires that all patients be treated without reference to their genetic, biological, social and economic backgrounds, gender or gender identity, and political views. The impacts of prejudices and biases against individuals of differing ethnicities, skin colours, social classes, political views, and coincidental health and lifestyle issues have adversely influenced both access to healthcare services and the quality and timeliness of healthcare services provided, possibly resulting in adverse healthcare outcomes.[4] [5] [6] For example, individuals with obesity and smoking related comorbidities and illnesses are often viewed as "responsible" for their health challenges and subject to biases, whereas recreational middle distance runners are rarely viewed negatively for their anterior cruciate ligament (ACL) injuries or joint osteoarthritis.

Healthcare professionals thus have a moral obligation to acknowledge this vulnerability in themselves and to never let these biases or prejudices interfere with our provision of care. Our prejudices may well harm patients and/or prevent them from achieving optimal healthcare outcomes. This is particularly an issue when professionals are working under stress and task saturation, when we tend to take shortcuts in diagnosis and may rush to solutions or be less sympathetic and compassionate to those who are "not like us". Disparities in care are dangerous variables when providing safe, high-quality healthcare for everyone.

Summary

The principles of biomedical ethics apply directly to the fundamental moral imperative to provide the highest quality care while avoiding mistakes, errors and harm to patients. We must ensure that what matters most to patients influences our approach to their care and, thus, to adherence to this moral imperative.

The foundational pillars of medical ethics also require professionals to be honest with patients when things go wrong and to focus on sustaining the relationships between patients and their care providers. Therefore, healthcare professionals are advised that before walking into their clinics, surgeries, hospitals, etc., they should stop and pause momentarily to reflect upon who they are as professionals, the moral imperative they work under and the professional behaviours that must align with the moral imperative. We must recognise the challenges of working in a complex environment and be especially careful. Stress degrades behaviour for all of us and, from time to time, I have been as much at fault as anyone. It’s called being human.

Be part of the solution, not part of the problem.

References

1. Beauchamp TL, Childress JF. Principles of Biomedical Ethics, 8th Ed. Oxford University Press, USA, 2019.
2. Kachalia A, Kaufman SR, Boothman R, et al. Liability claims and costs before and after implementation of a medical error disclosure program. Annals of Internal Medicine 2010; 153(4): 213–21.
3. Kachalia A, Sands K, Van Niel M, et al. Effects Of A Communication-And-Resolution Program On Hospitals’ Malpractice Claims And Costs. Health Affairs 2018; 32(11): 1836–44.
4. Lavizzo-Mourey RJ, Besser RE, Williams DR. A Half-Century of Progress in Health: The National Academy of Medicine at 50: Understanding and Mitigating Health Inequities — Past, Current, and Future Directions. N Engl J Med 2021; 384:1681–4.
5. Sabin JA. Tackling Implicit Bias in Health Care. N Engl J Med 2022; 387:105–7.
6. Fernandez A, Chin MH. Keep Your Eyes on the Prize – Focusing on Health Care Equity. N Engl J Med 2024; 390:1733–6.

Further reading on the hub from Dan:

• Clarity and the Art of Communication for Patient Safety
• Late night reflections on patient safety: commentaries from the frontline (2014)
• Diagnostic errors and delays: why quality investigations are key
• Patient Safety Spotlight Interview with Dr Dan Cohen, Patient Safety Learning Trustee
• Structures, processes and outcomes for better or worse: Personal responsibility in patient safe care
• What does all this safety stuff have to do with me? How one professional’s arrogance led to new insights
• Interview with Dr Dan Cohen on human performance

About the Author

International consultant in patient safety and clinical risk management, senior healthcare executive with extensive leadership experience, former US Department of Defense (DoD) physician executive with career culminating as Chief Medical Officer/Executive Medical Director for the DoD TRICARE health plan currently providing health care to over 9 million beneficiaries world-wide. Most recently served as Chief Medical Officer for Datix where he championed the company’s comprehensive patient safety thought leader efforts internationally through innumerable conference presentations, publications and commentaries.