Unlike the holy books mentioned earlier, these authors did not claim divine inspiration but rather were guided by reasoning that people could achieve and live peacefully in a civil society. The idea that the people could do this by governing themselves instead of being governed by a monarch or dictator was a doctrinaire concept until Thomas Jefferson and his 4 colleagues proclaimed it could be done by a nation. Governments, he said, derive “their just powers from the consent of the governed” (6). Since the “governed” rarely speak with one mind, democracies required that all agree to abide by the will of the majority as opposed to the will of a ruler.

Subsequently, as more nations adopted democratic governments with separation of religion and state, it was inevitable that ethics (i.e., doing the right thing in civil societies) became more mutable depending on the choices of the majority. Thus, sometimes disparities can arise between rules created by the majority and rules that certain believers avow were created by God. Abortion is one example. To believers of many faiths, even though it may be legal and ethical to the majority, it is morally wrong and therefore abjured for “how can God be wrong?” Therefore, their views are more refractive to change (1). Some have therefore prescinded those rules of behavior derived from the spiritual from those derived from the secular realms. By placing the former under the rubric of morals and the latter under the rubric of ethics, it is possible to avoid the pejorative of “situational ethics.” By designating ethics as derived from man’s rules as far as the majority is concerned, it can be realized that ethics can vary within any society, be they primitive or advanced. On the other hand, if we designate morals as derived from God’s rules as far as believers are concerned, the era and prevailing opinion do not matter.

When the ethics decided by the majority conflict with the morals held by a minority, avenues are available for resolution through debates, essays, blogs, even litigation and the political process, but not violence since that would be a primitive society’s methodology, not a civil one’s. It would seem the more diverse a society is, the more Jefferson’s ideals could be realized, since as James Madison said, it would be harder for one segment of society to force its will on all the others, thereby fostering compromise—a concept often referred to as “Madisonian democracy” (7).

As health care providers, we have guidelines for ethical behaviors reached by the majority of our representatives in our professional organizations. As will be discussed later, these have evolved over the years and have been influenced by the Hippocratic Oath, the Nuremberg Code, the Helsinki Declarations, the Belmont Report, the Code of Federal Regulations, and the American Medical Association’s Code of Medical Ethics, which was compiled by its Council on Ethical Affairs (1). The latter provides guidance for hospital ethics committees and all health care providers. It contains judicial rulings and expert opinions garnered by the committee and is an extremely valuable resource that provides precedence for difficult decisions one may be called upon to make, helping the reader to balance patient autonomy with professional beneficence in the society in which we live.

RESEARCH

All practicing physiatrists, whether contributing to the advancement of knowledge in physical medicine and rehabilitation (PM&R) through research activities or keeping pace with that advancement through educational activities, have an interest in the quality of research, whether it might be anticipated as a breakthrough, simply an explanation of an existing phenomenon, or an improvement upon a prevailing treatment.

Durable, credible research must be planned, executed, and analyzed honestly, without bias. The Nuremberg Code, crafted in 1947 following the atrocities committed by Nazi researchers, provided the first path for medical investigators to follow.

Its essential ingredients include: (a) The voluntary consent of the human subject is essential. There must be no coercion, no deceit, and a full explanation of risks and benefits by the investigator(s). (b) There must be an expectation of gaining useful knowledge. (c) Thorough preliminary studies must be conducted before human studies. (d) Avoidance of unnecessary suffering or injury is mandatory. (e) There must be no expectation of death or injury as an outcome. (f) Risks must not exceed benefits. (g) Proper facilities are required. (h) Only qualified investigators should be allowed. (i) Subject(s) can withdraw at any time. (j) Investigator must terminate the study if harm seems likely (8,9).

Subsequently, the Helsinki Declarations, the Belmont Report, and 45CFR46, as noted earlier, expanded on the Nuremberg Code’s initial guidelines. 45CFR46 is now law in the United States, which all investigators in the health care realm must abide by. Academic researchers also have on-site guidance from their Institutional Review Board (IRB). Manufacturers of pharmaceuticals and medical devices have the Food and Drug Administration (FDA) to advise them and approve their discoveries before they can be marketed (1).

Readers of published work and society in general expect that researchers will truthfully report what works, what just seems to work, what seems not to work, and what doesn’t work at all. Patients in turn trust that practitioners will truthfully convey that information to them. The National Academy of Sciences (NAS) has warned that trust in all these areas must never become eroded or the results would be calamitous; they have even expressed the fear that such breaches of ethics could be an expression of a broader pattern of deviation from traditional norms. Hopefully, this fear will never materialize (12). Nevertheless, realizing that scientists are only human and subject to the same temptations and distractions as anyone else, the ORI has pointed out that the responsibilities to safeguard adherence to honesty and ethical principles lie with several entities along the research process. The scientists, their scientific societies, and their institutions must create an environment where carelessness, apathy, and fraud will not be tolerated. This applies not only to the conduct of the research but also to other aspects such as honest time–effort reporting, full disclosure of funding sources, priorities of coauthorship, conflicts of interest, pressures to ascend the academic or business ladder, and/or overstatement of conclusions, which must not be allowed to stain the process of discovery (13). By adherence to such ethics in research, a proper example is shown to young investigators as they in turn strive to seek funding, secure space and recognition, and pass on their respect for honesty in their investigations to their protégés.

ETHICAL FRAMEWORKS

Medical ethics has been described as a system of moral principles that apply values and judgments to the practice of medicine. As a scholarly discipline, medical ethics encompasses its main practical application in clinical settings (14).

The art and science of medical ethics on one level is fundamental and timeless and on the other level is constantly changing and evolving. A physician must be prepared to reaffirm what is fundamental, like the physician–patient relationship, and learn new emerging issues ranging from confidentiality and electronic medical records to human biological material and research.

From genetic testing before conception to dilemmas at the end of life, physicians, patients, and their families are called upon to make difficult decisions. This section is intended to facilitate the process of making ethical decisions in clinical practice. The goal is to teach and explain underlying ethics principles, as well as the physician’s role in society and with colleagues, with specific issues and cases relevant to the field of physical medicine and rehabilitation.

In the medical profession, practitioners put the welfare of the client or patients above their own welfare. Professionals have a duty that might be thought of as a contract with society. As modern medicine brings a plethora of diagnostic and therapeutic options, the interaction of the physician with the patient and society becomes more complex, potentially raising the ethical dilemmas. The American Board of Internal Medicine and the European Federation of Internal Medicine have jointly proposed that medical professionalism should emphasize 3 fundamental principles (15).

The professional responsibility of primacy of patient welfare emphasizes the fundamental principle of the medical profession and helps provide a moral compass that is not only grounded in tradition but also adaptable to the current practice of medicine. The physician’s altruism must not be affected by economic, bureaucratic, and political challenges that are faced by the physician and the patient.

Altruism is a central trust factor in the physician–patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle. There is concern, however, that, in today’s health care environment, the physician’s commitment to the patient is being challenged by the conditions of medical practice and external sources (16).

The principle of patient autonomy asserts that physicians make the recommendations, but patients make the final decisions. The physician is an expert advisor who must inform and empower the patients to base a decision on scientific data and how this information can and should be integrated with the patient’s preferences. The patient’s decision about his or her care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care. Only in the latter part of the 20th century did the public begin to view the physician as an advisor.

The importance of social justice symbolizes that a patient–physician interaction exists in a community or society. The physician has a responsibility to the individual patient and a broader society to promote access and to eliminate the disparities in health and the health care system. This calls upon the profession to promote a fair distribution of health care resources (17).

Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, religion, or any other social category. Physicians who use these and other attributes to improve their patent’s satisfaction with care are not only promoting professionalism but also reducing their own risk for liability and malpractice (18).

METHODOLOGY—ETHICAL DECISION MAKING

The Decision-Making Process

The conjoint decisions made by patients with physical impairments and disabilities and their physicians can profoundly affect the quality of a patient’s life. When physicians and patients face ethical decisions about emotionally charged issues such as withholding or withdrawing life-sustaining treatment, the model of shared decision making can ensure communication and respect for the multiple and sometimes conflicting needs of physicians, patients, and family members.

Steps in the Process for Making Ethical Decisions

1.  Professional commitment

2.  Systematic evaluation of the case

3.  Communication among all involved

4.  Consider ethical principles

5.  Make the decision

6.  Document the decision

7.  Implement the decision and change it when necessary

8.  Respond to objections and challenges

Step 1. Professional Commitment

Every physician has an obligation to uphold ethical and professional behavior and redouble his or her commitment to professionalism, especially when dealing with ethical dilemmas. The American Board of Internal Medicine, ACP-ASIM Foundation, and the European Federation of Internal Medicine have jointly proposed “the charter on Medical Professionalism” (15) that comprises three principles and ten commitments:

Step 2. Systematic Evaluation of the Case

When complicated issues require a formal decision-making process, a thorough evaluation of the patient’s situation is the necessary first step. Often what appears to be a complex moral dilemma may be nothing more than a disagreement based on inaccurate or inadequate knowledge of clinical facts, biographical facts, or cultural facts. It is the responsibility of the care provider to gather all relevant information about the decision to be made. Potentially important questions to be answered are related to the aspects of clinical status, preferences of the patient, surrogate and others involved, life history, risks and benefits of proposed treatments, and decision making. Every clinical case, when seen as an ethical problem, should be analyzed by means of four topics (20).

Adapting to this method, a practical approach in the form of a “four-box model” is organized and presented by the American Academy of Hospice and Palliative Medicine.

This four-box model can help evaluate the vast majority of ethical dilemmas in clinical practice.

This model also provides a hierarchy to keep in mind: Clinical and biographical facts focus on what makes sense medically, respects the patient’s wishes, and are given more weight than quality of life or cultural facts. The quality of life and cultural facts are not insignificant and attuned to the avoidance of unnecessary conflicts or dilemmas. The sample case analysis demonstrates how this model can be practically used.

Step 3. Communication Among All Involved

Step 4. Consider Ethical Principles

There are some main beliefs that can be invoked to address bioethical dilemmas encountered in clinical activities. These can be broadly categorized into four groups—principle based, virtue based, caring based, and respect for personhood.

A. PRINCIPLE BASED. The four generally accepted values that make up the foundation of modern medical ethics are beneficence, autonomy, nonmaleficence, and justice (21,22).

Beneficence: Promote the patient’s well-being. The principle of beneficence, which is synonymous with the Hippocratic obligation to always act in the best interests of the patient, is grounded in the concept of promoting the patient’s well-being. In physical and rehabilitating settings, the principle of beneficence implies positive acts, including effective treatments for physical and cognitive impairments and pain and the provision of psychosocial and emotional support.

Limitations: Although the obligation to promote a patient’s well-being is basic to the physician–patient relationship, its implementation can be problematic. For example, the development of medical technologies such as ventilators and total parenteral nutrition has resulted in confusion about when and for how long such treatments should be provided to ensure a patient’s well-being and the provision of ethical patient care. Their existence makes it difficult to remember that they are ethically neutral; when considered alone, medical treatments offer neither benefit nor burden. It is only within the context of applying a particular medical intervention to a specific patient that the treatment’s contribution to a patient’s well-being can be determined.

Autonomy: Respect the patient’s self-determination. The principle of autonomy, or patient’s self-determination, recognizes the right of a patient with decision-making capacity to make decisions about treatments according to his or her own beliefs, cultural and personal values, and life plan, even when these decisions differ from what has been advised or recommended by a physician.

Patient autonomy means any patient with decision-making capacity is free to reject, without coercion or fear of retribution, any form of medical therapy, including life-prolonging or life-sustaining therapy. A patient’s right to refuse unwanted treatment, including nutrition and hydration, is absolute. In physical and rehabilitation settings, the principle of autonomy includes the patient’s right not only to refuse a particular course of treatment but also to ask that the treatment be modified to meet other needs, such as the need for privacy, mental alertness, or care in a particular setting at a specific time.

Limitations: Although the emphasis on patient autonomy may challenge health care professionals, they are obligated to respect a patient’s considered choices about treatment. Autonomy is not served when a physician makes unilateral decisions or recognizes a patient’s right to make health care decisions only when those decisions concur with the physician’s opinion. Furthermore, a patient’s disagreement is not grounds for a determination of diminished capacity to make decisions (19).

The principle of autonomy upholds the patient’s right to reject any form of medical therapy, but it does not extend to the patient a right to demand any and all treatment regardless of its likely benefit or cost. The principle does not require the provision of treatments that, in the judgment of the physician and the interdisciplinary team, are likely to be harmful or futile or that counter the ethical principle of justice, nor does autonomy always outweigh other ethical principles.

Nonmaleficence: Do no harm. The principle of nonmaleficence is synonymous with the Hippocratic obligation to avoid doing harm to a patient. Nonmaleficence obligates respect for the inherent worth and dignity of every patient and the avoidance of treatments and interventions that may harm them. The principle of avoiding harm is particularly applicable to patients in the physical and rehabilitation setting, many of who are frail, frightened, and vulnerable when receiving care.

The following are examples of possible violations of the principle of nonmaleficence: