Ethical reasoning in medical decisions: the physician-patient dilemma

Abstract

Ethics is essential to ensure responsible medical practice, committed to the well-being of patients and society. Hence, understanding patient autonomy and their active participation in decisions about treatments and medical procedures is paramount. A systematic literature review was conducted on articles published between December 2008 and May 2023 to assist in the ethical debate and professional conduct about what should be considered in a conflict between the medical decision and the patient’s wishes, and thus provide perspectives on how to manage this issue. The 18 articles selected address ethical issues related to physician-patient relations, highlighting the importance of advance directives, honest communication and respect for patient autonomy. We aim to provide perspectives and guidelines for managing ethical conflicts in medical practice.

Keywords
Ethics, medical; Physician-patient relations; Personal autonomy

Resumo

A ética é essencial para garantir uma prática médica responsável e comprometida com o bem-estar do paciente e da sociedade. Diante disso, a compreensão da autonomia do paciente e sua participação ativa nas decisões sobre tratamentos e procedimentos médicos são fundamentais. Realizou-se revisão sistemática da literatura, entre dezembro de 2018 e maio de 2023, com o objetivo de auxiliar o debate ético e a conduta profissional acerca do que deve ser ponderado em uma situação de conflito entre a decisão médica e a vontade do paciente e, assim, fornecer perspectivas sobre o gerenciamento dessa temática. Os 18 artigos selecionados abordam questões éticas relacionadas à relação médico-paciente, destacando a importância das diretivas antecipadas de vontade, comunicação honesta e respeito à autonomia do paciente. Assim, busca-se fornecer perspectivas e orientações para o gerenciamento de conflitos éticos na prática médica.

Palavras-chave
Ética médica; Relações médico-paciente; Autonomia pessoal

Resumen

La ética es esencial para garantizar una práctica médica responsable y comprometida con el bienestar de los pacientes y la sociedad. Así, es fundamental comprender la autonomía del paciente y su participación activa en las decisiones sobre tratamientos y procedimientos médicos. Se realizó una revisión sistemática de la literatura entre diciembre de 2018 y mayo de 2023, con el objetivo de aportar al debate ético y la conducta profesional sobre lo que debe considerarse en una situación de conflicto entre la decisión médica y la voluntad del paciente, y así proporcionar perspectivas sobre la gestión de este tema. Los 18 artículos seleccionados abordan cuestiones éticas sobre la relación médico-paciente, destacando la importancia de las voluntades anticipadas, la comunicación honesta y el respeto a la autonomía del paciente. Así, se espera ofrecer perspectivas y directrices para gestionar los conflictos éticos en la práctica médica.

Palabras clave
Ética médica; Relaciones médico-paciente; Autonomía personal

Ethics is fundamental to guarantee quality medical practice, responsibility, and commitment to the well-being of the patient and society, as care represents a relationship of dependence between physician and patient. The professional needs to be cautious when judging the individual needs of the person under their care, a fact that is legitimized by experience and scientific knowledge. However, it is necessary to highlight the change in the health-disease process that has occurred in recent decades and the redefinition of the role of health workers, whose bonds with patients have weakened due to technologies, bureaucratization, and specialization ¹.

Medical ethics is an essential topic for the practice of medicine and seeks to enable longevity without compromising quality of life. Therefore, it is necessary to understand the patient’s autonomy and relationship with the family and the multidisciplinary healthcare team, ensuring their right to participate in decisions involving treatments and medical procedures actively. This situation can provide a better healing process or maintenance of palliative care when everyone involved agrees with conduct ².

Advances in science and technology bring new ethical challenges to medicine, and it is necessary to be prepared to deal with these issues with common sense, as accepting specific diagnoses and treatments can cause suffering without bringing benefits. Furthermore, it should be noted that the entire medical team has the power to make situational diagnoses and can meet the wishes of the patients they treat. On the other hand, in emergencies or terminal cases, the need to keep the patient alive outweighs the patient’s desire, as they now consider the usefulness of the care ³.

Furthermore, the environment in which the patient and physician are inserted must be understood, as, at certain times, ethical aspects identified by the professional are impeded by external factors. From this perspective, the justification for providing services is based on the actual benefit and risk assessment ⁴, and it is essential to highlight that the physician is free to choose their actions according to their conscience ⁵. Therefore, medical ethics is based on several principles, such as respect for the principles of autonomy, non-maleficence, beneficence, and justice.

Bioethical principles guide decision-making and conduct in the biological field ⁶, but they can conflict, requiring medical consideration on what to prioritize. For example, beneficence, which is about the responsibility to act for the patient’s benefit, focusing on life-saving measures, should be preferred when a cure can be achieved. In contrast, in the case of a terminally ill patient, when the alleviation of suffering takes precedence over the protection of life since death is inevitable, non-maleficence prevails, with the relief of suffering as the objective and no longer the search for a cure ⁷.

The principle of autonomy protects the patient’s right to express their wishes and choose among the therapeutic alternatives offered by the professional team, in addition to being correctly informed about their clinical condition and possible complications. Thus, complicated issues arise when there is a divergence between the patient’s wishes and medical opinion, with one of the main challenges being to reconcile the autonomy of patients, for example, in a state of terminal illness, with therapeutic expectations ⁸.

In this sense, it is relevant to search for articles that can assist in the ethical debate about what should be considered in a situation of conflict between medical decisions and the patient’s will and medical conduct in this type of situation. Thus, we seek to provide perspectives on the management of this topic.

Method

This is a systematic review study, of an exploratory and descriptive nature, in which searches were carried out on the SciELO and LILACS research platforms using terms present in the Health Sciences Descriptors (DeCS/MeSH) database. The following combinations of descriptors and the Boolean operator ‘and’ were used: ‘ética médica and relação médico-paciente,’ ‘ética médica and legislação médica,’ ‘ética médica and assistência médica,’ and ‘ética médica and atitude frente à morte.’

The inclusion criteria were be written in Portuguese, be available in full, be published between 2018 and 2023, and answer the research question. Editorials, repeated articles, and articles that did not fit the proposed theme were excluded. The final sample comprised 18 articles, read in full and analyzed based on the proposed objective (Figure 1).

Figure 1
Flowchart of the selection of articles found after applying the inclusion and exclusion criteria

Results and discussion

The review corpus addressed the primary considerations that must be assessed when faced with ethical conflicts. Table 1 presents a synthesis of reflections on different themes, namely patient autonomy, the process of finitude, and blood transfusion. Therefore, based on the congruences identified, three topics were delimited: 1) human dignity (respect for the patient’s autonomy), 2) decision-making in the finitude process, and 3) medical responsibility and blood transfusion.

Chart 1
List of articles with what should be considered in situations of conflict between medical decisions and the patient’s wishes

No.	Author; year	Title	Ponderations
1	Armendane; 2018 9	Por um cuidado respeitoso	In medicine, the patient’s wishes regarding the diagnosis and treatment process must be fulfilled, except cases that indicate imminent death. Therefore, the physician needs to guarantee privacy, confidentiality, and fidelity.
2	Cogo, Lunardi; 2018 3	Diretivas antecipadas: uma análise documental no contexto mundial	In finitude situations, if the patient’s prior declaration of will conflicts with medical dictates, the physician may refuse to implement orthothanasia as long as there is another physician on standby, able and willing to take their place.
3	Lima, Byk; 2018 6	Trauma e transfusão sanguínea precoce: o desafiante manejo de hemorragias em testemunhas de Jeová	In a scenario with a traumatized victim, although the patient has freedom in choosing treatment, the physician cannot refrain from providing care.
4	Scottini, Siqueira, Moritz; 2018 10	Direito dos pacientes às diretivas antecipadas de vontade	The professional needs to meet the needs of patients with terminal illnesses with respect for autonomy, with the support of advance directives.
5	Souza and collaborators; 2018 11	Dilemas bioéticos na assistência médica às gestantes adolescentes	During care for a pregnant adolescent, ethical principles must be respected, such as privacy, confidentiality, secrecy, and patient autonomy, in addition to taking actions that guarantee the establishment of bioethical principles such as non-maleficence and beneficence.
6	Cogo and collaborators; 2019 12	Concepções médicas e dos cuidadores familiares diante das diretivas antecipadas de vontade	Regarding conduct and decisions related to end-of-life care, patients must be given appropriate advice and the opportunity to know their diagnosis, allowing them to make decisions and express their wishes as long as they can judge.
7	Monteiro, Silva; 2019 13	Diretivas antecipadas de vontade: percurso histórico na América Latina	When a patient does not have the ability to make their own decisions, it is important to evaluate advance directives.
8	Pastura, Land; 2019 1	Escritos de Alasdair MacIntyre sobre medicina e ética médica	The patient commonly places the responsibility on the physician’s authority. Therefore, physicians must be able to judge prudently to address individual needs.
9	Teixeira, Cardoso; 2019 14	Como discutir sobre não ressuscitação cardiopulmonar na unidade de terapia intensiva?	The physician must be committed not only to the decision-making process but also to the outcome of the patient’s or their family’s choice.
10	Medeiros and collaborators; 2020 15	Conflitos bioéticos nos cuidados de fim de vida	It is essential to balance doing what is best for the patient (beneficence) and respecting their freedom (autonomy). Furthermore, the team must manage expectations, especially in end-of-life care, and ensure the decisions made by the person.
11	Oliveira; 2020 16	Aspectos bioéticos dos cuidados em saúde às pessoas idosas ao fim da vida	Therapeutic approaches in end-of-life care must consider preserving bioethical principles, especially when they involve palliative sedation. Another point to be considered is the shared decision between team members, patient, and family, aiming to increase the chances of finding the right balance in a clinical approach.
12	Silva and collaborators; 2021 17	Perspectivas e princípios bioéticos na assistência aos pacientes submetidos à traqueostomia	Despite the physician’s scientific expertise in decision-making, it is essential to clearly communicate the treatment options to the patient, allowing them to be actively involved in choosing the procedure and respecting their autonomy.
13	Cecconello, Erbs, Geisler; 2022 7	Condutas éticas e o cuidado ao paciente terminal	When diagnosing a patient’s terminal illness, honest, frank, and compassionate communication is essential. Therefore, conduct based on ethical principles must be applied after discussion with the team and those responsible for the patient.
14	Fusculim and collaborators; 2022 18	Diretivas antecipadas de vontade: amparo bioético às questões éticas em saúde	Given the need for deliberation in ethical conflict, values and duties must be considered, not through abstraction, but through reflective analysis of the problem and conduct, which, sometimes, do not aim for the ideal solution but for a reasonable and prudent one.
15	Gomes, Goldim; 2022 2	Diretivas antecipadas de vontade em unidade de emergência hospitalar	In hospital emergencies, checking whether the patient’s advance directives are registered and available is crucial. Ethical and legal implications must be weighed, and the decision must be made based on the patient’s best interests and in compliance with medical ethical principles.
16	Lima and collaborators; 2022 19	Diretivas antecipadas da vontade: autonomia do paciente e segurança profissional	In terminal illness situations, the physician must respect the patient’s final disposition.
17	Santana, Câmara; 2022 20	Percepção e expectativas de pacientes com câncer acerca das diretivas antecipadas de vontade	The patient’s decisions must be respected to promote well-being and human dignity.
18	Sena and collaborators; 2022 21	Considerações éticas relacionadas às condutas terapêuticas de pacientes terminais	When discussing terminality, it is necessary to direct assistance towards measures to alleviate suffering, thus respecting the perspectives of human life and dignity.

Human dignity: respect for patient autonomy

Freedom is a fundamental right guaranteed in Art. 5 of the Federal Constitution of 1988 ²², being also the pillar of the principle of autonomy. The effectiveness of this principle is influenced by the social, cultural, and family context in which the patient is inserted, the patient-professional relationship, and the creation of a welcoming environment ²³.

Furthermore, autonomy is one of the foundations of the Brazilian Unified Health System (SUS) and constitutes a guaranteed right, along with equity and comprehensiveness ²⁴. Given this, the dimensions of the individual-patient are crucial to improving the quality of healthcare services and comprise essential elements, such as individualization of care, humanization of care, and access to information ²⁵.

In this sense, in a consultation, the patient looks to the physician for technical skills and respect for their physical, psychological, social, and spiritual dimensions. Therefore, reconciling autonomy and the team’s expectations of treatment becomes a major conflict, as those responsible for care believe they are distancing themselves from care due to the feeling of failure in not being able to save lives ¹⁰.

Likewise, when respecting the patient’s autonomy, the professional can present an image of indifference and individualism, which increases the importance of informing the risks of not following the procedures presented ⁹. Therefore, the physician must be honest and transparent with their actions to establish a relationship of trust that strengthens the integrity of their practice. This attitude permeates the decision-making and responsibility process, as it also encompasses the results of choices made by the patient or their family members ¹⁴.

Furthermore, it is essential to highlight that ‘ethical dilemmas’ and ‘ethical conflicts’ are usually confused and used to refer to the same domain of reflection. In fact, the former concerns complex situations that involve clashes of values in which there is no homogeneous solution ²⁶, while the latter, on the other hand, refers to divergences of point of view between participants, which generate discussions. In this sense, finding a resolution requires an individual, responsible, and reflective approach, considering all available alternatives ²⁷.

Therefore, strategies to minimize these conflicts include good communication between professionals, patients, and families, respect for the patient’s wishes, ensuring dignity during care provision, and creating bonds between professionals and patients for more humanized and holistic care. The latter requires caution in the context of extreme vulnerability, not to get involved beyond what is expected, to avoid exacerbations and professional compassion fatigue, which, in an attempt to avoid death at any cost, leads to prolonged suffering ¹⁵.

Decision-making in the finitude process

The loss of consciousness and the ability to make decisions and communicate them in the final stage of life cannot take away from the individual the power to decide in advance about how their last moments will be conducted. Thus, death is understood as a phase of life and, therefore, should not be ignored, and it is necessary to guarantee the right to human dignity ¹⁹.

In this process, the patient’s autonomy is often threatened, as there are variables that increase or limit their ability to perceive their own preferences ⁶. Among them, medical standards on the quality and reasonableness of care, the availability of services, and family relationships stand out.

Thus, although no constitutional article legitimizes and guarantees any right to the patient if they cannot express their will, some laws reinforce the principle of patient autonomy ¹³. Art. 15 of the Brazilian Civil Code, for example, ratifies this autonomy by clarifying in its text that no one can be forced to undergo, at risk to their life, medical treatment or surgical intervention ²⁸.

From this perspective, specifically in the context of older patients, Art. 17 of Law 10,741/2003 establishes that, even if incapacitated, the individual has the right to participate in decisions about their treatment. In life-threatening situations, the decision can still be made by the guardian, family members, or physician ²⁹.

Also, Resolution 1,995/2012 of the Federal Council of Medicine (CFM) supports the patient’s autonomy with the regulation of advance directives (AD), defined as a set of desires previously and expressly expressed by the patient regarding care and treatments that they want, or not, to receive at a time when they are unable to express, freely and autonomously, their wishes ³⁰.

Therefore, this resolution establishes that the patient’s expressed wishes must be recorded in the medical record in AD format. If they are incapable of making decisions, this record must be taken into consideration by the physician when making decisions. This directive takes precedence over any other non-medical opinion, including the wishes of family members.

Among the conduct and decisions at the moment of the patient’s finitude, the individual’s capacity for judgment must be considered and differentiated between autonomous decisions, which must be respected, and those that may require verification. While the physician has sufficient scientific knowledge to make decisions, it is necessary to clarify the alternatives to the patient to allow them to decide how to conduct the health-disease process ¹⁷. Therefore, paying attention to the adequate description of the information in the AD is necessary. If poorly explained, they can influence the patient’s perception and reaction ¹².

Many professionals are unable to prepare documents related to the wishes of patients at the end of their lives, sometimes due to a lack of preparation during graduation and sometimes due to fear of legal punishment. Therefore, despite CFM Resolution 1,995/2012 addressing the topic, no legislation supports the preparation of the document, so the team is unmotivated to apply the AD, which limits patient dignity and autonomy ²⁰.

Furthermore, in the context of terminal illness, when death is imminent, regardless of the application of any intervention measures, it is essential to adopt a humanistic approach through an effective interpersonal relationship, which should not be limited to words but also contain attentive listening and non-verbal language ⁷. Therefore, the physician, as the recipient of the AD and chosen by the patient as the recipient of their wishes, must be responsible for complying with what has been established ¹⁸.

Finally, in specific situations, such as orthothanasia, if the wishes expressed in the AD are contrary to the physician’s ethical principles, they may choose not to perform it as long as another physician is available, competent, and willing to assume this responsibility. However, it is essential to highlight that, in no way can the physician act exclusively based on their conscience, as the will expressed by the patient prevails over that of the physician in this specific context ³.

Medical responsibility and blood transfusion

Medical care in delicate situations involves a series of ethical challenges and complex decisions. In a scenario with a traumatized victim who refuses blood transfusions, there is a conflict between disrespect for the patient’s autonomy and the unlimited exercise of the principle of beneficence. However, the Code of Medical Ethics opens up the possibility for medical attitudes to override patient autonomy:

Chapter IV: Human Rights

The physician is prohibited from:

Art. 22 – Failing to obtain consent from the patient or their legal representative after explaining the procedure to be performed, except in cases of imminent risk of death ³¹.

Thus, while the patient is free to choose their treatment, the medical professional cannot abstain from their responsibility for care appropriate to the context ⁶. For example, in the face of the patient’s refusal to receive the blood transfusion, the physician must respect the decision. However, if this rejection poses a risk of death to the patient, after having exhausted all possible means to preserve life, the professional must resort to blood transfusion ³². Otherwise, they may be held liable for a commission crime by omission or a crime of improper omission under the terms of Arts. 13, § 2, a, and 146, § 3, I of the Penal Code ³³, as pointed out by Cobbe and Winter ³⁴.

Final considerations

The physician-patient relationship often faces challenges in reconciling professional responsibility and patient needs. Given this, the importance of balancing the patient’s demands with compliance with ethical principles and duties as a physician was highlighted. Professionals need to be transparent and honest in their conduct and establish a relationship of trust that strengthens the integrity of medical practice.

Furthermore, it is essential to recognize that patient autonomy must be respected and valued, considering that each individual is free to make decisions about their health based on their beliefs, values, and preferences and the information offered by the healthcare professional. Therefore, the context of decisions and the individual’s ability to deliberate about themselves must be considered, and it is crucial to adopt a collaborative approach in which dialogue and negotiation play a central role.

In the context of finitude, guaranteeing the right to human dignity and respect for patient autonomy is essential. Regarding this process, the CFM reinforces the importance of expressing the patient’s wishes in advance through AD, which must be considered by the physician when making decisions. However, there are still challenges in the effective application of AD due to the lack of preparation of professionals and the lack of specific legislation, so the legislator must urgently establish a law that supports the institutionalization of AD and provides guidelines for its application.

Concerning medical responsibility and blood transfusion, the reflections include respect for the patient’s autonomy by the physician. However, in the event of an imminent risk to life and all alternatives have been exhausted, the physician may resort to transfusion. In this context, the professional must act according to the Code of Medical Ethics and legal principles, avoiding criminal liability for omission.

In summary, respect for patient autonomy and the promotion of human dignity are fundamental principles of medical ethics. Healthcare professionals must internalize and apply these values in their daily practice, establishing an ethical and responsible relationship with patients, even in complex situations.

Thus, respect for patient autonomy, assertive communication between physician and patient, protection of life, and use of AD are essential to dealing with conflicts. Therefore, by adopting shared decision-making and respecting individual choices, healthcare professionals can promote humanized care, preserving patient integrity and autonomy while seeking the best available therapeutic options.

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Publication Dates

• Publication in this collection
  14 June 2024
• Date of issue
  2024

History

• Received
  17 Aug 2023
• Reviewed
  23 Jan 2024
• Accepted
  25 Jan 2024