Ethical reasoning in medical decisions: the physician-patient dilemma

Andrade, Guilherme de Souza Almeida; Alves, Gustavo Pires; Melo, Tauá Alves; Santos, Vitória Amaro dos; Oliveira, Adailson Henrique Miranda de

doi:10.1590/1983-803420243658EN

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Research • Rev. Bioét. 32 • 2024 • https://doi.org/10.1590/1983-803420243658EN copy

Ethical reasoning in medical decisions: the physician-patient dilemma

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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

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.

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