Ethics in practice

Elementary topics of medical ethics

Since the early 1980s, four key aspects have been particularly emphasised that lead to a requirement to be realised in dealing with the sick (Beauchamp & Childress, 2019)

1. Autonomy and self-determination - The principle of autonomy recognises the right of every person to have their own opinions, make their own decisions and take actions that correspond to their own values. This includes not only freedom from external coercion and manipulative influence, but also a positive right to the promotion of one's own decision-making ability.
2. Avoiding harm - Describes the obligation to weigh up the benefits and risks of all interventions on a case-by-case basis and to discuss them together with the patient or their relatives. This is particularly important in the treatment of serious illnesses with far-reaching therapies.
3. The welfare of the patient is the highest law - The principle of care requires active support and also includes preventive measures, it leads to the essential question: What should be done to best help this patient? This question requires an individual reassessment in every situation.
4. Every patient should be treated equally - patients whose cases are similar have the right to the same treatment. If the overall view of the individual case reveals clear differences, the greatest possible benefit for the patient should be carefully weighed up and implemented.

These ethical principles focus on a high requirement profile, which can be divided into three categories for outpatient practice:

• Dealing with the sick
• The attitude of therapeutic professionalism
• The professional collegial attitude

The boundaries between these aspects are fluid in practice and require permanent situational adaptation. According to this view, an ethical concept grows with its tasks and is constantly refined by reflecting on the tasks mastered against the background of new findings. In this sense, it is always provisional, open in its development to newly emerging questions, but at the same time as crisis-proof as possible in its foundation and based on an concept of man that makes the person dependent on help, the vulnerable, the person affected by disease, in the spectrum of life from the newborn to the ageing and dying person, the starting point for action.

Dealing with the sick

The ethical stance for the diagnostic-therapeutic self-image in outpatient practice comprises twelve guiding principles:

1. It offers its knowledge and expertise, but does not override the patient's self-determination.
2. Each treatment is designed to accompany the patient on his or her path to finding meaning in reflection of his or her physical, mental and spiritual ideas about life.
3. The possibilities and limits of the respective diagnostic and treatment methods are adhered to and always stated transparently.
4. An open and self-critical attitude is adopted towards one's own abilities.
5. There is a self-commitment to developing one's own skills and an authentic dialogue on shortcomings in working together, including within colleagues
6. Wherever this is desired by the patient and does not run counter to the practitioner's own basic convictions based on well-founded contexts, interdisciplinary co-operation with other healthcare professions is sought in order to find the best solutions in individual cases.
7. Any serious treatment requires a deep conviction or motivation to help and support and, if it is practised as a gainful activity, distances itself from the excessive pursuit of profit.
8. Proactive treatment of patients is characterised by respect for their dignity.
9. Manipulation and deception, for whatever motives, should be ruled out.
10. Realistic clarification of expectations, one's own and those of the patient, are an expression of a responsibility that is aware of the respective situation.
11. Communication between practitioner and patient is characterised by clarity and openness, which always includes benevolent empathy while maintaining professional distance.
12. Mistakes happen and are not an ethical problem as long as they are addressed openly and dealt with in a self-reflective manner.

In this way, professional practice understands ethics as an open discourse that is constantly open to new insights and welcomes fair criticism of its own foundations and positions in relation to all other perspectives that determine medicine.

Therapeutic professionalism

The commitment to therapeutic professionalism (Kiene & Heimpel, 2010) condenses the tasks for professional practitioners in everyday practice and in this way prevents abuse of power and therapeutic hubris by emphasising seven aspects in particular:

1. The conscientious medical approach to anamnesis and diagnosis
2. The continuous endeavour to acquire sound medical and psychological expertise and the advancement of knowledge in the associated sciences
3. Knowledge of diagnostic and therapeutic alternatives to their own actions, including their possibilities and limitations
4. The proactive and willing disclosure of the theoretical, epistemic and empirical foundations of one's own views and working methods
5. Providing information about therapeutic alternatives to one's own profession in as non-judgemental and professional a manner as possible
6. Respect for the individual cognitive perspective of the patient and their decision-making processes
7. Practical, realistic and comprehensible information on possible outcomes of diagnosis and treatment

Therapeutic integrity therefore obliges everyone actively working in the healthcare system to undertake continuous further training and education on their own responsibility.

The professional collegial attitude

A practised ethical attitude relates not only to patients and practitioners, but also to the interaction between all professional groups working in the healthcare sector. This brings the collegial attitude to the fore. This is reflected in several fields of work:

• Collegial intervision and supervision,
• within the scope of consulting activities,
• during patient handovers,
• in working groups,
• during interdisciplinary co-operation,
• within research teams, as well as
• between employees in their own practice,
• with colleagues in joint practices, and
• in the positioning and discussion in public, including
• Internet and social media presence.

The ethical attitude defines and differentiates the ability to deal with difficult situations in such a way that the professional values can continue to develop so that the desired goals can be achieved in the various situations. This primarily includes three aspects:

• Development and reflection of personal competences
• Behaviour in actions and communication
• Dealing with collegial differences of opinion and conflicts

Personal competences

• Realistic self-assessment: The ability to adequately contribute the promised professional competences - "Can I deliver what I promise: professionally, communicatively and in terms of time?".
• Obligation: The fulfilment of obligations entered into, irrespective of the consideration.
• Loyalty: Completing tasks that have been started, regardless of one's own advantages and disadvantages
• Behaviour: Object-orientated instead of ego-orientated action - "being committed to the task - not primarily to personal ideas and needs".
• Ability to work in a team: Willingness to self-reflect and respect the strengths and weaknesses of all participants in order to promote joint development.

Behaviour in actions and communication

• Honesty: Making the promised contributions in the promised manner without reservation and actively working to improve them.
• Honesty: Sincere renunciation of deception, manipulation and fraud.
• Reliability: Keeping promises and clarifying any unspoken expectations as soon as they are realised.
• Transparency: Talk and action match: "He does what he says and vice versa... and discloses all motives".
• Clarity: Speak "plainly", even if you don't like it.
• Courage: Centralised, representing one's own convictions, even against the resistance of a group opinion or if they are socially undesirable. This also applies if they are not backed up by authorities.
• Benevolent interaction: Maintaining a constructive willingness to engage in dialogue, especially in conflict, which includes in particular the ability to distinguish between the people involved and their actions.
• Care: when formulating one's own points of view in relation to differing positions.
• Willingness to contribute: The will to actively contribute one's own appropriate share to the overall result and to develop together with others.

Behaviour in the event of differences of opinion and in conflicts

Having the "courage to disagree" in order to be able to weigh up majority decisions and objective actions against each other in their respective contexts with the aim of working towards the best possible accomplishment of the task is also an ethical principle. This includes in particular

• Supporting unpopular decisions and helping to make them a success if they are clearly necessary and sensible for the task at hand, instead of driving them back if they do not meet your own expectations.
• If a group consensus does not correspond to your own ethical ideas and principles and your own counter-arguments are well-founded, this must be communicated accordingly in order to find a better solution.
• If this is not possible due to the situation, the only thing left to do is to clearly state that the decision cannot be supported and, ultimately, to show a willingness to leave the group. Such a decision requires serious professional and ethical justification.
• The open willingness to accept and constructively support a neutral mediator for conflict resolution in decision-making processes where necessary.

The ethical spectrum in medical practice

Overall, the ethical principles focus on a high requirements profile that encompasses the three categories presented

The boundaries are fluid and require permanent situational adaptation. According to this view, an ethical concept grows with its tasks and constantly refines itself by reflecting on the tasks it has mastered.

In this sense, it is always provisional and, in its development, open to newly emerging questions, while simultaneously being as crisis-proof as possible in its foundation, based on an image of humanity that makes the person dependent on help, vulnerable, affected by illness, newly born, ageing and dying the starting point for action.

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Sources and References

[1] Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.

[2] Brüllmann, P. & Müller, J. (2023). Cicero: de Officiis.

[3] Kiene, H. & Heimpel, H. (2010). Ärztliche Professionalität und Komplementärmedizin: Was ist seriöses Therapieren? Deutsches Ärzteblatt | Jg. 107 | Heft 12 | 26. März 2010. https://www.aerzteblatt.de/archiv/70330/Aerztliche-Professionalitaet-und-Komplementaermedizin-Was-ist-serioeses-Therapieren

Further Reading

• Beauchamp, T. L. (2007). The ‘four principles’ approach to health care ethics. In Principles of Health Care Ethics (pp. 3–10). John Wiley & Sons, Ltd.
• Beauchamp, T. L., & Faden, R. R. (2017). The right to health and the right to health care. In Health Rights (pp. 9–22). Routledge.
• Bergner, T. (2021). Mentale Gesundheit für Ärzte und Psychotherapeuten: Ein Praxisbuch zur Verbesserung der Lebensqualität.
• Biller-Andorno, N., Monteverde, S., Krones, T. & Eichinger, T. (2021). Medizinethik. Springer VS.
• Childress, J. F. (2022). Respecting personal autonomy in bioethics: Relational autonomy as a corrective? In Philosophical Studies Series (pp. 135–149). Springer International Publishing.
• Childress, J. F., & Beauchamp, T. L. (2022). Common morality Principles in Biomedical Ethics: Responses to critics. Cambridge Quarterly of Healthcare Ethics: CQ: The International Journal of Healthcare Ethics Committees, 31(2), 164–176. https://doi.org/10.1017/s0963180121000566.
• Curlin, F. & Tollefsen, C. (2021). The Way of Medicine: Ethics and the Healing Profession. Universty of Notre Dame Press
• Gahl, K. (2005). Urban Wiesing (Hrsg. in Verbindung mit Gisela Bockenheimer-Lucius, Eduard Seidler und Georg Marckmann) (2003) Diesseits von Hippokrates. 20 Jahre Beiträge zur Ethik in der Medizin im Ärzteblatt Baden-Württemberg. Gentner Verlag, Stuttgart, 411 Seiten, ISBN 3-87247-615-7. Ethik in der Medizin, 17(1), 75–76. https://doi.org/10.1007/s00481-005-0357-y
• Maio, G. (2017). Mittelpunkt Mensch: Ethik in der Medizin: Ein Lehrbuch - Mit einem Geleitwort von Wilhelm Vossenkuhl. 2. Auflage. S. 477ff.

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Authors: glt | Rev.:smi | Editor: pz | Last modified Feb 19 2025

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Authors: glt | Rev.: gbh, hss, mnr, sfm, smi | Ed.: pz | Last modified Feb. 2, 2025