# 12 - 12 Ethical Issues in Clinical Medicine

## 12 Ethical Issues in Clinical Medicine

Treatment and with more recent articles that have confirmed their 
persistence and explored their root causes. Furthermore, another 
influential IOM report, Crossing the Quality Chasm, has highlighted 
the importance of equity—i.e., no variations in quality of care due to 
personal characteristics, including race and ethnicity—as a central 
principle of quality. Current efforts in health care reform and transfor­
mation, including a greater focus on value (high-quality care and cost 
control), will sharpen the nation’s focus on the care of populations who 
experience low-quality, costly care. Addressing disparities will become 
a major focus, and there will be many obvious opportunities for inter­
ventions to eliminate them. Greater attention to addressing the root 
causes of disparities will improve the care provided to all patients, not 
just those who belong to racial and ethnic minorities.

PART 1
The Profession of Medicine
■
■FURTHER READING
Buchmueller TC et al: The ACA’s impact on racial and ethnic dis­
parities in health insurance coverage and access to care. Health Aff 
(Millwood) 39:395, 2020.
Dwyer-lindgren L et al: Inequalities in life expectancy among us 
counties, 1980 to 2014: Temporal trends and key drivers. JAMA 
Intern Med 177:1003, 2017.
Kreuter MW et al: Addressing social needs in health care settings: 
Evidence, challenges and opportunities for public health. Annu Rev 
Public Health 42:11, 2021.
Krieger N: Measures of racism, sexism, heterosexism, and gender 
binarism for health equity research: From structural injustice to 
embodied harm: An ecosocial analysis. Annu Rev Public Health 
41:37, 2020.
LaVeist TA et al: The economic burden of racial, ethnic, and educa­
tional health inequities in the US. JAMA 329:1682, 2023.
Medscape: Medscape Lifestyle Report 2016: Bias and burnout. http://
www.medscape.com/features/slideshow/lifestyle/2016/public/overview.
Vyas DA et al: Hidden in plain sight: Reconsidering the use of race cor­
rection in clinical algorithms. N Engl J Med 383:874, 2020.
Williams DR et al: Racism and health: Evidence and needed research. 
Annu Rev Public Health 40:105, 2019.
Christine Grady, Bernard Lo

Ethical Issues in Clinical 
Medicine
Physicians face both enduring and novel ethical dilemmas that can 
be perplexing and emotionally draining and can sometimes lead to 
moral distress. For example, physicians may worry about the intensity 
of care that is appropriate at the end of life, how to distribute time 
between critically ill patients, or their responsibilities for patients with 
limited access to needed care. Newer technologies such as artificial 
intelligence promise more coordinated and efficient care, but also raise 
concerns about confidentiality, the doctor–patient relationship, and 
accountability. New social and economic developments, such as greater 
attention to health disparities and the growth of for-profit enterprises, 
present additional issues. This chapter suggests how physicians can 
address important vexing ethical issues they encounter in their work. 
Physicians make ethical judgments about clinical situations every day 
and should prepare for lifelong learning about ethical issues so they 
can respond appropriately. Traditional professional codes and ethical 
principles provide instructive guidance but need to be interpreted and 
applied to each situation. When facing a challenging ethical issue, phy­
sicians may need to reevaluate their basic convictions, tolerate uncer­
tainty, and act in a manner that maintains their integrity. Physicians 

should articulate their concerns and reasoning, listen to and respect 
the views of others involved in the patient’s care, and utilize available 
resources, including members of the interdisciplinary health care team 
as well as ethics consultants in some cases. Ethics consultation services 
or a hospital ethics committee can help to clarify issues and identify 
strategies for resolution, including improving communication and 
dealing with strong or conflicting emotions. Through these efforts, 
physicians can gain deeper insight into the ethical issues they face and 
reach mutually acceptable resolutions to complex problems.
APPROACHES TO ETHICAL PROBLEMS
Several approaches are useful for addressing ethical issues, including 
approaches based on ethical principles, virtue ethics, professional 
oaths, and personal values. Sometimes these various sources of guid­
ance may seem to conflict. In a diverse society, different individuals 
may turn to different sources of moral guidance. In addition, general 
moral precepts often need to be interpreted and applied to particular 
clinical situations.
■
■ETHICAL PRINCIPLES
Ethical principles serve as general guidelines to help physicians deter­
mine the right thing to do.
Respecting Patients 
Physicians should always treat patients with 
respect, which entails understanding patients’ goals, providing infor­
mation, communicating effectively, obtaining informed and voluntary 
consent, respecting informed refusals, and protecting confidentiality. 
Different clinical goals and approaches are often feasible, and interven­
tions can result in both benefit and harm. Individuals differ in how 
they value health and medical care and weigh the benefits and risks of 
medical interventions. Generally, physicians should respect patients’ 
values and informed choices. Respect is especially important when 
patients are responding to experiences of, or concerns about, disrespect 
and discrimination. Physicians should consider patient confidentiality, 
professional boundaries, and therapeutic relationships in all spoken 
and written communications.
GOALS AND TREATMENT DECISIONS  Physicians should provide rel­
evant and accurate information for patients about current clinical 
circumstances, diagnoses, expected future course, prognosis, treatment 
options, and uncertainties, and discuss how different options might 
realize patients’ goals of care. Physicians may be tempted to withhold 
a serious diagnosis, misrepresent it by using ambiguous terms, or limit 
discussions of prognosis or risks for fear that patients will become 
anxious or depressed. However, providing honest information about 
clinical situations promotes patients’ autonomy and trust. When shar­
ing bad news with patients, physicians should adjust the pace of dis­
closure, offer empathy and hope, provide emotional support, and call 
on other resources such as spiritual care or social work. Some patients 
may choose not to receive such information or may ask surrogates to 
make decisions on their behalf, as is common with serious diagnoses 
in some cultures.
SHARED DECISION-MAKING AND OBTAINING INFORMED CONSENT 

Physicians should engage in shared decision-making with patients, 
whenever appropriate. Physicians promote shared decision-making 
by informing and educating patients, eliciting and answering their 
questions, checking that they understand key issues, making recom­
mendations, and helping them to deliberate. Medical jargon, needlessly 
complicated explanations, or the provision of too much information 
at once may overwhelm patients. Increasingly, decision aids can help 
patients play a more active role in decision-making, improve the accu­
racy of their perception of risk and benefit, and help them clarify their 
values and goals. Informed consent is more than obtaining signatures 
on consent forms and involves disclosure of honest and understand­
able information to promote understanding and choice. Competent, 
informed patients may refuse recommended interventions and choose 
among reasonable alternatives. In an emergency, treatment can be 
given without informed consent if patients cannot give their own 
consent and delaying treatment while surrogates are contacted would

jeopardize patients’ lives or health. People are presumed to want such 
emergency care unless they have previously indicated otherwise, such 
as through a portable order for life-sustaining treatment (POLST).
Respect for patients does not entitle patients to insist on any care or 
treatment that they want. Physicians are not obligated to provide inter­
ventions that have no physiologic rationale, have already failed, or are 
contrary to evidence-based practice recommendations or good clinical 
judgment. Public policies and laws also dictate certain decisions—e.g., 
allocation of scarce medical resources during public health crises such 
as the COVID-19 pandemic, use of cadaveric organs for transplanta­
tion, and responding to requests for physician aid in dying.
CARING FOR PATIENTS WHO LACK DECISION-MAKING CAPACITY 

Patients with decision-making capacity can express choices and appre­
ciate their medical situation; the nature, risks, and benefits of proposed 
care; and the consequences of each alternative. Patient choices should 
be consistent with their values and not the result of delusions, hal­
lucinations, or misinformation. Physicians should use available and 
validated assessment tools, resources such as psychiatry or ethics 
consultation, and clinical judgment to ascertain whether individuals 
have the capacity to make decisions for themselves. Some patients 
are unable to make informed decisions because of unconsciousness, 
advanced dementia, delirium, or other medical conditions that impair 
cognition. Courts have the legal authority to determine that a patient 
is legally incompetent, but physicians usually determine when patients 
lack the capacity to make particular health care decisions and arrange 
for authorized surrogates to make decisions, without involving the 
courts. Patients who disagree with recommendations or refuse treat­
ment should not be assumed to lack capacity. Such decisions should 
be probed, however, to ensure the patient is not deciding based on 
misunderstandings and has the capacity to make an informed decision. 
When impairments are fluctuating or reversible, decisions should be 
postponed if possible and revisited when the patient recovers decisionmaking capacity.
Physicians seek an appropriate surrogate for patients who lack 
decision-making capacity. Patients may designate a health care proxy 
through a POLST or an advance directive; such choices should be 
respected (see Chap. 13). For patients who lack decision-making 
capacity and have not previously designated a health care proxy, family 
members usually serve as surrogate decision-makers. Statutes in most 
U.S. states delineate a priority order of relatives to make medical deci­
sions. For unrepresented patients who do not have relatives or friends 
who can be found and no previously appointed proxy, making deci­
sions presents difficult dilemmas and should follow a fair and careful 
institutional or legal process. Patients’ values, goals, and previously 
expressed preferences, when known, should guide surrogate decisions. 
However, the patient’s current best interests may sometimes justify 
overriding earlier preferences if an intervention is likely to provide 
significant benefit, previous statements do not fit the situation well, or 
the patient gave the surrogate leeway in decisions.
MAINTAINING CONFIDENTIALITY  Maintaining confidentiality is 
essential to respecting patients’ autonomy and privacy; it encourages 
patients to seek treatment and discuss problems candidly. However, 
confidentiality may be overridden to prevent serious harm to third 
parties or to the patient. Exceptions to confidentiality are justified 
when the risk is serious and probable, no less restrictive measures 
can avert risk, and the adverse effects of overriding confidentiality 
are minimized and deemed acceptable by society. For example, laws 
require physicians to report cases of tuberculosis, sexually transmitted 
infections, elder or child abuse, and domestic violence.
Beneficence or Acting in Patients’ Best Interests 
The prin­
ciple of beneficence requires physicians to act for the patient’s benefit. 
Patients typically lack medical expertise, and illness often makes them 
vulnerable. Patients rely on and trust physicians to treat them with 
compassion and provide sound recommendations and treatments 
aimed to promote their well-being. Physicians encourage such trust 
and have a fiduciary duty to act in the best interests of patients, which 
should prevail over physicians’ self-interest or the interests of third 

parties such as hospitals or insurers. A related principle, “first do no 
harm,” obliges physicians to prevent unnecessary harm by recom­
mending interventions that maximize benefit and minimize harm and 
forbids physicians from providing known ineffective interventions 
or acting without due care. Although often cited, this precept alone 
provides limited guidance because many beneficial interventions also 
pose serious risks.

CHAPTER 12
Physicians often provide care within interdisciplinary teams and 
rely on consultation with or referral to specialists. Team members and 
consultants contribute different expertise to the provision of compre­
hensive, high-quality care for patients. Physicians should collaborate 
with and respect the contributions of interdisciplinary team members 
and should initiate and participate in regular communication and plan­
ning to avoid diffusion of responsibility and ensure accountability for 
quality patient care.
Ethical Issues in Clinical Medicine
INFLUENCES ON PATIENTS’ BEST INTERESTS  Conflicts arise when 
patients’ refusals or requests for interventions thwart their own goals 
for care, cause serious harm, or jeopardize their best medical inter­
ests. For example, simply accepting a young asthmatic adult’s refusal 
of mechanical ventilation for readily reversible respiratory failure, in 
the name of respecting autonomy, is morally constricted. Physicians 
should elicit patients’ expectations and concerns, correct their misun­
derstandings, and try to persuade them to accept beneficial therapies. 
If disagreements persist after such efforts, physicians should call on 
institutional resources for assistance, but patients’ informed choices 
and views of their own best interests should prevail.
Drug prices and out-of-pocket expenses for patients have escalated 
in many parts of the world and may compromise care in the patients’ 
best interests. Physicians should recognize that patients, especially 
those with high copayments or inadequate insurance, may not be able 
to afford prescribed tests and interventions. Physicians should strive to 
prescribe indicated medications that are affordable and acceptable to 
the patient. Knowing what kind of insurance, if any, the patient has 
and whether certain medications are likely to be covered may help in 
determining appropriate prescriptions. Physicians or their team should 
follow up with patients who don’t fill prescriptions, don’t take their 
medications, or skip doses to explore whether cost and affordability 
are obstacles. Clinical pharmacists, technicians, or social workers can 
help the prescribing physician appeal for coverage or find funding for 
needed medications. It may be reasonable for physicians to advocate 
for coverage of nonformulary products for sound reasons, such as 
when the formulary drugs are ineffective or not tolerated.
Organizational policies and workplace conditions may sometimes 
conflict with patients’ best interests. Physicians’ focus and dedication to 
the well-being and interests of patients may be negatively influenced by 
perceived or actual staffing inadequacies, unfair wages, deficiencies in 
equipment or infrastructure, work-hour limitations, corporate culture, 
violence, and other risks in the workplace. Physicians should work with 
institutional leaders to ensure that policies and practices support their 
ability to provide quality care focused on patients’ best interests.
Patients’ interests are served by the increasing use of evidence-based 
practice guidelines and performance benchmarking. However, practice 
guideline recommendations may not serve the interests of each indi­
vidual patient when another plan of care would provide substantially 
greater benefits. In prioritizing their duty to act in the patient’s best 
interests, physicians should be familiar with relevant practice guide­
lines, be able to recognize situations that might justify exceptions, and 
advocate for reasonable exceptions.
Acting Justly 
The principle of justice provides guidance to physi­
cians about how to ethically treat patients and make decisions about 
allocating important resources, including their own time. Justice in a 
general sense means fairness: people should receive what they deserve 
or are owed. Justice also entails similar treatment of people who are 
similar in ethically relevant ways, in order to avoid arbitrary, biased, 
and unfair decisions. Justice forbids discrimination in health care based 
on race, religion, gender, sexual orientation, disability, age, or other 
personal characteristics (Chap. 11). Distributive justice requires fair

and equitable allocation of limited health care resources, which should 
be distributed equally or according to relevant moral considerations 
such as need, probability of benefit, or other factors.

ALLOCATION OF RESOURCES  Universal access to medically needed 
health care remains an unrealized moral aspiration in the United States 
and around the world. Patients with no or inadequate health insurance, 
especially those with chronic diseases, often cannot afford needed care 
and lack access to safety-net services. Even among insured patients, 
insurers sometimes deny coverage for interventions recommended 
by their physician. Physicians should advocate for patients’ affordable 
access to indicated care, try to help patients obtain needed care, and 
work with institutions and policies to promote wider access.
PART 1
The Profession of Medicine
Allocation of health care resources is unavoidable when resources 
are limited, such as during medication shortages due to manufacturing 
and quality problems or during public health crises. Allocation policies 
should be fair, transparent, accountable, responsive to the concerns of 
those affected, and proportionate to the situation, including the supply 
relative to the need. Difficult decisions about allocation of available 
scarce resources are inevitable. A fair process should aim to prioritize 
patients who are likely to have a large and irreversible decrement in 
health outcomes without the interventions; avoid discrimination; 
mitigate health disparities; save the most lives; and promote the good 
of the community.
First-come, first-served allocation is often not fair, because it disad­
vantages patients who experience barriers to accessing care. To avoid 
discrimination, allocation decisions should not consider personal 
social characteristics such as race, gender, or disability, nor consider 
insurance status or wealth. Allocation policies should aspire to reduce 
health care disparities often due to social determinants of health 
including poverty, unhealthy living conditions, and poor access to 
health care.
Fair and well-considered guidelines help mitigate emotional and 
moral distress for clinicians and patients when difficult allocation 
decisions are made. Physicians should act as patient advocates within 
constraints set by society, reasonable insurance policies, and evidencebased practice. Ad hoc resource allocation by individual physicians 
may be inconsistent, unfair, and ineffective. Many allocation decisions 
are made at the institutional or public policy level with physician and 
public input, for example, decisions and criteria for allocating cadaveric 
organs for transplantation.
■
■VIRTUE ETHICS
Virtue ethics focuses on physicians’ character and qualities, with the 
expectation that doctors will cultivate virtues such as compassion, 
trustworthiness, intellectual honesty, humility, and integrity. Propo­
nents argue that, if such characteristics become ingrained, they help 
guide physicians in unforeseen situations. Moreover, simply following 
ethical precepts or principles without any of these virtues could lead to 
uncaring doctor–patient relationships.
■
■PROFESSIONAL OATHS AND CODES
Professional oaths and codes are useful guides for physicians. Most 
physicians take oaths during their medical training, and many are 
members of professional societies with codes of ethics. Physicians 
pledge to the public and to their patients that they will be guided by the 
principles and values in these oaths or codes and commit to the spirit 
of the ethical ideals and precepts represented in oaths and professional 
codes of ethics.
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■PERSONAL VALUES
Personal values, cultural traditions, and religious beliefs are important 
sources of personal morality that help physicians address ethical issues 
and cope with any moral distress they may experience in practice. 
While essential, personal morality alone is a limited ethical guide 
in clinical practice. Physicians have role-specific ethical obligations 
that go beyond their obligations as good people, including the duties 
to obtain informed consent and maintain confidentiality discussed 
earlier. Furthermore, in a culturally and religiously diverse world, 
physicians should expect that many patients and colleagues will have 
personal moral beliefs that differ from their own.

ETHICALLY COMPLEX PROFESSIONAL 
ISSUES FOR PHYSICIANS
■
■CLAIMS OF CONSCIENCE
Some physicians, based on personal values, have legally protected 
conscientious objections to providing, or referring patients for, certain 
treatments such as contraception, abortion, or physician aid in dying. 
Although physicians should not be asked to violate deeply held moral 
beliefs or religious convictions, patients need medically appropriate 
and timely care, rely on physicians for medical advice, and should 
always be treated with respect. Institutions such as clinics and hospitals 
have a collective ethical duty to provide medical care that will avert 
serious risks and suffering to patients while accommodating health 
care workers’ conscientious objections—for example, when possible, 
by arranging for another professional to provide the service in ques­
tion or by referral to another institution. Ethically, patients seeking a 
relationship with a doctor or health care institution should be notified 
in advance of any conscientious objections to the provision of specific 
interventions. Since insurance often constrains patients’ selection of 
physicians or health care facilities, switching providers can be prob­
lematic after an illness is recognized. There are also important limits on 
claims of conscience. Health care workers may not insist that patients 
receive unwanted medical interventions or refuse to treat or illegally 
discriminate against patients because of their race, ethnicity, disability, 
genetic information, or diagnosis. Refusal to treat patients because of 
personal characteristics, such as sexual orientation, gender identity, or 
immigration status is ethically inappropriate because it falls short of 
helping patients in need and respecting them as persons.
Importantly, some physicians may object to laws, institutional policies, 
or insurance policies that restrict them from providing or even describing 
medically appropriate care to their patients. In some of these cases, work­
arounds are justified on the ethical basis of sound clinical practice.
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■PHYSICIAN AS GATEKEEPER
In some cases, patients may ask their physicians to facilitate access 
to services that the physician has ethical and clinical qualms about 
providing. For example, a patient might request a prescription for a 
cognitive enhancing medication to temporarily augment cognitive 
abilities in order to take an exam or apply for employment, or request 
that the physician sign a disability form when the patient does not meet 
disability criteria. Patients may request more pain medication than the 
physician believes is warranted for the given situation, or the physician 
may feel uncomfortable prescribing attention-deficit/hyperactivity 
disorder medications to a young child because of concerns that the 
possible benefit does not justify the risks despite the parent’s request. 
In these and similar circumstances, the physician should work with 
the patient or parent to understand reasons for their requests, some 
of which might be legitimate. In addition to considering possible risks 
and benefits to the patient, the physician should consider how meeting 
the request might affect other patients, societal values, and public trust 
in the medical profession. If the physician determines that fulfilling the 
request requires deception, is unfair, jeopardizes professional responsi­
bilities, could undermine the physician’s credibility or trustworthiness, 
or is inconsistent with the patient’s best medical interests, the physician 
should decline and explain the reasons to the patient.
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■OCCUPATIONAL RISKS AND BURDENS
Physicians accept some risks in fulfilling their professional responsi­
bilities, including exposure to infectious agents or toxic substances, 
abuse from patients or families, distress, and violence or threats in the 
workplace. Nonetheless, most physicians, nurses, and other hospital 
staff willingly care for patients, despite personal risk, grueling hours, 
and sometimes inadequate resources or information. Health care 
institutions are responsible for preventing and addressing occupational 
risks and burdens and for providing proper information, training and 
supervision, resources, infrastructure and workflow modifications, and 
emotional and psychological support. Clinical leaders should acknowl­
edge fears about personal safety and take steps to mitigate the impact of 
work on family responsibilities, moral distress, and burnout.

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■MORAL DISTRESS AND WELL-BEING
Clinicians, including residents, medical students, and experienced physi­
cians, experience moral distress when they feel that ethically appropriate 
action is hindered by institutional policies or culture, decision-making 
hierarchies, limited resources, or other reasons. Moral distress can lead 
to anger, anxiety, depression, frustration, fatigue, work dissatisfaction, 
and burnout. A physician’s health and well-being can affect how they 
care for patients and interact with colleagues. Discussing complex or 
unfamiliar clinical situations with colleagues and seeking assistance with 
difficult decisions can help mitigate moral distress, as can a healthy work 
environment characterized by open communication, mutual respect, 
adequate support and resources, and an emphasis on the common goal 
of good patient care. In addition, physicians should take good care of 
their own health and well-being and be aware of the personal and system 
factors associated with stress, burnout, and depression. Health care orga­
nizations should provide a supportive work environment, counseling, 
and other support services as needed.
CONFLICTS OF INTEREST
Acting in patients’ best interests may sometimes conflict with a physi­
cian’s self-interest or the interests of third parties such as insurers or 
hospitals. From an ethical viewpoint, patients’ interests are paramount. 
Transparency, appropriate disclosure, and management of conflicts 
of interest are essential to maintain the trust of patients, colleagues, 
and the public. Disclosure requirements vary for different purposes, 
and available software can assist physicians in complying with specific 
requirements. Importantly, not all conflicts are financial. Physicians 
sometimes face conflicts of commitment between their patient’s inter­
ests and their own personal interests, professional goals, responsibili­
ties, and aspirations or the interests of the health care institutions or 
corporations that employ them. Physicians should prioritize patients’ 
interests while recognizing possible conflicts and use disclosure, dis­
cussion with institutional officials, and management of the conflict or 
recusal when appropriate.
Medical institutions themselves may have conflicts of interest arising 
from patent rights, industry-funded research programs, donations from 
individuals and companies, and priorities of the health care system, 
pharmacy benefits managers, insurers, and private equity or corporate 
owners. Institutions should be transparent about the presence and 
amount of such relationships and about the steps taken to prevent such 
relationships from influencing clinical or financial decisions. Institutions 
should take steps not to benefit from donations or honor donors when 
there is good evidence that a donor breached ethical or legal standards.
■
■FINANCIAL INCENTIVES
Physicians have financial incentives to improve the quality or effi­
ciency of care that might lead some to avoid patients who are older, 
chronically ill, or have more complicated problems, or to focus on 
benchmarked outcomes even when not in individual patients’ best 
interests. In contrast, fee-for-service payments might encourage physi­
cians to order more interventions than necessary or to refer patients to 
laboratory, imaging, or surgical facilities in which they have a financial 
stake. Regardless of financial incentives, physicians should recommend 
available care that is in the patient’s best interests—no more and no less.
■
■RELATIONSHIPS WITH PHARMACEUTICAL 
COMPANIES
Financial relationships between physicians and industry are increasingly 
scrutinized. Many medical centers have banned drug-company gifts, 
including branded pens or notepads or meals to physicians, to reduce 
risk of undue influence or subconscious feelings of reciprocity and to 
decrease possible influences on public trust or the costs of health care.
The federal Open Payments website provides public information 
on the payments and amounts that drug and device companies give 
to individual physicians. The challenge is to distinguish payments for 
scientific consulting and research contracts—which should be encour­
aged as promoting professional and academic missions—from those 
for promotional speaking and other activities that aim to increase sales 
of company products.

■
■LEARNING CLINICAL SKILLS
Medical students’, residents’, and physicians’ interests in learning, which 
fosters the long-term goal of benefiting future patients, may sometimes 
conflict with the short-term goal of providing optimal care to current 
patients. When trainees are learning procedures on patients, they lack 
the proficiency of experienced physicians, and patients may experi­
ence inconvenience, discomfort, longer procedures, or increased risk. 
Increasingly, institutions are developing simulation-based clinical skills 
laboratories and requiring students to demonstrate proficiency before 
carrying out procedures such as venipuncture and intravenous lines in 
patients. Furthermore, teaching hospitals are establishing proceduralist 
services in which procedure-specialist faculty members directly super­
vise interns for procedures such as lumbar puncture and thoracentesis 
and certify their proficiency. Medical students may need to defer learn­
ing such invasive procedures until internship. It is always important 
to seek patients’ consent for trainee participation in their care, par­
ticularly for intimate examinations, such as pelvic, rectal, breast, and 
testicular examinations, and for invasive procedures. Patients should 
be told who is providing care and how trainees are supervised. Failing 
to introduce students or trainees who will be performing procedures 
undermines trust, may lead to more elaborate deception, and hin­
ders patients’ informed choices about their care. Most patients, when 
informed, allow trainees to play an active role in their care.

CHAPTER 12
Ethical Issues in Clinical Medicine
■
■RESPONSE TO MEDICAL ERRORS
Errors are inevitable in clinical medicine, and some errors cause harm 
to patients. Most errors are caused by lapses of attention or flaws in 
the system of delivering health care; only a small number result from 
blameworthy individual behavior. Many health care institutions have 
adopted a communication and resolution system that encourages open 
and honest reporting of errors as essential to quality of care and shifts 
the focus from individual blame to system redesign for improvement 
in quality and safety (Chap. 7). This approach is more likely than a 
punitive approach to improve patient safety. However, professional 
discipline is appropriate for cases of gross incompetence, reckless 
behavior, physician impairment, and boundary violations. Physicians 
and students may fear that disclosing errors will damage their careers. 
Physicians and health care institutions show respect for patients by 
disclosing and explaining errors, offering apologies, offering appropri­
ate compensation for harm done, and using errors as opportunities to 
improve the quality of care.
■
■PHYSICIAN IMPAIRMENT
Physicians may hesitate to intervene when colleagues impaired by alco­
hol, drugs, or psychiatric or medical illness place patients at risk. How­
ever, society relies on physicians to regulate themselves. Colleagues of 
an impaired physician should take steps to protect patients and help 
their impaired colleague, starting with reporting their concerns to their 
clinical supervisor or director, and institutions should have programs 
in place for assessing physician competence.
ETHICAL ISSUES IN CLINICAL RESEARCH
Clinical research is essential to translate scientific discoveries into 
beneficial interventions for patients. However, clinical research raises 
ethical concerns because participants face inconvenience and risks in 
research designed to advance scientific knowledge and not specifically 
to benefit them. Ethical guidelines require researchers to rigorously 
design and conduct research, minimize risk to participants, and obtain 
informed and voluntary participant consent and approval from an 
institutional review board (IRB). IRBs determine whether risks to par­
ticipants are acceptable and adequately minimized, and recommend 
appropriate additional safeguards when research includes vulnerable 
participants.
Physicians may be clinical research investigators themselves or in a 
position to refer or recommend research participation to their patients. 
Physician-investigators are likely to feel some inherent tension between 
conducting research and providing health care. Awareness of this ten­
sion, familiarity with research ethics, collaboration with research and 
clinical team members, and utilizing research ethics consultation can