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ETHICS

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Clinical ethics, arguably an ambiguous term and a far-ranging topic, provides a framework upon which healthcare workers can base patient care decisions when moral dilemmas or conflicts arise. Clinical ethics refers both to clearly defined codes of conduct that govern the actions of all clinicians and to novel moral dilemmas.

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Most ethical dilemmas in medicine can be identified, analyzed, and resolved by reference to one of four principles: patient autonomy, nonmaleficence, beneficence, and justice.

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Autonomy

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The principle of patient autonomy refers to the patient’s right to make decisions about their medical care. Autonomy allows healthcare providers to educate patients with regard to risks, benefits, and alternatives of diagnostic and therapeutic maneuvers and to even recommend a particular course of action. However, the patient has the ethical right to accept or refuse such recommendations. Patient autonomy reflects the patient’s right of self-determination. Concrete examples of this inalienable right are the concepts of advanced directives and informed consent.

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Nonmaleficence

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The principle of nonmaleficence means that healthcare providers have an obligation to not harm patients. Healthcare providers must not intentionally provide ineffective treatment to patients as they offer no benefit while subjecting patients to potential risks.

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Beneficence

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The principle of beneficence refers to healthcare providers’ obligation to promote the welfare of patients. Beneficent actions help prevent harm to or improve the condition of the patient. This principle affirms the professional obligation to develop and maintain skills and knowledge and continually update training.

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Justice

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The principle of justice refers to the obligation of healthcare workers to distribute care versus burdens in an equitable manner. This principle may relate to access to healthcare as a matter of social policy. For example, the administration of influenza vaccines preferentially to high-risk groups in the initial stages of the production and release of the vaccine represents a decision reflecting the principle of justice.

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ADVANCED DIRECTIVES

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Both the medical ethics literature and in judicial rulings support the right of patients to forgo aggressive medical treatment. Most hospitals operate under a policy of a full cardiopulmonary resuscitation (CPR) response with defibrillation and intubation/mechanical ventilation in any patient who suffers cardiac arrest without a documented, do not resuscitate, or DNR order, regardless of overall medical condition or prognosis. However, a properly documented DNR order requires that the patient’s wishes be respected.

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Perioperative DNR

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To allow a DNR order in the operating room means that the surgical team must withhold treatment of a potentially reversible cardiopulmonary arrest. Cardiopulmonary arrest in the operating room often results from the administration of anesthetic agents or from surgical events rather than the patient’s disease process. This logic serves as the basis for automatic suspension of DNR orders during surgery. However, two arguments refute ...

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