Pankaj D. DESAI MD (O&G)
• Consultant Obgyn Specialist
Janani Maternity Hospital, Vadodara, India
• Dean (Students), A. Professor and Unit Chief (VR)
Department of Obgyn, Medical College and S.S.G. Hospital
Vadodara, India

·         Past President: FOGSI


Ethics are very important in clinical practice as in all spheres of life. The behavior of doctors was always scrutinized by society well before the Consumer Protection Act became applicable to the medical profession in India. In more recent times, I remember returning to my seat on the dais, after giving the inaugural address at a medico-legal conference as president FOGSI, I had then spoken on “Ethics in Medical Practice”. The Late jurist Shri Ram Jethmalani, who was the guest of honour for that conference whispered in my ears, “Doctor, this is most relevant. More relevant than all what we are going to deliberate on legal angles at this conference”.

The Challenge of Medical Ethics

Ethics are defined as rightful behaviour. The precincts of ethics are much larger than the law of which law are just one part. Medical ethics involves examining a specific problem, usually a clinical case, and using values, facts, and logic to decide what the best course of action should be. Many times it is a tight rope walking. Some ethical problems are straightforward, as and when one has to decide a right from wrong. But others can be more perplexing, such as deciding between two ethics that conflict with each other. Both seem to be right. To give an example – Patient’s right to choose the route of delivery.

A 2016 Medscape survey, identified some common problems where at least some physicians held different opinions 1:

• Withholding treatment to meet an organization's budget, or because of insurance policies;
• Accepting money from pharmaceutical or device manufacturers;
• Up-coding to get treatment covered;
• Getting romantically involved with a patient or family member;
• Covering up a mistake;
• Reporting an impaired colleague;
• Cherry-picking patients;
• Prescribing a placebo;
• Practicing defensive medicine to avoid malpractice lawsuits;
• Dropping insurers; and
• Breaching patient confidentiality owing to a health risk.

The so-called high professional standards are a way to provide some guidance on ethical problems, but they cannot address every issue, and they may not address troubling nuances, such as reconciling two conflicting values.

Critical Standards for Determining Ethical Issues

Many professional ethicists recommend using four basic values, or principles, to decide ethical issues 2.
• Autonomy: Patients basically have the right to determine their own healthcare.
• Justice: Distributing the benefits and burdens of care across society.
• Beneficence: Doing well for the patient.
• Non-malfeasance: Making sure you are not harming the patient.

There are other important values also to consider, such as telling the truth, transparency, showing deference to the patient and her family, and showing reverence for the patient’s values.

Besides, medical ethics is not just a thought process. It also involves the competence to handle people. This is in such a way so as to gather the facts required for decision-making and the ob-gyn specialist must be able to present these in such a way to gain the confidence of all involved.

Listening skills including patience are an indispensable part of medical ethics. Often, ethical disagreements occur from not knowing all the facts, or not providing all the facts to patients. A well-prepared ethical choice could be overlooked if one could not win the confidence of the patient.

Sometimes ethics are often perceived as a blinkered activity—telling us what we cannot do. But if one sees with a broad-view, ethics can be very liberating. Ethics can reassure you that you are doing the right thing. If one goes through a proper ethical process, the ob-gyn specialist has greater confidence that he/she is on the right path. Once freed of irritating doubts, he/she will be able to proceed more unswervingly and more energetically with the chosen health-care plan.

As the health system evolves, ethical decisions could become more challenging. For example, the cost factor in private medical care facilities can make the patients avoid or altogether not take the care they need, and this disturbs the clinician's drawn health care plan.

Difference between Ethics and Ethos:

Ethics are constant. They don’t change. Ethos can change. Ethics are the same all through generations but some behaviour may be ethical in one generation and unethical in the other. These are ethos. Primum non-nocere – (Do no harm) was a core ethical behaviour in the time of Hippocrates and is a core ethical behaviour in medical practice even now. On the other hand, euthanasia was once a big NO, is being accepted as ethical and legal by many societies and countries now.

Practical Consequences of Medical Ethics

Some doctors think of medical ethics as a very mysterious field, delinked from the practical considerations of clinical practice. But this is not true. A practice where decisions are taken that are not congruent with ethics is never justifiable. In reality, a society where these type of practices become a routine, the common patient loses faith in its doctors very quickly.
Here are some reasons to take medical ethics seriously 2:

• To help resolve disputes between family, patients, physicians, or other parties. Often, the parties involved are operating strictly on emotion, which makes it difficult to come to a logical and fair decision. Ethics adds another dimension to help make decisions.

• To maintain a clear conscience. All doctors want to be sure they have done the right thing. Being an ethical physician is more important than making money or seeing as many patients as possible.

• To not make yourself look uninformed. Physicians sometimes stumble onto poor decisions because they did not understand their role, had not bothered to identify an ethical challenge, or hadn't thought the situation through to its logical conclusion.

• To maintain the respect of your patients. Ethical missteps can destroy the bond between doctor and patient. Patients often implicitly trust their doctors, but once that trust has been breached, it is difficult to repair.

• To maintain respectful relationships with other clinicians. Your colleagues often have very definite opinions about what is ethical, often enshrined in various codes of ethics of the profession or learned from mentors. Those codes and ethics role-modeling are created by people who practice some form of ethical decision-making.

• To maintain some efficiency. Although ethical decision-making often requires extra time, it also can save time by anticipating disagreements that can slow down the care process. If you aren't ethical, patients or other caregivers who are upset with your decisions can seriously impede your work.

• To reduce burnout. One cause of burnout is incongruence between physicians' personal values and those of their organization. Physicians who can describe their ethical concerns and use negotiating skills may be able to change the organizational policies that produce burnout.

After working through this dilemma, you may still decide to close off your practice, but you will have thought the issue through. You will be aware that the people you are turning away still need a doctor, and some physicians might decide to find a way in which they can help such people without burning themselves out, such as volunteering in a free clinic occasionally.

Ethics, Morality, and Religion

Medical ethics differs from morality. Ethics are based on values and reasoning and needs coaxing to get its message through. On the other hand, morality is relatively easy. It involves obeying to a detailed belief system or some code of conduct. Morality relies at times on scriptures like The Vedas or The Bhagwat Gita or the Bible, to defend its message. Morality does not just involve religion. It can be political or personal. In contrast, medical ethics has a flexible set of solutions. It is based on facts and logic, and not religious doctrine. You can still have political opinions and religious faith, but you will need to set them aside when forming and offering an ethical opinion to those who do not follow your morality.

A good scientist, who is observing medical phenomena, would have a pragmatic attitude about life, sickness, and death. Medicine gets its human face from ethics. Ethical decisions should respect the values and attitudes of patients. In a predominantly vegetarian society like where I practice, animal sources of Omega-3-fatty acids have to be very carefully handled before prescribing. Pharma companies were forced to come out with vegetarian sources of these fatty acids as the value systems of the patients did not permit its consumption if it was from an animal source.

Respecting the patient's wishes has a practical consequence: Doctors who simply overrule the patient often end up seeing their treatments fail. This is because patients will never be convinced to follow their treatment advice. Patients who are overruled do not tell the truth. It is therefore advisable to be in dialogue and negotiations with the patients. Sometimes it may mean coming to a reasonable compromise - even if the doctor doesn't completely approve of it.

When Patients or Families Disagree With the Doctor

Sometimes when patients or their families disagree with the doctor, the obvious ethical decision isn't the right one. Here's an example that occurred. A primigravida mother was found to have severe fetal distress. She passed thick meconium-stained liquor and the heartbeats of the fetus became irregular. She and her family disagreed with the attending obstetrician for a cesarean section. They stated that no one had ever needed a cesarean section in their family. In spite of intense counseling and persuasion, they refused to consent for the operative delivery. In due course of time, she delivered vaginally. The new-born was grossly asphyxiated. It was revived after a very energetic and active resuscitation. But alas the child developed cerebral palsy and had all its challenges in life.

Although we obstetricians need to respect patients' values, it is imperative that our own values should not control the decisions. Conscience and the religious faith of the physician should not automatically overrule the patient's need to get the best treatment possible. For example, an obstetrician cannot refuse medical contraception services to her clients because his/her religious beliefs do not approve of the same.

Who Decides?

First and foremost, the doctor’s own integrity is the biggest deciding factor on ethics. His/her own conscience becomes their personal light-house guiding in most day to day decision making situations. As regards the organizations, in India Medical Council of India reviews, arbitrates and decides ethics in different situations in all aspects of medical practice including research.

Doctors also look to their hospitals' ethics committees for answers, but these committees aren't intended to be the final authorities on medical ethics. Most hospitals, however, do not have ethical committees. These committees are educators and work in an advisory capacity. Their role is to develop specific hospital policies, educate staff about clinical ethics, and oversee ethical consultants on staff.

So who is the ultimate arbiter of clinical medical ethics? It is the individual doctor, working in concurrence with the patient. A doctor’s ethical decisions should go hand-in-hand with their clinical and technical decisions.

The Grey Area:

Because there is no predetermined answer to most ethical predicaments, disagreements on ethical solutions to problems are not uncommon. Although they tend to hold the same basic values ethical decisions can change over time. The morals that guide certain ethical decisions can change. For example, prescription of certain medicines in early pregnancy for pregnancy “support” was very critically evaluated and most of the times despised by ethicists. Over a period of time, with new data coming in, prescribing some of these agents are not considered irrational or unethical. Performing frequent sonography in pregnancy was looked at very critically by ethicists. However, over some time some relaxations have been granted in this by the ethicists responding to the prevailing societal norms and demands. Cesarean section in breech was limited to very specific breech presentations like breech with hyperextended head. Now, liberal use of cesarean section for all breech presentations is not considered unethical.

It must be reassuring to find that whenever doctors make a clinical decision, they are almost always making an ethical decision, consciously or not. Interestingly, rather than not discerning about the ethical dimension of health care, it makes more sense to be conscious of it and make sure that our decision is sound.

Is It Ethical to Refrain From Judging Colleagues' Behavior?

Doctors who don't have a managerial role over their colleagues have an unspoken responsibility. They are expected to uphold the well-being of patients in general, not just their own patients. They have a duty to report a doctor who is indulging in drug abuse or are outraging the modesty of their patients, for example. Indeed, the AMA Code of Medical Ethics states that physicians should report colleagues' behavior "in the first instance so that the possible impact on patient welfare can be assessed and remedial action taken”3. However, criticizing a colleague’s clinical treatment decision or skill is unethical and undesirable.

Medical Ethics and the Law

Medical ethics may have different standards from the law. Medical ethics are the universal set of which law is a subset. As the law is created by judges or legislators and may not share the values and reasoning of ethical physicians, there will be a difference. While terminating a pregnancy is legal but terminating it without properly ascertaining that it satisfies the tenets of law, is unethical.

Not getting a patient's informed consent for a procedure, another ethical problem, also has an important legal element. Doctors who do not get informed consent can be liable for malpractice, even if the procedure meets all the standards of clinical care4.

Additional Reading:

For those readers who are interested in this area of medical practice, the article published in Medscape titled “What Is Medical Ethics, and Why Is It Important?” can be a valuable resource 2. This article also gratefully draws much from it.


1. Reese S. Medscape Ethics Report 2016: money, romance, and patients. Medscape News & Perspective. December 1, 2016. Source Accessed April 21, 2018.

2. Course: Medical Ethics: What Is Medical Ethics, and Why Is It Important?

3. American Medical Association. Reporting incompetent or unethical behaviours by colleagues. Code of Medical Ethics. Opinion 9.4.2. Source Accessed April 13, 2018.

4. Medical malpractice cases: lack of informed consent. The Law Office of Alan H. Crede. Source Accessed April 13, 2018



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