Euthanasia can be active or passive. Currently, active euthanasia, which actively gives a drug to cause death, is illegal under federal law in the United States; However, passive euthanasia may be permitted. The removal of ventilators or the withholding of food that may cause natural death is permitted and currently indicated in living wills or living wills when patients indicate that they do not want extraordinary measures to preserve life. Examples of patients` rights in everyday language are listed below. Some rights are influenced by only one of the principles discussed above, some rights are influenced by several principles, and others are influenced by other ethical principles. A patient who can defend his or her judgments has the right to make decisions that are not consistent with what the physician considers beneficial to that patient. This philosophical concept has essentially become a legal claim throughout the Western world. Given that precedents have advanced patient autonomy requirements more than the demands of health care providers` charities, patient autonomy has arguably become the dominant principle affecting patients` rights. For example, a patient may refuse treatment that the doctor considers an act of charity. In such cases, the unwritten social contract between patient and physician requires that health care professionals nevertheless attempt to inform the patient of the possible consequences of a procedure against medical advice.

A patient`s autonomy is violated when family members or members of a health care team pressure a patient or when they act on behalf of the patient without the patient`s permission (in a non-emergency situation). The Hippocratic Oath contains little about the patient`s right to make their own health decisions or their right to be fully informed and involved. Medical paternalism has been the accepted standard of medical practice for centuries. In 1871, Oliver Wendell Holmes said in an address to the graduating class of Bellevue Hospital Medical College: «Your patient is no more entitled to the whole truth than to all the medicines in your saddlebags. He should only get what is good for him. Justice speaks in favour of equality and fairness of treatment. Hippocrates applied ethical principles to the individual relationship between doctor and patient. Today`s ethical practice must extend beyond the individual to the institutional and social sphere. This means that in addition to treating the patient fairly, the facility and staff must also be treated fairly. For example, it is not fair that a patient cannot make payments and that the institution must pay for treatments already performed for the benefit of the patient.

In 1914, Benjamin Cardozo, a judge on the New York Court of Appeals and later an associate justice on the Supreme Court, issued a decision that articulated the principles underlying the consent model for the conduct of medical procedures. Each of the 4 ethical principles must be considered a prima facie obligation that must be fulfilled, unless it conflicts with another principle in the specific case. In such a conflict, the physician must determine the actual obligation to the patient by examining the respective weights of the competing prima facie obligations, both in terms of content and context. Let`s take the example of a conflict that has a simple solution: a shock patient who was treated with urgent fluid resuscitation and the placement of an indwelling intravenous catheter caused pain and swelling. Here, the principle of charity takes precedence over the principle of non-malevolence. However, many of the conflicts physicians face are much more complex and difficult. Consider rejection of a life-saving procedure by a competent patient (e.g., induction of mechanical ventilation) or request for a life-threatening measure (e.g., removal of mechanical ventilation). Nowhere in the realm of ethical decision-making is conflict more pronounced than in the conflict of the principles of charity and autonomy. The Bolam test was found to be inappropriate for cases related to discussing risks with patients because the extent to which a physician may be inclined to discuss risks with patients is not determined by medical learning or experience. Case 1 At first glance, the patient`s autonomy must always be respected. Such respect is not only a matter of attitude, but a way of acting to recognize and even promote the autonomous action of the patient.

The autonomous person may freely choose values, loyalties or religious belief systems that restrict that person`s other freedoms. Jehovah`s Witnesses, for example, believe that it is wrong to accept a blood transfusion. Therefore, in a life-threatening situation where a blood transfusion is necessary to save the patient`s life, the patient should be informed accordingly. The consequences of refusing a blood transfusion should be clearly explained to the patient who is at risk of dying from blood loss. In the desire to «benefit» the patient, the physician may want to provide a blood transfusion, believing it to be a clear «medical benefit.» If the patient is properly and compassionately, he is free to choose to accept the blood transfusion in accordance with a strong desire for life or to reject the blood transfusion by giving greater priority to his religious beliefs about the falsity of blood transfusions, even to the point where he accepts death as a predictable outcome. This communication process must be compassionate and respect the patient`s unique values, even if they deviate from the standard goals of biomedicine. Not unique to the medical profession, but essential to its function, is the trust (Latin: fiducia) that the client places in the professional. First and foremost, it is assumed that the health professional will act in a manner that is in the best interests of the client. There is an inherently unequal power within a patient-physician relationship. As the Illinois Supreme Court noted, Judge Cardozo`s two reservations are «adulthood» and «common sense.» The patient must be «competent,» that is, over or below the legal age of consent, and judged intellectually and emotionally competent to make his or her own decision. The latter is called «Gillick» competence, named after the case in which this principle was established.2 The scriptures that specify ethical obligations (both in general and by physicians) come from millennia of writings that specify human rights (both in general and for patients).

The first writings containing ethical principles date from the Old Kingdom of the Egyptians, for example the autobiography of Nefer-seshem-re, around 2340 BC. Ethics began to flourish as a scientific discipline during the golden age of Greece (the time of Socrates, Plato and Aristotle) in the 5th century BC. In these respective cultures, discussions about the ethical duties of physicians date from the same period, for example an inscription on the tomb of Nenkh-Sekhmet, «Chief of Physicians», around 2400 BC, and the writings of the Hippocratic school of Kos in the 5th century BC. Deontological ethics or «duty» (which stems largely from the writings of Immanuel Kant in the late 18th century and is a dominant form of ethics in modern law and health care) imposes on individuals the obligation to respect the rights and freedoms of others. Based on decades of teaching and mentoring experience, I see doctors with «heart» and «head» qualities. Ethical and humanistic values shape the former, while knowledge (e.g. through study, research, practice) and technical skills (e.g. medical and surgical procedures) form the latter. Figure 1 is a representation of this model.

The morality that forms the basis of the model and the ethical principles that flow from it have been explained above. Virtues, some more closely than others, are linked to the principles of ethics. Compassion, a prelude to care, presupposes sympathy, is expressed in charity. Discernment is particularly valuable in decision-making when ethical principles collide. Reliability leads to trust and is a necessary virtue when patients put themselves in the hands of physicians during their most vulnerable time.