Three virtues to help doctors navigate ethical questions and not be too defensive

Recently, a patient with a rare autoimmune condition was under our care but unfortunately died less than two weeks into his admission. We had offered a treatment that could have prolonged his life but he declined for fear of adverse effects.

As he had been initially well and deteriorated very rapidly beyond our anticipation, we wondered in hindsight if we should have advocated more strongly for the potent but potentially toxic treatment that may have saved him.

Should we have pushed for the possibly life-saving treatment, or did we practise too defensively in emphasising the side-effects?

Such considerations will increasingly be on the minds of doctors here, after several incidents in recent years where doctors were censured for failing to adequately inform patients of potential adverse events from treatment.

This has fuelled concerns about a possible rise in defensive medicine, which involves doctors enumerating countless possible adverse outcomes from a recommended treatment for fear that one such outcome might befall the patient.

Clearly, this undermines the trust crucial in a doctor-patient relationship. If a doctor is too worried about untoward complications — or even legal action — to apply his professional judgement, the doctor-patient encounter is reduced to a mere transaction.

A vicious circle of a lack of trust with the attendant fear of harm for patients and blame on doctors perpetuates the adoption of defensive medicine.

This calls into question the relevance of the conventional medical ethics framework based on deontology in moderating defensive medicine.

In medical ethics, deontology is anchored by the four principles of beneficence, autonomy, non-maleficence and justice. Beneficence pertains to doing good to the patient while non-maleficence refers to doing no harm.

Autonomy entails respecting the patient’s right to choose and decide on his or her own care while justice considers the wider implications of any decision, which needs to be equitable to everyone.

Many medical treatments, while beneficial, also carry the risks of adverse outcomes. However, even if the benefit far outweighs possible harm, the final decision on pursuing a particular treatment lies with the autonomous patient.

The limits of a deontological framework become apparent in patients who refuse recommended treatments and face the inevitable dire consequences.

In geriatric practice, on occasions we encounter older patients who decline potentially curative surgery for malignant tumours due to a combination of reasons, including fear of peri-operative complications, resignation given their advanced age and a lack of trust in the medical team.

Here, the doctor’s duty to do good and desire to respect the decision of the patient are at odds and the existing ethical framework feels inadequate.

While deontology espouses beneficence, it does not provide guidance on what that entails. Furthermore, doctors may be inclined to practise defensively and hesitate to advocate for surgery for fear of blame should complications ensue. This is where virtue ethics can help.

Virtue ethics in Western civilisation originated from the Greek philosophers, in particular Aristotle. It focuses on the character of the person rather than the rightness of the action.

The cardinal virtues of prudence, fortitude and temperance can complement conventional medical ethics and make their execution more effective by equipping doctors with the qualities that enable them to realise the good they want to do.

Prudence alludes to the practical wisdom medical professionals possess by virtue of their expertise and experience to decide on the best treatment plan.

Fortitude is needed to persevere in the face of resistance from the patient so that the doctor will continue to act in the patient’s interest.

Temperance affords self-control as varied emotions and motivations can feature in the doctor-patient relationship.

We see virtue ethics at work in a recent commentary by Dr Desmond Wai. In his desire to do good and treat the patient, he almost overlooked the need to seek patient consent.

However, exercising prudence in discerning the most appropriate course of action and temperance in holding back his inclinations eventually helped him navigate the best path in that situation.

Indeed, doctors need to have temperance and prudence to maintain the delicate balance between holding back and advocating for the treatment deemed most beneficial so that the patient can exercise his autonomy in a way that is most helpful to him.

This is especially so when emotions can easily be stirred up in the course of doctor-patient communication on treatment options owing to differing opinions.

A lack of prudence and temperance, for example, can cause a breakdown in communication and thwart the good that the doctor wants to do.

A doctor who is wanting in fortitude, on the other hand, may easily give up on advising a patient who was quick to reject a proposed treatment.

Ultimately, by applying virtues, doctors can better build trust which enhances the doctor-patient relationship to secure the final good of the patient.

Defensive medicine will remain as long as there is mistrust between doctors and patients.

Most doctors already "do good” intuitively but virtue ethics makes the conventional medical ethical principles more tangible and helps doctors better appreciate the qualities they need to practise good medicine.

There is value for doctors to be reminded to apply these virtues daily to refine their medical practice. These virtues can be taught, but they are probably more effectively learnt through role modelling senior doctors who embrace and embody these virtues in their day-to-day medical practice.

To be sure, it would entail travelling the long road from the head to the heart and the hands and it may well be unrealistic to expect every single doctor to sign on to it.

Beauty, according to Thomas Aquinas, encompasses integrity, clarity and harmony. The beauty of medicine can be advanced by integrity of intent and action, clarity of information and communication, and harmony between doctors and patients.  

By embracing virtue ethics, a virtuous circle of trust founded on medical competence and upholding the patient’s best interest can help to defuse the cloud of mistrust and dispel the gloom of defensive medicine.

ABOUT THE AUTHORS:

Philip Yap is a Senior Consultant at the Department of Geriatric Medicine and director of Geriatric Centre, Khoo Teck Puat Hospital. Gabriel Wong is a Year 4 medical student of Yong Loo Lin School of Medicine, National University of Singapore.