#47174: Medical Ethics for Physicians

In today's ever-changing societal and healthcare environments, physicians are confronted with choices concerning what is best for their patients, their practice, their institution, or themselves; such choices often impose ethical considerations that challenge the physician to render a decision in accordance with the principles and values of the profession. These choices can become enmeshed in ethical dilemmas that emerge from conflicting values or administrative rules and legalities. Ethics issues range from the extraordinary, such as end-of-life decisions, to the mundane, such as whether to accept certain gifts from a pharmaceutical company, but all require some understanding of the ethical principles that govern best professional practice and test one's resolve to act in accordance with these values. When ethical dilemmas or conflicts of interest do arise, it is useful to be well informed as to how similar issues have been adjudicated in the past and what tools are at hand to assist in the decision-making process.

The precepts and principles contained within various ethical systems can assist in conceptualizing a problem-solving approach allied in resolving an ethical dilemma. Whether decision-making involves an individual facing end-of-life choices or an institution setting administrative policies, these systems and principles can help the healthcare professional clear the blurred lines that may develop in difficult ethical situations. For example, if a known use of illicit drugs demands opioid pain management, how then should appropriate treatment choices be made by those responsible for care? Other examples of potential management dilemmas might be an individual with alcohol use disorder needing a liver transplant, a patient with diabetes who seemingly refuses to adhere to a diet protocol, a sedentary businessman who resists lifestyle changes necessary for cardiovascular risk reduction, or a physician whose stress level is beyond the coping stage.

Oftentimes, the patient's aspirations or goals may not correspond with what the family or physician believes would be best. Even between seemingly alike individuals, with similar education and background, value systems may prove to be radically different. Consider the patient who refuses life support while the family insists they want every lifesaving measure taken, or conversely, the comatose patient whose family members want life support and other interventions stopped, even as the physician refuses to discontinue therapy.

Until fairly recently, the majority of clinical and ethical decisions in medicine were made by physicians acting in a paternalistic manner toward their patients. Questions regarding many issues, such as organ transplantation, assisted life support, patient self-determination, appropriation of dialysis, in-vitro fertilization, cloning, and even the use of generic drugs, did not arise. The reason is simple: these techniques and procedures were not available.

In order to better understand contemporary medical ethics, it is helpful to look back at how ethical principles, frameworks, and/or codes have evolved over centuries. More specifically, it is important to recall several 20th century events in research and medicine that solidified the need for the study and application of ethics and lead to the emergence of the field of bioethics. The following pages present a brief discussion of some of the information regarding ethical issues in medicine as it pertains to the role of physicians in the 21st century.

Bioethics is a relatively new field that emerged in the 1960s, prompted in part by rapid technologic advances in medicine and the subspecialization of clinical care. The advent of antimicrobial and cancer chemotherapy, valve and joint replacement surgeries, and organ transplantation provided the means to greatly improve outcomes and prolong life but added new complexities to the clinical decision-making process. The convergence of modern means and rising healthcare costs created the need to talk about how medical and healthcare regulations should be made, who should make them, and what their implications might be for the long term. In the late 1960s, philosophers, theologians, physicians, lawyers, policy makers, and legislators began to write about these questions, hold conferences, establish institutes, and publish journals for the study of bioethics. In 1969, the Institute of Society, Ethics, and the Life Sciences was established at Hastings-on-the-Hudson, New York. Two years later, the Kennedy Institute of Ethics was established at Georgetown University, in Washington, DC.

Prior to the 1960s, medical care decisions were part of the paternalistic role of physicians in our society. Patients readily acquiesced care decisions to their physicians because they were regarded almost as family. What drove this resolve of patients to acquiesce their medical care and treatment decisions to their physicians? David Rothman, as discussed in his book, Strangers at the Bedside: A History of How Law and Bioethics Transformed Medical Decision Making, believes physicians were given such latitude by their patients because they were well-known and trusted by their patients and the community in which they practiced [1]. There were essentially no specialists. One physician took care of a patient and family for a lifetime. The frontier physician often knew the patient from birth to adulthood, made house calls, and was a family friend who knew best what the patient should do with a healthcare concern. Since the 1960s, physicians have generally become strangers to their patients.

The trend away from the family doctor making all the healthcare decisions toward a healthcare system replete with specialists, policy makers, ethical codes, administrative codes, and informed consent was brought about largely by three events in U.S. History. First, World War II research and experimentation (e.g., experimentation on concentration camp prisoners by the Nazis, research on atomic bomb survivors) brought attention to people as test subjects and what rights should be recognized on their behalf. Second, the modern structuring and organization in healthcare delivery moved patients from their familiar surroundings of home and neighborhood clinics to the often intimidating, large hospital. Third, the medical technologic boom brought life-saving interventions; people now live longer due to major advances, such as improved diagnostic procedures, antibiotics, new surgical techniques, and vaccines.

Extensive publicity about three research projects resulted in the establishment of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The first project involved elderly patients with chronic illness who were injected with live cancer cells in an effort to discover whether the cells would survive in a person who was ill but did not previously have cancer. No consent was obtained from patients or family members before proceeding.

The second project began in 1932, when the Public Health Service initiated a syphilis study on 399 black men from Tuskegee, Alabama. The goal of the study was to observe the men over a period of time to examine how the disease progressed in individuals of African descent. When the study began, there was no cure for the disease; however, fifteen years into the study, penicillin was discovered to be a cure for syphilis. The research participants were never informed, and treatment was withheld in spite of the fact that by the end of the experiment in 1972, 128 men had died either from the disease or related complications [2].

Finally, in 1967, children with mental retardation at the Willowbrook State School, New York, were given hepatitis by injection in a study that hoped to find a way to reduce the damage done by this disease. Although consent was obtained in this study, the consent sometimes had an element of coercion. Gaining admission to the school was difficult and parents were given a guarantee their child would be admitted if they consented to the participation of their child in the study.

In response to these events, the National Commission for the Protection of Human Subjects was created in 1974 by public law. Finally, in 1979, the commission published The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research [3]. This commission recommended that all institutions receiving federal research funding should establish institutional review boards (IRBs). These boards, made up of researchers and lay people, were to review biomedical and behavioral research proposals to ensure that they met ethical standards for protecting the rights of the potential subjects. For many, this was an initial entry into what would later be called bioethics.

In 1973, the first edition of the Hastings Center Studies pointed out the problems they felt were most important to consider when developing healthcare research projects [4]. Remarkable advances were projected in the areas of organ transplantation, human experimentation, prenatal diagnosis of genetic disease, the prolongation of life, and control of human behavior. All of these had the potential to produce difficult problems, thus requiring that scientific knowledge be matched by ethical insight.

Soon, the federal government, private philanthropists and foundations, universities, medical schools, and committed professionals moved quickly to address these questions. The federal government supported programs through the National Science Foundation's Ethics and Values in Science and Technology (EVIST) and the National Endowment for the Humanities, which developed applied medical ethics courses for medical students and college undergraduates. Universities established departments, institutes, and programs in bioethics, including some in which graduate studies could be pursued. Professional organizations (including local bar and medical associations) began to establish committees to look at ethical issues in healthcare. In addition, such interdisciplinary organizations as the Society for Health and Human Values came into existence, including among their members physicians, nurses, social workers, attorneys, theologians, and philosophers.

Hospitals also began to consider how bioethical concerns affected the care they provided patients. In 1976, the Massachusetts General Hospital Critical Care Committee published its recommendations for treating hopelessly ill patients and for using critical care facilities. In Catholic hospitals, committees were formed not only to discuss such specific care issues as sterilization, but also to consider the more general question of how Catholic values should be implemented in their hospitals.

In November 1978, The President's Commission for the Study of Ethical Problems in Medicine and Medical and Biobehavioral Research was created [5]. Its members began work in January 1980. The United States Congress charged them with conducting studies and reporting on a number of topics, including the definition of death, informed consent, and access to healthcare. By spring 1984, the commission had published nine reports addressing many of the problems facing the healthcare system.

These reports stand as a foundation for the organized and socially sanctioned study of the ethical implications of high-technology medical care and ethical regulation of the healthcare industry. The remainder of the 1980s and early 1990s saw continued emphasis on the protection of individual rights. However, more attention began to be paid to the allocation of resources and the effectiveness of complex treatments, especially in terms of the quality of life associated with the prolonging of lives.

The President's Commission, like the National Commission for the Protection of Human Subjects before it, established a model for finding consensus and for articulating ethical conflicts when consensus could not be found. They did for the nation what each ethics committee does for its own hospital or individual health agency.

It was during these transitional years that ethics, law, and medicine began to form an alliance. The legal and medical professions were often on opposite sides of an issue. However, they found themselves increasingly working toward the same goals.

It was the New Jersey Supreme Court Decision in the Karen Ann Quinlan case that brought bioethics to the level of the individual through the media and transformed physician paternalistic authority into patient-physician shared decision making [6]. Patient autonomy issues came into public focus in the 1970s when the legal community set a precedent for deciding withdrawal/withholding of life-sustaining treatment. Although there were many related cases with decisions on medical treatment and decision making for competent and incompetent patients, two cases are recognized as landmark cases and were the most important in influencing the medical and legal community. These two cases were most responsible for moving the primary healthcare decision making into the hands of the individual. These court cases are the previously mentioned New Jersey Supreme Court Decision in the Matter of Karen Ann Quinlan (1976) and the U.S. Supreme Court Decision in the Matter of Nancy Cruzan (1990) [7]. From these two cases, and more specifically from the Nancy Cruzan case, the Patient Self-Determination Act (PSDA) of 1990 was enacted [8].

The National Comprehensive Cancer Network recommends asking patients if they have a living will, medical power of attorney, health care proxy, or patient surrogate for health care. If not, patients should be encouraged to prepare one.

(https://www.nccn.org/professionals/physician_gls/pdf/palliative.pdf Last Accessed: January 13, 2023)

Level of Evidence: Expert Opinion/Consensus Statement

Although this multi-state consensus was not without exception, these were the precursor principles to the PSDA of 1990, a federal law given over to the states to implement as of December 1, 1991 [8]. This new legislation applied to hospitals, nursing homes, hospice, HMOs/PPOs, and any other facilities that received funds from Medicare or Medicaid programs. It mandated that each of the affected facilities must advise their patients of their legal rights and options for accepting or refusing treatment if they (the patients) should become unable to speak for themselves. The primary provisions of the PSDA are:

Finally, legislation was created to keep end-of-life medical decision-making issues out of the courts and in the appropriate arena, with the appropriate players: the patient/family and the healthcare professionals. The central focus of the law is the provision of patient education. The means or the tool for the individual to document his or her wishes for future healthcare decisions is called an advance directive. There are two types of advance directives available. Although both are not required to be completed together, most people are encouraged to do so.

STANDARDS OF ETHICS, RIGHTS, AND RESPONSIBILITIES

Many situations require only listening and someone to support the patient and family through the process of decision making. The Joint Commission has established standards on patient rights, including ethical decision making. Very clearly, the Joint Commission has outlined that hospitals should have defined policies and procedures allowing patients to create and modify advance directives. The 2000 Joint Commission Standards regarding patients' rights to formulate an advance directive, to have a mechanism in place to deal with ethical issues, and for their rights to accept or refuse care, is found in Figure 1. Because the information in Figure 1 presents so many useful concepts in a single page, it remains a part of this course although it is no longer contained in the current Joint Commission manual [9].

JOINT COMMISSION PATIENT RIGHTS STANDARDS ON ETHICAL ISSUES

Figure 1

Source [4]

This form has since been replaced with an entire section titled "Rights and Responsibilities of the Patient," which appears in the 2022 revision of the Comprehensive Accreditation Manual for Hospitals published by the Joint Commission [9]. This section outlines the standards that healthcare organizations must follow in order to obtain or maintain accreditation. The expanded standards section makes it easier for healthcare organizations to test their compliance and for reviewers to rate them.

The Joint Commission requires healthcare organizations to follow their state laws. If a person is from out of state, they may have an advance directive that does not comply with the state laws where the patient is hospitalized. Some attorneys advise hospitals treating patients who bring advance directives from out-of-state to ask them to complete an advance directive for the state in which they are being treated. What if the patient presents to a hospital in a coma? The hospital must work with the advance directive provided. Some states allow surrogate decision makers for patients under certain conditions, such as terminal illness or vegetative state. Those laws usually require the physician to certify that the patient meets the medical conditions before allowing a surrogate decision maker to step in. When there is no advance directive, some states allow the patient's spouse or adult children (or other direct relatives listed in a specified order of preference) to decide for the patient.

The major ethical principles of significance to physicians and other healthcare personnel are respect for persons, autonomy, veracity, beneficence, non-maleficence, justice, fidelity, and right-to-know [10]. These terms are used widely in bioethics and should be briefly defined:

Ethical decision making is the generic term for the process of making a decision within an ethical context in a specific setting (e.g., business, education, or medicine). Ethics are the beliefs an individual or group maintains about what constitutes correct or proper behavior [11]. To put it simply, ethics are the standards of conduct an individual uses to make decisions. The term morality is often confused with ethics; however, morality involves the judgment or evaluation of an ethical system, decision, or action based on social, cultural, or religious norms [11,12]. The word "morals" is derived from the Latin word mores, which translates into customs or values.

The foundation from which ethical principles originated began from debates and discussions in ancient times. These ethical principles then became the theoretical framework upon which actions as individuals and societies are based. Most prominently, the Hebrew biblical covenants and the teachings of Greek philosophers, such as Plato and Aristotle, form the basis for most of the familiar ethics and morals prevalent in Western society today.

How then are theoretical ethics translated into the day-to-day practical application of those principles in today's rapidly changing, technology-driven world? It really boils down to a deductive reasoning process that starts with the broad and generally accepted ideas of what constitutes proper respect for the individual and how people should act within society. Then, the process narrows in focus to a smaller group or individual situation in which the ethical principles serve as a guide for daily living. When a situation presents itself that contradicts the established "norm," it may cause a dilemma. When these dilemmas are of an ethical nature, we often say the situations are controversial or have called into question or infringed upon a group or individual's rights based upon accepted ethical theories and moral practices.

How does one move from general ethical concepts, based on religious or philosophical theoretical frameworks (discussed later in this course), to practical application for patient/society healthcare decision making? Ordinarily, an ethical conflict presents itself when a person's or group's ethical values or principles are challenged or conflict with one another over some decision related to clinical care. It is imperative to identify what principles or values are in conflict so that an appropriate resolution can be made.

A dilemma occurs when one is faced with what is perceived (or is in reality) to be no alternative, only one alternative, or an either/or choice situation. This dilemma scenario leaves the individual with limited, often painful choices. "Have the surgery or die," may be the only two alternatives given to a patient. This can leave the patient immobilized, powerless, feeling subservient and victimized, and with no sense of control. Providing options accompanied by explanation, context, probabilities, and one's professional judgment, while no less dire, may assist the individual by giving him or her a sense of freedom and participation in the decision-making process. Whether an ethical dilemma exists or not should be the first question. It may simply be conflict arising out of poor communication, which is usually resolved when clarification occurs. Once an ethical dilemma or conflict is determined to exist, one can begin a step-by-step process to open the discourse and begin the decision-making process.

There are a myriad of ethical issues facing patients, families of patients, and physicians today. Examples of these issues include organ transplantation, fetal surgeries, infants with severe anomalies, lifesaving surgery, stem cell research, inability to reach health services, and the rationing of healthcare. Still other issues involve competency of healthcare workers, nurse-physician relationships, treating non-compliant patients, and many more situations that apply to individuals or to the nation on a societal level.

One of the most common ethical issues facing healthcare professionals in patient care settings is the withholding or withdrawing of treatment. Most healthcare institutions are required to have policies and procedures in which the rights of the patient/family and the duties of the healthcare professionals are outlined. It is only when there is a conflict between the parties involving value or moral principles that a dilemma may arise. Often, the real problem may be one of three non-ethical related issues: poor communication between the involved parties, an administrative misunderstanding, or a legal ambiguity.

The first step that should be taken is to gather information about the patient's diagnosis, prognosis, and treatment options, followed by the best medical judgments regarding life expectancy and quality of life with or without treatment. This must include a discussion of the risks and side effects of such treatment. Of equal importance, the patient (if legally competent) must be fully informed and have his or her statement of wishes honored.

Should the patient be temporarily or permanently unable to speak for him or herself, the immediate family, if available, should be consulted. As discussed, most statutes on the right to die, withholding and withdrawing life sustaining treatment, and organ donation identify an individual's immediate family member (usually in a specific order of priority) who can speak for the individual. One question to ask the patient, if competent, is whether or not he or she has an advance directive. This is usually accomplished by the nursing staff, but all healthcare professionals should be certain that it has been done. Administrative factors, such as the risk of liability, current institutional policies, and economic factors that affect the individual family, must also be evaluated.

With this information gathered, it should be apparent whether or not a value conflict exists. Many times, just the process of gathering information allows for clarification and for differences to be resolved. If an ethical dilemma ensues, the next step is to articulate the ethical principles that are opposing one another.

There are numerous ethical theories. Six fundamental theories that directly concern healthcare professionals are deontologic, teleologic, motivist, natural law, transcultural, and relative/multicultural ethical theoretical systems. These systems are each made up of principles, precepts, and rules that form a specific theoretical framework to provide the follower with general strategies for defining the ethical actions to be taken in any given situation.

It is important to remember that ethical theories are just that, theories. They do not provide absolute solutions for every ethical dilemma. They do provide a framework for ethical decision making when adjoined to the critical information gathered from patients and families.

In reality, most healthcare professionals combine the theoretical principles that fit best for the particular patient situation. Whenever the physician-patient relationship is established, a moral relationship exists. Though not an inherent gift, moral courage combined with moral reasoning is required in order to reach ethically sound decisions. This is a skill, and moral reasoning must be practiced so it becomes a part of any healthcare professional's life.

Although all ethical systems concern decisions about ethical problems and ethical dilemmas, the decision reached in regard to a specific conflict will vary depending on the system used. For example, a healthcare professional assigned to care for a patient in the terminal stages of acquired immune deficiency syndrome (AIDS) might have strong fears about contracting the disease and transmitting it to his or her family. Is it ethical for him or her to refuse this assignment?

In answering this question on the basis of utilitarianism, one might weigh the good of personal family members against the good of the patient. Based on the greatest good principle, it would be ethical for the healthcare provider to refuse to care for the patient. In addition, because utilitarianism holds that the ends justify the means, preventing the spread of human immunodeficiency virus (HIV) to the worker's family would justify refusal of the assignment.

Applying deontology to the question, duty and justice are the underlying and unchanging moral principles to follow in making the decision. A person who becomes a healthcare worker accepts the obligations and duties of the role. Caring for patients with infectious diseases is one of those obligations; therefore, refusal would be a violation of this duty. In this system, another unchanging moral principle, justice, would require healthcare professionals to provide adequate care for all patients. Refusing to care for a patient with AIDS would violate this principle.

According to the natural law system, refusing to care for a patient with AIDS would be unethical. One of the primary goals of the natural law system is to help the person develop to maximum potential. Refusing to have contact with the patient with AIDS would diminish the patient's ability to develop fully. A good person, by natural law definition, would view the opportunity to care for a patient with AIDS as a chance to participate in the overall plan of creation and fulfill a set of ultimate goals.

Although such decisions are usually made on a practical, not a theoretical level, at times it is important to be able to relate a decision to its underlying system or principle.

In the course of medical training, physicians are frequently taught to apply a very strict standard in the determination of a patient's capacity or ability to make decisions. A framework for ethical decision making presupposes that physicians making decisions know that a system of ethics exists, the content of that ethical system, and that the system applies to similar decision-making problems despite the multiple variables. As an example, many institutions have adopted policies that do not allow a medicated patient to sign consent forms within a specified time. But the chronic pain management patient on continuous high-dose opioid pain control may not have the capacity of reason.

From an ethical point of view, the patient is a capable decision maker if he or she can understand information relevant to the decision at hand, interact and communicate with caregivers about the decision, and weigh the possible alternatives. A general checklist upon which to set up an ethical framework comes from the Handbook for Hospital Ethics Committees. One might abide by the following steps [18]:

Whenever possible, the patient or family makes the final healthcare decision. The first and most important step is the collection of a database, which involves gathering and assessing the facts. The nursing staff can be instrumental in facilitating the stages of ethical action. The following is a general outline of each step and the process that develops as one moves through the individual stages. In each step, questions are offered to help the healthcare professional gather all the information necessary to assist the patient and healthcare team in the decision-making process.

It is important to note that using professional interpreters for patients and with limited English proficiency will help ensure quality care. Convenience and cost lead many clinicians to use "ad hoc" interpreters (e.g., family members, friends, bilingual staff members) instead of professional interpreters. However, professional interpreters are preferred for several reasons. Several states have laws about who can interpret medical information for a patient, so healthcare professionals should check with their state's health officials about the use of ad hoc interpreters [19]. Even when allowed by law, the use of a patient's family member or friend as an interpreter should be avoided, as the patient may not be as forthcoming with information and the family member or friend may not remain objective [19]. Children should especially be avoided as interpreters, as their understanding of medical language is limited, and they may filter information to protect their parents or other adult family members [19]. Individuals with limited English language skills have actually indicated a preference for professional interpreters rather than family members [20].

Most important, perhaps, is the fact that clinical consequences are more likely with ad hoc interpreters than with professional interpreters [21]. A systematic review of the literature showed that the use of professional interpreters facilitates a broader understanding and leads to better clinical care than the use of ad hoc interpreters, and many studies have demonstrated that the lack of an interpreter for patients with limited English proficiency compromises the quality of care. The use of professional interpreters improves communication (errors and comprehension), utilization, clinical outcomes, and patient satisfaction with care [20,22]. One review of case studies regarding professional interpretation noted that "patients with limited English proficiency in the United States have a legal right to access language services, and clinicians have legal and ethical responsibilities to communicate through qualified interpreters when caring for these patients" [23].

Many physicians have known an old, wise, and respected clinical colleague who told of helping patients with terminal cancer in intractable pain "go more easily (and quickly) with a bit of extra morphine sulfate." Of course, this action was performed quietly, with permission from the patient and/or his or her family (not written) and the tacit understanding of the nursing staff. This is in contradistinction to the retired pathologist Dr. Jack Kevorkian, who flagrantly performed an assisted suicide on a patient with national television coverage in 1998. He was subsequently convicted of second-degree murder for the act and sentenced to 10 to 25 years in prison. In October 2002, the U.S. Supreme Court rejected his appeal to overturn the verdict. As will be discussed, in 1997 the Court had previously decided that there is no constitutional right to physician-assisted suicide.

The physician-assisted suicide debate, like the abortion issue, is many sided, with differing opinions from members of all religious and cultural groups. What is somewhat unusual is that the subject has appeared on the ballots in some states to allow the voting public to cast an opinion. However, as noted, the judiciary's opinion in the matter often leads to the final decision. There are two court cases that are of major importance in this matter; they are the cases of Dennis Vacco v. Timothy Quill, MD, et al. in New York and the State of Washington v. Glucksberg.

On June 26, 1997 the U.S. Supreme Court decided these two cases, reversing the landmark court of appeals decisions that had invalidated laws in New York and Washington that criminalize physician-assisted suicide [24].

In March 1996, the Ninth Circuit Court of Appeals had concluded in Compassion in Dying v. State of Washington (now titled State of Washington v. Glucksberg) that there is a constitutionally protected liberty interest in determining the time and manner of one's own death. It then ruled that a Washington state law prohibiting physicians from prescribing life-ending medication for use by terminally ill, competent adults violates this Fourteenth Amendment due process right [24].

The Second Circuit Court of Appeals in Quill v. Vacco, invalidating New York's similar law on a narrower ground, concluded that the statute violated the equal protection rights of mentally competent, terminally ill persons. Given that those on life support systems are permitted to hasten their deaths by having their doctors take them off life support, the court found no reason to prohibit those in the final stages of their illnesses who are not on life support from making the same choice by requesting lethal medication from their physicians [25].

In opinions authored by former Chief Justice Rehnquist, the Supreme Court rejected the argument that the state statutes outlawing assisted suicide infringed upon any fundamental right, and concluded that, because all competent persons are entitled to refuse lifesaving medical treatment and no one is permitted to assist a suicide, that there was no different treatment of similarly situated persons to trigger the Equal Protection Clause of the Fourteenth Amendment [24].

Although all nine justices agreed with the result, there was observation that this result "permits the debate [about assisted suicide] to continue, as it should in a democratic society" [24]. A majority of the justices made it clear that after public debate and legislative consideration have run a reasonable course, they might rule differently in a different case at a later time [25]. It is interesting that in both of these cases the plaintiffs included physicians and terminally ill patients who desired to overturn state statutes that made it illegal for physicians to assist patients in ending their lives.

Some states, most notably Oregon, have used voter initiatives to attempt to change the law. In January 2006, the Supreme Court upheld Oregon's 1997 Death with Dignity Act (DWDA), a unique initiative that allows physicians to prescribe lethal doses of prescription medicines to patients diagnosed with a terminal illness that will lead to death within six months [26]. As it now stands, a patient may make a written request that medication be prescribed to end his or her own life. There must be two witnesses to attest that the patient is competent, one of which shall not be a family member; the attending physician also may not be a witness. No criminal, civil, or disciplinary action may be brought against any person involved in implementing or witnessing the act. The Act requires the Oregon Health Authority to collect information about patients and physicians who participate in the Act. In 2021, 238 people had died from ingesting the prescribed medications. This number included 20 patients who had received physician prescriptions in previous years [27].

The American Medical Association (AMA) published its first Code of Medical Ethics in 1847, shortly after establishment of the organization that same year [28]. The AMA Council on Ethical and Judicial Affairs (CEJA)—composed of seven practicing physicians, one fellow or resident, and one medical student—is responsible for developing, maintaining, and updating the AMA's ethical guidelines to keep pace with the evolution of medicine and healthcare practice [29]. The Code is updated periodically to address the changing conditions of medicine. The current edition, adopted in June 2016, is the culmination of an eight-year project to comprehensively review, update, and reorganize guidance to ensure that the Code remains a timely, easy-to-use resource. The Code is accessible online at the AMA website and may be downloaded or purchased in book form.

The "Principles of Medical Ethics" is the first section of the current AMA Code and outlines basic standards of practice [30].

Familiarity with and adherence to the AMA Code of Medical Ethics can offer a degree of protection from the various pitfalls of practicing medicine in contemporary American society, such as administrative sanctions and malpractice suits. Following federal, state, and local laws, along with any/all ethical codes or rules where practicing, offers further protection from legal or administrative action; however, ethical medical principles are primarily intended to benefit the patient during their time of uncertainty. The goal of ethics, and ethical practice, is to do right by the patient, avoid harm, and maintain trust with the patient and the public, so essential to the humane and safe practice of medicine. The physician with a good understanding of ethics is equipped to serve the patient well; to listen, inform, and provide a measure of autonomy; and, when necessary, confront difficult choices or ethical dilemmas with the confidence required to make sound decisions.