**4. Other medical ethical principles**

Aside from the four basic biomedical ethical principles, we will discuss the following ethical principles: medical confidentiality, truth-telling, and futility.

#### **4.1 Medical confidentiality**

In a trust-based patient-physician relationship, medical confidentiality is a fundamental prerequisite that goes back to the Hippocratic oath [45]. Putting forth that physicians must keep their patients' secrets, the principle of medical confidentiality is one of the most respected moral obligations in medical ethics [46]. Medical confidentiality involves respecting the privacy of others regarding their health and keeping their secrets; those who do not fulfill this obligation face criminal sanctions in many countries. A physician-patient relationship is primarily characterized by medical

confidentiality, which means that physicians must remain silent about their patients' information [47].

#### **4.2 Truth-telling**

The patient-physician relationship and communication are based on trust and telling the truth is a key way to develop and maintain this trust [48]. Telling the truth is often considered a virtue and there is almost a universal phenomenon that physicians are obliged to tell the truth and not lie [49]. Kant assumes that it is a prominent duty, to tell the truth, and deontologically, competent patients must be told the truth, no matter the consequences [50]. The obligation, to tell the truth, is accompanied by a sign of respect for the patient's autonomy. For such cases, the question is how patients can learn the truth about themselves, given that they are entitled to full and accurate information about their medical condition [51]. For example, after diagnosing a life-threatening illness, it may seem appealing and sensible to tell the patient that it can be cured by other physicians, avoiding delivering bad news by eliminating or minimizing the severity of the condition, but it is absolutely unacceptable from an ethical perspective [52]. Still, hiding information from patients, deliberately giving false information, lying, and delivering false information without lying have occurred in nursing and medical practices for centuries [53, 54].

#### **4.3 Futility**

Most oncology patients can receive various supportive treatments to have their lives extended for a short time, which brings along prolonged suffering [55]. When treatment becomes meaningless, such treatment decisions should be reviewed. Withdrawal or withholding of life-sustaining treatment decisions are common across emergency departments and adult, pediatric, and neonatal intensive care units, and they are often made before most deaths occur [56]. Withdrawal or withholding of life-sustaining treatment cannot be considered murder or suicide [57], nor passive euthanasia [55].

Withdrawal or withholding of life-sustaining treatment has been increasingly used in institutions that provide end-of-life care [58]. Conceptually, withholding refers to the discontinuation of a treatment that is deemed necessary for living, while withdrawal refers to the discontinuation of a life-sustaining treatment [59]. Though both concepts are used together in this context, withdrawal seems more appropriate at the end of life [60]. In the intensive care units in North America and Europe, lifesustaining treatment has some form of limitation, but end-of-life practices are highly variable [61].

The futility approach is not a new concept; its discussion in the medical and ethical literature began in the 1980s [62]. "Physicians have been advised by Hippocrates to *refuse to treat those who are overmastered by their disease, realizing that in such cases medicine is powerless*" [63, 64]. According to Lo et al., physicians are advised to limit treatment for these four reasons: "the treatment is futile, the patient declines the treatment, the quality of life is unacceptable, or the costs are too great" [62]. According to Trotter, for medical futility to occur, three conditions must be met: setting a target, undertaking an action to achieve this target, and determining the certainty that the action will fail [65].

There is no mutually agreed definition for medical futility, as most definitions tackle the concept from different perspectives. One definition goes as follows:

"a physician's prognostic pronouncement that as a consequence of irretrievable illness or injury, further therapy will not improve the patient's condition and, therefore, should not be attempted" [66]. Still, regardless of the circumstances, if the families are in a position to make decisions, they may demand the continuation of life-sustaining treatment, even if it may not be beneficial for the patient [67].

#### **4.4 Examples**

The relatives of a patient who receives end-of-life care may be emotionally overloaded, leaving them vulnerable to manipulation or driving them to manipulate the physicians. The most appropriate way to eliminate such manipulations from either party is medical ethical principles.

Patients and/or their families may be guided by a healthcare professional to seek a nonbeneficial, alternative treatment for an oncological disease that cannot be cured by modern medicine, and they may get false hopes regarding such treatments. They may even make catastrophic expenditures, using all their savings to seek such healthcare. This is quite a common example. Let us look at this example from the perspective of the four biomedical ethical principles. The patient and their families were not told the truth, and they were given incorrect information, which is against the principle of respect for autonomy and telling truth. The patient and their family were given false hope with methods that may harm them, which violates the principle of nonmaleficence and beneficence. The physician involved services that are not beneficial or evidence-based, which is against the principle of beneficence. Finally, the patient's chance to spend quality time with their loved ones was taken away, causing them to make catastrophic expenditures, which violates the principle of futility and beneficence.

A male patient did not respond to non-opioid analgesics and had pain and severe weight loss. He was diagnosed with incurable pancreatic cancer and was receiving PC at the hospital center. The patient's pain subsided after the opioid analgesic. The patient's daughter was in tears, worried that her father would become an opioid addict, so she wanted the opioid analgesics to be discontinued for 1 month. She also wanted to know if metastatic cancer in his liver grew, and therefore she requested radiological examinations. Believing that the demands made by the patient's daughter might be the patient's last wishes, the physician discontinued the opioid analgesics and ordered radiological imaging. Let us look at this example from the perspective of the four biomedical ethical principles. The physician discontinued the medication and requested radiological examinations without asking the patient's opinion, which violates the principle of respect for autonomy. The physician discontinued a drug that the patient was benefitting from, which is against the principle of beneficence. The physician caused more pain by discontinuing the drug, which violates the principle of nonmaleficence. Finally, the physician requested unnecessary radiological examination, which is against the principle of justice.
