**5. Issues in implementing ethical principles**

In theory, the description of ethical principles seems to give a clear overview of medical ethics and the procedures to be followed when making treatment decisions.

However, in clinical practice, the application of ethical principles is increasingly complex and is often affected by issues that complicate the decision-making process and come into conflict with ethical principles. Some issues arise when different principles clash with each other; others are linked to patient-specific situations, while yet others are linked to the organisation of services.

With regard to the conflict between principles, a common opposition may arise between the principles of autonomy and beneficence, for example in terminal cancer patients. According to the principle of autonomy, the patient should be told that her

**317**

*The New Challenges for Medical Ethics DOI: http://dx.doi.org/10.5772/intechopen.94833*

than one result and contrasts two principles [17].

2.the improvement in quality of life

3.the duration of the benefit to the patient

4.the urgency of the patient's condition

older people remain open.

condition is now terminal, to allow her to freely choose among treatment options and decide what to do with the time she still has to live. However, under the principle of beneficence, one might argue that providing such accurate information might cause deep pain, and hence be harmful to the patient, affecting negatively her will to live and her quality of life in the time left to her. Moreover, the conflict between the two principles is not an abstract one; on the contrary, it is experienced by the parties to the decision-making process, with real consequences. The principle of autonomy can be interpreted in very different ways by doctors. For example, some doctors might resort to the legacy of medical paternalism and feel authorised to deliver all the bad news to the patient; other doctors could rely on the principle of autonomy to avoid making difficult decisions by shifting the responsibility onto the patient and/or her family members, placing a heavy emotional burden on the patient; still other doctors may not provide the full set of options to their patient to prevent her from making decisions that the doctor does not consider beneficial to her, resorting to a sort of 'palliative paternalism' [22] and thereby arbitrarily reducing the patient's free choice. Conflict may also occur between the principles of beneficence and non-maleficence. An example is found in pain management for terminal patients, where the use of opioids relieves pain and meets the beneficence principle, but may shorten life, thereby violating the non-maleficence principle. Both principles are not absolute and are often combined, as in the above example, giving rise to the 'double effect' phenomenon, a term that in bioethics refers to an action that can have more

1.Other issues in the application of ethical principles arise when healthcare systems have to contend with limited resources. In these cases, the first ethical problem is patient selection for access to and discharge from care, which clashes with the principles of beneficence, non-maleficence and justice [23, 24]. The American Medical Association [25] has provided guidance on the ethical implications of the allocation of organs for transplant, which may be helpful in the task of determining priority of access to scarce and costly medical resources. The AMA paper has identified five criteria related to the patient's Medical Needs, which should be considered when making resource allocation decisions: likelihood of benefit

5.only in some cases, the amount of resources required for successful treatment

These criteria help to maximise three primary goals of medical treatment: number of lives saved, number of years saved and improvement in quality of life. A hierarchy of objectives prioritises the goal of saving the greatest number of lives. [25] While the AMA document makes an important contribution to ethical decision-making, many questions about distributive justice and discrimination against

Furthermore, major social changes have affected the organisation of health systems and have further complicated the application of ethical principles. The globalisation of modern society, with its marked contradictions, inequalities and injustices has also inevitably affected healthcare systems. The undoubtedly successful McDonaldization phenomenon, [26], characterised by efficiency, productivity, cost reduction, procedural standardisation and control, has also influenced the

#### *The New Challenges for Medical Ethics DOI: http://dx.doi.org/10.5772/intechopen.94833*

*Bioethics in Medicine and Society*

no matter what, even if its positive impact may be minimal or zero (patient

4.What is the moral dilemma? The matter here is not to choose the best course of action, but to identify clearly the moral dilemma faced by the doctor and the whole team, spelling it out in the most explicit and detailed way. What must be decided is not whether to operate on a patient who demands a treatment that will yield little or no benefits, but whether to prioritise the patient's autonomy, and what he considers to be beneficial, or to prioritise the professional autonomy of the doctor, expressed through his clinical judgement on a procedure that he considers to be maleficent (a useless operation that will cause suffering to

5.What are the alternatives? All too often, emotionally charged situations lead to a polarisation of views between just two possibilities. In the example in point 3, the only two options considered are surgery versus non-surgery. Instead, all options should be considered and presented to both the patient and his family

6.Which was the initial spontaneous choice? It is always advisable to return to the first spontaneous choice and assess whether the position of the main parties has evolved, and whether they have moved closer or farther apart from each other or have otherwise changed their views. If a change of position did happen, it should be considered whether this could help to reduce the conflict.

7.Making the decision. The decision must be made after consultation with the main parties involved, first and foremost the patient, but also his family members (where their involvement is authorised by the patient), the medical team, etc. It is important to have an open attitude and to truly listen. The patient must be seen not only from a medical point of view, but as an all-round individual with a life story, beliefs and concerns. As J. F. Malherbe [21] said, the patient remains the protagonist of his illness and not just the object of treatment. One should not hesitate to consult a colleague to get a second opinion, or even the hospital's ethics committee. After exhausting all these steps, a decision must be made. The decision must be justified by taking into account the medical evidence for each situation, but also the ethical issues specific to the situation. It is essential to specify which elements justify the principles that

In theory, the description of ethical principles seems to give a clear overview of medical ethics and the procedures to be followed when making treatment

However, in clinical practice, the application of ethical principles is increasingly complex and is often affected by issues that complicate the decision-making process and come into conflict with ethical principles. Some issues arise when different principles clash with each other; others are linked to patient-specific situations,

With regard to the conflict between principles, a common opposition may arise between the principles of autonomy and beneficence, for example in terminal cancer patients. According to the principle of autonomy, the patient should be told that her

autonomy vs. doctor autonomy vs. fair allocation of resources).

the patient) and to entail an unfair allocation of resources.

members: chemotherapy, palliative care, home care, etc.

were given priority in the decision-making process.

while yet others are linked to the organisation of services.

**5. Issues in implementing ethical principles**

**316**

decisions.

condition is now terminal, to allow her to freely choose among treatment options and decide what to do with the time she still has to live. However, under the principle of beneficence, one might argue that providing such accurate information might cause deep pain, and hence be harmful to the patient, affecting negatively her will to live and her quality of life in the time left to her. Moreover, the conflict between the two principles is not an abstract one; on the contrary, it is experienced by the parties to the decision-making process, with real consequences. The principle of autonomy can be interpreted in very different ways by doctors. For example, some doctors might resort to the legacy of medical paternalism and feel authorised to deliver all the bad news to the patient; other doctors could rely on the principle of autonomy to avoid making difficult decisions by shifting the responsibility onto the patient and/or her family members, placing a heavy emotional burden on the patient; still other doctors may not provide the full set of options to their patient to prevent her from making decisions that the doctor does not consider beneficial to her, resorting to a sort of 'palliative paternalism' [22] and thereby arbitrarily reducing the patient's free choice.

Conflict may also occur between the principles of beneficence and non-maleficence. An example is found in pain management for terminal patients, where the use of opioids relieves pain and meets the beneficence principle, but may shorten life, thereby violating the non-maleficence principle. Both principles are not absolute and are often combined, as in the above example, giving rise to the 'double effect' phenomenon, a term that in bioethics refers to an action that can have more than one result and contrasts two principles [17].


These criteria help to maximise three primary goals of medical treatment: number of lives saved, number of years saved and improvement in quality of life. A hierarchy of objectives prioritises the goal of saving the greatest number of lives. [25] While the AMA document makes an important contribution to ethical decision-making, many questions about distributive justice and discrimination against older people remain open.

Furthermore, major social changes have affected the organisation of health systems and have further complicated the application of ethical principles. The globalisation of modern society, with its marked contradictions, inequalities and injustices has also inevitably affected healthcare systems. The undoubtedly successful McDonaldization phenomenon, [26], characterised by efficiency, productivity, cost reduction, procedural standardisation and control, has also influenced the

organisation of healthcare services. The double pressure to cut costs and make a profit has impoverished the healthcare system, hitting hardest the most vulnerable and deprived citizens and generating major inequalities in the access to healthcare services: this has deeply affected the ethical principle of justice and beneficence and has altered the doctor-patient relationship [27].

### **6. Current issues**

In 2020, the whole world was struck by the Covid-19 pandemic. The pandemic disrupted life for every person with an unexpected, novel situation and caused an unprecedented humanitarian emergency. Its sudden outbreak has put the health systems under massive strain, causing a number of ethical problems for healthcare staff and managers, and giving rise to real challenges to basic ethical principles.

Compounding the existing problems in applying ethical principles, the pandemic has brought about new complex scenarios and issues, which have not always been addressed appropriately and in line with ethical principles.

The first moral dilemma posed by the pandemic relates to the strain on healthcare quality caused by the surge in demand. The pandemic has spread quickly, catching the health structures unprepared to handle the rapid increase in workload. At the height of the crisis, the number of patients rose dramatically and the hospitals soon ran out of beds. The number of healthcare workers (doctors and nurses) was also insufficient to deal with the surge in cases. Many health workers faced the additional workload with great dedication and sense of responsibility, aware that their patients' lives also depended on their willingness to put in the extra hours. They prioritised the beneficence for their patients over their personal well-being. Many healthcare workers fell ill and many died [28]. At the peak of the pandemic, medical and nursing staff worked 12–14 hours a day wearing uncomfortable face masks, visors and coveralls. It is fair to assume that fatigue and stress at work may have affected the quality of care, hence the actual beneficence for patients. It can also be presumed that the quality of the care provided at the start of a work shift was higher than that provided by the same worker after 12 hours of gruelling work. Thus, the actual working conditions undermined both the principle of beneficence and the principle of justice, according to which all patients must be treated equally.

Moreover, the spike in patient numbers was so high that it produced an imbalance between the healthcare needs of the population and the availability of intensive care resources. The situation that came about was and still is an exceptional one, to the extent that it has been classified as 'disaster medicine' [29]. With regard to intensive care, in addition to the criteria for access to and termination of care, traditionally based on the appropriateness and proportionality of care, the criteria of distributive justice and appropriate allocation of limited health resources had to be applied. The 'first-come, first-served' criterion for access could not be applied. Healthcare workers were forced to carry out an unusual triage, in which they often had to apply the criterion of 'greater life expectancy'. In Italy, SIAARTI (the Italian Society of Anaesthesiology, Analgesia, Resuscitation and Intensive Care) issued 'Clinical ethics recommendations for the allocation of intensive care treatments, in exceptional, resource-limited circumstances' [29]. The recommendations are solidly grounded in ethical principles, to relieve clinicians from the burden of making subjective decisions, and establish explicit resource allocation criteria [29]. (SIAARTI). Robert et al. highlighted the ethical issues in patient management in intensive care units during the pandemic in France [30]. Despite the guidance provided, the dramatic pressure of the situation often forced physicians to grapple alone with the final decision about who should get life-saving care. While admittedly it was

**319**

*The New Challenges for Medical Ethics DOI: http://dx.doi.org/10.5772/intechopen.94833*

the ICU.

for them.

expected to rise [31].

and ethical challenges.

distress they experienced.

**7. Conclusions**

necessary to make a selection among the patients, we must also note that a dramatic discrimination occurred by age group, comorbidity and patient type. Elderly patients, patients with comorbidities and frail patients were often denied access to

The pandemic emergency also gave rise to other issues. Many patients could not even reach the hospital and died at home while waiting for an ambulance that never arrived. In those cases, the decision was not guided by any particular and specific recommendations, but was simply left to chance: the lottery of life decided

For the patients' protection, during their stay in hospital, the patient-family and healthcare worker-caregiver connection was severed, counter to more than 20 years of research and care practice aimed at improving those relationships for the patient's benefit [30]. Many patients were left to face death alone, without the comfort of family members, without any spiritual or religious care. As hospitals were overwhelmed, much was attempted to provide the benefit to the body but little was done to provide psychological and emotional care; healthcare moved back from

Yet other decisions have impacted ethical principles and good clinical practice in the management of chronic patients. For a long time now, the healthcare system has placed emphasis on prevention and early diagnosis programmes, educating the public about the importance of health screening and monitoring. The emergency has deeply disrupted this approach. Many cancer patients have been unable to attend their routine checks, and the same has happened to patients with heart conditions or diabetes. The principles of beneficence and non-maleficence have been severely compromised. An increase in deaths due to cardiovascular diseases has already been recorded, and the number of deaths secondary to cancer is also

The above overview confirms that the practical application of ethical principles in medicine is fraught with difficulties that may complicate the decision-making process. The current pandemic is confronting us with novel organisational, social

As a rule, major changes in healthcare occur at a much slower pace, giving us enough time to process them, adapt and make decisions. Today's explosive crisis calls instead for urgent emergency measures. The assessment tools we have used so far have been made obsolete by the extraordinary pace of the crisis. In the health sector, clinical guidelines have traditionally been the gold standard for good clinical practice, in addition to providing some protection from medical liability. However, many guidelines have lost their relevance in the pandemic, which has created an unprecedented health situation for which no specific guidance could be prepared. The dramatic developments have put ethical principles under strain in various circumstances and cases. Moral dilemmas have severely affected the emotional resilience of clinical staff; in the near future we will have to deal with the moral

Ethics, once a discipline of interest to scholars, has nowadays taken on a prominent role in the social debate. However, moral questions must be addressed and analysed critically, in order to define not only what is right, but also why it is right [32].

The rationalisation of healthcare resources – through major budget cuts, the push for standardised care processes according to the McDonaldization model,

Hopefully, we can draw some lessons from this tragedy.

caring for the whole person to focusing on the illness alone.

#### *The New Challenges for Medical Ethics DOI: http://dx.doi.org/10.5772/intechopen.94833*

*Bioethics in Medicine and Society*

**6. Current issues**

has altered the doctor-patient relationship [27].

organisation of healthcare services. The double pressure to cut costs and make a profit has impoverished the healthcare system, hitting hardest the most vulnerable and deprived citizens and generating major inequalities in the access to healthcare services: this has deeply affected the ethical principle of justice and beneficence and

In 2020, the whole world was struck by the Covid-19 pandemic. The pandemic disrupted life for every person with an unexpected, novel situation and caused an unprecedented humanitarian emergency. Its sudden outbreak has put the health systems under massive strain, causing a number of ethical problems for healthcare staff and managers, and giving rise to real challenges to basic ethical principles. Compounding the existing problems in applying ethical principles, the pandemic has brought about new complex scenarios and issues, which have not always

The first moral dilemma posed by the pandemic relates to the strain on healthcare quality caused by the surge in demand. The pandemic has spread quickly, catching the health structures unprepared to handle the rapid increase in workload. At the height of the crisis, the number of patients rose dramatically and the hospitals soon ran out of beds. The number of healthcare workers (doctors and nurses) was also insufficient to deal with the surge in cases. Many health workers faced the additional workload with great dedication and sense of responsibility, aware that their patients' lives also depended on their willingness to put in the extra hours. They prioritised the beneficence for their patients over their personal well-being. Many healthcare workers fell ill and many died [28]. At the peak of the pandemic, medical and nursing staff worked 12–14 hours a day wearing uncomfortable face masks, visors and coveralls. It is fair to assume that fatigue and stress at work may have affected the quality of care, hence the actual beneficence for patients. It can also be presumed that the quality of the care provided at the start of a work shift was higher than that provided by the same worker after 12 hours of gruelling work. Thus, the actual working conditions undermined both the principle of beneficence and the principle of justice, according to which all patients must be treated equally. Moreover, the spike in patient numbers was so high that it produced an imbalance between the healthcare needs of the population and the availability of intensive care resources. The situation that came about was and still is an exceptional one, to the extent that it has been classified as 'disaster medicine' [29]. With regard to intensive care, in addition to the criteria for access to and termination of care, traditionally based on the appropriateness and proportionality of care, the criteria of distributive justice and appropriate allocation of limited health resources had to be applied. The 'first-come, first-served' criterion for access could not be applied. Healthcare workers were forced to carry out an unusual triage, in which they often had to apply the criterion of 'greater life expectancy'. In Italy, SIAARTI (the Italian Society of Anaesthesiology, Analgesia, Resuscitation and Intensive Care) issued 'Clinical ethics recommendations for the allocation of intensive care treatments, in exceptional, resource-limited circumstances' [29]. The recommendations are solidly grounded in ethical principles, to relieve clinicians from the burden of making subjective decisions, and establish explicit resource allocation criteria [29]. (SIAARTI). Robert et al. highlighted the ethical issues in patient management in intensive care units during the pandemic in France [30]. Despite the guidance provided, the dramatic pressure of the situation often forced physicians to grapple alone with the final decision about who should get life-saving care. While admittedly it was

been addressed appropriately and in line with ethical principles.

**318**

necessary to make a selection among the patients, we must also note that a dramatic discrimination occurred by age group, comorbidity and patient type. Elderly patients, patients with comorbidities and frail patients were often denied access to the ICU.

The pandemic emergency also gave rise to other issues. Many patients could not even reach the hospital and died at home while waiting for an ambulance that never arrived. In those cases, the decision was not guided by any particular and specific recommendations, but was simply left to chance: the lottery of life decided for them.

For the patients' protection, during their stay in hospital, the patient-family and healthcare worker-caregiver connection was severed, counter to more than 20 years of research and care practice aimed at improving those relationships for the patient's benefit [30]. Many patients were left to face death alone, without the comfort of family members, without any spiritual or religious care. As hospitals were overwhelmed, much was attempted to provide the benefit to the body but little was done to provide psychological and emotional care; healthcare moved back from caring for the whole person to focusing on the illness alone.

Yet other decisions have impacted ethical principles and good clinical practice in the management of chronic patients. For a long time now, the healthcare system has placed emphasis on prevention and early diagnosis programmes, educating the public about the importance of health screening and monitoring. The emergency has deeply disrupted this approach. Many cancer patients have been unable to attend their routine checks, and the same has happened to patients with heart conditions or diabetes. The principles of beneficence and non-maleficence have been severely compromised. An increase in deaths due to cardiovascular diseases has already been recorded, and the number of deaths secondary to cancer is also expected to rise [31].

### **7. Conclusions**

The above overview confirms that the practical application of ethical principles in medicine is fraught with difficulties that may complicate the decision-making process. The current pandemic is confronting us with novel organisational, social and ethical challenges.

As a rule, major changes in healthcare occur at a much slower pace, giving us enough time to process them, adapt and make decisions. Today's explosive crisis calls instead for urgent emergency measures. The assessment tools we have used so far have been made obsolete by the extraordinary pace of the crisis. In the health sector, clinical guidelines have traditionally been the gold standard for good clinical practice, in addition to providing some protection from medical liability. However, many guidelines have lost their relevance in the pandemic, which has created an unprecedented health situation for which no specific guidance could be prepared. The dramatic developments have put ethical principles under strain in various circumstances and cases. Moral dilemmas have severely affected the emotional resilience of clinical staff; in the near future we will have to deal with the moral distress they experienced.

Ethics, once a discipline of interest to scholars, has nowadays taken on a prominent role in the social debate. However, moral questions must be addressed and analysed critically, in order to define not only what is right, but also why it is right [32].

Hopefully, we can draw some lessons from this tragedy.

The rationalisation of healthcare resources – through major budget cuts, the push for standardised care processes according to the McDonaldization model,

the emphasis on hi-tech and highly specialised care – has not withstood the test of the pandemic. While of course it is hard to say which model would withstood the Covid crisis, it remains a fact that the current one failed, and this requires some reflection.

First, we should strengthen the human dimension of the physician-patient relationship. The focus on performance and profit has reduced the time available for listening to patients and their family members; as medical professionals, we have contributed to the achievement of the productivity targets set by the health authorities, but we have not always respected the ethical principles of an authentic doctorpatient relationship based on caring for the individual as opposed to simply treating a medical condition. Health professionals should take the brave step of fostering the relationship with their patients and prioritising quality over quantity, eschewing the industrial assembly line model: people are not machines and do not function like machines.

Social systems as a whole should revisit their resource allocation models. For a long time now, policy makers from all sides have made major cuts to health care; the pandemic has shown that 'sick countries' with difficulties in the delivery of healthcare are also countries with persistent economic problems. The share of public spending allocated to healthcare should be fairer, instead of treating the health service as the poor relation.

During the pandemic, we helped the patients with the greatest chance of survival, but we were unable to help the frailest ones. We went back to the model of Sparta, the ancient Greek city where frail male infants were tossed off a cliff, to train the others to become strong and valiant warriors. However, the Spartan model was not the one that prevailed in ancient Greece, nor the one that produced the greatest protagonists of classical culture. Healthcare systems, with the contribution of medical ethics, should develop care models that protect the frailest and shelter them from 'competition' for survival in which they would be doomed from the start.

We should also send the message that medical ethics is not just a matter for the individual health professional but is the responsibility of the whole community. The pandemic is teaching us that the responsible behaviour of each of us plays a key role in preventing the spread of the infection. The principles of medical ethics, beneficence and non-maleficence should be better known, understood and applied not only by health workers but by all persons.

Last but not least, the expectations placed on doctors today are very high, if not excessive, as concerns both clinical skills and patient relations. Although ethical issues are now on the front line, there is still very little training in biomedical ethics for health professionals. The development of science and technology require that physicians be knowledgeable of ethical issues pertinent to end-of-life care [33, 34]. It is crucial to invest more in this of training, to ensure that the new generations of doctors and other health professionals, within their respective roles, are better equipped to face the new challenges for medical ethics.

**321**

**Author details**

Liliana Lorettu1

University of Sassari, Italy

University of Genoa, Italy

\*, Jocelyn Aubut<sup>2</sup>

\*Address all correspondence to: llorettu@uniss.it

provided the original work is properly cited.

and Rosagemma Ciliberti3

1 Psychiatric Clinic, Department of Medical, Surgical and Experimental Sciences,

3 Department of Health Sciences, Section of History of Medicine and Bioethics,

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

2 Department of Psychiatry, Université de Montréal, PQ, Canada

*The New Challenges for Medical Ethics DOI: http://dx.doi.org/10.5772/intechopen.94833* *The New Challenges for Medical Ethics DOI: http://dx.doi.org/10.5772/intechopen.94833*

*Bioethics in Medicine and Society*

some reflection.

machines.

service as the poor relation.

not only by health workers but by all persons.

equipped to face the new challenges for medical ethics.

the emphasis on hi-tech and highly specialised care – has not withstood the test of the pandemic. While of course it is hard to say which model would withstood the Covid crisis, it remains a fact that the current one failed, and this requires

First, we should strengthen the human dimension of the physician-patient relationship. The focus on performance and profit has reduced the time available for listening to patients and their family members; as medical professionals, we have contributed to the achievement of the productivity targets set by the health authorities, but we have not always respected the ethical principles of an authentic doctorpatient relationship based on caring for the individual as opposed to simply treating a medical condition. Health professionals should take the brave step of fostering the relationship with their patients and prioritising quality over quantity, eschewing the industrial assembly line model: people are not machines and do not function like

Social systems as a whole should revisit their resource allocation models. For a long time now, policy makers from all sides have made major cuts to health care; the pandemic has shown that 'sick countries' with difficulties in the delivery of healthcare are also countries with persistent economic problems. The share of public spending allocated to healthcare should be fairer, instead of treating the health

During the pandemic, we helped the patients with the greatest chance of survival, but we were unable to help the frailest ones. We went back to the model of Sparta, the ancient Greek city where frail male infants were tossed off a cliff, to train the others to become strong and valiant warriors. However, the Spartan model was not the one that prevailed in ancient Greece, nor the one that produced the greatest protagonists of classical culture. Healthcare systems, with the contribution of medical ethics, should develop care models that protect the frailest and shelter them from 'competition' for survival in which they would be doomed from the start. We should also send the message that medical ethics is not just a matter for the individual health professional but is the responsibility of the whole community. The pandemic is teaching us that the responsible behaviour of each of us plays a key role in preventing the spread of the infection. The principles of medical ethics, beneficence and non-maleficence should be better known, understood and applied

Last but not least, the expectations placed on doctors today are very high, if not excessive, as concerns both clinical skills and patient relations. Although ethical issues are now on the front line, there is still very little training in biomedical ethics for health professionals. The development of science and technology require that physicians be knowledgeable of ethical issues pertinent to end-of-life care [33, 34]. It is crucial to invest more in this of training, to ensure that the new generations of doctors and other health professionals, within their respective roles, are better

**320**
