Hospitalists, like all physicians, must master not only the clinical, but also the interpersonal and ethical dimensions of medical practice. Four features of Hospital Medicine generate particular ethical challenges for the practicing clinician. First, hospitalized patients often face urgent medical issues in the midst of uncertainty. Second, the patient and the hospitalist are usually strangers to one another, having met for the first time when the patient is admitted to the hospitalists’ service. Decisions about code status, end-of-life care, or aggressiveness of care, difficult under the best circumstances, become even more difficult because hospitalists do not have the continuity of care many outpatient physicians have with their patients. Third, despite laudable efforts by many hospitalists to communicate with primary care providers, the absence of long-standing relationships with patients increases the challenge of knowing and representing their wishes and best interests during the course of clinical care. Finally, hospitalists’ shift work also poses challenges to the communication and trust required for sound clinical decision making. Patients and family members may begin a conversation about the goals and plan of care with one hospitalist only to have to continue such a conversation with another covering physician.

Nevertheless, the ethical challenges that hospitalists face may also create opportunities to help navigate some of the most difficult clinical ethical issues in medicine. For example, the greater familiarity of hospitalists regarding decision making with the acutely ill may allow them to develop greater comfort and expertise with frequently encountered ethical dilemmas. The hospital setting also provides additional human resources to navigate the moral complexities of clinical care. These include interdisciplinary teams of nurses, social workers, chaplains, ethics consultants, and medical consultants that may be much harder to assemble in an outpatient setting.

This chapter will describe the purpose and principles of clinical ethics, explore frequently encountered inpatient clinical challenges that raise important ethical issues, and finally, highlight a number of ethical and professional issues that hospitalists face.

Many fields of ethical inquiry focus on values, standards of conduct, and moral judgment. Clinical ethics provides a structured approach for identifying, analyzing, and resolving ethical issues in clinical medicine. In addition, it allows clinicians to speak in a common language about justifications for clinical decisions that have ethical implications.

Traditionally, bioethics has been guided by four principles: respect for autonomy, beneficence, nonmaleficence, and justice. Autonomy, personal rule of the self, is the notion that individuals acting with understanding and intentionality, free from coercion or external control, can control what happens to their bodies. Beneficence is a positive duty to act for the benefit of others, while weighing the benefits and harms to the individual nonmaleficence requires the clinician to not intentionally cause harm. Justice is defined as fair, equitable, and appropriate treatment based on what is due to a person. While it is important to know and understand each of these principles, they do not provide a concrete way to solve the ethical dilemmas often faced by clinicians.

Clinicians are encouraged to use a deliberative process of clinical ethical analysis such as the four-quadrant model described by Jonsen and colleagues in Clinical Ethics. Similar to a SOAP note (Subjective, Objective, Assessment, and Plan) that provides a consistent, practical approach for organizing and discussing clinical problems, the four-quadrant model offers a structured heuristic for ethical analysis. By considering the four quadrants—medical indications, patient preferences, quality of life, and contextual features—clinicians can delineate the ethically relevant facts of the case, show where further information is needed, and begin to weigh and balance these four considerations to help reach a clinical-ethical decision that is right for the patient. While clinicians may still arrive at a decision that some might disagree with, the four-box model encourages clinicians to be deliberative and explicit in their reasoning. Each of the following cases illustrates some frequently encountered ethical issues as well as relevant concepts from clinical medical ethics.

This case, based on an actual clinical consultation, raises several questions. Why is the patient refusing treatment? Why does she not believe she is sick, especially given her recent blindness? What accounts for the discordant preferences of the patient and her husband? Most essentially for the clinician struggling to determine the best course of action, the case raises the question of whether the patient has the decision-making capacity to make the specific decisions at hand of refusing treatment for the brain tumor.

Competency and Decision-Making Capacity

Competency is a legal concept, a “yes/no” question decided by a judge on whether a person has the legal authority to make personal decisions, like financial or health care decisions. By contrast, decision-making capacity is a clinical concept that determines whether the person has the capacity to make his or her own health care decisions in a specific clinical circumstance. Decisional capacity is dynamic; it can change over time for an individual patient. It is also decision specific. For example, a patient may have had decisional capacity with regard to a decision to be admitted for acute chest pain, but in later lose decisional capacity to accept or refuse coronary bypass surgery.

Despite the centrality that decisional capacity plays in allowing patients to make autonomous choices, such as accepting or refusing treatment, there are no uniform and objective criteria to assess it. Generally, a person is thought to have decision-making capacity if he or she can communicate a choice, understand relevant information, appreciate the situation and its consequences, and manipulate information rationally. The stringency of the criteria is often based both on the probable risks and benefits of the proposed treatment, and the reasonableness of the choice. That is, a relatively low threshold for decisional capacity is required for a person to consent to antibiotics for an uncomplicated pneumonia since it is a high benefit, low risk decision and a reasonable choice. A more stringent assessment of decisional capacity is required for a person to refuse antibiotics for a neutropenic fever; it is a high-risk decision that most people would deem unreasonable. In emergent, life-threatening situations when patient’s refuse a potentially life-saving intervention without giving a reason for refusal, physicians often may treat such patients and try to clarify decision-making capacity when the patient stabilizes. If uncertainty remains, clinicians should seek consultation and guidance from psychiatrists, ethics committees or consultants, and hospital attorneys.

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