Microethics: the ethics of everyday clinical practice.

Over the past several decades, medical ethics has gained a solid foothold in medical education and is now a required course in most medical schools. Although the field of medical ethics is by nature eclectic, moral philosophy has played a dominant role in defining both the content of what is taught and the methodology for reasoning about ethical dilemmas. Most educators largely rely on the case-based method for teaching ethics, grounding the ethical reasoning in an amalgam of theories drawn from moral philosophy, including consequentialism, deontology, and principlism. Using this approach, cases used for teaching tend to focus on extreme or unusual situations. For example, because truth-telling is widely regarded as a noncontroversial principle, case discussions tend to focus on exceptional situations where lying to patients may be ethically justifiable. Similarly, because informed consent is generally accepted as an ethical requirement, educators often prioritize unusual cases in which clinicians may reasonably treat patients without obtaining consent. Finally, traditional approaches to teaching medical ethics commonly emphasize controversies that generate media attention, such as debates about lifesustaining treatments, euthanasia, or abortion. While recognizing the value and importance of principles to case-based ethics education, we suggest that this approach may fall short in capturing the full spectrum of ethical considerations encountered in clinical care. As Paul Komesaroff has observed, “Crucial ethical issues [arise] in those clinical decisions which at first sight appear to be the simplest and most straightforward.” To give one common example, anesthesiologists regularly obtain informed consent from otherwise healthy patients for routine low-risk anesthesia. Although the informed consent document typically lists “death” as a potential complication of anesthesia, few patients actually read the form, and anesthesiologists vary widely about whether they use the word “death” when they speak with patients. Some never do; some always do. Others customize their approach depending on whether the patient seems like the kind of person who would want to know all the details, versus someone who might prefer to know less rather than more. In our own work, we have found resident anesthesiologists to have remarkably little preparation or insight into how to navigate these and other ethical challenges in their conversations with patients. Relational judgments like these are rarely framed as “ethical” decisions. Yet these kinds of choices arise in everyday clinical encounters, and even seasoned professionals struggle with how to think about them. Bioethicist Rebecca Dresser collected an anthology of experiences from bioethicists who, like herself, had been diagnosed with cancer. Reflecting on comments from Arthur Frank, she wrote,