Ethics and medical decision-making.

There is a tendency for physicians to approach ethical problems in a manner similar to that in which they approach medical problems. Instead of disease categories (such as congestive heart failure or diarrhea), the physician substitutes moral quandaries (such as euthanasia or abortion). The goal is to learn what the "right" rules are for this particular problem at this particular moment. Although this method has important practical and instructive value, it can produce an empirical attitude toward ethics akin to that found in students who strive to learn medicine solely by algorithms. Using theoretical models as a center for discussion, this article has attempted to approach medical ethics as a decision-making process derived from the physician-patient relationship model in use. What is the type of physician-patient relationship that forms the soundest base for making ethical decisions? It must be realized that the contractual relationship cannot be ignored, for in our consumer-oriented society it will surely remain as a protection for the patient against the incompetent or immoral physician. It should not become the sole guide of physician behavior, however, lest we be satisfied with mediocre behavior as the maximal standard. Likewise, although technical competence is required for one to make the right and good decision, it is insufficient alone as a guide for moral behavior. Given the medically correct facts, a multitude of responses are available which necessitate a moral choice. Physicians need a guiding principle that goes beyond any aesthetic code of behavior, or protection of self-interest, and which enables them to deal with all the unexpected ethical questions faced in providing care to patients. Moral principles such as truth-telling, promise-keeping, and protecting the patient when he is vulnerable, help the physician to act in a moral manner, but lack the encompassing nature of the covenantal promise. The covenantal model includes a donative element that empowers the physician to go beyond any specific prescriptions of behavior in repayment of his gifted position. It inspires fidelity to the patient and the profession and respect for the patient's rights as an individual without either falling prey to the presumptuous attitude of the parental model or the legalistic tone of the contractual model.