Clinicians have many different roles in the provision of healthcare, including individual patient care, public health delivery, health services management, and policy development. Each of these roles involves complex decisions and interactions that require ethical reflection. However, for the majority of clinicians, those who provide day-to-day care in hospitals, clinics, and patients’ homes, it is the relationship with individual patients that forms the professional and ethical core of their work. It is this relationship that initially attracted attention from ethicists as the field of clinical ethics developed, and which has been the main focus of regulatory guidance from professional organizations. This section focuses on three key concepts that define this relationship, namely consent, confidentiality, and truth telling.
A common thread that runs through these three aspects of the patient–clinician relationship is the importance and use of information. Patients provide information to their clinicians about their symptoms, their concerns, and their expectations of what the clinician can do to help them. Clinicians take this information, and then seek further information to develop a differential diagnosis of the patient’s problem, select appropriate investigations, and identify possible treatments or management plans. Clinicians provide information to their patients about diagnoses, investigations, treatment options, progress, and outcomes. The therapeutic relationship is thus founded on sharing of information. The way in which information is used by both patient and clinician within this relationship is explored in the following chapters.
The first four chapters in this section describe in detail the concept of consent, which forms the cornerstone of clinical practice. Chapter 2 provides an overview of consent, relating it to the underlying ethical principle of respect for autonomy and pointing out that consent is not simply about acceptance of a suggested treatment but about choice between a range of options, including the option of refusing treatment. The three elements of a valid consent, capacity, information, and voluntariness, are each addressed in the subsequent chapters. Chalmers in Ch. 3 describes the ethical and legal importance of capacity as the key to determining the clinician’s approach to treatment decisions. Determination of capacity is not always straightforward and this chapter leads the reader through some of the difficulties and idiosyncrasies in this process. Strategies for optimizing capacity in the clinical setting are suggested and two approaches to formal assessment are described. A key component of these assessments includes the provision of relevant information to ascertain whether the patient is able to understand and evaluate the information necessary to make a treatment decision. The importance of disclosure and the legal requirements governing its provision are discussed by d’Agincourt-Canning and Johnston in Ch. 4. They document the change in standards relating to the degree of information required that has taken place in since the 1980s, reflecting an increasing emphasis on individual patient autonomy within both the healthcare and legal systems. However, access to relevant and comprehensive information is not sufficient for a patient to make an autonomous decision about his or her healthcare. Freedom to make a specific choice is also required. The concept of voluntariness and what this means in the context of a patient’s relationship with both an individual clinician and the wider healthcare system is considered by Dykeman and Dewhirst in Ch. 5.
The ethical requirement to provide patients with information is not restricted to situations where consent to treatment is necessary. Patients have a right to know what is wrong with them, and keeping such information from them demonstrates a lack of respect, as well as potentially causing them harm. But bad news can cause distress and some patients may not want to hear it. So can it ever be ethically justified to withhold information from a patient, or even to lie to them? Chapter 6 explores the nature of truth telling in the patient–clinician relationship and its correlation with respect for persons and maintenance of trust. The authors emphasize the importance of communication skills in sharing information with patients. It is not only what information is provided but how it is provided that is crucial to good clinical practice. In the final chapter in this section, Ch. 7, we move from concerns about sharing information with patients to the issue of sharing information about patients with others. Slowther and Kleinman discuss the concept of confidentiality in the increasingly complex field of healthcare, acknowledging new and diverse challenges including the increased use of electronic information systems and the impact of genetic technology.
The chapters in this section summarize specific aspects of information sharing within the patient–clinician relationship, providing an overview of the legal and ethical principles involved. The ethical concepts of respect for persons, individual autonomy, and trust, considered here in the context of individual clinical care, are threads that run through all aspects of information sharing in healthcare. Consequently, the discussions in this section will be of wider relevance to clinicians as they reflect on the ethical issues that they face in their professional practice.