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Understanding the principles of ethics in health care: a systematic analysis of

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DOI: 10.18203/2394-6040.ijcmph20180738

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International Journal of Community Medicine and Public Health
Kemparaj VM et al. Int J Community Med Public Health. 2018 Mar;5(3):822-828
http://www.ijcmph.com pISSN 2394-6032 | eISSN 2394-6040

DOI: http://dx.doi.org/10.18203/2394-6040.ijcmph20180738
Review Article

Understanding the principles of ethics in health care: a systematic

analysis of qualitative information
Vanishree M. Kemparaj1, Umashankar G. Kadalur2*

Department of Public Health Dentistry, 1Maaruthi Dental College, Bangalore/ Rajiv Gandhi University of Health
Sciences, 2MR Ambedkar dental college, Bangalore/ Rajiv Gandhi University of Health Sciences, Bangalore,
Karnataka, India

Received: 30 December 2017

Accepted: 01 February 2018

*Correspondence:
Dr. Umashankar G Kadalur,
E-mail: drumashankargk@yahoo.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Despite incorporating ethical teaching in medical curricula there is paucity in knowledge of ethics among our
practitioners. To improve the ethical knowledge it is important to understand the ethical issues or challenges
encountered in the present scenario. The issues encountered by the health professionals helps to understand how the
ethical principles are in day to today practice. Empirical researches have shown that qualitative research brings
research closer to decision making. Hence data obtained from peer-reviewed qualitative articles were used for
assessing ethical principles in every day practice by health professional. The studies have shown that autonomy,
beneficence, justices are some of the principles health professionals consider before taking the decisions in health
care.

Keywords: Ethics, Health care, Qualitative research, Informed consent

INTRODUCTION care, consent, priority setting or women‘s health. Despite

incorporating ethical teaching in medical curricula there
All health care professionals have an obligation for the is paucity in knowledge of ethics among our
duty of care in alleviating pain and minimize suffering. practitioners. Recognizing the importance of ethics in
Thus every action taken by the doctor or health care health care practice the MCI and DCI has prescribed the
professional constitute ethical and moral dimension. This teaching hours of ethics to more at under graduate level.
is guided by the set of ethical principles aimed at To improve the ethical knowledge it is important to
improving the quality of patient care by identifying, understand the ethical issues or challenges encountered in
analysing and attempting to resolve any issues arising in the present scenario. A thorough review of literature
practice. According to Beauchamp and Childress, no one would help us understand the dilemmas and help to us
principle is higher than other and depends on the context formulate better research in this regard.
of given situation. Beauchamp and Childress consider the
four principles as prima facie binding, i.e. they must be Empirical research have shown that the evidence that
fulfilled, unless they conflict on a particular occasion quantitative methods alone is not sufficient since
with an equal or stronger principle.1 phenomena examined by ethics researchers are deeply
entwined into the fabric of professions, organizations and
In the past clinical ethics was intended to be defined by human lives. Hence qualitative methods have begun to
the clinical area that focused on for instance, end of life play its role. Empirical studies exploring the ethical
dimension of the physician practice mainly rely on

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interview, focus group discussion and observation of Only peer-reviewed articles pertaining to qualitative
clinical practice. The systematic review in this regard is studies in health care ethics and which were published in
an important tool for the evidence based medicine and English literature were included. Thus there were 34
practice which aims to bring research closer to decision research articles pertaining to the review in focus.
making.2-7
Data extraction was done. After verification of a study‘s
In this systematic review an attempt has been made to eligibility for inclusion in the review; study details such
review articles which emphasize on research which as name of the study, authors, journal, research design
prioritizes the daily activities of the doctor within the used, data collection, data analysis methods, results and
clinical encounter rather than on the research which conclusion were determined by the researcher and
emphasize life threatening and emergency situation. included in the final analysis by all the authors.
METHODS Data analysis
Collection of data sources For data analysis guidelines for critical review form for
qualitative studies developed by the McMaster University
To identify a comprehensive data search, different Occupational Therapy was followed.4
strategies used for identifying qualitative research papers
in area of health care ethics was used. It included
RESULTS
―Semantic‖ based strategies, thesaurus, free text terms
relevant to qualitative research and ―broad-based‖ terms
There were 10 relevant qualitative studies collecting the
such as interview, focus group discussion, qualitative
data regarding the ethical issues in health care practice.
research and also using citation in health care ethics.
The studies were related to use of ethical principles such
Articles were searched in medical, dental, nursing and
social science literature. Choosing of the article aimed to as autonomy, informed consent, beneficiance, non-
include all relevant studies related to ethical issues in beneficiance, and justice in health care decision making.
healthcare ethics.

Table 1: Showing the ethical dilemmas faced by the research participants in different research studies.

Author/ year Themes Responses

"I cannot remove any parts of a person's body unless they are
Respecting patients
accountable; unless they themselves comprehend that it is necessary".
"Sometimes you are asked to do something you do not think is right.
Resolving You are for instance asked to do things in a particular way, and then you
Torjuul, Nordam, differences in think that it is difficult to go against the decisions of those who are more
1.
Sørlie opinions experienced. It does not need to be anything strictly right or wrong, but
minor things, like you would have chosen another type of drug".
"On the one hand you realize that surgery is complicated, and you
Incompetent
cannot blame people for a single decision or a single action that is
colleagues
wrong".
... We are employed here to produce drugs for the benefit of the patients,
so we have to see things in a broader perspective... of course, that is not
where your focus is when you are about to clone something and
beneficence considering what restriction sites to apply. At that moment, the overall
perspective is not the focus of your attention, but you have to keep it in
the back of your mind as part of your daily activities in order for things
to make sense in the end.
... if you were a seriously ill or terminally ill patient, I think I would
Autonomy
2 Ebbesen et al accept just about any treatment, because you would accept the risk
Informed consent
involved.
Resources are scarce and the number of patients in need of radiotherapy
is increasing... you have so many patients
and you want to be able to cure as many as possible from their cancer,
Justice
which is, after all, the main problem. But
Just distribution
what is the best way to do it so that the patients become most well-
functioning afterwards, cosmetically and
functionally?

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Author/ year Themes Responses

Most participants agreed that it was perfectly acceptable to use
Information alternative words like ―growth‖ or ―mass‖ rather than use the term
―cancer‖ and this did not amount to deception.
3 Jafarey, Farooqui ―I try and tell the patient all possible complications of a procedure so
that if something does go wrong, at least he was forewarned. I however
Apprehensions
tend to loose patients also by this approach as they sometimes choose to
go to a surgeon who does not alarm them with all the possibilities‖.
When facing the ethical difficulties they described, most of the
Looking for respondents looked for assistance. This could come from persons
assistance involved with the patient, or from persons trusted by the respondent for
other reasons.
4 Hurst, et al
An example in which avoidance of conflict meant not facing it is
illustrated in the following situation. In this case, deception was used:
Avoiding conflict
the respondent did what he thought was right, and pretended to the
patient‘s family that he had done what they thought was right.
A female patient enters the practitioners‘ office, seems stressed and
talks fast in broken Norwegian. She sinks into a chair. Patient: ‗‗I‘m so
ill; I do not have the energy to do anything. My neck hurts, I‘m freezing,
I‘m weak,
I have to do an assignment, but this is not working out…‘‘ Doctor:
‗‗Your neck hurts?‘‘ Patient: ‗‗Yes, my throat is soar and I‘m aching
here [pointing at the side of her neck]. I always get a soar throat, maybe
Break down every month. I thought I should have an operation…‘‘ Doctor: ‗‗Does it
hurt anywhere else?‘‘ Patient: ‗‗Yes, my back
hurts. And my chest. And my legs are hurting a bit too.‘‘
Doctor: ‗‗A little bit of everywhere, I gather? Do you have fever?‘‘
Patient: ‗‗Yes.‘‘ Doctor: ‗‗Have you measured your temperature?‘‘
Patient: ‗‗No, I do not have a thermometer.‘‘ Doctor: ‗‗Then you must
get hold of one! Do you have fever now?‘‘ Patient: ‗‗No, I don‘t think
5 Agledahl, et al so.‘‘ [Feels her forehead] Doctor: ‗‗Do you have a cough?‘‘.
Doctor I: She has been admitted for rehabilitation. She is poorly
mobilized and nourished, and she is low in albumin. Nurse: Is she the
one with the black toes?
Concretizing Doctor II: They are not black; they are poorly circulated.
Doctor I: We have to at least mobilize her into a chair. Doctor II: She
also has diarrhoea and a positive Hemofec. It is somewhat hard to
interpret. But judging her blood values, everything looks better.
Interviewer: ‗‗Your first patient today mentioned that she had
discomfort in her chest. What were your thoughts about that?‘‘ Doctor:
‗‗She brought it up somewhat late in the consultation and I was
Categorizing beginning to run out of time. It didn‘t sound that serious, and it wasn‘t
anything acute, she had had it for several years. I could have taken a
spirometry of course… Most likely it is muscular, she is sitting quite
tense, like this.‘‘
―The biopsy came back that he had lung cancer... our attending wanted
to wait until his primary
Concern over attending came back a week later before telling him. We... myself and
telling the truth, my intern, felt very uncomfortable waiting
... he [the patient] kept asking us, ‗Do you know the results?‘... and
we‘d have to tell him... ‗we‘re waiting for the results.‘ Even though we
6 Rosenbaum, et al knew.‖
―It felt difficult for us to live with the fact that we had done something
to her that had killed her.... Sometimes I just feel really evil. Doing
Preventing harm, things to people. That‘s my way of saying it. But I feel, a lot of times,
we do different procedures to people that are—putting in lines or
whatever—in their so-called best interest. I just wonder a lot of times
whether it really is.‖

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Author/ year Themes Responses

―... I‘m transferring them [a patient] to somebody and meeting
resistance, just feeling uncomfortable because they [co-resident] say,
Managing the limits
‗why didn‘t you do this?‘ or ‗why didn‘t you do that?‘ or ‗they‘re not
of one‘s
really appropriate for me right now. You called me too soon.‘ Just
competence
feeling like I‘d been inadequate, inadequately working up the patient
and why would I call them prematurely. I feel that, actually, a lot.‖
Dr Newton: I felt I looked after them [these patients who were elderly],
to the best of my ability, in fact
Extremely well. And at times I‘d put myself out a lot—not just a little
bit—but a lot, on individual instances, and that had always been
appreciated, or seemed to have been appreciated. And yes, I‘ll give you
some beautiful examples. Some of these home visits I did when I went
to pick the gentleman who had fallen often onto his wife, and couldn‘t
Accessibility
move, I went because nobody else would go, and the family wouldn‘t
go. The family said, no, get the doctor. And when I got there all I
actually had to do was get him back on his feet, and make sure that they
8 Braunack-Mayer were all right. And that would happen, at virtually any hour of the day
or night. They would ring, but I went. Well, I always went myself, and I
never sent a locum … That‘s going beyond the call of duty, on the
whole.
Dr Kingsford: specialists are a different type of doctor to a GP. I think
specialists know a lot about a certain case. They can be very bright in
one or two areas, but quite often they have no bedside manner at all … I
comprehensiveness mean, there‘s some very good specialists that are very good— like
psychiatrists,—that they can talk to people very well, but so many of
them are just technicians, purely technicians and very good technicians,
but very poor doctors. I‘ve found this many times.

DISCUSSION Research method

The most of the articles reviewed under this systematic The studies in this systematic review have utilized
review acknowledge the importance of using ethical interview, observation and focus group discussion
principles in their day to day practice. A range of issues method which is most opt for qualitative research
were encountered by the health care professionals in method.
following the principles of ethics. Issues were more
getting complicated when one principle was overridden Sample size
by the other and this led to the confusion as what has to
be followed. Disagreement between families and health Malterud in his ―Qualitative research: standards,
care professionals, long waiting list, access to needed challenges and guidelines‖ mentions that even though
health care, informed consent and substitute decision qualitative study utilizes small sample size because of the
making were viewed as the top ethical challenges in many varied sample and clinical situation assessed the
health care practice study can be generalized to other clinical situations.8,9

Research design Sampling technique

Most of the research design used phenomenology, All the research studies used purposive sampling and it is
ethnography, Delphi method and grounded theory justified that the purpose is interpretive explanation and
approach which is opt for the qualitative research. The not prediction of the conflicts and challenges of health
assumption behind phenomenology is that there is an care ethics. Hence it is most suitable for qualitative
essence to shared experience. It comes from the social research.8,9
sciences and requires a researcher to enter into an
individual‘s life world and use the self to interpret the Data analysis
individual or group experience. The goal of ethnographic
research is to tell the whole story of a group‘s daily life, Most of the research used inductive reasoning approach
to identify the cultural meanings, beliefs and social in which we move from specific observation to broader
patterns of the group. Grounded theory focus is on generalizations and theories. Also called as bottom up
searching to identify the core social processes within a approach. Theoretical concepts and relationship between
given social situation.2-9 the concepts have been explained. The research studies

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enhanced their validity by using two researchers reading, Justice

coding and comparing the finding of research. Few
studies have also cross checked with the participants for This principle suggest regardless of caste, creed and
the validity of the concepts they formed finally.2-9 social status every individual should be treated equally.
In a study done by Ebbesen et al the doctor‘s were in
Data revealed that the participants in the research studies agreement to distribute the scarce resources available so
encountered conflicts in adopting the universal ethical as to provide treatment to as many patient‘s as possible.
principles before coming to treatment decisions of the Residents in Julie study reported to compromise in telling
patient. the truth as they felt it could harm the patient. This
involved them in manipulating information in many ways
Autonomy like delaying, framing or omitting information related to
their treatment.1,12 They also concluded that trust is very
Autonomy is respecting patient‘s wishes or decisions important in doctor patient relationship and continuity of
about one‘s own body. The study done by Torjuul et al, care for long term.
Ebbesen et al, Jafarey et al is in line and agrees to respect
patient decisions regarding treatment. In these studies In few articles the participants have raised concern and
health care professionals have expressed a dilemma in dilemma related to the competences of the dentist,
adopting the ethical principle when they think the
various managements strategies of the patients and
patient‘s level of comprehension is compromised or in
importance of establishment of ethical consultations
case of vulnerable patient‘s who is not able to decide on
themselves or when the patient is terminally ill and is committees.
ready to accept any option the health care professionals
suggest. And this is in line with the study done by Julie et Competences
al where the health care professionals have expressed the
dilemma to accept patient or family wishes when the In a study done by Rosenbaum et al residents raised
patient ability is compromised and in a study done by concerns about their own competence in handling
Hurst et al the participants said that they avoided the patients. They were also concerned how their peers,
conflict by pretending to do what patient wanted. In a attending physician and superiors perceived their
study done by Jafarey suggest that the doctor need to give competence. There was also tension of balancing their
sufficient time and consent should be taken at a level the professional responsibility to challenge, intervene or
patient can understand to his level of comprehension. report the inappropriate or inadequate behaviour of their
When patient is terminally ill the other substitute decision colleagues. This was in line with the study done by
makers should be consulted in taking decision about the Torjuul et al where in the respondents said that they
patient treatment. Regarding the necessary information to cannot blame other person for the wrong that happens in
be disclosed for consent the participants in the study done treating patients.10,12
by Jafarey agree that true information should be disclosed
while few participants have contradictory statement that Management of ethical practice
sometimes it is better to use deceptive words.1,10-13
In a study done by Agledalal et al focus on how doctors
Beneficience and non-maleficience handle the moral aspects of the day-to-day clinical
practice. In this the doctor used the process called clinical
The doctor‘s first and foremost duty is not to harm the essential sing. The process consisted of breaking down
patient the patient and next comes the beneficience.
the clinical situation into smaller units which are of
Torjuul and Ebbesen in their study have acknowledged
manageable parts. The next approach was to concretize
the importance of beneficience whether it is clinical
by objectifying the patient‘s descriptions and reach
practice or research. In a study done by Julie et al the
participants expressed the dilemma regarding the mutual understanding. The third approach was to
principle non malefficience wherein much medical categorize the patient‘s symptoms which could be entered
procedure has both harmfull and beneficial effect on the into record and in an effort to focus the attention the
patient. In the study done by Torjuul study indicate a doctor‘s took existential filtering. The next approach was
dilemma of patient expectation versus duty of doctor the functional focus which draws the doctor‘s attention to
where the patient walking with severe pain expects a benefiting patient‘s physical and mental function. Even
miracle of cure as they cannot see the connection between though essentializing the doctor disregarded for the
treatment and illness. 1,10,12 Mayer in his study his patient‘s private feelings their implicit clinical practice
participants stressed the importance of accessibility of constantly emphasized the moral value of benefiting
patients to the doctor and told that doctor may have to go patient‘s physical and mental function.13 Nik-Sherina and
out of the way to help patient, sometimes home visits in Chirk-Jenn in their study explains the challenges of
odd working hours. Participants felt that general maintaining the family and professional role in treating
practitioners are more comprehensive in assessing the family members.14
patient need and specialists know lot certain case and
sometimes are purely technicians.17

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Frequency of ethical conflicts and establishment of REFERENCES

consultations
1. Ebbesen M, Pedersen BD. Empirical investigation
A study done by Hurst reported that there is indeed a of the ethical reasoning of physicians and molecular
good frequency of encountering the ethical conflicts by biologists – the importance of the four principles of
health care professionals and by being aware of the biomedical ethics. Am J Med. 2004;116:402-7.
ethical conflict help health care professionals to manage 2. Thomas J, Harden A. Methods for the thematic
the ethical problem effectively. They suggested the synthesis of qualitative research in systematic
importance of establishments of ethical consultation reviews. ESRC National Centre for Research
committee in the hospitals. Subjects also reported that Methods, NCRM Working Paper Series Number
when confronted with ethical difficulties the doctor (10/07). Available at: http://eppi.ioe.ac.uk/cms/
looked for assistance may be from person involved with Default.aspx?tabid=188. Accessed on 3 August
patient or whom he trusted.13 2017.
3. Rogers WA. Ethical issues in public health: a
Draw back qualitative study of public health practice in
Scotland. J Epidemiol Community Health.
Some researchers argue that synthesis of qualitative 2004;58:446-50.
research on the grounds that concept identified in one 4. Reis S, Biderman A, Mitki R, Borkan JM. Secrets in
setting is not applicable to others. This can be overcome Primary Care: A Qualitative Exploration and
by checking that each transfer is valid and understanding Conceptual Model. J General Internal Med.
gained. 2007;22:1246–53.
5. Praestegaard J, Gard G. The perceptions of Danish
More over most of the investigations are done by the physiotherapists on the ethical issues related to the
doctors themselves and hence are in a position to physiotherapist patient relationship during the first
understand the terminologies and meanings of the clinical session: a phenomenological approach. BMC
situations and thus minimizes the bias in the study. Medical Ethics. 2011;12:21.
6. Butters KJ. A qualitative study of the ethical
Recommendations practice of newly graduated nurses working in
mental health. A thesis presented in partial
1. Educating health care professionals- incorporating fulfilment of the requirements for the degree of
theory base ethical teaching to clinical based Master of Philosophy in Nursing at Massey
teaching. Making mandatory for health care University. 2008.
professionals to update their knowledge though 7. Malek JI, Geller G, Sugarman J. Intensive course on
attending continuing medical education programme. health care professionals talking about cases in
Studies have shown that professionals justified the
bioethics: the effect of an intensive course on health
ethical issues more precisely after the intensive
care professionals. J Med Ethics. 2000;26:131-6.
course on bioethics.
8. Marshall M. Sampling for qualitative research.
2. Establishing ethical consultative committee for Family Practice. 1996;13:522-5.
advising when there is a disagreement or conflict 9. Sbaraini ASM. How to do a grounded theory study:
with the case. a worked example of a study of dental practices.
BMC Med Res Methodol. 2011;11:128.
3. Examining the patient‘s ethical perspective in
10. Torjuul K, Nordam A, Sørlie V. Action ethical
clinical situation.
dilemmas in surgery: an interview study of
practicing surgeons. BMC Med Ethics. 2005;6:7.
CONCLUSION
11. Jafarey AM, Farooqui A. Informed consent in the
Pakistani milieu: the physician‘s perspective. J Med
Ethical issues in health care practice are many. Various
factors autonomy, beneficence and other principles were Ethics. 2005;31:93-6.
considered by the health professionals to address the 12. Rosenbaum JR, Bradley EH. Sources of Ethical
problem. Sometimes the issues are emotionally Conflict in Medical Housestaff Training: A
challenging since the one principle of ethics can be more Qualitative Study. Am J Med. 2004;116:402-7.
important than the other. Getting sensitized and training 13. Agledahl KM, Førde R, Wifstad Å. Clinical
by the health professional would help him to handle the essentialising: a qualitative study of doctors‘
clinical ethical situation better. Thus adding the quality to medical and moral practice. Medicine, Health Care,
the clinical care. and Philosophy. 2010;13(2):107-13.
14. Nik-Sherina H, Chirk-Jenn NG. Doctors treating
Funding: No funding sources family members: A qualitative study among primary
Conflict of interest: None declared care practitioners in a teaching hospital in Malaysia.
Ethical approval: Not required Asia Pacific J Family Med. 2006;5(2):1-6.

International Journal of Community Medicine and Public Health | March 2018 | Vol 5 | Issue 3 Page 827
 Kemparaj VM et al. Int J Community Med Public Health. 2018 Mar;5(3):822-828

15. Hurst SA, Hull SC, DuVal G, Danis M. How Cite this article as: Kemparaj VM, Kadalur UG.
physicians face ethical difficulties: a qualitative Understanding the principles of ethics in health care:
analysis. J Med Ethics. 2005;31:7-14. a systematic analysis of qualitative information. Int J
Community Med Public Health 2018;5:822-8.

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