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Why dedicate yourself to bioethics? Seven reasons to get you started
¿Por qué dedicarse a la bioética? Siete razones para comenzar a hacerlo
a Servicio de Medicina Interna, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain
b Servicio de Medicina Interna, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain
c Grupo de Trabajo de Bioética y Profesionalismo, Sociedad Española de Medicina Interna, Spain
d Instituto de Ética Clínica «Francisco Vallés», Universidad Europea de Madrid, Madrid, Spain
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Siete razones para comenzar a hacerlo" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Background</span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">What is the meaning of bioethics? What does bioethics seek?</span><p id="par0005" class="elsevierStylePara elsevierViewall">Ethics is the practical knowledge that deals with human activities. It attempts to answer the question “What is the best that I can do (in this specific situation)?” To answer this, we have to consider the context of the problem, the values involved and the consequences of the decision to be made. Based on what factor is assigned the greatest importance, we can find, roughly, 2 types of ethical arguments: <span class="elsevierStyleItalic">principlism</span>, where the decision is made based on a set of principles; and <span class="elsevierStyleItalic">utilitarianism</span>, where the consequences of the decision are most important. In any of its forms, ethics must be rational. To this end, we use a form of reasoning known as deliberation.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">1</span></a> The Royal Spanish Academy defines deliberation as the careful and thorough consideration of the pros and cons of the reasons for decisions before adopting them. However, in the context of an ethical analysis, the deliberation is performed through a structured procedure, a specific technical method that needs to be learned and practiced and that helps weigh the most important factors involved in each problem (context, values and consequences) in order to arrive at the best solutions in a state of uncertainty.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">2,3</span></a> Effective deliberative processes need to have honest and relevant participation from all members, acceptance among the participants of a moral symmetry (or rejection of preferred opinions or those of greater weight, at least <span class="elsevierStyleItalic">a priori</span>) and the accompanying of all arguments by coherent reasons and justifications.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In recent decades, we have been participants in major societal and cultural changes, some of which have affected medical practice. The progress of technology, the growing complexity of medicine, the developments in the field of research, the changes in the doctor–patient relationship and the limited healthcare resources have entailed increasingly complex and diverse ethical problems. Clinical bioethics is the branch of ethics that deals with helping find better solutions to these problems. Mark Siegler defined clinical bioethics as the practical area that helps patients, their families and healthcare practitioners to reach correct clinical decisions, considering both the medical facts of the situation and the preferences and values of the patient and the family.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">This article presents some of the reasons why bioethics is an active and fundamental part of daily medical practice. The main intent of the proposals considered herein is to reflect on why it is essential to have bioethics knowledge and skills in daily clinical practice and why it is crucial to promote a proactive mindset in clinical research in the field of bioethics. With these ideas, we attempt to increase clinicians’ interest in bioethics and encourage greater collaborative participation in this discipline.</p></span></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Reasons for devoting oneself to bioethics</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">It is impossible to conduct our daily work without assessing it</span><p id="par0020" class="elsevierStylePara elsevierViewall">Humans are incapable of living without assessment. In fact, most decisions made over the course of a day are value decisions; they are assessments. The uncertainty between buying a brand-name t-shirt, which I like, and a cheaper one (esthetic vs. financial value) or deciding whether to maintain a diet or eat an ice-cream in the afternoon (<span class="elsevierStyleItalic">esthetic</span> value, or even <span class="elsevierStyleItalic">health</span> value, vs. <span class="elsevierStyleItalic">physical pleasure</span>), are day-to-day value conflicts that we are obliged to deal with. To reach a decision in any of these cases, not only is the values system of each individual important but so are the contextual issues. Although someone might consider that health values take precedence over pleasure in their value system, eating an ice-cream on a hot summer day would not represent a morally inadequate decision. In fact, 2 opposite decisions on the same issue can be equally justified and just as reasonable. This is the complexity of ethics, specifically clinical bioethics. In our day-to-day activities, decisions such as prescribing furosemide at breakfast and lunch instead of breakfast and dinner; choosing between amoxicillin-clavulanate and a carbapenem in the umpteenth hospitalization for sepsis by <span class="elsevierStyleItalic">Escherichia coli</span> carrier of a broad-spectrum beta-lactamase in a patient with advanced dementia; or the countless debates on the numerous end-of-life issues for hospitalized patients, either for the indication of nasogastric catheter, for the use of vasoactive amines, for admission to the intensive care unit, or for its rejection, due to the start of terminal sedation are all incredibly common value conflicts. In all of these situations, the issues of clinical indication have to be reconciled with the patient's preferences and values, the quality of life assessment and many other contextual issues (the family's preferences, financial and societal issues, etc.).<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">5</span></a> The growing plurality of the multicultural society in which we live makes it possible to find different and simultaneous value hierarchies in our daily life and work. Given that it is impossible to find a single hierarchy that serves for all members of society, conflicts within the clinical relationship are common, because they appear when different value hierarchies confront each other.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">The rules of the game have changed</span><p id="par0025" class="elsevierStylePara elsevierViewall">Medicine has become more complex, richer and more varied. Since the beginnings of the medical profession and until very recently, many conflicts of values have been minimized in the context of paternalistic professional ethics. The patient was considered incapable (<span class="elsevierStyleItalic">infirmus</span>) of sharing in clinical decisions. The physician was the only one responsible for the patient's well-being. The physician was the one who defined that well-being, according to the Latin maxim “<span class="elsevierStyleItalic">salus aegroti suprema lex”</span> (the health of the patient is the highest duty/law”).<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">6</span></a> Following the development of the subjective rights of humans in the 18th century (the right to freedom of conscience, to privacy, etc.), a radical change occurred in the paradigm. We began to become aware of the individual as an autonomous individual imbued with rights.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">7</span></a> This new vision did not reach the medical field until the end of the 20th century, when the clinical relationship became a relationship of mutual respect, based on the recognition of the patient's moral value as an individual.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">8</span></a> In today's medical practice, the healthcare practitioner is not just the authority that prescribes but also the advisor, companion, informer and guide.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">We will all be patients</span><p id="par0030" class="elsevierStylePara elsevierViewall">Multiple studies have shown how, over the course of a physician's professional career, various factors help build a certain perception of invulnerability against disease.<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">10,11</span></a> However, we understand that this statement is not rationally supportable. Disease causes changes in perspective for certain habits and assumptions that were previously considered immutable. A study conducted in the United Kingdom with physicians who had experienced severe disease observed that, for a significant portion of these clinicians, living as a patient led them to further assess their own vulnerability, to modify their clinical practice and address patients in a different manner.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">12</span></a> In a number of interviews, the physicians insisted on the need to extend medical student training in these issues (vulnerability, doctor–patient relationship, etc.). Therefore, training in bioethics appears to be important not only for the patient but also for the physician, as shown by the self-care-based arguments, which are also Kantian in nature, based on the golden rule, “do unto others and you would have them do unto you.”<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">13,14</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Bioethics serves to prevent emotional burnout</span><p id="par0035" class="elsevierStylePara elsevierViewall">Emotional burnout in the workplace is a well-known syndrome which broadly includes fatigue, depersonalization in the care and treatment of patients and a sense of ineffectiveness in one's job.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">15</span></a> The factors that lead to this emotional burnout include work overload, feelings of loss of control on the job, insufficient compensation, lack of fairness in these compensations and conflicts of values.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">16</span></a> These conflicts can occur when certain external factors impede health professionals from providing patients with the attention they deserve (or that practitioners want to give). These factors include having insufficient time during the consultations, providing information mechanically and in a “prefabricated” manner, and pressure to encourage early discharges.<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">17</span></a> Moral stress has been estimated to cause 60% of cases of emotional burnout among practitioners.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">18</span></a> Methodologies for conflict resolution, including ethical conflict resolution, communication and negotiation skills, are the most useful tools for preventing and fighting this condition. Thus, training in bioethics can help not only provide better patient care and increase personal job satisfaction but also provide savings in emotional and financial costs, both for the individual and for the healthcare organizations.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">15</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Bioethics helps manage resources fairly</span><p id="par0040" class="elsevierStylePara elsevierViewall">In recent years, the cost dedicated to care and research have grown exponentially in all Western countries.<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">19,20</span></a> There are no data indicating that this trend will decrease in the near future. However, we are increasingly confronted with the need for cost containment, especially if we want continue to preserve our healthcare system. In recent years, there has been increased debate on what the limits should be for coverage under a public health system. In simple terms, there are policies that favor increasing the tax burden to finance the increasing expenses and others that advocate cost containment.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">21</span></a> The large models for cost containment have so far been based on available clinical evidence to assess what treatments should be included and which should not. However, the scientific evidence is insufficient for reaching broad consensus. A deeper debate is needed on the standards, principles and values that should govern this cost containment. To this end, a number of issues have been proposed for consideration: (1) abandoning the idea that the evidence offers neutral and assessable information <span class="elsevierStyleItalic">per se</span>; (2) the changing role of the physician, who should act not only as an informer in the decision-making process but also as a guide for establishing a general healthcare plan, a timely advisor when the treatments are not achieving a clear improvement in the patient's health or quality of life; and (3) consideration of the fact that access to highly innovative treatments, with a marginal or dubious benefit, might not be within everyone's reach.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">21</span></a> The use of evidence to make these decisions will only be useful if it is accompanied by an underlying ethical reflection that considers the regulatory principles that we generally agreed to in order to decide who gets treated, what treatments or diagnostic tests to cover and, in short, where to direct healthcare resource expenses. Finding the best method for managing these resources is a central and urgent ethical issue; bioethics is therefore fundamental for implementing a more equitable policy of cost containment and savings.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Bioethics is a field with significant research possibilities</span><p id="par0045" class="elsevierStylePara elsevierViewall">One of the reasons why a certain field of work or set of disorders is attractive is due to the research possibilities it offers. Bioethics appears to have been, until now, a “science” conducted in faculty departments, far from the patient's bed. However, recent literature is filled with practical examples of “bedside” research in clinical bioethics. Studies on the questionable equivalence in available evidence on the strategies of prophylaxis in bacterial endocarditis<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">22</span></a>; the ethical analysis of clinical trials performed with eplerenone or denosumab<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">23</span></a>; and the recently published studies on informed consent<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">24</span></a> and on the ethical aspects of terminal sedation (New England Journal of Medicine)<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">25</span></a> are examples of how research into clinical bioethics has an enormous presence and a great future. In addition to boosting research in the field of clinical bioethics, it is important to introduce bioethics into clinical research. Examples of this are the voices that increasingly advocate the obvious inclusion of patient preferences in the preparation of clinical practice guidelines.<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">26</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Bioethics is a future opportunity</span><p id="par0050" class="elsevierStylePara elsevierViewall">Today's medicine has increasingly fewer general practitioners without an area of specialization. The rich proliferation of study groups in the headquarters of the Spanish Society of Internal Medicine is a good example of this specialization. Within these specialties, there have always been areas with greater interest, either due to their prevalence (such as vascular risk and heart failure) or multiple-organ character (such as systemic autoimmune diseases). For this reason, many first-level hospitals in Spain have specialized areas and practitioners dedicated to these fields. However, there are the few practitioner dedicated to bioethics. This is precisely the reason why bioethics is an excellent opportunity for the future. In a job market as segmented as Spain's, bioethics is presented as an important but poorly covered need.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">27</span></a> There will be an increasing need for experts in bioethics to form part of the ethics committees of hospitals,<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">28,29</span></a> quality committees, who are in charge of teaching bioethics in the institution, and clinical consultants in bioethics, a position that is becoming increasingly common in the United States of America and in other countries in Europe.<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">30–34</span></a></p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conclusions</span><p id="par0055" class="elsevierStylePara elsevierViewall">The exercise of clinical bioethics is complex but tremendously rich and urgently needed. It requires not only a good dose of talent and skills (knowledge and expertise) but also a good sense of humor and approach. All of these can be acquired with effort, perseverance and a willingness to improve one's day-to-day actions, not to mention proper training on the subject. Only thus, encouraging active listening, promoting respect and tolerance for the opinions of others and defending consistency and authenticity of one's own values can we act ethically. These reflections serve to increase the interest and understanding in this subject and to encourage participation in collaborative research projects in this field, which promote a better and more just clinical practice.<span class="elsevierStyleDisplayedQuote" id="dsq0005"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">“Great spirits have always encountered violent opposition from mediocre minds” − Albert Einstein</p></span></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Funding</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have received no funding of any type, either public of private, in preparing this manuscript.</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres669397" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec675797" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres669396" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec675798" "titulo" => "Palabras clave" ] 4 => array:3 [ "identificador" => "sec0005" "titulo" => "Background" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "What is the meaning of bioethics? What does bioethics seek?" ] ] ] 5 => array:3 [ "identificador" => "sec0015" "titulo" => "Reasons for devoting oneself to bioethics" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "It is impossible to conduct our daily work without assessing it" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "The rules of the game have changed" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "We will all be patients" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Bioethics serves to prevent emotional burnout" ] 4 => array:2 [ "identificador" => "sec0040" "titulo" => "Bioethics helps manage resources fairly" ] 5 => array:2 [ "identificador" => "sec0045" "titulo" => "Bioethics is a field with significant research possibilities" ] 6 => array:2 [ "identificador" => "sec0050" "titulo" => "Bioethics is a future opportunity" ] ] ] 6 => array:2 [ "identificador" => "sec0055" "titulo" => "Conclusions" ] 7 => array:2 [ "identificador" => "sec0060" "titulo" => "Funding" ] 8 => array:2 [ "identificador" => "sec0065" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec675797" "palabras" => array:3 [ 0 => "Bioethics" 1 => "Doctor–patient relationship" 2 => "Health assessment mechanisms" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec675798" "palabras" => array:3 [ 0 => "Bioética" 1 => "Relación médico-paciente" 2 => "Mecanismos de evaluación de la salud" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The aim of clinical bioethics is to promote rational clinical decisions that take into account the clinical facts and the preferences and values of individuals involved in a situation that entails a moral problem. The objective of the present study is to list the reasons why we consider bioethics knowledge and skills to be essential in daily practice and to promote a proactive mindset in clinical bioethics research. The arguments set forth include the need to adapt to changes in the clinical relationship in recent decades, the importance of an ethical approach both for the physician and the patient, the role of bioethics in preventing professional burnout, the ability of ethics to promote a more equitable distribution of resources and the possibility of conducting clinical research in bioethics, a field that has scarcely been explored in Spain.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La bioética clínica se encarga de promover decisiones clínicas racionales teniendo en cuenta los hechos clínicos, las preferencias y valores de todos los individuos implicados en una situación que plantea un problema moral. La intención del presente trabajo es exponer algunas de las razones por las que consideramos esencial tener conocimientos y aptitudes bioéticas en la práctica diaria, así como potenciar una mentalidad proactiva en la investigación en bioética clínica. Entre los argumentos ofrecidos destacan la necesidad de adaptarse a los cambios en la relación clínica de las últimas décadas, la importancia de una actitud ética tanto para el médico como para el paciente, el papel de la bioética en la prevención del «<span class="elsevierStyleItalic">burnout</span>» del profesional, su capacidad para promover una distribución de los recursos más justa, y la posibilidad de desarrollar la investigación clínica en bioética, un territorio escasamente explorado en el ámbito español.</p></span>" ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Real de Asú D, Herreros B. ¿Por qué dedicarse a la bioética? Siete razones para comenzar a hacerlo. Rev Clin Esp. 2016;216:271–275.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">The views expressed by the authors of this manuscript reflect their own personal point of view and do not necessarily reflect the institutional perspective of the Bioethics and Professionalism Workgroup of the Spanish Society of Internal Medicine.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:34 [ 0 => array:3 [ "identificador" => "bib0175" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "La bioética en la práctica clínica" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Sánchez-González" 1 => "B. 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