Ethics is the application of values and moral rules to human activities. Bioethics applies ethical principles and decision making to solve actual or anticipated dilemmas in medicine. Much like clinical practice, which relies on general rules and case-based experiences, bioethical reasoning relies on learned and accepted moral rules, prior bioethical decisions derived from thoughtful reflection, and unique factors in each individual situation. This method of case-based reasoning is termed casuistry, although physicians better know it as clinical reasoning [1]. The term ethics in this article refers to normative ethics, a type of practical activity through which we try to determine what we ought to do and how our institutions should function. Contemporary medical ethics is a tapestry that interweaves a range of philosophical theories. The following four clusters of moral "principles" are central to medical ethics: (1) autonomy (respecting the decision-making capacities of individuals), (2) nonmaleficence (avoiding the causation of harm), (3) beneficence (providing benefits and balancing benefits against risk and costs), and (4) justice (the fair distribution of benefits, risks, and costs). Historically, nonmaleficence and beneficence have played a central role in medical ethics, whereas respect for autonomy and justice were neglected in traditional medical ethics but have come into prominence in the last 30 years [2]. Autonomy is the most significant value that has been promoted by contemporary medical ethics. The acknowledgment of autonomy has served to discredit medical paternalism and has led to the promotion of the patient from recipient of treatment to being the partner in a treatment plan. However, the acceptance of autonomy as the benchmark of good has led us to ignore other values. There is a social dimension to life that is potentially equally enriching. Autonomy must be qualified by the legitimate interests and expectations of others, and economic constraints. Clinical medical ethics focuses on the recognition, clarification, and management of ethical issues that arise in the care of patients and on the prevention and resolution of conflicts associated with ethical issues. Topics include, but are not limited to, the following: professional responsibility, informed consent and determination of decision-making capacity, refusal of treatment (especially life-sustaining medical treatment), treating patients despite their refusal, treating pain at the end of life, truth telling, medical futility, and confidentiality. In addition, clinical medical ethics emphasizes basic values that underline clinical interaction, such as honesty, integrity, commitment to patient well-being, and compassion. Ethical issues in hospital medicine are unique because of the clinical setting. There is the need for rapid decision making, often based on incomplete information and without a prior patient-physician relationship, and difficulty in establishing trust. The explosive growth of managed care has helped lead to an increased role for hospitalists, physicians specializing in the general medical care of hospitalized patients, in the US health care system. The hospitalist models of inpatient care challenge many of the basic assumptions of generalists, health care organizations, and managed care organizations. The traditional relationship between patients and primary care physicians provides many ethical protections for patients, including confidentiality, shared decision-making, and respect for patient autonomy. Hospitalist models, which introduce purposeful discontinuity of care, may threaten these protections and raise further ethical concerns [3]. It is important to remember, however, that fundamental ethical principles in medicine should not change with geographical location or duration of relationship; these values are based on the belief that physicians are competent, compassionate toward the sick, and will put the interests of their patients before their own. This article addresses fundamental ethical principles, such as informed consent, competency and decision-making capacity, confidentiality, and ethical issues related to Jehovah's Witnesses, for physicians in the hospital environment. The article discusses ethical conflicts in the emerging fields of medical informatics and in cases of medical error. In adddition, this articlel outlines ethical challenges in hospitalist systems, including the divide between office-based and hospital-based physicians, potential conflicts of interest regarding utilization of resources, and patients' right to choose hospitalist versus traditional models of hospital care.
