Background 

Definitions

• Ethics: ethics is a broad term that covers the study of the nature of morals and the specific moral choices to be made.[1] Ethics deals with the distinction between what is considered right or wrong at a given time in a given culture.[2]
• Medical ethics: medical ethics applies moral principles to the solving of dilemmas that occur in the management of patients. Four basic values, or principles should guide the resolution of medical ethical issues: beneficence, nonmaleficence, autonomy, and justice.[1]
• Beneficence: it is the obligation of a clinician to act for the benefit of the patient. The principle calls for not just avoiding harm, but also to benefit patients and to promote their welfare.[1]
• Nonmaleficence: it is the obligation of a clinician not to harm the patient. This is particularly important and pertinent in difficult end-of-life care decisions on withholding and withdrawing life-sustaining treatment, medically administered nutrition and hydration, and in pain and other symptom control.[1]
• Autonomy: this principle deals with the patient's right to self-determination (i.e “Every human being of adult years and sound mind has a right to determine what shall be done with his own body” ).[3] Autonomy is the basis for other principles such as informed consent, truth-telling, and confidentiality [1]:
• Informed consent: the process of informed consent occurs when communication between a patient and clinician results in the patient’s authorization or agreement to undergo a specific medical intervention. [4] The requirements of an informed consent for a medical or surgical procedure, or for research, are that the patient or subject (i) must be competent to understand and decide, (ii) receives a full disclosure, (iii) comprehends the disclosure, (iv) acts voluntarily, and (v) consents to the proposed action.[1]
• Truth-telling: truth-telling refers to the moral obligation of the healthcare provider to tell the patient the truth about their medical condition and diagnosis while balancing the principle and moral obligation of ''to do no harm'' to the patient. Truth-telling is a vital component in a clinician-patient relationship; without this component, the clinician loses the trust of the patient.[1]
• Confidentiality: refers to the obligation that clinicians have to keep a patient's personal health information secure and private, unless the patient provides consent to release the information.
• Patient privacy: in the United States, the Health Insurance Portability and Accountability Act (HIPAA) was created to protect patient privacy.
• Justice: refers to the fair, equitable, and appropriate distribution of health-care resources determined by justified norms that structure the terms of social cooperation [1] 
• In addition, medical ethics also involve the ability to show respect for patients' and families' values and people skills.

ETHICAL SCENARIOS IN WOUND CARE

Ethical Principles And Wound Care

Wound care clinicians may face specific ethical scenarios when treating patients with chronic wounds, such as the examples listed below: 

• Consideration of treatment choices: when delineating a care plan, respecting the patient's autonomy and preference is of utmost importance.[5][6]  A competent patient has the right to make decisions with respect to their health care. As such, patients may accept or refuse any recommended medical treatment.[5] If a patient is not capable of making decisions, clinicians should: 
• Refer to the patient's advance directives with the patient's wishes.
• Consult the person who holds the patient's durable power of attorney (an "agent").[7]
• A durable power of attorney for health care is a legal document that helps people plan for medical emergencies and decline in mental functioning. A durable power of attorney for health care names a person (often referred to as an “agent”) to make medical decisions on the patient's behalf if the patient is no longer able to make health care decisions. This document is also known as a health care proxy or health care power of attorney.[7]
• If the patient does not have a health care agent, clinicians must follow their state law about the selection of individual decision makers (often referred to as “surrogates”). The default surrogate typically is a patient’s guardian or spouse.[7]
• Consideration of when to initiate palliative care: this decision often involves the principles of beneficence, nonmaleficence and autonomy. The decision should be made jointly by clinicians, patients and caregivers, based on a comprehensive assessment of ulcer healability (i.e., the ability of a wound to undergo functional healing) and determination that the ulcer is non-healable rather than undertreated.[5] See topic "How to Determine Healability of a Chronic Wound". 
• Pressure ulcer/injury (PU/PI) prevention: following the principle of nonmaleficence, institutions have the ethical responsibility to prevent harm to an individual, including preventing PU/PI. To properly do so, institutions are responsible for ensuring adequate staffing and skill set to ensure patient safety. Understaffing or inadequate training may result in patients not receiving regular skin care, repositioning and other PU/PI preventative interventions. [8][9] 

Ethical Dilemmas: Conflict Between Principles

Each of the four principles above should be diligently followed by clinicians, unless it conflicts with another principle. In such cases, clinicians have to determine the actual obligation to the patient by examining the respective weights of the competing obligations based on both content and context.[1]

Examples of conflict between principles observed in wound care include: 

• Cases in which the principle of beneficence overrides that of nonmaleficence: for instance, a critically ill patient under mechanical ventilation at an intensive care unit would desaturate every time his head of bed was lowered to less than 30 degrees. As a result, his head of bed had to be maintained above 30 degrees, which was against recommendations of pressure ulcers/injuries (PU/PI) prevention guidelines.[10] The patient's life was saved, but he ended up developing an unstageable PU/PI despite other preventative measures. For details, refer to the case study "Case: When Pressure Ulcer/Injury Happens..."
• Cases in which the principles of beneficence and autonomy collide: for instance, a 90 year old woman who lives independently and is fully informed and competent, declines all interventions to manage her weeping venous leg ulcers and phlebolymphedema. Clinicians might feel compelled to influence the patient by a variety of ways, consistent with their thinking of what is best for the patient. However, since the patient is informed and competent, her autonomy should be respected. When the principles of beneficence and autonomy collide, reconciliation may be achieved by interpreting beneficence as inclusive of patient autonomy as “the best interests of the patients are intimately linked with their preferences” from which “are derived our primary duties to them".[1][11]

PRACTICAL APPROACH TO PROBLEM-SOLVING IN ETHICS

One of the basic and not infrequent reasons for disagreement between clinician and patient or caregiver on treatment issues is their divergent views on goals of treatment.[1] In wound care, the determination of healability of a wound, that is, the ability of a wound to undergo functional healing, is a prerequisite to setting realistic treatment objectives and ensuring responsible use of available resources. Upon determining healability of a chronic wound, the wound is classified according to their ability to heal as healable, nonhealable, or maintenance.[12] This determination should be based on a comprehensive patient and context assessment guided by principles of ethics, as illustrated by the framework below adapted from Jonsen et al. and Varkey.[1][13] In addition, the approach enables clinicians to identify the principles that are in conflict, and more easily decide which principle should prevail. For details on how to determine healability of an ulcer, refer to topic "How to Determine Healability of a Chronic Wound". 

Table 1. Application of principles of ethics in wound care [1][13][14]