Microethics in medical education and practice.

"Microethics" is an avant-garde in the field of ethics. When the term "ethics" is brought into discussion in medical education or clinical practice, it customarily points to the traditional ethics, that is, biomedical ethics that deals with the ethical issues faced during unaccustomed or rare clinical circumstances. In contrast, microethics is a continuous ethical science existing in the physician-patient interaction that happens each day in every physician's clinical liaison. These ethical issues of everyday importance need to be introduced in the ethics training programs of medical institutions to provide insight and thereby promoting improvement in medical care and outcome.

Medicine is a continuously emerging field of science directly dealing with the pain, suffering, and death of human subjects. Conflicts arise when there is the difference in opinion or moral values or traditions in medical practice, and hence, certain code of ethics or regulations has been evolved in the past few decades in the context of medical care. These are called as the biomedical ethics or “bioethics.” Two new terminologies that have been widely used in ethics are “Macroethics” and “Microethics.” These terms are relatively new in medicine although used widely in other specialties. Macroethics refers to the ethical issues dealing with the allocation, utility and management of health resources, and funds. These issues are basic and precedes bioethical and microethical issues.[1] In contrast to bioethics which deals with the ethical issues in life-sustaining situations and critical decisions, microethics deals with the complete process of interactions occurring between the doctor and the patient, that is, history taking, physical examination, choice of various investigations and therapeutic options, and their execution. These ethical issues exist as a continuous process and constitute components from both the doctor and the patient. In terms of the doctor, the degree of concern, manner in which questions are asked, content and clarity of the information provided, suggestions/responses made to patient's doubts, vocabulary, voice tone, facial expressions, providing comfortable, and safe environment during physical examination are few microethical issues which helps in gaining trust of the patient, thereby contributing to a better outcome when combined with the technical decisions and skills. Although, there are patient factors contributing to a better outcome like openness to the doctor, providing reliable information and receptiveness to suggestions, these are dependent or contributory to the physician's microethical factors. These issues exist till there is null interaction/relation between the doctor and the patient. For a successful outcome of a medical encounter, a combination of microethical and technical domains exists of which microethical domains would predominate. In spite of its crucial role in the medical outcome, these issues are barely discussed or dealt with in medical ethics.[23]

Crucial ethical issues are involved not just in the great questions of life and death, but also in those clinical decisions that, at first sight, appears to be the simplest and most straightforward.

Ethics is what happens in every interaction between every doctor and every patient.[2]

-Paul A. Komesaroff

These microethical concepts had been emphasized in a simplified way by Truog et al. in their publication “Microethics: The Ethics of Everyday Clinical Practice.” The traditional bioethics has been characteristically described as the “view from the outside” and the microethics as the “view from the inside,” wherein the outside view (bioethical issues) is consistent and theoretically analyzable and the inside view (microethics) is subtle, variable, arising, and linked to any interactive methods existing between the physician and the patient. Although both concepts are contrasting, they are interrelated and together contribute to the outcome of a medical decision-making. Various approaches have been practiced globally in educating clinicians regarding professional ethics, most of which pertain to the topic of traditional bioethics, e.g., ethical issues of abortion, euthanasia, informed consent, cloning, and life-sustaining treatments. The education of clinicians regarding microethical issues that lays the backbone of the medical encounter is highly lagging worldwide. Numerous ethical workshops have been recently focusing on training physicians on this important topic of microethics. The authors have brought insight on the three common areas of microethical issues. These include:

Respecting and constructing patient values and preferences, where physicians need to analyze each patient's values and preferences, helping them approach an appropriate medical decision thereby maintaining patient's autonomy instead of eliciting various medical options available

Self-awareness and management of physicians’ values and biases: When patients are approached for investigation work-up or therapeutic process, it is common for physicians to obtain consent from patients for procedures/treatment process, which they think to be suitable for the patient. Instead, the options available, with their advantages and disadvantages should be furnished thereby facilitating the patient to choose an appropriate process. The authors had observed and commented that expression of such physician-oriented values and biases prior to the elucidation of various options can prevent physician values biasing the patients’ decision-making process

The management of medical information by physicians: Managing medical information commonly pertains to the context of “confidentiality” in biomedical ethics, whereas in microethics, the content and the level of the information come into the role. The level of information constituting an adequate informed consent itself still remains an ethical debate. The bridge between the area of adequate information creating a placebo response and that creating a negative response for the medical process is quite narrow, and hence, depends on the clinical situation faced by the physician.[45]

These microethical issues are highly variable and apparently appear difficult to standardize in medical practice when compared to the traditional biomedical ethics. Yet, these ethical predicaments play a pivotal role in a physician-patient relationship, thereby affecting the medical outcome. Hence, institutional medical education programs should commence the implementation of microethics practice sessions along with the traditional biomedical ethics for the physicians to provide better insight and improved patient care.

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Conflicts of interest

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