Most physicians have no interest in the theoretical aspects of ethics.
Walk into the physician’s lounge at a hospital ( those that still have them), and start discussing Kant’s Categorical Imperative, or Nietzsche’s poetic reflections about individual moral relativism, and you will quickly find yourself sitting alone at a table.
However, if you ask how aggressive you should to be doing a strep test on a 5 year old who has clamped his mouth shut and is refusing a test, you may get into a ethical discussion which lasts for several hours.
The discussion will go something like this:
The first set questions will center around on how sick the child appears, and the entire medial scenario. Is the child drooling and toxic, in which case even looking at the child’s throat may be contraindicated outside of an ER setting with ENT backup due to concerns about epiglottis and airway obstruction? Does he have a fever, and if so, are their other sources of fever, such as a UTI? Are the parents complaining of a sore throat, or is the child complaining of a sore throat?
These types of questions are all quite reasonable, but often don’t give you the information you really need – which is what does the throat look like, whether or not there is an abscess, and does it warrant a swab and the associated gag response?
Next may come a discussion of the parental expectations. What are the parental concerns? For example, if the parents and child are complaining of an ear infection, and the child has an ear infection, and the child is not ill, do you really need to even look at the throat? Are the parents requesting a strep test, or do, as a physician, think you need a strep test to make a treatment recommendation?
(In a perfect world, for an ear infection it is nice to have a complete Ear, Nose, Throat exam, but it probably isn’t that essential to look at it, and it is reasonable to discuss waving the need for forcing the issue of a look at the throat with the parents)
The patient’s antibiotic exposure risk may also need to be factored in.
For example, if you have a reasonable suspicion of strep throat, (fever, enlarged neck nodes, and no other respiratory findings) would it be reasonable to strep outside the standard of care and just start an antibiotic without at least looking at the throat?
Most doctors would say no, and not just because of malpractice concerns. Every experienced doctor has seen bad reaction from an antibiotic, and it is our responsibility to the patient ( and to the parents) not to expose the child to this risk without a solid diagnosis.
How about the autonomy of a child to refuse an intervention ( such as looking at his throat), despite the desire of the parents to find out what is wrong? To what extent does a 5 year old have a right to refuse evaluation and treatment considering they don’t yet have the have the cognitive ability to make an informed choice?
( Trust me, if asked, every five year old I have met would rather die than get a blood draw! )
Now, in the simple case above, and as most experienced pediatricians can tell you, the physician can navigate the entire situation with patience and empathy.
The child’s fear is quite real, but so is their desire to get out of the doctors office and go to McDonalds; often just patience and time will solve the problem ( in fact, in my case, with over +100,000 patients over 20 years, only once was I not able to look into a child’s throat when I felt I needed to).
The key point is experienced doctors navigate these ethical scenarios, which encompass ethical topics (ranging from personal autonomy, informed consent, risk and benefits, and right to privacy, to name just a few), dozens of times a week, each usually within matters of minutes.
The experience gained from these interactions may not give a doctor a lot of insight into Kant and Nietzsche’s writings, but they do make us exceptional good as practical ethicists.