Putting Ethics into the Medical Record

• Medical records
• Ethical analysis
• Decision making
• Knowledge, attitudes, practice
• Physician role

The medical record is a sensitive indicator of how care is administered, reflecting not only the structure of clinical thinking but also the values embedded in medical practice. Ostensibly, the medical record identifies all the existing clinical issues, assesses each individually, and then integrates these issues to ensure that the patient receives thorough care. But the aspiration toward integrated, comprehensive health care remains, and the medical chart continues to be piecemeal and, more telling perhaps, incomplete—clearly revealing lingering frustrations facing patients and their health care providers. Physicians are in the midst of a self-conscious reappraisal of how care can be administered more effectively and, at the same time, with more empathy (1, 2). From this perspective, I offer my proposal.

Consider an addition to the medical record—one that heretofore was implicitly present but now must be made explicit: Insert a section called Ethical Concerns. It will be integrated into the medical chart, starting with the admission note and then the progress notes and, finally, the discharge summary. Ethical, in this context, refers to the deliberations concerning all matters related to the value-based decisions that are constantly made when caring for a patient. Broadly speaking, value judgments inform and guide implementation of knowledge. The scientific and technological tools of clinical medicine are applied in a context of complex personal and social factors. In short, medical decisions are made and implemented in a “moral space” of patient values. Thus, beyond the exercise of their knowledge of clinical science, physicians must draw on their empathy and moral understanding to address the myriad challenges that arise in the exercise of effective care. These matters, as crucial as they might be, are rarely voiced in the medical record and thus remain conspicuously muted.