Ethics is a discipline of philosophy. Generally speaking it deals with questions concerning the good and the attitude that should determine human action. Ethics is about questions arising from the interaction between individuals of a society. Using philosophical methods ethics attempts to demonstrate the fundamental principles for a just and meaningful action in living together with others. Ethics is effective when it is about acting with or deciding for other individuals. Ethical principles and justifications should not rely on external authority or convention, they should be applicable universally with reason and sense, and they should take a higher-ranking position than morals [13].

In simpler, more pragmatic terms the Austro-American Physician and Bioethicist Erich H. Loewy explains ethics as a discipline that proposes the question “How should I act when also someone else could be affected?” Ethics theoretically inquires about the “good” and the “bad”, but in practice – in most of the situations – it is about he “bad”, the “worse” and the “even worse”. Ethics is not about the exchange of unfounded arguments, it is concerned with general rules and guidelines as well as with problems in individual cases. Ethics calls for tolerance of other opinions in a human framework [15].

The theologian and ethicist Ulrich Körtner defines ethics as the “self-reflexive theory of morals”. That means judging the morality of human action according to the categories of “good” and “bad”. Contrary to “ethics”, the ancient Greek term “ethos” or the Latin “moralis” describes behavioral norms in a society or a group accepted and stabilized by tradition [12].

Ethics is not an individual’s personal morality. One’s own conception of morality can be derived from religion, culture, tradition, personal experience and conscience but it will not be the same for a person of another tradition, with different experiences. Ethics attempts to find a common denominator for different world-views, religions and cultures and whenever possible to propose a framework in which different individual moral conceptions can be expressed. Ethics tries to reflect critically and objectively what has been established as moral habit in a society and to look for generally acceptable, objective criteria and rules for modes of behavior. Ethics should question prejudices and established procedures, demand exact definitions, it should help to logically reflect problems, to pose questions in a systematic, structured way. In a secular and pluralistic society ethics should be kept free of all religious and ideological premises [23].

Medical ethics is not only about presenting and discussing individual patient cases, it is not just the application of “moral common sense” of physicians. Medical ethics is no special ethics, it means rather ethics in special situations – like for example ethics in geriatrics. It refers to physicians’ actions and to patients’ attitudes, to situations common in the hospital, the nursing home, the doctor’s office. Beyond that it encompasses ethical problems of institutional actions, like for example issues of distributional justice in the healthcare system [24].

Good ethics needs some prerequisites: first of all it needs a good knowledge basis and good facts. In medicine this means that physicians who are not competent enough in their domain, who do not continuously keep themselves informed, who are not up-to-date with the latest developments in their specialty cannot act also ethically correctly. Good ethics begins with good facts, not with groundless assumptions [16]. Good, ethical decisions are not possible without optimal knowledge and competence in diagnosis, prognosis, and treatment alternatives.

Another aspect to keep in mind is the fact that professionally and ethically good medical action – as Erich Loewy said – does not happen “in a vacuum”. The framework in which the physician has to act is determined by the institution (the hospital, the healthcare system) and thus by the society. It is very difficult to act in an ethical way in an institution that is not based on ethical principles. It is equally difficult to build a just, ethical healthcare system in an unjust society [18].

Why should ethical considerations have such a high level of significance particularly in geriatrics? Especially when – as mentioned above – ethics is about the search for basic principles for just, meaningful, judicious, reasonable – in one word: good – action. There are a few explanations:

Therefore, ethics is a fundamental part of geriatric action. This is particularly true when considering frailty, the risk of dependence on help and care by others.

The discussion of ethical problems in geriatrics circles around two poles: one is autonomy, the right of a person to determine his or her own fate, to exert his or her own will – even though taking into account certain limits set by society. With geriatric patients frequently the question arises whether he or she possesses the competence to comprehend and to judge the situation and if he or she has sufficient independent decisional capacity. The other pole is beneficence, the obligation to do well to others, to help minimize suffering. Oftentimes this borders on paternalism – one acts and decides in conflict with the principle of autonomy (see below).

The infantilization of the older person is wrong and unethical, even in the presence of cognitive impairment (dementia) that may lead to a gradual loss of cognitive capacities. But there are variably long individual progressions of cognitive functional deficits between early and advanced stages of dementia. The presence of this diagnosis does not automatically imply an incapacity to comprehend and to chose and decide independently.

Present day biomedical ethics is guided by four key considerations proposed by Beauchamp and Childress as moral principles to help focus everyday decisions in medical practice. They are the basis of an ethical system termed “principlism” that guides medical decision-making in our pluralistic society, they provide a basic analytical framework for reflecting on moral issues within biomedicine [2].

These four guiding principles are:

Tensions and conflicts between these four principles may arise, frequently they cannot be eliminated, and one has to able to tolerate them in a constructive way [4].

The four guiding principles of bioethics should be applied also in interventional cardiology, for example in deciding whether or not to perform a transcatheter aortic valve replacement in geriatric patients [3]. Weighing expected benefit and potential harm for the individual patient, thus following the principles of beneficence and non–maleficence, is crucial. When considering such an intervention, the fundamental question is the extent to which the patient’s quality of life will be improved. This key question must be considered and discussed with each individual being assessed – thus honoring his or her autonomy.

In this respect “what can be done” and “what should be done” are not equivalent questions. A patient’s right do die with dignity must be respected. The principle of autonomy also makes informed consent in decision-making obligatory. The patient should be provided with clear, comprehensible information about the expected benefits and risks of the procedure. In particular the patient should be made aware of the risk of death or serious complications such as stroke. In the case of the transcatheter aortic valve replacement, the patient should understand the still prevalent uncertainty about long-term benefits and risks of TAVI and valve durability (Boothroyd 2013). The intervening physician must provide information about the risks and benefits of different strategies to the patient and family and balance also the benefit of thorough discussion, perhaps requiring time for reflection, with the benefits of rapid intervention [14].

The principle of justice implies that patient selection criteria are as objective and transparent as possible and that access to the procedure is fair and just. It is also the physician’s duty to treat the individual patient responsibly with due consideration of other patients and stakeholders in the health care system [14]. Respecting the principle of justice also requires the consideration of how decisions regarding one patient may also affect other patients and providers.

The principle of justice calls for an unbiased, equal allocation of resources that are limited. Nevertheless, “ethically speaking”, medical interventions should be planned and care provided with the sole intention of improving the individual patient’s quality of life and/or decreasing his or her risk of mortality “independent of reimbursement considerations and without inappropriate bias or influence from industry, administrators, referring physicians and other sources” [5].

An ethical problem is present when in a situation requiring a decision or an action uncertainty or disagreement arises in judging the decision or action according to the categories good and bad or right and wrong. With the aim of productively transforming this uncertainty or disagreement into a realistic course of action a process should start in which moral judgments become clear and can be expressed [31].

The response to an ethical question, the solution of an ethical problem, is not only a certain action, but in addition also an explanation and justification based on specific knowledge and facts. Thus the question by which to start an ethical case discussion should first of all aim at the course of action in the particular situation.

Here are some examples of more or less general question with ethical implications arising in everyday medical, nursing or rehabilitative care of geriatric patients. A practical suggestion how to approach them in a structured, systematic way will follow: