An ethical dilemma is a situation having two or more undesirable alternatives.

It can also be defined as a confusing problem that offers a choice between equally unsatisfactory alternatives.

An ethical dilemma is a situation that will often involve a conflict that brings questions on which to obey as one would result affecting the other.

Ethical dilemma addresses ethical questions of right vs. wrong.

In order for a problem to be an ethical dilemma it must have three characteristics­

The problem cannot be solved using only empirical data (empirical data is information derived from observation/experiences)

The problem must be so confusing that deciding what facts and data need to be used in making decision is difficult.

The results of the problem must affect more than the immediate situation; and there should be far reaching effects.

Dilemmas of Beneficence

Involve deciding what is good as opposed to what is harmful.

Often occur when a clinician, patients, or family members disagree about what course of action is in the best interest of the patient.

Involves the avoidance of harm.

These issues often involve a clinician’s responsibility to ‘blow the whistle’ if she sees others compromising the patient’s safety.

In these situations, a clinician notifies higher authorities on weaknesses in the care they provide by not following established communication channels

Involves deciding what course of action maximizes the patient’s right of self-determination.

Autonomy issues are related to beneficence issues, especially when individuals other than the patient must determine what is best for the patient

The patient has a right to refuse or choose their treatment

Involves issues of fairness and equality, such as dilemmas that involve dividing limited health care resources fairly.

Involves issues that involve honouring promises.

These may include the extent and limits of a clinician’s role and duties to patient that might conflict with other duties such as duties of the laboratory technician

This is an obligation to be truthful to patients and to cultivate their understanding of relevant consideration.

This may involve even delivering bad news to patients and relatives.

With vivid examples discuss different sources of Ethical Dilemmas 4 points

Problems arise when one or more ethical principles conflict with each other.

Patients and clinicians- For example human rights are involved when a patient refuses to commit herself in signing consent while the clinician believes it is ethically appropriate to get his/ her permission.

The value system, beliefs and culture- For example a patient who belongs to Jehovah’s Witnesses refuses blood transfusion at the time when blood will save the life of that individual.

Dilemma may arise from justice and conflicts between clinician and other health care professionals, health care organizations, administrators or patients and family members.

Example one: Quick service provided to patients who can pay extra money and leaving patients with low economical status to wait.

Example two: Family members may demand the HIV results of a patient and create a difficult situation.

Example three: A woman may demand abortion for her school age girl who has been raped by a school teacher.

Technology advancement- Knowledge among people is growing and patients may come to the hospital with full information of their expectations including services like DNA, such as when the clinician is asked to conduct tests to confirm if the claimed father is a true father of the child or not.

Technological advancement provides challenges when we are required to extend life support services for terminally sick patients and simplifies accessibility to information.

There are no clear ways of solving the dilemmas.

Different strategies and ways need to be applied in solving the dilemma as described below.

First the medical practitioner defines her obligations, to patients and fellow employees which helped her to analyze ethical conflicts

To maximize a patient’s wellbeing.

To balance the patient’s need for autonomy and, in the case of a minor, his/her parents’ responsibilities for his or her wellbeing.

To support each family member and enhance the family support system.

To carry out the hospital’s policies.

To protect the other patients’ good.

To protect his or her own standards of care.

Collect as much information as possible about the patient and other significant persons in the situation.

Describe probable consequences of each of the courses of action being considered, for the patient and the significant others in the situations.

Consider who should make the final decision in the matter.

Consult other health practitioners, especially those who are prepared by practice, ethical committee and education to contribute meaningfully to solving problems of an ethical nature

Even after taking the steps described above, solutions may not necessarily be forthcoming when ethical conflicts are present.

Commitment to ethical standards of practice is an essential part of medical care, as is the commitment to respecting the rights and dignity of the person receiving care.

In medical practices there are various situations that can be encountered and found to be a dilemma to the performance of medical duties.

These working situations include

Medical research

Torture to human being

Capital punishment

Abortions

Disaster & emergency situations.

HIV and AIDS and other infectious diseases

Medical examination required by employer

Publicity and advertisement

Diagnosis of death (Brain dead)

Health management organizations

Practitioners appearance, presentation and attire

Health care providers face different issues that require some ethical solutions.

The kind of solution is normally determined by nature and situation of the task as follows.

Familiarity with research methods is essential for competent medical practice and the best way to gain this familiarity is to take part in research projects.

The most common method of research for practicing clinicians is clinical trial.

In conducting research, the ethical values of the medical practitioner compassion, competence, autonomy, dignity apply to medical researcher as well as long as the medical practitioner understand and follow the basic rules of research ethics

There are several procedures required to make the research legal and this shall be dealt with in Research Module.

It is the obligation of the practitioner in the service of humanity, to preserve and restore physical and mental health of the client.

The practitioner shall

Not participate in any way in the practice of torture of human being or other forms of cruel, inhuman or any form of degrading procedures no matter whether such practice or procedure is ordered after due process of law.

Not provide any premises, instrument, substance or knowledge to facilitate the practice of torture or other forms of cruel, inhuman or degrading treatment, or to diminish the ability of the victim to resist such treatment.

Medically induced abortion is not allowed by the laws of the country.

Abortion is not legal in Tanzania; only in some medical conditions where mother’s health is compromised by the presence of the pregnancy.

The practitioner while attending a client held in prison or detention is urged to provide professional services to the best interest of the health of the prisoner or detainee and the general community of that prisoner.

The practitioner shall

Draw to the attention of the responsible authority of an existing or impending unhealthy environment or condition.

Take all necessary steps to preserve dignity of the prisoner or detainee

In disastrous and emergency situations like floods, road accidents, earth quakes, and fire outbreak, practitioner shall practice the profession with conscience and dignity, and the health of the clients shall be paramount.

The practitioner shall have an obligation during life threatening emergencies to take immediate steps to ensure that necessary treatment is given to the victim without discrimination and undue delay.

In the management of HIV and AIDS and other infectious diseases, the practitioner may encounter ethical problems embodied in the special nature of the disease, its fatality, and absence of cure, public stigma and imminent danger to the society.

The practitioner shall

Balance the need to observe confidentiality and save human life against deliberate acts likely to infect potential victims.

Acquire adequate knowledge and skills on counselling related to the special aspects of HIV&AIDS other infectious diseases including prevention and transmission

Ensure that individuals infected with HIV or suffering from AIDS and other infectious diseases are informed or supportive measures available.

Ensure that individuals infected with HIV&AIDS or any other chronic disease are afforded opportunity to agree or decline from being research subjects and to the method applied for scientific research, teaching, and taking of photographs, video or film.

Practitioners shall ensure that an employee is fully aware and consent to medical or dental examination requested by the employer

Sound relationship between a practitioner and colleagues is essential for fostering the esteem and truthfulness of the medical profession.

Practitioners shall be aware that matters of general interest are paramount and practitioner shall refrain from adopting methods aimed at advertising a particular person, institution, remedy or technique

A situation may arise whereby the human body is controlled by a brain which is damaged to an uncertain degree and poses ethical dilemma for termination of life.

In such a situation a patient shall be considered dead when there is irrevocable establishment of brain stem death.

Death shall be clinically ascertained by not less than two physicians and one of them shall be the doctor in charge of the care and another one should be an experienced and clinically independent of the first.

In any case the examination must be done over twenty four hours at eight hourly intervals.

Health Management Organizations (HMOs) have their basis, profit making by ‘managing’ health funds.

This, at times, leads to unreasonable exclusion from key investigations, drugs therapy, surgical procedures and others and interference in the confidentiality of the clients.

Practitioners must have interest of their clients at heart and should not barge to HMO’s pressures.

In every aspect of practice the patient’s welfare remains the practitioner’s responsibility irrespective of the influences of the health agents.

A practitioner shall, at all times in and outside the place of work, appear in smart, proper and decent dress and behave in a manner becoming of the profession.

At a place of work, a practitioner shall present himself and appear in official attire that shall include proper uniform and identification name tag.