Ethical Dilemmas: Extended Notes

Ethical Dilemmas: Extended Notes

ETHICAL DILEMMAS AND ETHICAL ISSUES IN SPECIAL SITUATIONS IN MEDICAL PRACTICE.

Learning Objectives

• By the end of this session, students are expected to be able to:
• a) Define the term ethical dilemmas
• b) Explain the characteristic of ethical dilemmas
• c) Explain common ethical dilemmas
• d) Identify sources of ethical dilemmas
• e) Describe strategies used to solve ethical dilemmas

f) Describe several special situations with implications in medical ethics

SESSION CONTENTS

DEFINE THE TERM ETHICAL DILEMMAS

An ethical dilemma is a situation that will often involve a conflict confusing problem, offers a choice between equally unsatisfactory alternatives, that brings questions on which to obey as one would result affecting the other.

CHARACTERISTICS OF ETHICAL DILEMMAS

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.

COMMON ETHICAL DILEMMAS

• 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.

• Dilemmas of Non-maleficence

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.

Dilemmas of Autonomy

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, even clinician will be affected by the decisions that will be made.

Dilemmas of Justice

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

• Dilemmas of Fidelity

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.

Dilemmas of Veracity

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.

IDENTIFY SOURCES OF ETHICAL DILEMMAS

• Sources of Ethical Dilemmas

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.

STRATEGIES USED TO SOLVE ETHICAL DILEMMAS

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/his obligations, to patients and fellow employees which helped her/his to analyze ethical conflicts.

• She/he notes that six steps proved useful to define those obligations:-

To maximize a patient’s wellbeing.

To balance the patient’s need for self determinations 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.

After examining one’s obligations, it is usually recommended that four additional steps should be taken:

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.

SEVERAL SPECIAL SITUATIONS WITH IMPLICATIONS IN MEDICAL ETHICS

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
• Abortions
• Prisoners
• HIV and AIDS and other infectious diseases
• Medical examination required by employer
• Publicity and advertisement

Diagnosis of death (Brain dead)/death confirmations

Case 1:

A woman enters the emergency room with stomach pain. She undergoes a CT scan and is diagnosed with an abdominal aortic aneurysm, a weakening in the wall of the aorta which causes it to stretch and bulge .The physicians inform her that the only way to fix the problem is surgically, and that the chances of survival are about 50/50. They also inform her that time is of the essence, and that should the aneurysm burst, she would be dead in a few short minutes. The woman is an erotic cancer; she worries that the surgery will leave a scar that will negatively affect her work; therefore, she refuses any surgical treatment. Even after much pressuring from the physicians, she adamantly refuses surgery. Feeling that the woman is not in her correct state of mind and knowing that time is of the essence, the surgeons decide to perform the procedure without consent. They anesthetize her and surgically repair the aneurysm. She survives, and sues the hospital for millions of dollars.

• Questions for Case 1:
• Do you believe that the physician's actions can be justified in any way?

Is there anything else that they could have done?

Is it ever right to take away someone's autonomy? (Would a court order make the physicians' decisions ethical?) What would you do if you were one of the health care workers?

Case 2:

You are a general practitioner and a mother comes into your office with her child who is complaining of flu-like symptoms. Upon entering the room, you ask the boy to remove his shirt and you notice a pattern of very distinct bruises on the boy's torso. You ask the mother where the bruises came from, and she tells you that they are from a procedure she performed on him known as "cao gio," which is also known as "coining." The procedure involves rubbing warm oils or gels on a person's skin with a coin or other flat metal object. The mother explains that cao gio is used to raise out bad blood, and improve circulation and healing. When you touch the boy's back with your stethoscope, he winces in pain from the bruises. You debate whether or not you should call Child Protective Services and report the mother.

Questions for Case 2:

Should we completely discount this treatment as useless, or could there be something gained from it?

When should a physician step in to stop a cultural practice? (If someone answers "when it harms the child" remind that person that there is some pain in many of our medical procedures, for example, having one's tonsils removed) Should the physician be concerned about alienating the mother and other people of her ethnicity from modern medicine?

Do you think that the physician should report the mother?