Ethical dilemmas and ethical issues

Ethical dilemmas and ethical issues in special situations in medical practice

objectives

• Define the term ethical dilemmas
• Explain the characteristics of ethical dilemmas
• Explain common ethical dilemmas
• Identify source of ethical dilemmas
• Describe strategies used to solve ethical dilemmas

Describe several special situation with implication in medical ethics

Definition of Ethical Dilemmas

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.

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 The patient has a right to refuse or choose their treatment

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.

Refers to situations where individual must navigate conflicting loyalties responsibilities or promises.

Dilemmas of Fidelity

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.

Balancing loyalty to a patient’s best interests against organizational policies or limited resources.

Dilemmas of Veracity

Arises when there is conflict between the ethical obligation to tell the truth and other competing duties or considerations such as protecting someone's feelings 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.

Dilemmas of Veracity

Veracity means adherence to truthfulness and honesty.

The dilemma occurs when telling the truth could lead to harm or conflict with other ethical principles

ASS 2

With vivid examples discuss different sources of Ethical Dilemmas 4 points Ethical dilemmas arise when individuals face conflicting values or principles, making it difficult to decide on the right course of action. Below are four key sources of ethical dilemmas, each illustrated with vivid examples:

1. Conflict Between Professional Duties and Personal Values Professionals may encounter situations where their personal beliefs clash with their professional responsibilities.

Example:

A pharmacist who is morally opposed to abortion may struggle with dispensing emergency contraception. While their professional duty is to provide prescribed medications without bias, their personal values might prevent them from doing so, creating an ethical dilemma.

2. Confidentiality vs. Harm Prevention The need to maintain confidentiality can conflict with the ethical obligation to prevent harm.

Example:

A psychiatrist learns that a patient is planning to harm someone but the patient refuses to inform the intended victim. The psychiatrist faces a dilemma:

Option 1: Respect confidentiality and risk harm to another person.

Option 2: Break confidentiality to warn the intended victim, violating the patient's trust.

3. Allocation of Scarce Resources

Limited resources, such as funding, time, or medical supplies, can force tough decisions about prioritization.

Example:

In a hospital with only one ventilator left during a pandemic, the medical team must choose between two critically ill patients. One is a young parent with a higher chance of recovery, and the other is an elderly professor with significant contributions to society. The team faces a dilemma in deciding who should receive the ventilator.

4. Autonomy vs. Beneficence

Respecting an individual's autonomy can sometimes conflict with acting in their best interest.

Example:

A diabetic patient refuses insulin despite the risk of severe complications. The healthcare provider must choose between respecting the patient’s decision (autonomy) and administering treatment against their will to save their life (beneficence).

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.

Ethical dilemmas and ethical issues

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.

Ethical dilemmas and ethical issues

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.

Sources of ethical dilemmas are rooted in situations where moral principles, duties, or values conflict, making it difficult to determine the right course of action. Below are the primary sources of ethical dilemmas with brief descriptions:

1. Conflict Between Ethical Principles Ethical principles like autonomy, beneficence, non-maleficence, and justice can come into conflict, forcing individuals to prioritize one principle over another.

Example: A doctor must decide whether to respect a patient's wish to refuse life-saving treatment (autonomy) or intervene to save their life (beneficence).

2. Resource Scarcity

When resources are limited, deciding how to distribute them equitably while ensuring the best outcomes can create ethical dilemmas.

Example: In a triage situation during a disaster, healthcare workers must prioritize who gets treatment based on survival chances, potentially leaving others untreated.

3. Competing Professional and Personal Values Professionals often encounter conflicts between their work responsibilities and personal beliefs or values.

Example: A nurse who personally opposes euthanasia must decide whether to assist a patient seeking physician-assisted death, as allowed by law.

4. Cultural and Societal Norms

Cultural differences can lead to ethical dilemmas when an action deemed acceptable in one culture conflicts with professional or ethical standards.

Example: A healthcare provider treating a patient from a culture where family members make medical decisions may face a dilemma about respecting this practice versus prioritizing the patient’s autonomy.

5. Unclear or Conflicting Regulations Inadequate or contradictory policies and laws can create dilemmas, especially when the rules do not align with ethical considerations.

Example: A lawyer knows their client is guilty of a crime but is legally bound to defend them to the best of their ability, even if it feels ethically troubling.

6. Pressure from Stakeholders

Conflicting demands from different stakeholders, such as employers, clients, or the public, can create ethical tensions.

Example: A journalist must decide whether to publish a story that exposes corruption but risks harming individuals' reputations based on unverified claims.

7. Advances in Technology

Technological advancements, such as artificial intelligence or genetic engineering, often present new ethical challenges due to their potential impacts on society.

Example: A scientist developing AI for medical diagnoses faces a dilemma about balancing innovation with the potential for misuse or errors.

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

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

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.

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.

special situation with implication in medical ethics

A "special situation with implication in medical ethics" refers to unique or challenging circumstances in healthcare that require careful ethical consideration. These situations often involve conflicts between ethical principles such as autonomy, beneficence, non-maleficence, and justice, and they may arise due to advancements in medicine, cultural differences, or complex patient scenarios.

• Examples of Special Situations with Ethical Implications

End-of-Life Decisions

Situation: A terminally ill patient requests assisted suicide in a region where it is legal.

Ethical Implication: Balancing the patient's autonomy (right to choose) with the principle of non-maleficence (avoiding harm) and the physician's personal or cultural beliefs.

Treatment of Minors

Situation: A 16-year-old refuses life-saving treatment, but their parents want the treatment to proceed.

Ethical Implication: Deciding whether to respect the minor's autonomy or follow the parents’ wishes for beneficence.

Confidentiality vs. Public Safety

Situation: A patient reveals they have a communicable disease (e.g., HIV) but refuses to inform their sexual partner.

Ethical Implication: Balancing the duty to maintain confidentiality with the need to protect others from harm.

Allocation of Scarce Resources

Situation: During a disaster, a hospital has limited ventilators and must decide who gets access.

Ethical Implication: Ensuring fairness (justice) while maximizing the number of lives saved (beneficence).

Informed Consent in Emergencies

Situation: A patient is unconscious and requires urgent surgery, but their preferences are unknown.

Ethical Implication: Acting in the patient's best interest (beneficence) without clear consent, potentially conflicting with the principle of autonomy.

special situation with implication 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
• Capital punishment (death punishment)

Abortions

Prisoners

• 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

Approaches to Special Situations Based on Medical Ethics

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.

Medical Research

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.

Torture of Human Being

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.

Abortion

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.

Prisoners

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

Disaster and Emergency Situation

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.

HIV& AIDS and other Infectious Diseases

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

Ethical dilemmas and ethical issues

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.

Medical Examinations Requested by Employer

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

Publicity and Advertisement

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

Diagnosis of Death

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

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.

Practitioner Appropriate Presentation and Attire

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.