Resolving Ethical Dilemmas: Guide for Clinicians Readings

Resolving Ethical Dilemmas: Guide for Clinicians Readings

An Approach to Ethical Dilemmas in Patient Care

What Is Clinical Ethics?

Clinical limits our topics to the doctor-patient encounter in the office or at the hospital bedside, when a physician is caring for an individual patient.

Ethics refers to judgments about what is right or wrong and worthy of praise or blame; but this means moral judgments, not biotechnical or clinical judgments.

Clinical ethics is distinguished from other fields. Health policy refers to public policies that set the context in which physicians deliver care to patients, including health insurance, access to care for uninsured, allocation of scarce resources, etc. Bioethics refers to broader philosophical questions raised by biomedical advances.

How Does Clinical Ethics Differ from Professional Ethics?

Many physicians seek ethical guidance from professional codes and the oaths they took as students at white coat ceremonies or at graduations. However, while oaths are good, they have shortcomings. No input from patients or public, content has been criticized, don’t address all issues, can contradict some situations.

How Does Clinical Ethics Differ from Law?

Statutes, regulations, and court decisions may guide physicians on what they may or may not do, and laws often reflect ethical consensus in society.

Law identifies what acts are so wrong that the physician would be held legally liable for committing them. In contrast, ethics focuses on what is right, or the best decision, in a situation.

Sources of Moral Guidance

Distinguishing Morality and Ethics

Moral choices ultimately rest on values or beliefs that cannot be proved but are simply accepted.

Ethics connotes deliberation and explicit arguments to justify particular actions; it refers to a branch of philosophy that deals with the “principles governing ideal human character.”

Personal Moral Values

Personal moral values might not address important issues in clinical ethics, especially if the physician’s moral values differ from those of the patient or other health care workers.

Claims of Conscience

Conscience involves self-reflection and judgment about whether an action is right or wrong. Deeply held claims of conscience are generally honored because it would be dehumanizing to compel people to act in ways that violate their sense of integrity and responsibility.

Claims of Rights

To philosophers, rights are justified claims that a person can make on others or on society. However, rights of one person can often overlap with rights of another.

How Can Clinical Ethics Help Physicians?

Physicians can become familiar with similar cases and how to handle them and anticipate associated problems.

Identify Ethical Issues

Studying realistic cases that illustrate common ethical problems can help physicians better recognize problems in their own cases.

Understand Areas of Ethical Consensus and Controversy

Philosophers distinguish between actions that are obligatory, permissible, and wrong.

An Approach to Ethical Dilemmas in Clinical Medicine

What Is the Problem or Dilemma?

What Are the Medical Facts?

Diagnosis, prognosis, and options for care needs to be clarified.

What Are the Clinicians’ Concerns, Values, and Preferences?

Physicians must try to identify their own values and to distinguish their medical expertise from value judgments, where the patient’s and preferences must be taken into account and often should be decisive.

What Are the Patient’s Concerns, Values, and Preferences?

Informed consent and shared decision making require the physician to understand these. A good first step is to ask open-ended questions about the patient’s understanding of the clinical situation.

What Are the Ethical Issues?

More fruitful to frame ethical issues in specific terms.

What Ethical Guidelines Are at Stake?

What Practical Considerations Need to Be Addressed?

What is the Plan for Communication?

The physician should consider how to discuss the ethical issues with other health care workers, patients, and surrogates. Team meetings can help clarify these things.

What Psychosocial Issues Complicate the Case?

Emotions, misunderstandings, interpersonal conflicts, and time pressures.

When Should Physicians Seek Assistance?

In difficult cases physicians can seek assistance from the hospital ethics committee or an ethics consultant, as well as a second opinion from an uninvolved physician.

What Are the Legal Constraints?

Physicians need to know the legal risk, but the decision should be made on the basis of defensive medicine. Usually the law is ambiguous or silent.

Overview of Ethical Guidelines

Respect for Persons

Autonomy literally means “self-rule.” They act intentionally and are informed, and should be free from interference and control by others, as well as unwanted bodily intrusion or touching.

If capacity is lost, physicians should still treat patients at people with individual characteristics, preferences, and values, as well as treat them with compassion and dignity.

Respect also requires physicians to avoid misrepresentation, maintain confidentiality, and keep promises.

Maintain Confidentiality

Respects patient privacy as well as encourages patients to seek treatment and discuss problems frankly. Protects them from harms that might occur if diagnoses were public, as well.

Avoid Deception and Nondisclosure

Deception violates autonomy because it causes them to make decisions based on false premises. Also undermines trust of patients.

Keep Promises

Generate expectations in other people that they make plans on. Keeping promises enhances trust, but not keeping them undermines it.

Act in the Best Interest of Patients

Nonmaleficence means “do no harm,” which forbids physicians from providing ineffective therapies or from acting selfishly or maliciously.

Beneficence requires physicians to provide a net benefit to patients: the benefits of an intervention must outweigh the burdens and be proportionate.

Unwise Decisions by Patients

Physicians need to listen to patients, educate them, try to persuade them to accept beneficial treatment, or negotiate a mutually acceptable compromise. If disagreements persist, then the patient’s informed choices and view of his best interests should prevail.

Patients Who Lack Decision-Making Capacity

Physicians should be guided by the patient’s best interests if the patient’s choices and preferences are unknown.

Conflicts of Interest

Physicians need to act in the patient’s best interest over their own self-interest when conflicts of interest occur.

Allocate Resources Justly

Justice is used in a general sense to mean fairness – that is, people should get what they deserve. It requires people who are situated equally to be treated equally, and very important that cases are treated consistently that are similar in ethically relevant ways.

Justice also refers to the allocation of health care resources.

The Use of Ethical Guidelines

Guidelines Need to Be Interpreted in the Context of Specific Cases

Exceptions to Guidelines Might Be Appropriate

Physicians who make exceptions should be able to justify them. It shouldn’t apply to just that case, but to all cases similar to it.

Prima facie – more binding than rules of thumb. The burden of proof is on those who claim that an exception to the guideline is warranted, and when these guidelines are overridden people often experience regret or remorse.

Different Guidelines Might Conflict

Respecting patient’s wishes might conflict with their best interest, etc.

Principles, Rules, and Duties

Principle connotes a “basis for reasoning or a guide for conduct or procedure.” Also refers only to a comprehensive ethical theory that explains how to resolve conflicts among different precepts.

Consequentialist theories judge the rightness or wrongness of actions or guidelines by their consequences.

Utilitarianism is a consequentialist theory that considers actions and rules appropriate when the overall benefits to all parties outweigh the overall harms. They would consider it justified to tell a lie, etc. if the benefits outweighed harms.
Deontological theories claim that the rightness or wrongness of an action depends on more factors than the consequences of an action. Telling a lie is inherently wrong.

Other Approaches to Ethics

Casuistry

Looking at the concrete details of particular cases. Clear cut, paradigmatic cases and seeing if your case compares and can be treated similarly. Moves to complex, ambiguous cases to teach physicians how to perceive ethics.

Ethics of Caring

Argument that following principles and rules/guidelines to ethics are not always superior to maintaining or restoring relationships among individuals and avoiding interpersonal conflicts within the family.

Virtue Ethics

Merely following guidelines might lead to a thin view of ethics. The lack of spirit behind ethics is a problem. Virtue ethics emphasizes that the physician’s characteristics are ultimately more important than the doctor’s specific actions and their congruence with ethical principles.

Helpful because it emphasizes importance of compassion, dedication, and altruism in physicians.

Promoting the Patient’s Best Interests

Bedside Rationing of Health Care

Rationing on the Basis of Cost

Reasons for rationing health care to save cost are weaker than to be able to benefit multiple other patients.

Objections to Bedside Rationing on the Basis of Cost

No Public Policy Authorizes Physicians to Ration on the Basis of Cost

Bedside Rationing Based on Costs Would Be Unfair

Patients would not receive equal treatment based on the hospital they went to.

Money Saved by Rationing Cannot Be Reallocated

Could actually go to increasing administrative salaries, etc.

Tiered Formulary Benefits

For example, patients may have tiered co-pays for preferred, non-preferred, and non-formulary prescriptions. Best for physician to recommend a preferred formulary drug to save the patient cost, as long as side effects don’t occur.

Suggestions for Physicians

Try to Get More Resources for the Patient within the System

Make Decisions Openly

Allows others to present rebuttals and expose hidden value judgments.

Get a Second Opinion

Might think of other options or expose unwarranted value judgments.

Notify Patients or Surrogates When Care Is Rationed

Ethical Issues in Organ Transplantation

Donation of Cadaveric Organs

Ethical Concerns about Cadaveric Donation

Harm to Donors

Hastens or causes patient’s death? Misunderstandings about brain death.

Respect for Organ Donors

Conflicts of Interest

Decisions about the potential donor’s care must be separate from and take priority over decisions about procurement and transplantation. The physician for the donor may not be part of the transplantation team.

The Current System for Cadaveric Donation

Voluntary system

Uniform Anatomical Gift Act allows people to use an organ donor card to grant permission to use their organs for transplantation after their death. (Usually attached to driver’s license.) Even though these cards have legal authority, next of kin is usually contacted for permission.

Only ~50% of relatives give permission.

Nonheart-beating Cadaver Donors

Most cadaver donors are declared dead by brain criteria and have effective circulation until the organs are harvested.

A growing number are being declared dead by cardiorespiratory criteria rather than neurological for “brain death.” Ethical issues: is the patient dead? Typical time is 5 min, so circulation couldn’t really come back spontaneously.

Proposals to Increase the Donation of Cadaveric Organs

Mandated Choice

People required to state choice when renewing driver’s license or filing taxes. Don’t have to worry about next of kin.

Following Donor Cards

Follow what people indicated on cards, even if next of kin disagrees. Legally, this is just implementing what is already in place. Ethically it agrees with patient autonomy and advance directives. Might, however, meet staunch adverse publicity and cause public mistrust of physicians.

Presumed Consent

Organs are harvested unless patient or family explicitly objects.

Financial Incentives for Donation

Regulated market in organs to increase supply. Criticisms: undermines altruism, treats the human body as a commodity, results in exploitation, fraud, or coercion, particularly in underdeveloped countries.

Donation of Organs from Living Donors

In 2007, 54% kidney transplants were from living donors. Numbers are increasing.

Most donors have a relationship with the recipient in some way. Only ~80/year had no relationship with the recipient.

Ethics Issues Regarding Live Donation

Harm to Donors

Doctors sort of violate “do no harm” for this.

People with medical conditions increasing operative risk or with abnormal

organ function can’t donate.

Motives of Donors

Donating to a friend or family member is understood.

Donating to a stranger needs to be evaluated: searching for publicity,

financial gain, internal psychological conflicts?

Consent from Donors

Decision must be free and informed of the risks. People can be emotional; they should be able to explain their decision to donate in a coherent manner and the decision should remain stable after the donor receives more information and has had time to reflect.

Donors often kept anonymous to recipients if they’re strangers so the recipient does not become dependent and indebted to the donor.

Child donors are a last resort only if no adults can be found and approval from courts should be sought since no adult can require a child to give such a sacrifice and the child cannot give consent for themselves in this case.

Payment to Donors

Happens in a lot of impoverished countries. In India, donors reported being worse off after surgery despite payments. Coercion, exploitation, and abuse are also big issues.

What about incentives? (Medical leave, life insurance, higher priority for transplantation if the donor ever needs it themselves?) Financially neutral for donors; restore donors to their financial status before donation without making them better off.

Confidentiality of Recipient

Prospective donors should receive information that is pertinent to their decision to donate, but patient confidentiality is also an issue. Thus, potential recipients should give permission to disclose the condition causing their need for an organ to prospective donors.

Current System for Live Donation

Live donors undergo extensive education and medical and psychosocial evaluation to ensure donations are informed, free, altruistic, and that donor is medically suitable.

Selection of Recipients

Historical Background

In 1960’s only a limited number of dialysis machines were available and were allocated based on perceived social worth. There were concerns selection was based on prejudice and unwarranted value judgments, so Congress decided to fund dialysis for all patients with end-stage renal disease.

Limited number of organs, so United Network for Organ Sharing (UNOS) is contracted by government to fairly distribute organs.

Beneficence

Scarce organs should go to the patient who will receive the greatest net medical benefit (utilitarianism). So successful medical outcome is crucial.

Psychosocial factors can influence success: adherence to medical regimens, substance abuse, lack of family support, etc.

Justice