Bioethics Discussion Blog: What is an Ethical Dilemma?

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Tuesday, March 08, 2005

What is an Ethical Dilemma?

I see that a visitor had been directed to my blog from a web search engine with the question “What is an ethical dilemma?” I am not sure that I have defined this term previously. I would like to do so now. I found a definition noted by T.Y. Lee to which I agree. The examples below, however, are my own. Maybe a valuable mind game would be to think of some other examples.

“What is an ethical dilemma?” It is a Conflict between…

Ones PERSONAL and PROFESSIONAL values
A physician has a duty to his family (go to the football game) but he also has a duty to the patient (admit the patient to the hospital).

Two values/ethical PRINCIPLES
A patient has right to reject a treatment (autonomy) but a physician has a responsibility to protect the patient from a harmful decision (non-malificence)

Two possible actions, each with reasons strongly FAVORABLE and UNFAVORABLE
Treating the patient with a drug which though may have bad side-effects could possibly improve patient’s illness but by withholding the drug the patient has a possible chance of spontaneously improving and not be burdened by the bad side effects of a drug.

Two UNSATISFACTORY alternatives
The patient with terminal cancer who has stopped breathing will die quickly if nothing is done but his family would not be able to arrive soon enough to be with him before the patient’s death. However intubating the patient and putting the patient on a respirator will allow time for the family to come to visit him but only prolong an uncomfortable period of dying.

One’s VALUES/PRINCIPLES and one’s PERCEIVED ROLE
A physician has personal values that define abortion as immoral and yet as an obstetrician in a small community far from medical centers is now asked by a long-time patient to perform an abortion.

The need to ACT and the need to REFLECT
The psychiatrist suspects that his patient might commit a homicide and should notify authorities about his suspicion but he is uncertain that he should divulge to the authorities the patient’s private history without more proof of the patient’s intentions.

An important point about ethical dilemmas to carry away is that it is wise to try to avoid the situation, if possible, where they can occur but also one should be aware that not all ethical dilemmas if they do occur are settled to everyone’s satisfaction. Often in medical ethical dilemmas, it requires some consensus amongst the public and/or physicians, ethicists, lawyers and the courts to provide guidance.

I hope this posting helps those who wonder what are ethical dilemmas. ..Maurice.

ADDENDUM 9-2-2008: Those who would like to "play" ethicist and try to solve some hypothetical ethical dilemmas, after you have, if desired, read the comments or posted here, you may go to the "Ethical Dilemmas:Playing Ethicist: Almost Anyone Can Do It" thread.

7 Comments:

At Tuesday, June 20, 2006 9:13:00 AM, Anonymous Anonymous said...

ok, if you are a Physician, opposed to abortion for personal and/or religious reasons, and your OB practice (only one) is in a small town, and you have a patient that wants or needs an abortion, what should you do?

 
At Tuesday, June 20, 2006 10:36:00 AM, Blogger Maurice Bernstein, M.D. said...

There is a difference between the professional obligations of a physician to a patient regarding an abortion the patient "wants" and an abortion the patient "needs". "Needs" usually means that the life of the mother could possibly be in danger. In that case, if the physician had been trained to perform an abortion, the physician should do so even without his or her own moral agreement with the procedure. The only alternative would be to transfer the mother to another institution elsewhere for the abortion but only if such transfer would in no way harm the mother's recovery. If the woman simply requests an abortion which is not medically indicated and the physician is opposed, the physician, so as not to abandon the patient, must provide references to other physician resources who might comply with her request. There is an ethical distinction between "wanting" and "needing". ..Maurice.

 
At Thursday, May 15, 2008 8:26:00 PM, Anonymous Anonymous said...

Hi I was wondering what the ethical dilemma in this instance is? You work as a mental health support worker. You have been working with Isabella (aged 37) for the past 4 years. Isabella has had a long history as a consumer with a number of mental health services in your local area and has a diagnosis of bipolar disorder. During a recent meeting with Isabella, she tells you she has been feeling pretty good. She says her moods have evened out, and she is sick of being on the medication, which she says makes her forgetful, and has made her gain weight. Isabella tells you she has started to reduce the dose of her medication prescribed her psychiatrist, with a view to completely stopping in a few weeks. She confides in you that although she has felt pretty good, she alludes to a growing tension in her relationship with her partner Roberta. You have previously been concerned about Roberta becoming violent with Isabella, but when you express concern about Isabella’s safety now, commenting on a large bruise on her arm and another possible bruise on her chest, Isabella withdraws from you and tells you there is no problem. Isabella has been taking this medication since before you started working with her and you are concerned about the impact of this decision on her mental health and on her relationship with Roberta. Isabella is resolved in her decision and pleads with you not to talk with Roberta or to mention it at her case planning review meeting with is scheduled for next week.

 
At Thursday, May 15, 2008 10:39:00 PM, Blogger Maurice Bernstein, M.D. said...

In the example given by Anonymous today, I would say from the point of view of any physician, a psychiatrist or even a mental health support worker, confidentiality is a well established professional ethical requirement and represents the ehical principle of autonomy. If the patient who has the capacity to make her own personal decisions insists on confidentiality, this request must be followed unless as in many jurisdictions there are laws requiring these professionals who detect evidence and suspect child, marital or elder abuse to report to authorities.

As noted in the thread narrative above, one of the issues which can lead to an ethical conflict would be "to act vs the need to reflect".
If the professional has enough information available to reasonably suspect that Isabella has been physically abused by her partner, then acting by reporting suspicions to a civil authorities would be the decision with the intent to attempt to prevent further abuse or severe injury or death. But if the information is equivocal and the suspicions are not strong, then one must reflect and follow the request of the patient regarding confidentiality knowing that breaking confidentiality would be unethical (disregarding autonomy) but if wrong, allowing the patient to be harmed by not acting (disregarding non-malificence) would also be wrong---an ethical dilemma. ..Maurice.

 
At Friday, October 03, 2008 12:41:00 PM, Anonymous Anonymous said...

If a patient comes into a medical facility and is diagnosed with (STD) and is very well known in the community. The (MA) recognizes her and looks in her charts and emails her husband and the info becomes made public. What is the medical dilemma ethically speaking in this case?

 
At Friday, October 03, 2008 7:47:00 PM, Blogger Maurice Bernstein, M.D. said...

Warning the husband that his wife has a sexually transmitted disease which the husband may have already acquired from his wife or acquired it elsewhere and transmitted it to his wife. In either case, the warning should encourage the husband to have himself checked for that disease and treated if present. If he is not as yet infected, the warning should caution him to avoid sex with his wife until her infection is cleared. This is all an ethical good.

On the other hand, there is the issue of confidentiality of medical information if the wife did not give permission for her husband to be notified. Preserving confidentiality for the patient is also an ethical good.

The conflict between these two ethical goods make up an ethical dilemma.

With regard to communicable diseases, the public law may resolve the dilemma by requiring the physician of a communicable disease patient to notify a governmental agency who may then notify the contacts.

In the scenario Anonymous described today, a medical assistant has no ethical right to look into the chart and to e-mail the information to the husband, let alone permitting the information to become public. Therefore there is no dilemma in that scenario. That behavior was unethical. ..Maurice.

 
At Friday, October 03, 2008 10:23:00 PM, Blogger Maurice Bernstein, M.D. said...

I received the following from a visitor today:




DEAR DOC MAURICE... I NEED SOME MORE DISCUSSON ON THIS ETHICAL DILEMMA.. WHAT DO U UNDERSTAND FROM THE FACTS OF THIS CASE, WHAT INTERACTIONS DID YOU READ, ARE THERE ETHICAL,SPIRITUAL,SOCIAL,PROFESSIONAL OR ECONOMIC CONSIDERATIONS TO BE TAKEN? WHAT ARE YOUR INTUITIONS.
Mr. Singh is a 75 year old mentally competent married male with four children. He arrives to the emergency department with abdominal pain, jaundice and fatigue. He is accompanied by two of his daughters. After several diagnostic tests, it has been concluded that he has metastatic cancer with the bowel being primary origin. He has been transferred to the palliative/complex medical unit. The daughter overhears the physician speaking to Mr. Singh’s nurse stating “The most difficult part of my job is what I am about to tell Mr. Singh. I have to tell this lovely man that he has end stage cancer and is only expected to live for a couple of months”. After hearing this statement, the daughter immediately interrupts the physician pleading him not to tell her father about the cancer and his life expectancy. The daughter further explains that her father has a history of alcoholism and becomes physically and verbally abusive to their mother when he is intoxicated. Although he has not had a drink in one year, it has been known for him to start drinking and act out when he feels stressed, overwhelmed or receives bad news. She further explains that this is not the way the family would like their mother and father to spend their last months together. The physician agrees and writes an order on the chart as follows, “Do not disclose any information regarding the patient’s condition or diagnosis to the patient at this time”. Two weeks later, while caring for the patient, you notice that the patient is beginning to question every aspect of his care and why he is in the hospital for so long. Mr. Singh asks the nurse, “What is happening to me? I think something is wrong but no one is telling me anything. Am I dying”?


I responded with the following:


The standards of medical practice in the United States as well as I presume also is in Canada require physicians to discuss with the patient issues of medical significance for the patient. This is our medical culture which also includes informed consent, which not only reflects the ethical principle of patient autonomy in our culture but also is also a legal requirement. Informed consent represents a discussion by the physician with the patient about the patient's current status and options so that the patient can give consent for further managment for their condition. Except in an emergent situation, the information need not be given all at once and can be presented to the patient gradually based on what and how much the patient wants to know. Patient and family coming from other cultures where medical information to the patient is handled differently needs to be made aware of our culture. This doesn't preclude that with the patient's understanding and permission a family member, for example, could be assigned by the patient as a legal surrogate. A patient with capacity to make their own medical decisions but who desires another person be made aware of the facts and even make the informed decision, certainly has the right to do so. (California has such a right written into state law). It is then the duty of the surrogate to learn the facts from the physician and to answer, in the way the surrogate finds appropriate, the questions of the patient.&nbs p; The doctor is not abandoning the patient by this surrogacy but simply giving the patient with capacity the autonomy to select how, if at all, the information is transferred and how medical decisions will be made.

The scenario presented shows the devestating effect and consequence of the absence of all communication of the physician to the patient about a life ending medical condition as the patient trying to understand what is happening to himself asks "am I dying?". While it is necessary to the emotions of the family to protect the patient from upsetting information, the physician must remember to whom the physician has the primary responsibility for trust and care--the patient. Without talking to the patient and understanding the patient's own desires about understanding the illness, the physician is ignoring that responsibility. ..Maurice.

 

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