Clinical Ethical Issue and Ethical Dilemma: What They Are and What They Are Not

I would like to provide to my visitors more insight into what are ethical issues in medicine and what are not, what ethical dilemmas are and what are not. In a number of previous threads, I have written about activities and duties of hospital clinical ethics committees and described ethical dilemmas. In this thread I would like to further describe the work of the committee in parsing out what is and is not an ethical issue and what is and is not an ethical dilemma.

An ethical dilemma can be a conflict between at least two ethical principles both of which could be readily applied to the decision making process and provide an equal good or, indeed, and equally bad outcome but one has to be selected. An ethical issue is not a dilemma if there is no conflict. In the practice of medicine, there are ethical issues that arise frequently but they may seem like a dilemma but actually are not since there is general consensus in such a situation that one principle trumps the other. The main principles that we use in medicine are those of autonomy (self-decision making), beneficence (to do good to the patient), nonmalificence (to do no harm to the patient) and justice (to be fair to the patient and others.) Examples of other ethical conflicts can be read on my thread “What is an Ethical Dilemma?”

A good part of the consultative work of clinical hospital ethics committees for example is sorting out those issues brought to them for advice between what is an ethical issue and what is not. Many times people jump to the conclusion that a clinical ethical problem is present in medical care and management when actually there is no ethical problem but simply (or not so simply) a problem in proper communication between parties. Often the basis for the problem in communication is one party providing inadequate information to another party, either from being rushed and skipping the telling of needed facts or that there are no such facts available. Also, when facts are available there may be inadequate explanation of the facts and the consequences of a medical decision. Sometimes the situation involves conflicts in the relationships, functions and duties of individuals or groups within the administration of a hospital with a subsequent potential impact on clinical care but not an issue about a specific clinical case conflict. This could, however, represent an institutional ethics problem. Another non-ethical problem could be related to standards of medical practice which usually is based on evidence-based decisions or medical consensus and have nothing directly to do with ethics involving the case under review.

Finally, if the case represents an ethical issue and if there is a consensus in the ethical and legal experience with such issues that one principle should and will trump another then no ethical dilemma exists. I should explain that such consensus is based on agreement amongst bioethicists,lawyers, courts and, of course,general public opinion. For example, there is both legal and ethical consensus that any adult who has the mental capacity to make their own medical decisions has the ethical and legal right to withhold or withdraw any treatment for themselves, even treatments which are or would be life supporting. Yes, before the consensus was obtained a decision to withhold or withdraw would have been an ethical dilemma for example between autonomy and nonmalificence. That is between allowing the patient to make their own medical decisions but the physician by not doing something or by doing something that would cause harm to the patient. Autonomy now trumps nonmalificence in such a situation and there is no dilemma. Another resolved dilemma is that of the possibility of a terminally ill patient dying from an unintentional overdose of morphine in an attempt to keep the patient comfortable and free of pain and distress. Here beneficence trumps nonmalificence because of the principle of "double effect". The premature and unintended death of an otherwise dying patient who was given palliative treatment to relieve pain and discomfort is considered ethical and acceptable.

The role of the hospital clinical ethics committee is to clarify the issues in terms of being of ethical significance and of being an ethical dilemma, to educate the parties involved in the ethics and the law and to facilitate and mediate the parties own decisions based on the facts, the ethics and the law. ..Maurice