Ethical Dilemmas:Playing Ethicist: Almost Anyone Can Do It
You don’t have to sell yourself as an ethicist in order to “play" an ethicist, suggesting answers to hypothetical cases. My view, previously expressed on this blog, is that most every awake and interested person has the capacity based on their own knowledge, experience and viewpoint, to play ethicist and make a significant contribution toward resolution of an ethical dilemma.
Just to demonstrate the validity of my view, I have created 4 potential ethical dilemmas and request my visitors to play ethicist pretending that you are faced with the issue and have the responsibility of talking to the doctor, patient or family member about what you would suggest as a solution to the dilemma. By the way, in attempting to solve an ethical dilemma, it is essential that the ethicist or “play ethicist” make sure that they have all the facts of the case needed to help resolve the dilemma. Without the necessary facts, one cannot generally make an ethical decision. Try these hypothetical cases out and then write and let me know your answers to the questions and your decisions. ..Maurice.
1. A 65 conscious man on a ventilator for life support tells the doctor, by writing a note, that he wants the ventilator turned off. The doctor knows that if she turns off the ventilator the patient will die in a few minutes. What further information would you need to know in order to advise the doctor whether what is requested by the patient is ethical and legal?
2. A baby born 6 days ago without a brain but with a brain stem that is allowing the baby to breathe and maintain blood pressure has developed pneumonia. The mother insists that the doctor treat the pneumonia. The father wants the doctor to allow the child to die. What would you recommend to the parents and the doctor?
3. Two children one age 5 and the other age 7 were born with a genetic disorder which limits their life to less than 15 years. The mother is again 2 months pregnant and asks the doctor for advice as to what to do. However, the doctor holds moral views and by religion is against abortion. What would you advise how the doctor should respond to the mother?
4. A father brings into the emergency room his 3 year old child for a bloody nose but is found by the doctor to have a fresh bruise on the left buttock and right shoulder. What facts should the doctor know before breaking patient confidentiality rules and report these findings to governmental authorities as suspected child abuse?
posted by Maurice Bernstein, M.D. @ 4:10:00 PM
7 comments
7 Comments:
As a spare time ethicist, I'd only comment that all these questions and potential responses are colored by your own ethical and religious values and need to be adjusted by an intimate knowledge of the laws in your own state, especially for the first 3 scenarios. There is usually no unique 'right answer.'
The bottom line for a physician is that if you're uncomfortable going against patients' or family wishes, there's little recourse except to have the case legally adjucated the result of which will be a legal decision, not necessarily a decision that fits with your own ethical values.
Joel, I agree that there well may be no "right" answer but most ethical conflicts cannot go unanswered. Postponing a decision may be a "right" answer but it also can be the "worst" answer.
In recommendation by an ethicist regarding an ethical decision in the care of a patient, the ethicist's own views or moral values or the ethicist's own interests should not play a role in a decision which is to be directed to end up with an action which is consistent the patient's values and in the patient's best interest.
A physician who is managing a patient is actually one of the stakeholders and may be in a position not able to separate his or her self-interests or moral values satisfactorily in the decision-making process. That is why physicians come to ethics committees requesting assistance, help in finding among the various routes, known or unknown, the pathway to what is most rational but also the most in keeping with the patient wishes and best interest.
Though all the facts within all the cases are unknown, all the 4 "playing ethicist" cases can have some ethics response. ..Maurice.
The meetings I've been at may come to a consensus but usually there are many differing opinions and slants.
But I'll bite:
The first case depends on the competence of the patient and state law.
I agree with the father in the second case, but the parents have to get together. It's too difficult to end life support to a minor if the parents disagree.
The doctor in the third case should send the mother for a 'neutral' opinion.
The 4th case is out of my medical sphere. I'm sure it is well defined in the pediatric literature. State laws also apply.
Good beginning, Joel. Anyone else have some suggestions? ..Maurice.
Case 1: Depending on state laws and the competency of the patient to make the decision, one must respect the patients choice. O/W this could be viewed as "assault."
Case 2: This is tough situation. While the mother is still grieving, the father has come to terms with the situation. This is going to have to be a decision between them. Likewise, this is a moot point in that anencephalic babies will not live longer than 2 weeks. Sometimes respecting her wishes may give her comfort.
Case 3: Refer to geneticist.
Case 4: Failure to report suspected child abuse in my state is punishable. A detailed H&P may locate another source for the findings. In other words, do your job and go with your gut.
So, what are your solutions Dr.B?
Joel, if I presented my views as one who "does clinical ethics" (as Chair of my local community hospital ethics committee), I might be inhibiting others who have as much right and validity to their opinion from writing to this thread.
But I can make some comments on previous visitor responses.
Case 1.- Competence is a court of law determined state. Capacity is the proper term which characterizes whether the patient can make a specific medical decision. A patient may be legally incompetent to care for their finances but still have the capacity to make a personal medical decision. Capacity is established by clinical evaluation and includes determining about how well the patient understands the specific issue being presented and how well the patient explains the basis for the decision.
Case 2-An example of respecting wishes of the family when we deal with a patient who is brain dead and we keep the patient pink and warm by continuing pulmonary and vascular support for hours or a day until family members can arrive at the hospital from a distant city. (Note: an anencephalic is not technically brain dead and is not considered dead since the infant does have brain stem function which is absent in a brain dead patient.)
Case 3- All doctors should consider referrals to others if they lack the skills, capacity or moral will to provide the patient with standard managements.
Case 4- In the end, the goal of medical evaluation and management should be for the beneficence of the patient rather than the physician's self-interest. ..Maurice.
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