Making Clinical Ethical Decisions: Common Fallacies: 3. False Dichotomy

False dichotomy is where, in formulating a decision, the decision is based on a belief of “all or none” and forgetting that there may be a middle ground. Not all decisions need to be made as “black vs white” since often there are shades of “gray”, that middle ground.

This concept is particularly important in clinical ethics consultations where in most cases decisions are not emergent. Yes, in an emergency room environment, often decisions regarding diagnosis and therapy need to be made promptly without time available to philosophize over an issue and either something specific in therapy is done or something is not done. In contrast, by the time an issue of management comes to the hospital ethics committee consultation there may be a sense of urgency to some but in most cases there is time to look at and consider the whole clinical, ethical and legal picture in order to come to a satisfactory conclusion. And what first comes to the table as a decision for either a “this” or a “that” may actually during discussion find some middle decision as the most viable and beneficent solution. This finding of a “middle ground” is one of the functions of an ethics committee consult and is part of the process of mediation of conflicts.

As an example, a 75 year old man with chronic emphysema and diabetes who has had a massive stroke and is still unconscious in the critical care unit of the hospital after 2 weeks and there is advice by the attending physician that the patient should undergo a tracheotomy (semi-permanent opening to the windpipe for breathing) since he is expected to continue on the ventilator for a unknown period of time. Also at this time a tube inserted into the abdomen and entering the stomach (PEG procedure) was the professional advice for longer term feeding and hydration. One son sitting at a hospital ethics committee consultation agreed with the advice of the physician. He wants these procedures performed since he wants to continue life-supportive treatment to continue until his father recovers. Another son with whom the father had lived since the mother had died a few years earlier present at the meeting argued against these procedures. He said that his father would never awaken and if he did he would not want to be alive after such a stroke. The son wanted the ventilator to be turned off even if it meant the death of his father. A neurologist on the case presented her opinion that the current 2 weeks duration might be too soon to make a judgment about the prognosis though it was probably poor and if the patient survived he might continue either in a persistent vegetative state or profoundly neurologically impaired. So the possible decisions would seem to be 1) continue with supportive therapy, do a tracheotomy and PEG or 2) terminate life-support now. But this is where overriding the “false dichotomy” comes in: there is a middle ground which was offered by the ethics committee. The neurologist told the family that she might be able to give a more accurate prognosis on examining the patient in one or two weeks. The attending physician said that the ideal time to perform the procedures was now but he would wait for a week or two more but not much longer. The ethics committee suggested to both sons that a compromise of having a followup ethics meeting in 10 days after the patient was evaluated at that time may be the best decision at present. This also provided time for each son to re-evaluate his position on a final decision. This middle ground satisfied all parties who were present and they all shook hands as they left the meeting.

If this was your father and the physicians were in agreement with the conclusion of the consult would you too be satisfied that it was not necessary to have the decision end if not the one way then the other? ..Maurice.