Chapter 1: An Approach to Ethical Dilemmas in Patient Care

Intro

Introduction

This case is really bothering me. I haven’t been able to stop worrying about it. I’m just not sure what the right thing to do is.” Cases with ethical dilemmas can perplex physicians. Strong reasons for an action might be balanced by cogent countervailing arguments. Common sense, clinical experience, being a good person, and good intentions do not guarantee that physicians will respond appropriately. Ethical dilemmas often evoke powerful emotions and strong personal opinions; however, emotions and opinions alone are not a satisfactory way of resolving ethical dilemmas. The following cases illustrate the range of ethical issues in clinical medicine.


Case 1.1. Decisions about life-sustaining interventions

Mrs. D, an elderly woman with severe dementia, develops pneumonia. Her daughter insists that hospitalization and administration of antibiotics would be pointless and that the patient would not want such “heroics.” Her son, however, demands that her pneumonia be treated because he believes that life is sacred. Should the physician withhold or administer antibiotics? Who should be Mrs. D’s surrogate when she cannot speak for herself? Furthermore, what are the reasons that the physician can give to justify the decision to the patient’s children and to the other health care workers caring for the patient?

The physician can follow the recommendations in Table 1.1 .

What is the problem or dilemma? Should antibiotics be administered, and who should decide?

What are the medical facts and issues? How likely is it that Mrs. D will be discharged from the hospital, return to her own home, and regain her former functional status if she receives antibiotics?

What are the patient’s concerns, values, and preferences? Has Mrs. D indicated what is important to her and what she is concerned about? Has she indicated preferences for hospitalization and medical care in such a situation?

What are the clinician’s concerns, values, and preferences? A physician might believe that she should provide effective, low-risk treatments that prolong life.

What are the ethical issues or questions? When a patient has lost decision-making capacity, how should disputes between the daughter and son about medical treatment be resolved? Should antibiotics for pneumonia be considered heroic care in this context?

What ethical guidelines are at stake, and how can they be resolved? Surrogates should base decisions on what the patient would want, not what they would decide for themselves (see Chapter 13 ).

There are guidelines to evaluate what weight to give the patient’s previous statements about end-of-life care (see Chapter 12 ). The doctor should orient the son and daughter to thinking about what Mrs. D would want and to obtain more information on what the patient previously said about her medical condition and life-sustaining treatments.

What practical considerations need to be addressed? Some states do not explicitly authorize surrogate decision making by family members who have not been designated as proxies by the patient, even though this is standard clinical practice and ethically sound.


Case 1.2. Confidentiality of human immunodeficiency virus (HIV) test results

A 32-year-old man with a positive test for HIV antibodies refuses to notify his wife. “If she finds out, it would destroy our marriage.” Should the physician notify the wife despite the patient’s objections? Although maintaining patient confidentiality is important, it seems cruel not to warn the wife that she is at risk for a fatal infection. What are the reasons that justify the physician’s decision?


Case 1.3. Physician certification of eligibility

A 67-year-old man with chronic obstructive lung disease has dyspnea after walking one block. He is on an optimal medical regimen of inhaled bronchodilators and corticosteroids. His resting arterial O2 level is 65 mm Hg, and it does not decrease with exercise. This exceeds the level that qualifies for Medicare coverage of home oxygen. The patient pleads, “Can’t you just write that the oxygen level is 58? I need to do something about this breathing.”


In such cases, physicians cannot avoid difficult decisions. This chapter describes how clinical ethics can help physicians deal with such dilemmas and presents approaches to resolving them. Specific ethical problems are discussed in detail in subsequent chapters.

What Is Clinical Ethics?

We use the term clinical to limit our topics to the doctor–patient encounter in the office or at the hospital bedside, when a physician is caring for an individual patient. Such patient care is the essence of a physician’s work. Although the focus is primarily on the doctor’s interaction with the patient, the physician’s relationships with the family, other health care workers, and medical institutions, such as insurance companies, may also be pertinent.

We use the term ethics to refer to judgments about what is right or wrong and worthy of praise or blame; however, we refer to moral judgments about right and wrong, not biotechnical or clinical judgments about the most effective or safest test or treatment. Thus, in Case 1.1 the biotechnical issue is, which antibiotic would be most effective for community-acquired pneumonia? There may be medical uncertainty or controversy, for example, because of emerging patterns of antibiotic resistance. These biotechnical questions can often be resolved by referring to the medical literature or clinical experience. The clinical ethics question is whether to administer or withhold antibiotics.

We also distinguish clinical ethics from several other closely related fields that are beyond the scope of this book. Health policy refers to public policies that set the context in which physicians deliver care to patients. It includes health insurance, access to care for the uninsured, allocation of scarce resources, public health policies, and state laws regarding end-of-life care and confidentiality.

Bioethics refers to broader philosophical questions raised by biomedical advances, for example, whether genetically modified crops or germ-line gene therapy is acceptable.

How Does Clinical Ethics Differ from Professional Ethics?

Many physicians seek ethical guidance from professional codes and the oaths that they took as students at white coat ceremonies and at graduation. New members of the profession pledge to the public and to their patients that they will be guided by the principles and values in the oath or code. Although professional oaths are important, they have several shortcomings [1]. First, they are unilateral declarations by groups of physicians, without any input from patients or the public.

Codes of ethics and professional oaths do not acknowledge that society has granted the medical profession autonomy to set standards for training and certification and, therefore, in exchange, may insist on certain expectations. Second, the content of professional codes has been criticized. The Hippocratic tradition is highly paternalistic, granting patients little role in making decisions. For instance, it does not require physicians to disclose information to patients, be truthful, or allow them to make informed choices.

Third, oaths and codes articulate general precepts but are too brief to resolve specific dilemmas. Furthermore, the principles embodied in codes may be in conflict in a particular case, leaving the physician in a quandary about how to act. This book provides physicians the tools to interpret broad principles (such as those contained in professional codes) as they relate to specific situations and how to act when ethical principles conflict or do not apply.

How Does Clinical Ethics Differ from Law?

Statutes, regulations, and court decisions also guide what physicians may or may not do. On many issues, the law reflects an ethical consensus in society. Moreover, appellate courts give reasons for decisions and, therefore, provide an analysis of pertinent issues. Hence, physicians should be familiar with what the law requires regarding issues in clinical ethics. However, the law may not provide definitive answers to ethical dilemmas.

First, the law, particularly criminal law, sets only a minimally acceptable standard of conduct. It identifies acts that are so wrong that physicians will be held legally liable for committing them. In contrast, ethics may focus on the right or the best decision in a situation. In Case 1.3, the Medicare criteria for coverage of home oxygen are clear: an arterial oxygen level of under 60 mm Hg. Giving false information to obtain Medicare coverage is considered fraud, a criminal violation. Physicians, like all citizens, should follow the law. However, professional ethics requires physicians to go beyond their legal duties, to act with compassion and respect, and to respond to the patient’s distress.

The law cannot compel such aspirations. Second, the law explicitly grants physicians discretion in some situations. In Case 1.1, most states allow physicians to determine when a patient lacks decision-making capacity and, thus, when a surrogate should make decisions with the physician (see Chapter 13). In Case 1.2, some states give physicians discretion whether or not to override confidentiality to protect partners of HIV-infected persons. In these circumstances, physicians must turn to ethical and clinical considerations, not legal ones. Third, the law might provide no clear guide to action on certain topics.

For example, the law provides scant explicit guidance on the issue of disclosing genetic information to relatives when the patient objects to disclosure (see Chapter 42). Finally, law and ethics might differ. Abortion is currently legal throughout the United States, but remains controversial ethically. Conversely, people might consider some actions that are prohibited by law to be ethical. In a few states, the courts have rejected family decision making for incompetent patients who have not provided written advance directives or very specific oral directives. Ethically, however, the consensus is to respect surrogate decision making by concerned family members (see Chapter 12). In this situation, most physicians feel uncomfortable simply following the letter of the law.

Sources of Moral Guidance

Distinguishing Morality and Ethics

The terms “morality” and “ethics” are often used interchangeably to refer to standards of right and wrong behavior. It is helpful to draw some distinctions. Moral choices ultimately rest on values or beliefs that cannot be proved but are simply accepted. Morality usually refers to conduct that conforms “to the accepted customs or conventions of a people [2].”

Children usually learn from parents and religious leaders what their culture or group regards as correct and might accept it without deliberation. Ultimately, such fundamental moral beliefs are part of a person’s character. Yet ordinary moral rules, which usually provide an adequate guide for daily conduct, fail to provide clear direction in many clinical situations, as we have seen.

In contrast to morality, ethics connotes deliberation and explicit arguments to justify particular actions. Ethics also refers to a branch of philosophy that deals with the “principles governing ideal human character [2].” To philosophers, ethics focuses on the reasons why an action is considered right or wrong. It asks people to justify their positions and beliefs by rational arguments that can persuade others.

Personal Moral Values

Physicians, like all people, draw on many sources of moral guidance, including parental and family values, cultural traditions, and religious beliefs. However, additional guidance in clinical ethics is needed.

First, these personal moral values might not address important issues in clinical ethics. Often, doctors face an ethical dilemma for the first time during their training and clinical practice. Laypeople have little experience with such topics as life-sustaining treatment or surrogate decision making. In addition, personal moral values might offer conflicting advice on a particular situation. For instance, moral precepts to respect the sanctity of life can be used in Case 1.1 to justify both continuing and withholding antibiotics.

Second, physicians have role-specific ethical obligations that go beyond their obligations as good citizens and good persons. Doctors have special duties to maintain confidentiality, as in Case 1.2, and to avoid misrepresentation when certifying a patient’s medical condition, as in Case 1.3. Personal moral values do not address these special professional roles.

Third, the physician’s moral values might differ from those of the patient or other health care workers. The United States is increasingly diverse in terms of cultural heritage and religious beliefs. In such a pluralistic society, physicians cannot assume that other people directly involved in a case share their moral beliefs. Thus, physicians need to persuade other health care workers, patients, and family members of their plans to resolve ethical dilemmas in patient care, using reasons that do not depend on a particular religious or cultural perspective.

Claims of Conscience

Sometimes people explain their actions as a matter of conscience [3]; to act otherwise would make them feel ashamed or guilty or violate their sense of integrity or deeply held values [2]. Conscience involves self-reflection and judgment about whether an action is right or wrong. For example, in Case 1.2, a physician might declare, “I couldn’t live with myself if I didn’t notify his wife.”

Deeply held claims of conscience are generally honored. It would be dehumanizing to compel people to act in ways that violate their sense of integrity and responsibility. Respecting claims of conscience, even though one disagrees with the decision or action, fosters moral reflection and striving to act with integrity. Claims of conscience, however, often do not resolve a dispute. There may be countervailing interests and ethical principles in play.

Appeals to conscience do not end discussions; to persuade others to accept such claims, it is often necessary to provide reasons and arguments. Chapter 14 discusses physician insistence on interventions, and Chapter 24 discusses refusals to provide services, based on objections based on conscience.

Claims of Rights

To explain their positions on ethical issues, people often appeal to rights, such as a “right to die” or a “right to health care.” To philosophers, rights are justified claims that a person can make on others or on society [2]. The language of rights is widespread in US culture, yet appeals to rights are often controversial. Other people might deny that the right exists or assert conflicting rights.

For example, in Case 1.2, even if the seropositive patient has a right to confidentiality, the wife might have a countervailing right to know that she is at risk for a fatal infectious disease. Although claims of rights are often used to end debates, asserting a right should open a new discussion: whether there are persuasive arguments that support the claim of rights.