They can haunt you for life. They can keep you awake at night They can change forever how you practice medicine. And for many doctors, they are the stuff of everyday experience.
"They" are the "ethical dilemmas" that so thoroughly permeate medical practice as to become inseparable from it. And because these dilemmas are so enmeshed, it is often difficult to tease them out from the daily fabric of health care. Still, they regularly thread through medical decision-making between doctors and patients in clinics, and through hospital policy-making in the executive offices.
Broadly stated, an ethical dilemma occurs whenever "doing the right thing" is brought into question. Opposing views about what's right and what's wrong create friction that sparks an ethical conflict and, frequently, heated ethical debate. Just about any medical or health care issue can provide the kindling: abortion; government spending on Medicaid; hospital policy guiding organ transplantation; physician-assisted suicide. ...
An act as seemingly simple and value-neutral as signing an antibiotic prescription can bristle with ethical dilemmas. Should I prescribe an antibiotic because that will calm my extremely anxious patient -- or should I resist because it's wrong to waste resources and to risk the side effects from a medically ineffective therapy for her viral infection? Should I prescribe the antibiotic whose name is neatly emblazoned on the nifty pen I received from the peppy pharmaceutical rep -- or should I choose a cheap ol' generic instead? During a flu pandemic or national drug shortage, how do I decide which of two deserving patients should receive a scarce antibiotic?
Ethical dilemmas often arouse strong emotions and forceful personal opinions from people engaged in moral conflict, people waging an age-old battle between perceptions of right and wrong. That can make it extremely difficult to unearth what's actually at stake in the dilemma: the deeply rooted moral values at the bottom of all the emotions and opining.
We carry these personal moral values into the clinics and hospitals -- whether we are health care workers, patients, or administrators. And because they draw upon our intimate philosophical and religious beliefs, our family values, and our cultural traditions, they tend to anchor us firmly and meaningfully in a moral predisposition or attitude that infuses our self-identity. That is why these ethical dilemmas are often so difficult, so painful, so meaningful, and so resistant to simple solutions or surface agreements.
The field of medical ethics emerged as a discipline in the 1960s and '70s to assist patients, families, and health care workers who found themselves entrenched in moral conflict over health care decisions. Most large U.S. hospitals now provide medical ethics consultation by a trained consultant or ethics committee.
The first objective of consultation is to unearth all the moral values at stake in the ethical dilemma (not an easy task!) from all parties involved in the decision at hand. That makes it possible to see someone who holds an opposing view as a person taking a principled stand -- rather than as some wearisome obstructionist who stands unreasonably in your way. Quite often, humanizing each person's point of view in this way leads to common ground where dispute resolution can succeed.
Last week, WebMD released its latest Medscape survey of more than 24,000 U.S. doctors who were asked to identify the "top ethical dilemmas" they encountered in medical practice.
Reading the results, it's readily apparent that ethical dilemmas are as common as ... well, the common cold. Readers might be particularly interested to learn that doctors often differed dramatically in their views about the right and wrong way to handle those real-world clinical dilemmas. Notably, because many of them involved life-and-death decision-making, it will be critical to further study how physicians' personal points of view actually affect the care a patient receives.
In these troubled economic times, it's also salient to note how the surveyed physicians viewed their stewardship of health care expenditures. A sizable percentage would consider providing care that was ostensibly "futile" or intended only to alleviate malpractice fears.
Below are some of the Medscape survey questions. How would you respond? How "should" you respond? (Excerpted from: Medscape 2012 — Ethics Report. Available at www.medscape.com/features/slideshow/public/ethics2012.)
Would you ever give life-sustaining therapy if you believed it to be futile?
Yes: 35 percent
No: 24 percent
It depends: 41 percent
Would you ever devote scarce or costly resources to a younger patient rather than to one who was older but not facing imminent death?
Yes: 27 percent
No: 38 percent
It depends: 35 percent
Is it ever acceptable to perform "unnecessary" procedures due to malpractice concerns?
Yes: 23 percent
No: 55 percent
It depends: 22 percent
Would you hide information from a patient about a terminal or preterminal diagnosis to bolster their spirit?
Yes: 10 percent
No: 72 percent
It depends: 18 percent
Is it ever acceptable to cover up or avoid revealing a mistake if that mistake would not cause harm to the patient?
Yes: 16 percent
No: 63 percent
It depends: 21 percent
Should physician-assisted suicides be allowed in some situations?
Yes: 47 percent
No: 40 percent
It depends: 13 percent
Would you ever continue treating a patient -- despite a family's wishes to end treatment -- if you felt the patient had a chance to recover?
Yes: 23 percent
No: 32 percent
It depends: 45 percent
Would you ever report a physician, friend, or colleague who occasionally seemed impaired by alcohol or illness?
Yes: 78 percent
No: 4 percent
It depends: 18 percent
Kate Scannell is a Bay Area physician and syndicated columnist. You can visit her website at www.katescannellmd.com.