Moral Dilemmas

‘There may be medical tools in your hands to treat the patient, but those hands must be the hands of a loving, warm and conscientious human being’ – Abhijit Naskar

On this page, I will look at some ethical challenges that doctors face, and also the medico-legal system, and how this might be changed for ethical reasons. Ethics is the moral principles that govern a person’s behaviour or actions, and morals are the standards of behaviour; principles of right and wrong, which are shaped by many different factors: family, religion, age and culture. When looking at ethical scenarios, it is important not to rush (think through answer), to argue on both sides of the argument and come to a balanced conclusion (there is no right or wrong answer, just an incorrect way of approaching the situation), and this is the form that I will take in the below examples.

Medical ethics is a really big aspect of the work of a doctor or anybody working in the healthcare (one definition of healthcare is: healthcare is about removing obstacles to people’s biological and intellectual potentials) industry, therefore here is an introduction to medical ethics:

The first medical ethics document was written in the 5th century B.C., the Hippocratic Oath. Although not sworn anymore, it raises good points about never doing harm and keeping confidentiality.

Anybody that has been through medical school will know that the ‘Principles of Biomedical Ethics’ is the number one book detailing medical ethics. In the 2019 8th edition of this book Beauchamp and Childress refer to four key moral principles:

  • Respect for autonomy
  • Non-maleficence
  • Beneficence
  • Justice

Autonomy is the right to decide over your own body, different to capacity, which is the ability to decide over your own body. For a doctor, respect for autonomy refers to telling the truth to the patient so that they can make their own informed decisions, respect confidentiality and privacy so that they are safe from any judgement that they don’t want. It is also about obtaining consent about information and helping patients to make decisions when asked for help. The issues with respecting autonomy are if the patient is immature, incapacitated, ignorant, coerced or exploited, which is why informed consent is a key concept.

Non-maleficence refers to not doing harm to patients by abiding by the rules of non-treatment, never killing patients (though sometimes letting die is ok), never intentionally arranging deaths and protecting incompetent patients.

Beneficence is about protecting and defending the rights of patients, preventing harm from patients, removing conditions (obstacles from our definition) which may harm patients, helping patients in disabilities and rescuing persons in danger. A doctor should always strive to do good for their patient.

Finally, justice is about the justice of the nation, not necessarily the individual (Jeremy Bentham’s utilitarianism), though, of course, it also applies to being unbiased and non-judgmental to every individual. People should be given treatment according to need, effort, contribution and merit. This may have many implications, for example, someone that is employed being prioritised over someone that isn’t, or someone that is an alcoholic not being given a liver transplant. But, it is usually based on clinical need as the primary factor. It often looks at the rationing of resources, financial implications (QALYS) and the postcode lottery.

Of course, it is often a balance of these four values. To take a simple example, a surgeon has to do harm (cutting someone open) to do good; or a drug having bad side-effects, or, for example, to what extent do you protect someone’s autonomy if their individual belief will refuse treatment which will result in their death or their autonomy results in the harm of others. Overall the beneficence may outweigh the non-maleficence.

Often two measures are used to help treatment decisions: QALYs, CBA and DALY. QALYs is the quality-adjusted life-years and is a rank of one’s quality of life after treatment and for how many years they will likely live, to compare treatment options for them. It is used to guide decisions regarding the fair allocation of resources, and the resources would be given to those with the most QALY. It is the length of life x quality of life. The NHS spends about £20,000 per QALY gained. One apt example of this might be the lockdown which takes pressure off of the NHS but causes serious harm to the economy. At what point does the impact on the economy become greater than the physical harm caused by a lack of resources. DALY is a disability Adjusted Life Year, is a standardised quantitative measure of the burden of disease, which combines mortality (life expectancy of a healthy individual – age of death of an individual with the disease) with morbidity (each individual is given a disability rating from 0 to 1 and is multiplied by the number of years that they will have the disability). It allows the direct comparison of burden across diseases, and the summing burden across diseases, as well as permitting the comparison treated and untreated diseases. Finally, they allow the comparison of different types of treatment. DALYs are now the accepted way to quantify global disease burden, but generally, QALYs are better with bigger values and DALYs with smaller values. This is a good video which compares QALYs and DALYs. CBA is cost-benefit analysis, which is balancing costs, benefits and risks.

The doctor-patient relationship is also addressed by Beauchamp and Childress. They identify five key areas:

  • Veracity
  • Privacy
  • Confidentiality
  • Fidelity
  • Dual role of Investigator and Clinician.

I like the definition of the relationship as fiduciary: one who owes to another the duties of good faith, trust, confidence and candour.

Seedhouse's Ethical Grid (Seedhouse, 1998b). | Download Scientific ...

This is Seedhouse’s medical ethics grid. The inside layer is about the individual autonomy, the next layer is about duties and motives (intentions and accepted moral principles; respecting the patient), the next is the consequences (to the individual, other groups and society, and the next is external considerations and circumstances (sometimes this is the most important, and can take the decision of what to do out of the hands of the medic). It was made to help the user understand the ethical issues that they are facing. The limit of use is integrity.

The idea of the grid is that if you go layer by layer, box by box, you have addressed the situation as clearly as you can consider it. Some may be relevant in your situation, some may not be, but even if they aren’t, at least you have considered them. This is a good video which explains what each box means.

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Revealing Mistakes to Patients

A medical error can be defined as “the failure of a planned action to be completed as intended (i.e. error of execution) or the use of a wrong plan to achieve an aim (i.e. error of planning).” Medical errors will likely continue as long as clinicians remain fallible humans. Once they occur though, what should be the attitude of the medical profession? More people die annually from preventable adverse events related to healthcare than from motor vehicle accidents (43 458), breast cancer (42 297), or AIDS (16 516) in the United States. This grim report indicates how common it is for medical practitioners to make errors in their day to day clinical practice, and the figure may be under-reported as 50% to 96% of errors go unreported.

In a 2016 Medscape survey, 78% of doctors said that it was never acceptable to avoid revealing a mistake, 7% said it was acceptable, and 14% said that it would depend on the situation. But when primary care physicians at integrated delivery systems were asked about hypothetical situations of a delayed diagnosis of breast cancer or delayed response to the diagnosis, more than 70% said they would provide only limited or no explanation or apology.

for revealing all mistakes to patients

My initial thoughts were as follows: by keeping information disclosed, this creates a form of barrier between the patient and doctor, more specifically, a barrier of honesty; this may inhibit the doctor’s communication with the patient as they attempt to cover up their mistake. Furthermore, by covering up information, the doctor puts his interests above that of the patient, violating the patient-centred ethic.

But, the most compelling argument arguing for this side is as follows:  the patient-doctor relationship is a fiduciary relationship (one who owes to another the duties of good faith, trust, confidence and candour). It must, therefore, rely on principles of autonomy, non-maleficence, beneficence, justice and fidelity at all times.

Firstly, autonomy; non-disclosure of information to patients ignores their right of autonomy (the right of self-governance). Furthermore, deceiving patients interferes with the doctrine of informed consent, because patients may not understand the reason or need for additional interventions or a longer hospital stay that becomes necessary as a means of rectifying an undisclosed error. It is therefore important to disclose errors in order to respect autonomy and facilitate the giving of informed consent.

Secondly, non-maleficence; this means not inflicting harm on others. Of course, in making a mistake, harm may be done, but this harm can be accentuated by not disclosing the error to the patient. The patient may then worry about having an underlying disease that they haven’t been informed of, and this is the reason of their extended hospital stay. To reduce this psychological distress, and reduce the harm inflicted, the doctor should inform the patient of the truth.

Thirdly, beneficence; the moral obligation to act for the benefit of others. Failing to disclose a medical error and letting the patient assume that what he or she is going through is due to the disease is unkind and violates the principle of beneficence.

Fourthly, justice; fair treatment owed to people, which dictates that disclosure of an error is necessary in order to ensure compensation to patients, for increased health care costs or lost wages in addition to an apology from the doctor.

Finally, fidelity;  norms that specify the moral principles discussed above, in particular, those of autonomy and justice. Although doctors’ obligations of fidelity demand that they should be truthful with their patients, sometimes, a misguided desire to ‘protect patients from harm’ makes doctors less than truthful with patients. However, since most patients want to know about even minor errors, claiming that nondisclosure protects patients is false. Given that the heart of the doctor-patient relationship is honest communication, deceiving patients not only undermines the veracity of the individual doctor; it also casts serious doubt on the trustworthiness of the medical profession as a whole.

These arguments show that disclosure of medical errors to patients is justified on moral grounds and upholds principles of autonomy, nonmaleficence, beneficence, justice and fidelity that are fundamental to the fiduciary nature of the doctor-patient relationship.

Deception isn’t acceptable in any form in the medical profession, and non-disclosure is a form of deception, that shouldn’t be accepted.

Against Revealing all mistakes to patients

There are a few reasons why a doctor may disclose an error from a patient, which I will now look at.

Firstly, there is always the threat of legal liability and being sued if a mistake happens. However, close to half of malpractice cases could have been avoided through disclosure or apology but instead were relegated to litigation. What the majority of patients really wanted was simply an honest explanation of what happened, and if appropriate, an apology, and therefore this argument doesn’t stand.

Secondly, patients are more likely to become distressed to the point of becoming irrational or being severely damaged psychologically when they get to know about the errors that have occurred, rather than if they had remained ignorant of such errors, and it might reduce the patients trust in a doctor if they knew the error. However, the fact that patients may be distressed on being told about medical errors does not justify keeping such information from them. In addition, there is evidence to the fact that informing patients truthfully and compassionately about errors does not result in an increase in their distress. Although patients describe a variety of emotional responses after a medical error including sadness, anxiety, feeling traumatized, fearing additional errors, anger at prolonged recovery and frustration at the error being preventable, many also believed that their emotional responses after the disclosure was directly affected by the manner in which the error was disclosed. While patients indicated they would be less upset if the disclosure was done honestly and compassionately with an apology, they also indicated that their distress would be increased with error explanations that were evasive or incomplete.

Finally, there is the worry of reputation, privileges and potentially license revocation. But, although the temptation to protect one’s reputation may be high, it is worth remembering that the doctor will likely themselves in a worse situation when the patient eventually gets to know that not only was an error made, but the doctor failed to disclose the error. As the American Medical Association’s Council on ethical and judicial affairs states, “concern regarding legal liability which might result following truthful disclosure should not affect the doctor’s honesty with a patient”. What’s more, concern regarding damage to reputation, loss of privileges or their license should not prevent the doctor from doing the right thing by being honest with a patient. Finally, the medical profession and society more generally need to accept and recognise that mistakes as unavoidable, though they are an unfortunate part of clinical practice.

conclusion

Although there are therefore several reasons why doctors fail to disclose errors to patients, these do not justify the non-disclosure of errors to patients. It is important to note that at the heart of non-disclosure is deception, a violation of the moral rule “do not deceive.” In order for a violation of a moral rule to be justified, the following three conditions must be satisfied:

  1. Everyone agrees that all justified violations of the rules are such that if they are justified for any person,
  2. They are justified for every person when all of the morally relevant features are the same.
  3. It must be rational to favour everyone being allowed to violate the rule in these circumstances.

A violation is justified only if it is rational to favour that violation even if everyone knows that this kind of violation is allowed. Since deception of patients in the form of non-disclosure of medical errors does not satisfy any of the above conditions, it is an unjustified violation of an important moral rule.

Doctors might be permitted not to tell if they have good reason to believe that disclosure would undermine the patient’s autonomy in some way (e.g. incapacitate the already severely depressed patient). Or the patient might have told the doctor explicitly, ‘Doctor, if anything goes wrong, I don’t want to know about it. Since doctors are to “above all, do no harm” while doing what is beneficial for their patients, if disclosing a medical error is deemed harmful to patients, the doctor may be morally justified by not disclosing such information since it would not be in the patient’s best interest to know. The doctor is therefore able to uphold the ethical principles of nonmaleficence and beneficence instead of violating them.

Overall, I think that moral courage is needed to reveal a mistake to a patient, and training can certainly help this. I believe that training doctors and other hospital staff on how to disclose medical errors and providing emotional support for doctors who make mistakes in their efforts to treat patients and save lives is the best approach. If the choice is made, however, to not disclose a mistake, the mistake, even if only minor, should be discussed with clinical colleagues so that the doctor can learn from it. But even minor errors can eventually cause harm to the patient, and so I think that any error should be disclosed.

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When faced with critical shortages during a pandemic, who decides who gets a ventilator?

Using the QALY argument, those with the best chance of survival, with a good quality of life would be prioritised for ventilators. Furthermore, those who are considered to have the least good outcomes will be denied ventilators.

Some would use the ‘First Come argument’. That is to say that it is impossible to decide if one life is worth more than another, so they believe that the decision should be left to chance. If there is a ventilator available, they will get it, because is it right to deny one patient a ventilator because someone else might need one later?

If we look at beneficent, there is a limit to resources, so the opportunity to do good for one person loses the opportunity to do good for another. A lost opportunity to do good isn’t the same as actively doing harm, however (non-maleficence). Measures such as QALYs can be used to see where the biggest impact will come, but who gets to define quality of life, and individuals can have very different attitudes towards quality of life? Finally, does quality of life necessarily equate to value of life?

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Many patients have been waiting months for elective operations (non-emergency operations scheduled in advance), which have a significant positive impact on their quality of life. Since the pandemic, many have been postponed. How is quality of life valued in an emergency situation? What other factors are at play?

A pandemic is a critical situation, and the best way to prevent new cases and improve survival rates for the whole population is to pool resources together to combat COVID-19.

Elective surgeries aren’t emergencies, and to continue with elective surgeries would mean that a significant amount of resources and staff are employed for non-emergencies. This workforce (and resources) could otherwise be deployed to help COVID-19 patients. The NHS may be unable to cope with the pandemic without these resources.

According to the quality of life, elective surgeries can have a significant positive impact on one’s quality of life. Therefore, the QALYs gained for these patients may be greater than those gained by diverting resources towards COVID patients.

Regarding justice, many patients have been waiting for their elective operations for months, therefore, is it right to make them wait even longer, with greater uncertainty over if, and when, they will have their surgery.

However, there is increased patient risk if elective operations go ahead. It is well known that viruses can spread rapidly through a hospital population. All surgeries (and the associated hospital stay) have associated risks, and, with the COVID-19 pandemic, this risk is increased. The increased risk stems from the increased likelihood of a patient catching COVID-19 in a hospital environment, as well as the limitations on resources that would be available if complications occurred during surgery, and the patient required critical care.

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Due to the infective nature of COVID-19, relatives were banned from visiting dying patients in many hospitals. Is this right?

Doctors want to provide the best possible care to patients and their families, but they must balance the positive benefit of having family present at the death, against the potential risk of exposing them to COVID-19.

Regarding the unique value of family, we, as humans, share many of our closest relationships with family members. Therefore, it is no surprise that these are the people that we want to surround us when we die. Family members can provide comfort, and alleviate suffering during the dying process.

Furthermore, the family of the deceased may be better able to cope with the grief if they are able to give support to their relative as they die.

But, using Joseph Fletcher’s situation ethics, it may have a greater consequence (teleological) for individuals to not visit the death of their family. It is the for the greater good, as you have to weigh up the cost of dying alone to the benefit to the population in reducing COVID-19 infections.

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To cope with staff shortages and sickness, many retired staff returned to the NHS. As the retired are an at-risk group, is this fair?

As the COVID-19 pandemic intensified, so too did the amount of staff sickness. Many units were reporting staff sickness to be upwards of 50%. Understandably, it is difficult to staff a safe department or ward with so many staff off sick. But where can we get suitably skilled and trained staff from? Is bringing back retired staff the most suitable solution?

The NHS was understaffed before the pandemic, now the problem is accentuated – there is chronic understaffing. The NHS won’t be able to function without retired medical professionals returning to work. Due to the prevalence of the disease, many of those workers (including those who are in the at-risk groups) are needed on COVID-19 wards.

Returning to work has an element of personal risk involved, therefore individuals shouldn’t be forced to return to work. Instead, they should be asked to volunteer – this respects their autonomy. This is what happened, as Matt Hancock, the Health Secretary appealed to retired NHS doctors and nurses saying that the NHS needed them. Many doctors felt a sense of duty from this call out and therefore volunteered.

The members of staff that are at a higher risk, due to age or health conditions, shouldn’t be put to work in COVID wards. Instead, they should be deployed to low-risk areas such as oncology. The staff from these low-risk areas can then be redeployed to COVID wards if they are in good health. Alternatively, the most vulnerable staff should be given priority for PPE or they could offer advice to younger or healthier staff, without setting foot in the ward itself.

It’s ultimately weighing up the doctor vs the whole population. It may contradict non-maleficence for the doctor, but not for the population, and it may be beneficent and just for the doctor to return. I feel that, if you respect their autonomy, and give them sufficient PPE/don’t allow them to work in COVID wards, where possible, it should be ok for them to return.

Here is more research on how age affects prognosis.

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Upcoming:

  • Is it ok to refuse to treat a patient as you worry that you have insufficient PPE?
  • Would you buy a kidney for your mother?
  • Putting unconfirmed cases of COVID-19 together on a single ward increases the risk that the uninfected will become infected. Is it right to put others at risk in this situation?
  • Several existing medications have been suggested as possible treatments for COVID-19 patients. However, there is a very limited evidence base to support the use of these medications. Should we be using them?
  • A GP surgery in Wales was criticised recently for sending out letters to encourage older people, and those with commodities to agree to DNACPR (do not attempt CPR) forms. What are the ethical implications for CPR and taking these extraordinary methods in a pandemic setting?
  • And many more from here.