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Wednesday, November 9, 2005

Ethical dilemmas.

Ethical dilemmas.

From Journal of Post Graduate Medicine

Pandya SK
Department of Neurosurgery, Seth GS Medical College, Parel, Bombay.

Correspondence Address:
Department of Neurosurgery, Seth GS Medical College, Parel, Bombay.

How to cite this article:
Pandya SK. Ethical dilemmas. J Postgrad Med 1997;43:1-3

How to cite this URL:
Pandya SK. Ethical dilemmas. J Postgrad Med [serial online] 1997 [cited 2005 Nov 9];43:1-3. Available from:;year=1997;volume=43;issue=1;spage=1;epage=3;aulast=Pandya

:: Introduction Top

Dilemma: difficulty, impasse, perplexity, predicament, quandary.
All medical doctors face situations from time to time, where the proper course of action is not clear. We are tempted, then, to paraphase Hamlet: “To do, or not to do - that is the question ...”

Take the case of a patient with confirmed malignant cancer of the breast whose chest x-ray film shows a rounded metastatic deposit. She now presents with a history of a recent focal epileptic fit but without any neurological abnormality on examination. Computerised tomographic scan shows what is most probably a metastasis in the left parietal lobe over the motor strip. Are we justified in advising excision of the tumour, knowing that it might leave her hemiplegic and when her general prognosis as regards long-term survival is grim?
Under such circumstances, how do we arrive at a decision? What do we navigate by?

:: Guiding principles Top

Four fundamental ethical principles have received universal acceptance by medical professionals:
* non-maleficence - ‘primum, non nocere’: first of all, do no harm
* beneficence - whatever we do must be for the benefit of the patient;
* respect for autonomy - the patient has an absolute right to make decisions concerning his own well-being, on any test or therapy proposed for him and on measures for resuscitation, prolonged maintenance on a ventilator and other such events.
In order to make such decisions, the patient - and family - need to be adequately informed on the pros and cons of each step. It is the communication of such details, in a manner that is clearly understood, that forms the basis of informed consent.
Justice as with reference to fair distribution of scarce resources; respect for the rights of the patient and family in the context of the rights of society at large; the use of the least expensive means in investigation and therapy; and respect for morally acceptable laws. It also implies the overcoming of personal prejudices - as against homosexuals or chronic alcoholics.
Thoughtful application of these principles to specific instances often helps resolve dilemmas.

:: Some common ethical dilemmas Top

Let us take examples from either end of the spectrum of life.
The treatment of infertility:
In a country where untold numbers of orphaned or discarded infants and children languish in unfeeling institutions where they are denied the attentions of parents and the company of siblings, is it fair for us to embark on such expensive techniques as in vitro fertilization?
On the other hand we have the plea of the barren wife who is willing to sacrifice almost everything to achieve the status of mother.
Possible resolution of dilemma:
Since it is the mother who comes to the doctor seeking treatment and since she has the right to decide on what should be done to and for her, the position of the orphaned children should not be allowed to intrude on the management of her problem.
Those in favour point to the legal sanction afforded to the termination of the life of the unborn foetus. Some have gone so far as to say that this is a welcome means for controlling our mushrooming population. Others have used it to get rid of female foetuses in their quest for the male child.
Many, however, remain troubled. Is this law morally acceptable? Are we ever justified in snuffing out life?
Possible resolution of dilemma:
This will depend on the beliefs and values cherished by the individual doctor. The doctor who holds life, as a sacred boon granted to an individual must refuse to perform or advice an abortion except in the specific instance where continuation of pregnancy may kill the mother. (Here, the operative principle is that the life of the mother is of greater concern than the life of the unborn foetus.)
Must we always strive to keep every baby alive, irrespective of costs?
Take two examples:
A premature newborn weighing 600 grams. Left to itself, it will perish. We can make extraordinary attempts to help it survive. In the process we may lead to a situation where the family is saddled with a severely handicapped individual with poor mental abilities.
A baby is born with meningomyelocele, paraplegia, incontinence of urine and severe hydrocephalus. A light applied to the head shows brilliant transillumination of the intracranial contents suggesting a paper-thin brain. It is possible to repair the skin over the exposed and damaged spinal cord and insert a shunt to drain the accumulated cerebrospinal fluid into the peritoneum. Survival is now assured but the family will bear the burden of looking after a mindless person who unknowingly passes urine and stools reflexly and will never understand, appreciate or communicate.
Possible resolution of dilemma:
The doctor must place the pros and cons of treatment in either instance before the parents. The doctor sympathetic to the social milieu in which the family exists and of the precarious economic circumstances of a particular family will emphasize the liabilities to the parents should treatment be preferred. I have, at times, gone a step further and told the parents that were the child in question mine, I would have decided against treatment.
If it is decided not to treat, should the patient’s life be terminated by a fatal dose of a drug? Some advocate stopping all feeds and supplying only water to take away thirst. The logic offered is that by this means we are not taking away life but allowing nature to take its own course. Is starvation to death not more cruel than instant death?
Possible resolution of dilemma:
Here, as often is the case with ethical dilemmas, the individual doctor’s conscience must dictate the course of action. Such a decision, however, must take into account the fact that the law of the land does not permit any doctor to kill the patient by any act of commission.
Admission to an intensive care unit:
The intensive care unit is already full of seriously ill patients, each of whom needs the special attention afforded in it. A fresh patient is brought to the clinic who also needs this specialized care. There is no other nearby centre that can take him. What is to be done?
Do we continue to treat existing patients and place this patient in a room or ward without special facilities for monitoring and treatment and, in the process, lose this patient? Do we shift the ‘least seriously ill patient’ out of the unit to make way for the new arrival and, in doing so, jeopardize the life of someone who may be on the way to recovery?
What if the new arrival is a ‘V.I.P.’?
A similar dilemma is posed when one has to select which of two patients is to be provided the only available ventilator.
Possible resolution of dilemma:
A new patient presenting to a clinic or hospital has not yet established the doctor-patient relationship with the consultant. Existing patients in the intensive care unit are already under his treatment and he is responsible for their welfare. His primary concern, then, must be for patients already in the unit. If, however, there if definite evidence that one of them can, without any risk, moved out of the intensive care unit to the half-way house of the semi-intensive care ward, such a transfer can be affected so as to take in the new patient.
Demand for euthanasia by a terminally ill patient in unremitting agony:
A patient with widespread cancer is in severe agony, which persists despite use of the maximal therapeutic doses of powerful drugs such as morphine. He begs to be relieved of pain and asks for the use of much larger doses, knowing that such doses will be fatal. Should one oblige?
Possible resolution of dilemma:
Here, as often is the case with ethical dilemmas, the individual doctor’s conscience must dictate the course of action. Such a decision, however, must take into account the fact that the law of the land does not permit any doctor to kill the patient by any act of commission.
Shutting off the ventilator:
The law, as it stands, does not allow one to take a brain-dead patient off the ventilator unless this patient is a donor of an organ such as the heart. What about the patient who is not suitable to offer an organ but whose relatives can no more afford the cost of an intensive care unit?
Should we insist on following the letter of the law so that we are not subject to prosecution under the Consumer Protection Act or the Indian Penal Code?
Possible resolution of dilemma:
The law, in this instance, is faulty. It is illogical to permit removal of the heart, lungs, kidneys, pancreas and other organs for transplantation into another patient and not allow switching off the ventilator. Senior lawyers consulted by us inform us that judges would, in all probability, rule in favour of the doctor, provided the procedure for the diagnosis of brain death before switching off the ventilator was foolproof.

:: Some personal guidelines Top

I have found the following additional guidelines useful. I pass them on for your consideration.
* The golden rule: Do unto others, as you would have others to do unto you. I have often found it helpful to ask myself, “Were I the patient, what course of action would I have wished the doctor to follow?”
* The patient comes first. The raison d’etre of our profession is the patient. We are here to serve him. The sick patient, often in physical pain and always in mental distress, deserves our fullest attention and calls for the best qualities of our mind and heart. His interests and decisions must prevail above all else except when the patient is non compos mentis. In the latter instance, the decisions of his family must prevail.
* The poor patient deserves special consideration He has nowhere else to go. He does not possess the means to command or demand. In our milieu he is often reduced to seeking help with bowed head and hands folded together. And he is ill. Medically malpractice against this group is particularly abhorrent.
* Ensure that your decisions and actions are scientific, humane, effective and in the best interests of the patient and his family. Record them. Once this is done, you need fear no individual, administrator or tribunal.

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