Ethical Dilemmas

Every day, I encounter some dilemma of medical ethics.

Usually, it's a small thing: a patient demanding an inappropriate medicine; confidentiality issues involving sexually active teenagers; end-of-life care for elderly, demented patients.

Occasionally, I have been intimately involved in gut-wrenching, life-altering family dramas: removing ventilator support from a beloved mother who barely survived her own suicide attempt; administering chemically-castrating medication to a sweet (but potentially pedophilic) retarded teenager at his mother's request; whether to perform heroic (but futile) resuscitation to an essentially brain-dead child whose mother cannot let her go.

Nationally, medical ethics are all over the front page of the newspaper: Terry Schiavo, stem cells, organ transplantation, universal healthcare, cloning, physician-assisted suicide, emergency contraception . . . the list goes on.

When I first delved into medical ethics, I found it very frustrating that there did not seem to be a right answer. And in fact, there rarely is such clarity. Rather, in a true ethical dilemma, there are two "true"ethical tenets competing against each other: one valid tenet, "right" within its own sphere, infringes directly upon another "right" tenet when it is fully exercised. Abortion is the classic example: who can deny that a woman should have the right to control her own body? But conversely, who can argue that killing a fetus is a moral act? One trumpets choice, the other reveres life. Both are right; both have limits.

At some point in your life, devoted reader, you will confront your own ethical dilemma involving your (or a loved one's) health care. A framework to consider such dilemmas could be helpful. Here's a primer on fundamental Western medical ethics, founded on four basic tenets:

1) Autonomy: individuals have an inherent right to make their own choices in regard to their healthcare.

2) Beneficence: healthcare providers are bound to do good, or what is in the patient's best interests.

3) Non-maleficence: healthcare providers are bound to do no harm, or to refrain from what would be against the patient's interest.

4) Justice: a society must distribute healthcare goods and services in a fair and equitable manner.

Here's a brief case to cut your teeth on:

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Transfusion Error

A 70 year-old woman is rushed to the hospital in shock and semi-comatose. She is found to be hemorrhaging internally due to an unintentional overdose in blood thinners. She survives after being resuscitated with fluids and a number of blood products.

When she is removed from a ventilator a few days later, she asks a nurse what happened. The nurse responds that she almost bled to death, but that she's okay now. The patient states, "Well, at least they didn't give me any blood." The nurse cautiously asks, "What do you believe about blood products?" The patient responds, "Oh, honey. People that get transfusions go to hell and suffer for eternity. I'm glad that's not me."

The nurse leaves the room and calls the physician. Should she tell the patient the truth, even if it were to cause her unbearable emotional harm?

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This is a classic confrontation between Autonomy and Non-Maleficence. Which is paramount--our duty to respect her autonomy and tell her the truth? Or our duty to respect her well-being and avoid undue harm?

Theories are great, but you're a man or woman of action. Something must be done. What would you do? How do you justify your action? Please post a comment with your opinion.

(Remember, the good thing about medical ethics is there's no right answer--except for mine, of course.)